Abstract: Objective:To investigate the clinical efficacies of free endoscopic nasobiliary drainage (ENBD) in primary duct closure (PDC) following laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis.
Methods:The retrospective cohort study was conducted. The clinical data of 312 patients with extrahepatic bile duct stones accompanied with or without cholecystolithiasis who were admitted to the 11 medical centers ［86 in the Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 62 in the Second Affiliated Hospital of Zhejiang University School of Medicine, 44 in the West China Hospital of Sichuan University, 29 in the First Affiliated Hospital of Xi′an Jiaotong University, 27 in the First Hospital Affiliated to Army Medical University (Third Military Medical University), 25 in the Hunan Provincial People′s Hospital, 17 in the Beijing Friendship Hospital of Capital Medical University, 10 in the First Affiliated Hospital of Hainan Medical University, 5 in the Henan Provincial People′s Hospital, 4 in the Beijing Tian Tan Hospital of Capital Medical University, 3 in the First Affiliated Hospital of Fujian Medical University］ from January 2011 to June 2017 were collected. All patients underwent LCBDE+PDC, and 81 and 231 patients with and without ENBD were respectively allocated into the ENBD group and PDC group. Observation indicators: (1) comparisons of operation situations; (2) comparisons of postoperative recovery; (3) comparisons of postoperative complications; (4) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative complications up to June 2017. Measurement data with normal distribution were represented as ±s. Comparison between groups was analyzed by the t test. Measurement data with skewed distribution were represented M ［interquartile range (IQR)］, and comparison between groups was analyzed by the nonparametic test. Comparisons of count data were analyzed using the chi-square test and Fisher exact probability.
Results:(1) Comparisons of operation situations: all the 312 patients underwent successful laparoscopic LCBDE + PDC, without conversion to open surgery, including postoperative death of 1 patient in the PDC group. The common bile duct diameter, cases using interrupted sutures, continuous sutures, absorbable threads and non-absorbable threads were respectively (1.2±0.4)cm, 106, 125, 195, 36 in the PDC group and (1.1±0.5)cm, 76, 5, 79, 2 in the ENBD group, with statistically significant differences between groups (t=2.497, x²=56.706, 8.457, P<0.05). The numbers of stones, stone diameter, cases with common bile duct wall (≤3 mm and >3 mm), normal and abnormal Oddi sphincter contraction function, volume of intraoperative blood loss and operation time were respectively 2.1±1.7, (1.1±0.6)cm, 148, 83, 226, 5, 20 mL (10-45 mL), (116±49)minutes in the PDC group and 1.9±1.6, (1.0±0.6)cm, 49, 32, 75, 6, 20 mL (15-30 mL), (113±23)minutes in the ENBD group, with no statistically significant difference between groups (t=1.021, 0.329, x²=0.329, 3.428, Z=1.147, t=0.521, P>0.05). The further analysis: of 312 patients, cases and time using interrupted sutures and continuous sutures were respectively 182, 130 and (133±49)minutes, (103±34)minutes，with a statistically significant difference between groups (t=-6.605, P<0.05). The volume of intraoperative blood loss and cases with postoperative complications using interrupted sutures and continuous sutures were respectively 20 mL (15-31 mL), 21 and 20 mL (10-45 mL), 18, with no statistically significant difference between groups (Z=-0.285, x²=0.369, P>0.05). Of 312 patients, cases, operation time, volume of intraoperative blood loss and postoperative complications using absorbable threads and non-absorbable threads were respectively 274, (116±44)minutes, 20 mL (15-40 mL), 33 and 38, (115±35)minutes, 18 mL (10-26 mL), 6, with no statistically significant difference between groups (Z=0.971, t=0.023, x²=0.154, P>0.05). (2) Comparisons of postoperative recovery: recovery time of gastrointestinal function, time of abdominal drainage-tube removal, using time of antibiotics and duration of hospital stay were respectively (2.0±1.5)days, (4.0±2.4)days, (4.0±2.8)days, (5.5±3.0)days in the PDC group and (4.0±1.9)days, (6.9±3.5)days, (10.0±3.9)days, (11.1±3.7)days in the ENBD group, with statistically significant differences between groups (t=-9.507,-8.258,-15.103,-13.575, P<0.05). The total expenses of hospital stay in the Affiliated Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology were respectively (5.1±0.6)×104 yuan in the PDC group and (6.5±0.5)×104 yuan in the ENBD group, with a statistically significant difference between groups (t=-9.516, P<0.05). (3) Comparisons of postoperative complications: incidence of complications in the PDC group was 14.29%(33/231), including 16 with biliary fistula, 11 with biliary tract infection, 3 with wound infection, 1 with biliary tract bleeding, 1 with residual stones of common bile duct and 1 with death; incidence of complications in the ENBD group was 6.17%(5/81), including 2 with biliary fistula, 2 with biliary tract infection and 1 with biliary tract bleeding, showing no statistically significant difference between groups (x²=3.151, P>0.05). (4) Follow-up situations: of 312 patients, 252 were followed up for 2-67 month, with a median time of 15 months, including 175 in the PDC group and 77 in the ENBD group. During the follow-up, there was no occurrence of jaundice, cholangitis and pancreatitis, and stone recurrence and postoperative cholangiostenosis were not detected by abdominal color Doppler ultrasound or CT or magnetic resonanced cholangio-pancreatography.
Conclusion:On the basis of grasping operative indication strictly, ENBD in PDC following LCBDE for choledocholithiasis is safe and effective.