Abstract: Objective:To investigate the clinical efficacy of primary closure in laparoscopic common bile duct exploration (LCBDE).
Methods:The retrospective cross-sectional study was conducted. The clinicopathological data of 2 429 patients who underwent primary closure in LCBDE in the Second Hospital of Chengdu City from March 1992 to December 2017 were collected. Patients underwent laparoscopic cholecystectomy (LC) + stone extraction using LCBDE or extracorporeal shock wave lithotripsy (ESWL), laparoscopic endoscopic sphincteropapillotomy (LEST) was performed selectively, then underwent laparoscopic endoscopic nasobiliary drainage (LENBD) or laparoscopic transabdominal antegrade-guide common bile duct stent implantation, finally underwent primary closure of common bile duct. Observation indicators: (1) surgical situations; (2) postoperative recovery; (3) postoperative short-term complications; (4) follow-up situation. Follow-up using outpatient examination and telephone interview was performed to observe long-term surgical complications once every 3 months up to 1 year postoperatively. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range).
Results:(1) Surgical situations: of 2 429 patients, 2 251 underwent successful stone extraction using LCBDE, relief of the obstruction and primary closure of common bile duct, with depletion of stones; 15 underwent stone extraction using conversion to open surgery, with depletion of stones; 163 had residual stones or surgery-related complications. Of 2 429 patients, 1 144, 898, 223, 110 and 54 were respectively detected in grade N or 0, 1, 2, 3 and 4 of laparoscopic distal of the common bile duct smooth classification (LDSC); 599 underwent LEST, 367 underwent LENBD, 207 indwelled urinary catheter through cystic duct stump, 125 underwent laparoscopic transabdominal antegrade-guide common bile duct stent implantation and 1 131 underwent primary closure in LCBDE only. Number of removing the stones, diameter of common bile duct, volume of intraoperative blood loss and operation time was (2.5±0.2)per case, (0.7±0.4)cm, (22.4±2.6)mL and (100±12)minutes, respectively. (2) Postoperative recovery: time of postoperative gastrointestinal function recovery, duration of hospital stay and treatment expenses were respectively (2.5±0.5)days, (7.3±1.2)days and (2.7±0.3)×10⁴ yuan. Of 2 429 patients, 367 removed nasobiliary catheter at 3-7 days postoperatively, 207 removed urinary catheter at 3-6 weeks postoperatively, and 125 removed common bile duct stent through duodenoscope port at 1-4 months postoperatively. (3) Postoperative short-term complications: incidence of postoperative short-term complications in 2 429 patients was 6.711%(163/2 429). ① Ninety-four patients with bile leakage were cured after drainage and symptomatic and supportive treatment. ② Of 29 patients with residual stones: 25 with residual stones of common bile duct were cured by stone extraction using endoscopic sphincterotomy of duodenal papilla, and 4 with residual stones of intrahepatic bile duct didn′t receive treatment. ③ One patient died at 15 days after surgery for pancreatic cancer. ④ Of 39 with postoperative other complications: 2 with postoperative hemorrhage were cured by laparoscopic reoperation; 12, 19 and 3 were respectively complicated with postoperative inflammatory stenosis of duodenal papilla induced to short-term obstructive jaundice, mild acute pancreatitis and stress ulcer bleeding of upper digestive tract, and they were improved by endoscopy or non-operation treatment; 2 with stenosis of bile duct didn′t receive treatment; 1 had a miss ligation at bending section of front zone of nasobiliary catheter, and ligation was removed by endoscopic retrograde cannulation of the pancreatic at 19 days postoperatively. (4) Follow-up situation: of 2 429 patients, 1 749 were followed up for 3-12 months, with a median time of 6 months. During the follow-up, of 1 749 patients, 2 had mild stenosis in the primary closure area of common bile duct incision and 1 had stenosis of duodenal papilla, they were not treated, and other patients didn′t have related complications.
Conclusion:Controlling strictly the operative indication, primary closure of common bile duct in LCBDE is safe and feasible, with satisfactory clinical outcomes.