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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 50  |  Issue : 5  |  Page : 158-162

Common bile duct exploration for elderly patients with choledocholithiasis: Is laparoscopic method better?


1 Department of Surgery, Division of General Surgery, Chi Mei Medical Center; Department of Biotechnology, Southern Taiwan University, Chiali, Tainan, Taiwan
2 Department of Surgery, Division of General Surgery, Chi Mei Medical Center; Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Chiali, Tainan, Taiwan
3 Department of Surgery, Division of General Surgery, Chi Mei Hospital, Chiali, Tainan, Taiwan

Date of Submission04-Nov-2016
Date of Decision08-Feb-2017
Date of Acceptance19-Apr-2017
Date of Web Publication9-Oct-2017

Correspondence Address:
Yih-Huei Uen
The Superintendent's Office, Chi Mei Hospital Chiali, 606, Shinhwa Road, Chiali, Tainan, 722
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_97_17

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  Abstract 


Background: Choledocholithiasis is the most common cause of acute cholangitis which resulted in potentially life-threatening infection. The prevalence of common bile duct (CBD) stone increases with age.[1] Common bile duct exploration (CBDE) is one of the treatments. However, there are a few studies about this procedure in the elderly patients. Hence, we discover the outcomes of CBDE in elderly patients ≥70 years). The methods of CBDE, including open and laparoscopic (LC) method were also compared.
Material and Method: From January 2009 to December 2014, the elderly patients with proven choledocholithiasis who underwent CBDE were included. The deremographical information, surgical outcome and postoperative complication were all recorded and evaluated.
Result: There were 97 patients in open method group (Group A) and 21 patients in LC method group (Group B). The mean age was 76.9 years (70–93 years). The demographics and comorbidity in both groups were similar. The mean length of stay after operation for Group A was 11.2 ± 9.0 days and Group B was 5.67 ± 2.29 days (P < 0.0001). The complication rate was similar in both groups (Group A, 22.6%; Group B, 4.76%; P = 0.07). The overall complication and mortality rate was 19.5% and 0.8%, respectively. The clearance of CBD stone was 95.9% in Group A and 95.2% in Group B (P = 1.00).
Conclusion: CBDE can be performed safely in the elderly with accepted morbidity and mortality, and the stone clearance is also reliable. The LCBDE approach is safe in these elderly and has benefit for shortening the hospital stay.

Keywords: Choledocholithiasis, common bile duct exploration, elderly, laparoscopic


How to cite this article:
Lin YF, Tian YF, Uen YH. Common bile duct exploration for elderly patients with choledocholithiasis: Is laparoscopic method better?. Formos J Surg 2017;50:158-62

How to cite this URL:
Lin YF, Tian YF, Uen YH. Common bile duct exploration for elderly patients with choledocholithiasis: Is laparoscopic method better?. Formos J Surg [serial online] 2017 [cited 2017 Nov 20];50:158-62. Available from: http://www.e-fjs.org/text.asp?2017/50/5/158/216241




  Introduction Top


The open common bile duct (CBD) exploration (CBDE), laparoscopic (LC) cholecystectomy with pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP), and laparoscopic CBDE (LCBDE)[2] are several main managements of CDB stones. However, there is no consensus for the management of CBD stone still.[3] With these procedures, cholecystectomy, either open or LC method, is necessary due to up to 47% of patients will develop recurrent symptoms from cholelithiasis.[4] Hence, with ERCP, the treatment will be completed with 2 stages operation. It means that patients will receive twice anesthesia. Besides, ERCP still has a mortality and morbidity rate of up to 1% and 15.9%, respectively.[5],[6]

The safety and better outcome of LCBDE in the general population are well documented in several studies. However, for the high technical skills required, it is not accepted widely. Reviewing the literature, LC approach has an associated mortality rate of 0.3%–0.8% and morbidity of 3.7%–3%.[7],[8],[9],[10],[11] The outcome is variety, but the overall length of stay is shorter in LCBDE compared with the 2-stage method.[12] Although the incidence of CBD stones is more frequently in the elderly,[13] there are few studies about this procedure in this group of patients.[14],[15],[16] With this situation, our retrospective study aimed to evaluate and analyze the results of CBDE in elderly patients treated with the open or LC methods.


  Methods Top


Patients

A retrospective review of all elderly patients (≥70 years), who underwent CBDE in the Department of Surgery at the Chi Mei Hospital between January 2009 to December 2014, was performed. Data collected included patient demographics, comorbidity, presenting diagnosis, laboratory and radiologic investigations, operative details, the length of stay, and complications. A total of 141 CBDE were performed during this study period. All the patients had experience of acute onset of Right upper quarter or epigastric abdominal pain, and some of them suffered from sepsis or even septic shock. Patients who presented acutely with biliary obstruction and on-going sepsis would initially undergo decompression with either an ERCP or percutaneous transhepatic cholangial drainage (PTCD) or percutaneous transhepatic gallbladder drainage if ERCP was unsuccessful. All the patients underwent surgical treatment after the acute inflammation or sepsis subsided. All the patients had experience of the impression of CBD stone. The pre-operative diagnosis of CBD stones was made using a combination of ultrasonography, computerized tomography (CT) scan, or magnetic resonance cholangiopancreatography. Cholecystitis and cholangitis were diagnosed according to Tokyo guidelines criteria. Acute pancreatitis was diagnosed by the Atlanta classification.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Local Ethics Committee of the Institute. Informed written consent was obtained from all patients before their enrollment in this study.

Techniques

Laparoscopic common bile duct exploration

Four ports were utilized as for standard LC using an American approach. Patients would receive a single dose of antibiotic prophylaxis. All our patients received the transcholedochal approach. For the transcholedochal route, a longitudinal choledochotomy was made in the supraduodenal CBD after adequate exposure; next, a 5 mm choledochoscope was inserted and a basket was used to retrieve the stones. Then, the opening of CBD was closed with intermittent suture with T-tube placement as biliary drainage, unless there was an existed PTCD.

Open common bile duct exploration

After adequate exposure with Kocher's incision, Calot's triangle was dissected to expose the cystic duct and CBD. This was followed by cholecystectomy. A vertical choledochotomy was then made between stay sutures. A 5 mm choledochoscope and basket are used to retrieve stones under vision. Then, the opening of CBD was closed with intermittent suture with T-tube placement as biliary drainage, unless there was an existed PTCD.

Postoperative follow-up

Stone clearance after bile duct exploration may be examined with a cholangiogram performed for all the patients through T-tube or PTCD about 3 weeks after the operation. Then, the drain tube would be removed 1–2 weeks later if there was no residual stone. However, choledochoscopy should be performed if the residual stone is suspected. When the residual stones were identified, further treatment like choledochoscopy or ERCP would be performed to remove the stones.

Statistical analysis

Data analysis was performed using Stata v10.2 (Stata Corp., College Station, Texas, USA). The level of significance was set at 5%. The χ2 test as well as Student's independent t-test were used to compare characteristics between the two groups. The binary logistic regression model was used to study the independent association between the various factors and the two groups.


  Results Top


During the study period, 141 CBDEs were performed in the elderly with a mean age of 77.2 years (range, 70–93 years). Patients who underwent open and LC CBDE were designated Group A and Group B, respectively. There were 97 patients in Group A and 21 in Group B. There were 3 patients converted from LC method to open, and they were excluded from the study. Besides, 20 patients in Group A with a history of upper abdominal surgery were also excluded from the study.

Among these two groups, the age, sex, and comorbidity were no statistically significant differences [Table 1]. In this study, none of them underwent an emergent operation.
Table 1: Demographical information of patients

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The duration of surgery had the significant difference between these two groups (175 ± 69 min vs. 223 ± 65 min; P = 0.004) [Table 2]. The mean length of hospital stay after the operation was longer in Group A compared with Group B (11.2 ± 9.0 days vs. 5.7 ± 2.3 days; P < 0.001). The stone clearance did not differ with a residual stone rate 4.1% versus 4.8%, P = 1.00. There was a total of 27 complications in 23 patients with an overall complication rate of 19.5%, but only one mortality case (0.08%) in our study. The mortality case was in Group A but the mortality rate of these two group is not different (P = 1.00). Besides, the complication rate of both groups was also no difference (22.7% vs. 4.8%; P = 0.07).
Table 2: Surgical outcome

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The complications are listed in [Table 3]. The patients with infection diseases were treated with intravenous antibiotics and subsequently discharged home with oral antibiotics. Wound infection was the most common complications in our study and managed with antibiotics and wound wet dressing. One patient with bile leakage was diagnosed via drainage during the hospitalization, but no re-operation was performed. The leakage was subsided later with conservative care. The only complication was noted in the LC group is ileus with clinical symptoms as poor appetite and vomiting. Intravenous fluid support treatment was prescribed, and then it was improved. CBD residual stones were found in 5 patients (4 patients in Group A and 1 in Group B, P = 1.00) and no re-operation was done for residual stones. Two residual stones were removed by choledochoscopy after removing the T-tube. Three of them were removed by stone push through T-tube tract under fluoroscopy by the radiologist. The only mortality case was in Group A died on the day 95 days after the operation. There was no residual stone noted via cholangiography and choledochoscopy for the patient. However the patient was re-admission 40 days due to residual stone, discovered with abdominal CT scan, with cholangitis and then he died during the same hospitalization due to multiple organ failures resulted by infection.
Table 3: Post-operative complication

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  Discussion Top


Both surgical and endoscopic approaches are established modalities of CBD stone treatments. There are many advantage and disadvantage when comparing ERCP followed by cholecystectomy and CBDE, but “gold standard” treatment was not defined for CBD stones treatment yet. One of the CBDE advantages is the avoidance of the morbidities of ERCP, including perforation. The CBDE is necessary for certain situations such as those require a concomitant biliary enteric drainage and those that failed or could not tolerate LCBDE or ERCP. Now, LC cholecystectomy was the standard of treatment for cholecystitis due to its advantage compared with open method. LC biliary duct surgery should be considered for patients with CBD stones although the technique threshold is higher.

The elderly patients, usually with multiple comorbidities, are more complicated to treat. However, they also have the high incident rate of CBD stones.[14] With the advances in surgical techniques and critical care medicine, the mortality of surgical treatments for these patients is acceptable. For these patients with poor conditions, ERCP with or without stent placements without cholecystectomy is an option. However, there are significant recurrence rates and subsequent complications if cholecystectomy not performed. Thus, this treatment should be preserved for the patients those could not tolerant the operation.

LCBDE, like other LC procedure, is a highly effective and safe procedure, but this expertise is not available widely.[17] Furthermore, there are few studies about the outcome of this procedure in the elderly. In our study, there were 97 patients in the open group and 21 patients in the LCBDE group. All patients were over 70 years of age. The most common presenting diagnosis was cholangitis and acute cholecystitis. Both groups had comparable demographics and comorbidities.

The operating time in the LCBDE group was longer (P = 0.04). This is because of the technical difficulties. The complication rate of the open CBDE was higher (22.7%) as compared with the LCBDE group (4.8%), but there is no statistical difference (P = 0.07). We compared each complication in both groups and no significant difference was found. It is because only one complication was found in the LC group and few data to evaluate. The high risk of wound infection in open group may be due to large open wound and bile contamination, which just can be prevented by LC procedure. All the complications were managed with medical treatment. Neither re-operation nor intervention is necessary for these complications.

The mean length of stay after operation in the LCBDE was shorter compared with the open group (5.7 ± 2.3 days vs. 11.2 ± 9.0 days; P = 0.004). In our study, patients were treated when their disease became stable. Surgery was performed at the same hospitalization of disease acutely onset or in the next hospitalization after disease became stable. For our purpose that comparing the outcome of these two surgical methods for the elderly patients, the length of stay after the operation was evaluated instead of total hospitalization. Like other LC procedures, LCBDE has benefit in postoperative recovery, including shorter hospitalization.

There were three conversions in our study. The reasons for conversion include one patient with dense adhesions, one patient whose CBD stone could not be removed with the LC method, and one patient who's T-tube was difficult to place due to small caliber of CBD. The incidence of retained stones was 4.2% in our study, and it showed no difference between two groups (4.1% and 4.8%, P = 1.00). This is similar to other studies in the literature.[18] The management of retained stones included choledochoscopy through T-tube tract, and, most of them, stone push via T-tube tract under fluoroscopy by the radiologist.

There is a study [16] published in 2015 that had similar purpose and method to ours. In that article, LCBDE has benefit in shorter hospitalization. However, the operation time was not significantly different between two methods. In our study, longer surgical time was significant at the LC group. It may be because that our surgeons were not skilled in the LC method, especially in the early cases. There was no mortality in the LCBDE group in both studies, and another study has reported a mortality rate of 1.3% only in the elderly with LCBDE.[15] All the results revealed that LCBDE is safe for the elderly patients.


  Conclusions Top


The results of our study have shown that CBDE is a reliable procedure for elderly patients with acceptable mortality and morbidity. When compared with open CBDE, LC techniques can provide a shorted hospitalization to the elderly patients with stable conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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