Abstract: Objective:To investigate the clinical effect of laparoscopic reverse papillary intubation through cystic duct and laparoscope combined with duodenoscope in the treatment of cholecystolithiasis and thining choledocholithiasis. 
Methods:The retrospective cohort study was adopted. The clinical data of 192 patients with cholecystolithiasis and thining choledocholithiasis who were admitted to Chengdu Second People′s Hospital between May 2012 to August 2015 were collected. The 96 patients who underwent laparoscopic reverse papillary intubation through cystic duct were allocated into the case group, and the other 96 who received surgery by laparoscope combined with duodenoscope were allocated into the control group. All the patients underwent laparoscopic cholecystectomy (LC) according to routine approaches. The 96 patients in the case group received the placement of 4 Fr ureter catheter via cystic duct and placement of common bile duct inserted through the duodenal papilla under laparoscope, and then the duodenal papilla was resected using needle knife along the ureter catheter and stones were removed by basket lithotriptor and ball lithotriptor. The 96 patients in the control group received the intubation using the bow knife with zebra guidewire, and stones were removed by basket lithotriptor and ball lithotriptor. During the operations, it was observed whether there were residual stones by nasobiliary radiograph. The comparison was made between the 2 groups concerning (1) surgical situation: intubation and operation time. (2) Postoperative alanine transaminase (ALT), postoperative aspartate transaminase (AST), postoperative total bilirubin (TBil), postoperative blood amylase, postoperative lipase, complications and extubation time. (3) Situation of followup: followup was done by outpatient examination or telephone interview up to November 2015. The stones recurrence was detected by retrograde cholangiography through nasal bile duct, magnetic resonance cholangiopancreatography (MRCP) or ultrasonic examination. Measurement data with normal distribution were represented as ±s. Comparison between groups was done by the t test. Count data were analyzed by the chisquare test.
Results:(1) Surgical situation: 2 groups both underwent successful LC. Ureteral catheter in the case group was successfully imbedded through cystic duct, including 8 patients with being difficult to intubate. Five patients in the control group were failed in endoscopic sphincterotomy (EST) due to periamullary diverticula or other causes, and then EST was performed again by the duodenal papilla through ureteral catheter which was intubated through cystic duct. Operation time of the case group and control group was (89±17)minutes and (105±26)minutes, respectively, with a statistically significant difference between the 2 groups (t=5.05, P<0.05). (2) Postoperative situation: ALT, AST, TBil of the case group and control group were (163±54)U/L, (87±38)U/L, (43±18)μmol/L and (147± 49)U/L, (101±26)U/L, (37±17)μmol/L, respectively, showing no statistically significant differences (t= 0.97, 1.21, 0.84, P>0.05). Postoperative blood amylase and lipase of the case group and control group were (151±41)U/L, (198±72)U/L and (395±142)U/L, (549±217)U/L, respectively, showing statistically significant differences (t=16.18, 15.05, P<0.05). No pancreatitis was found in the case group while 6 patients in the control group complicated with mild pancreatitis were improved by symptomatic treatment of fasting, somatostatin administration and acid suppression, with no severe pancreatitis. No complications such as intestinal perforation, bile duct perforation and massive hemorrhage were detected in both groups after operation. No death occurred. The nasal bile duct in the patients without pancreatitis was removed at postoperative day 3. The nasal bile duct in the patients with pancreatitis was removed after the remission of abdominal pain and diet intake. In the case group, it was difficult to remove the nasal bile duct of 1 patient. Nasal bile duct radiograph showed that the bending section of nasal bile duct was mistakenly sutured by the absorbable thread at the lower margin of incision of junction of cystic ducts, and yet there was unobstructed biliary drainage. The nasal bile duct was removed and the patient was discharged from hospital at postoperative day 19. The abdominal drainage tubes were removed at postoperative day 3 to 5 in both groups. (3) Of 192 patients, 151 were followed up for a median time of 10 months (range, 3- 12 months). Patients had good recovery without recurrence of abdominal pain, jaundice and stones.
Conclusion Laparoscopic reverse papillary intubation through cystic duct for the treatment of cholecystolithiasis and thining choledocholithiasis is safe and feasible, and it can also reduce incidence of pancreatitis after nasobiliary drainage.