Clinical Research Of Laparoscopic Cholecystectomy (LC) Combined With Intraoperative Endoscopic Retrograde Cholangiopancreatography (ERCP) In The Treatment Of Concomitant Cholelithiasis And Choledocholithiasis In Older Patient

Background:Cholecystolithiasis is one of the most common disease in biliary surgery.It is reported that,up to 10% to 18% of gallbladder stones have accompanied with choledocholithiasis.And the morbidity was raising with aging.In patients age from 61 to 70,the morbidity was higher than31%,and it's even worse in patients age from 71 to 80,which were 48%.The conventional method to cure those patients is open surgery,with gallbladder resection and common bile duct lithotomy at the same time.In 1991,Phillip carried out the first case of laparoscopic common bile duct exploration(LCBDE)in the world.Henceforth,it became the classical therapeutic regimen of minimal invasive surgery,also it have some shortcomings like long-time T-tube placement.Along with technology improvement,as reported in many studies recently,ERCP combined with LC proved to be the most important treatment choice,and it have some advantages such as minimal invasive,quick recovery,less complications and no-need of T-tube placement,but the procedure always divided into two steps.Some researchers tried to finish ERCP and LC simultaneously,and the results were promising,this method have all the advantages and no differences in surgical effects and complications.As for surgery plan,there still have controversies,especially in older people.In this research,a randomized controlled trial were conducted prospectively to evaluate the feasibility,safety and clinical effects of LC combined with intraoperative ERCP(IOERCP)in older patients.Objective:To evaluate the clinical feasibility,effects and safety of LC combined with IOERCP in the treatment of cholelithiasis and choledocholithiasis in older patients.And to offer an safe and effective option of minimal invasive treatment for those patients.Methods:82 cases of older patients with concomitant cholelithiasis and choledocholithiasis were enrolled from May 2015 to October 2017 in Third Hospital of Mianyang city.And those patients were divided into two groups by random digital table method.There are 42 cases in group A,which were treated by LC and IOERCP.Other 40 cases in group B,were healed by LC and LCBDE.The successful stone removal rate,operative time,blood loss,conversion to open surgery rate,postoperative bleeding,pancreatitis,digestive tract perforation,hospitalization cost and length of hospital stay were analyzed comparatively.And long term follow-up,such as stone recurrence rate,cholangitis and pancreatitis were proceed as scheduled.Results : There are no statistically differences between two groups in gender composition,age,total bilirubin,transaminase,diameter of stones,common bile duct transverse diameter,calculus quantities,and overall complication rate(P>0.05),which means two groups have comparability in baseline clinical data.Also there are the same results in operative time,blood loss and conversion to open surgery rate(P>0.05).They have statistically differences about residual calculi rate(P<0.05),that indicate they have the same clinical effect and better calculi removal rate in IOERCP group.As for postoperative complications,the overall complication rate was 5% in group A(LC+IOERCP),and it was 5.12% in group B(LC+LCBDE).There are no critical complications,for instance,digestive tract perforation,acute severe pancreatitis,acute cholangeitis,bile duct injury,severe retroperitoneal infection and death.In group A,there are 1 case of hyperamylasemia,1 case of postoperative bleeding,2 cases of cannulation failure in ERCP which turned into LCBDE.In group B,there are 1 case of postoperative bleeding and 1 case of bile leakage.There are statistically differences in hospitalization expenses(P<0.05),but with regard to length of hospital stay,group A is shorter(P<0.05).Follow-up at 3 to 24 months,there are 2 cases of choledocholithiasis recrudescence in group A,and 3 cases in group B.No patients suffered cholangeitis and pancreatitis.Conclusion : LC combined with IOERCP can be a safe and effective option for concomitant cholelithiasis and choledocholithiasis in older patients at the qualified hospital,and also have some other advantages,such as rapid postoperative recovery,shortened hospital stay,and no need of long time T-tube placement.