Discussion
Since the advent of laparoscopic cholecystectomy, the management strategy for CBD stones has been a subject of much discussion but with the absence of an established consensus.
There were several methods in the management of patients with choledocholithiasis: Single stage laparoscopic procedures, two stage methods combining LC with pre- or post-operative ERC. For the single stage laparoscopic procedures, LC can be combined with laparoscopic exploration of the common bile duct, either as a choledochotomy or as a LTSE procedure. Preoperative Endoscopic sphincterotomy (EST) has been the procedure of choice for most physicians. Although the success rate for stone clearance equals 87% to 97%, ERCP and EST are associated with morbidity and mortality rates of 5% to 11% and 0.77% to 1.2%, respectively.
According to some randomized studies, the single-stage technique has been shown to have the advantages of shorter hospital stay and lower postoperative morbidity. The present study showed that LTSE was safe withthe postoperative complication rate of 13.5%. Bile duct stone clearance was was successful in 96.2% of LTSE patients, similar to that of LC cases. Compared to the LC group, the operating time and postoperative hospital stay were shorter and the expense was lower in the LTSE group. Total complication and biliary complication rates in were also significantly lower in the LTSE group than in the LC group.
Although attractive, the LTSE approach was confined to CBD stones smaller than 9 mm in size, fewer than 5 stones, and stone location in the CBD distal to the cystic duct confluence. If these criteria were not fulfilled, or the LTSE approach failed, LC had to be used.
Laparoscopic primary closure of CBD is safe and effective for the management of CBD stones, and can be performed routinely as an alternative to T-tube drainage. In our study, LC cases were randomized to either the T-tube or the primary closure groups. The the operation time and postoperative hospital stay were shorter and the hospital expenses lower in the primary closure group than in the T-tube group. We have shown fewer, but no statistical, complications in the group with the primary closure.
For Overall, the postoperative complication rate, in the primary closure group was insignificantly lower than that in the T-tube group. Similar to the findings reported previously, the most complication in the T-tube group in our study was related to the use of the T-tube. Therefore, postoperative T-tube drainage is unnecessary for decompression of the biliary tree. In addition, the use of intraoperative choledochoscopy and cholangiography can also help eliminate the overlooked biliary tree diseases.
The length of hospital stay was shorter in the primary group than in the T-tube group. We believe that the risks of dehydration and saline depletion in patients with open T-tubes at home are contraindications to discharge. Therefore, the patients need to keep their T-tube in the hospital until after the clearance by the T-tube cholangiogram. It is unacceptable to the majority of our patients to go home with a functioning T-tube. Prolonging hospital stay would not only increase the total hospital expense, but also raise the risk of complications and the need for transfusion.