Clinical Application And Surgical Options Of Minimally Invasive Surgery For Choledocholithiasis

Objective:To exploretheclinical application and surgical options of various minimally invasive surgery for choledocholithiasis,we analysis the clinical data of patientswith choledocholithiasis received by Laparoscopic common bile duct exploration(LCBDE)and by Endoscopic retrograde cholangiopancreatography/Endoscopic sphincterotomy(ERCP/EST).Methods:The clinical data of 494 patients with choledocholithiasis who received minimally invasive surgery such as LCBDE or ERCP/EST in recent 5 years in our hospital were retrospectively analyzed.Of these,258 patients received LCBDE(LCBDE group)and 236 patients received ERCP/EST(ERCP/EST group).In this study,we first compared and analyzed operationrate,operative time,postoperative hospitalization,pre-and post-operative transaminase,bilirubin,andpostoperative complications in LCBDE and ERCP/EST group.Then,we performed a subgroup analysis of operationrate,operative time,postoperative length of stay,transaminase and bilirubin,and postoperative complications of patients undergoing laparoscopic transcystic common bile duct exploration(LTCBDE)and choledocholithotomy in the LCBDE group.Finally,the clinical efficacy and safety of common bile duct primary suture and T tube drainage in LCBDE group were compared.Results:(1)In this study,the analysis showed no significant difference in the surgical success rate between the LCBDE group and the ERCP/EST group(P>0.05).The operation time of LCBDE group(128.56±53.25 min)was significantly longer than that of ERCP/EST group(55.59±20.96 min)(P<0.05).The postoperative hospitalization time of patients in the LCBDE group was 5.75±3.15d,which was significantly shorter than that in the ERCP/EST group(7.20±3.44d)(P<0.05).The total hospitalization expenses of patients in the ERCP/EST group were significantly higher than those in the LCBDE group(P<0.05).The analysis results of postoperative complications showed that the incidence of postoperative pancreatitis and gastrointestinal bleeding in ERCP/EST group were significantly higher than that in LCBDE group(P<0.05).However,the incidence of postoperative bile leakage was far lower than that of the LCBDE group(P<0.05).There was no significant change in stone residue and Clavien-dindo Score between the two groups.We also analyzed the indexes related to liver function before and after the operation,and the results showed that the serum glutamyl transpeptidase(GGT),glutamyl transaminase(AST),alanine transaminase(ALT)and total bilirubin(TBIL)of the two groups showed different degrees of decline on the first and third day after the operation.On the first day after surgery,AST and ALT in the ERCP/EST group were significantly lower than those in the LCBDE group(P<0.05).(2)We performed a subgroup analysis of LCBDE patients undergoing LTCBDE or choledocholigotomy,showed that the operation time and postoperative hospitalization time of patients undergoing LTCBDE were significantly reduced compared with those undergoing choledocholigotomy(P<0.05).There was no significant difference between the two groups in hospitalization cost and incidence of related postoperative complications.In the two groups,postoperative serological indexes such as GGT,AST,ALT and TBIL were decreased in different degrees.The serum AST and ALT levels of the patients in the LTCBDE group on the first day after surgery were significantly lower than those in the choledocholithotomy group(P<0.05).(3)We conducted a subgroup analysis of LCBDE patients who received primary suturegroup and T tube drainage group,and the results showed no significant difference in the surgical success rate between the two groups.The operation time of primary suturegroup was 116.82±36.80 min,which was significantly shorter than that of T tube drainage group(159.75±61.00 min)(P<0.05).The results also showed that the postoperative hospitalization time of patients in the primary suturegroup(4.34±1.60 d)was significantly shorter than that in the T tube drainage group(6.48±3.12 d)(P<0.05),and the total hospitalization cost was significantly lower than that in the T tube drainage group(P<0.05).In terms of postoperative complications,except that the incidence of postoperative bile leakage in the primary suturegroup was much higher than that in the T tube drainage group(P<0.05),there was no significant difference in other postoperative complications such as postoperative pancreatitis,gastrointestinal bleeding,calculus residue and Clavien-dindo Score.The analysis results showed that the postoperative serological indicators such as GGT,AST,ALT and TBIL were all decreasing in different degrees.The serum AST and TBIL of the patients in the primary suturegroup on the third day after the surgery were significantly lower than those in the T tube drainage group(P<0.05).Conclusions:(1)Both LCBDE and ERCP/EST have their own advantages and disadvantages.Patients in the LCBDE group had short hospital stay and low total hospital expenses,but the incidence of postoperative bile leakage was slightly higher.However,patients in the ERCP/EST group had shorter operation time,longer hospitalization time and higher total hospitalization cost,and postoperative complications such as pancreatitis and gastrointestinal bleeding are easy to occur.For the choice of operation,LCBDE is recommended for patients with big and large number of choledocholithiasis or combined with cholecystolithiasis.ERCP/EST is preferred for patients with small number of choledocholithiasis and no cholecystolithiasis or who cannot tolerate general anesthesia.(2)Subgroup analysis showed that patients with LCBDE who underwent LTCBDE had shorter operative time and postoperative hospitalization time,and could minimize the bile duct injury to the greatest extent.They also had fewer postoperative complications,faster postoperative recovery and less pain.However,due to the influence of factors such as the diameter of the gallbladder duct,the position and size of the stone,and the anatomical structure of the confluence of the gallbladder duct and the common bile duct,the success rate of the operation is relatively low,and its clinical application is limited.(3)Subgroup analysis showed that LCBDE patients receiving primary suture had shorter operation time,shorter total hospitalization time and lower total hospitalization cost,and were more consistent with the concept of minimally invasive and rapid recovery.Primary suture is recommended under the condition that there is no stricture or residual calculi in the common bile duct,and the operator is skilled in endoscopic operation and suture technology.If the inflammation is heavy,the bile duct is strictured or the calculi is large,the recommendation carries on the T tube drainage.