Application Of Laparoscopic Common Bile Duct Exploration In Elderly Patients With Recurrent Choledocholithiasis

BackgroundWith the development of living conditions and medical services for residents,human life expectancy has increased significantly over the last century.Overall human life expectancy rose from 65.3 years in 1990 to 77.3 years in 2021.The incidence of chronic diseases such as diabetes,hypertension,cerebrovascular disease,heart disease and lung disease increases with age.Therefore,elderly patients are often classified as high-risk patients for surgery.Common bile duct stones(CBDS)are one of the common diseases in the elderly,with an incidence of up to 30%in some reports[1,2]Currently,the commonly used minimally invasive treatments for CBDS include endoscopic sphincterotomy(EST)and laparoscopic common bile duct exploration(LCBDE).Since the first report of endoscopic sphincterotomy(EST),EST has gradually become the standard treatment for CBDS[3],but the invasive treatment of EST may cause related complications.It can occur even with the most experienced specialist procedures,where recurrence of CBDS has become a recognized late complication[4]Studies have shown that CBDS occurs in 10%-18%of patients with cholecystolithiasis after laparoscopic cholecystectomy[5],and 4-24%of patients will relapse after the first lithotomy,and even some patients will relapse after multiple lithotrips[6].The management of these cases is challenging.Compared with traditional surgery,EST surgery can be performed under local anesthesia,with the advantages of less trauma and faster postoperative recovery,so it was once accepted by most stone-related patients,especially elderly patients.Although EST has many advantages,the postoperative complications caused by it are often difficult for clinicians,and serious complications hinder the promotion and development of EST.With the gradual development of minimally invasive techniques and the training of laparoscopic techniques,laparoscopic common bile duct exploration(LCBDE),which is also less invasive and highly safe,has come into the public eye,and LCBDE has gradually become a treatment option for the gallbladder.The standard treatment of calculi combined with CBDS,however,there are still few studies at home and abroad for recurrent CBDS followed by LCBDE.At present,there are no relevant studies reporting the application of LCBDE in elderly recurrent CBDS.This study analyzed the clinical efficacy of LCBDE in the treatment of elderly recurrent CBDS from multiple aspects.PurposeThis paper retrospectively analyzed the clinical data of 311 elderly patients with recurrent CBDS who were diagnosed and treated in the First Affiliated Hospital of Zhengzhou University from January 2010 to December 2021.group(EST group)and laparoscopic common bile duct exploration and lithotomy group(LCBDE group),of which 186 patients were included in the EST group and 125 patients were included in the LCBDE group.After Propensity Score Matching(PSM),84 pairs of patients in each group were matched for inclusion in the study.The safety and feasibility of LCBDE in the treatment of recurrent CBDS in the elderly were systematically analyzed from the aspects of surgical results,postoperative recovery time,hospitalization costs,and postoperative short-term and long-term complications.Materials and methodsThe clinical data of 311 elderly patients with recurrent CBDS who were diagnosed and treated in the First Affiliated Hospital of Zhengzhou University from January 2010 to December 2021 were collected.The results were systematically analyzed from the aspects of surgical outcome,postoperative gastrointestinal recovery time,and postoperative short-term and long-term complications.According to the operation method,they were divided into endoscopic sphincterotomy lithotomy group(EST group)and laparoscopic common bile duct exploration lithotomy group(LCBDE group).Among them,186 patients were included in the EST group and 125 patients were included in the LCBDE group.After PSM,84 patient pairs were matched for inclusion in the study.The medical records of the two groups were collected for statistical analysis.Clinical medical records included general information of patients,intraoperative and postoperative recovery,and postoperative short-term and long-term complications.General information included age,gender,admission symptoms,underlying diseases,history of previous biliary tract surgery,and the diameter of the common bile duct and the largest stone diameter on imaging examinations.Intraoperative conditions included the rate of conversion to surgery and the rate of residual stones.Postoperative recovery includes gastrointestinal recovery time,and liver function recovery three days after surgery.Recent complications include fever,bile leakage,pancreatitis,biliary hemorrhage,and duodenal perforation.Long-term complications include cholangitis,stone recurrence,and bile duct strictures.Univariate analysis was performed on these factors.All statistical analysis was done using SPSS 26 software.The measurement data that did not conform to the normal distribution were expressed as quartiles.The measurement data before PSM were compared by Mann-Whitney U test,and the measurement data after PSM were compared by Wilcoxon rank.and inspection.The enumeration data were expressed as rate,the enumeration data before PSM was analyzed by χ2 test,and the enumeration data after PSM was analyzed by Macnemar test,P<0.05 was considered statistically significant.ResultAmong elderly patients with recurrent CBDS,125 received LCBDE and 186 received EST.After PSM,each group was matched to 84 patients for inclusion in the study.Before PSM,the proportion of male patients and the proportion of patients with cardiovascular disease in the LCBDE group were lower than those in the EST group,the preoperative TBIL and DBIL in the LCBDE group were higher than those in the EST group,and the preoperative maximum stone diameter in the LCBDE group was greater than that in the EST group,with statistically significant differences(P<0.05),after PSM,there was no significant difference in general data between the two groups(P>0.05).Statistical analysis between the LCBDE group and the EST group showed that the intraoperative conversion rate of the LCBDE group was significantly lower than that of the EST group(x2=5.4,P<0.05),and the difference was statistically significant.3 patients in the LCBDE group were converted to laparotomy because of severe intraperitoneal adhesions,in order to avoid damage to surrounding tissues and organs during the separation of the dense adhesions under laparoscopy.The operation was terminated due to repeated intubation failures,and 6 patients were transferred to LCBDE treatment because the stones were too large to be removed under endoscopy.The operation time of LCBDE group was longer than that of EST group(z=-7.908,P<0.001),and the difference was statistically significant.The TBIL and DBIL in the LCBDE group were lower than those in the EST group three days after operation(Z=-1.676,-2.219,P<0.05),and the difference was statistically significant.There was no significant difference in residual stone rate and gastrointestinal recovery time between the LCBDE group and the EST group,and there was no death in the two groups.In this study,there were no perioperative deaths in the two groups.Among 84 patients in the LCBDE group,4 cases of bile leakage occurred,and the overall incidence was 4.8%(4/84);there were 84 patients in the EST group,and 6 cases of bile duct hemorrhage occurred.There were 5 cases of pancreatitis,and the overall incidence was 7.1%(6/84)and 5.9%(5/84);the overall incidence of recent complications in the EST group was higher than that in the LCBDE group,P<0.05,the difference was statistically significant significance.In the LCBDE group,1 case of stone recurrence occurred in 84 patients,and the overall incidence rate was 1.2%(1/84).10.7%(9/84),1.2%(1/84),and 1.2%(1/84);the overall long-term complication rate in the EST group was higher than that in the LCBDE group,P<0.05,and the difference was statistically significant.ConclusionIn elderly patients with recurrent CBDS treated with LCBDE or EST,in the context of propensity score matching,LCBDE was similar to EST in the treatment of elderly recurrent CBDS in terms of residual stone rate,but LCBDE was successful.It has the advantages of high rate,quick recovery of postoperative liver function,few long-term complications,and high postoperative quality of life.Under the condition that the patient’s physical condition can tolerate surgery,it can be used as the first choice for the treatment of recurrent CBDS in the elderly.