A Comparison of the Relative Safety and Efficacy of Laparoscopic Choledochotomy with Primary Closure and Endoscopic Treatment for Bile Duct Stones in Patients with Cholelithiasis

Background: To date, several clinical trials have demonstated that both one-stage laparoscopic cholecystectomy (LC) combined with common bile duct exploration (LC+BDE) with primary closure and one-stage LC combined with endoscopic stone extraction (LC+ESE) are the two primary clinical approaches to treat cholelithiasis. However, no studies to date have directly compared the LC+BDE with primary closure and one-stage LC+ESE procedures. We, therefore, conducted a retrospective analysis of patients with cholelithiasis who had been treated through LC+ESE or LC+BDE to compare these two approaches for the treatment of cholecystitis and common bile duct stones (CCBDS). Methods: Consecutive CCBDS patients with cholelithiasis in our hospital who were diagnosed through Media Resource Control Protocol (MRCP) and ultrasound between June 2010 and February 2017 were randomly assigned to undergo either LC+ESE or LC+BDE, as both procedures are routinely used to treat cholelithiasis in our hospital. All patients were made aware of the risks and benefits of the surgery preoperatively, and this study was approved by the ethics committee of our institute. Outcomes in these two groups, including rates of success and reasons for operative failure, were then compared, as were data pertaining to patient demographics, clinical findings, postoperative stay duration, and medical expenses. In addition, biliary reflux as measured through computed tomography or gastrointestinal imaging was monitored for a minimum of 2 years. Results: In total, 207 CCBDS patients were identified during the study period and were randomized into the LC+ESE ( n  = 103) or LC+BDE ( n  = 104) treatment groups. We found that patients treated through LC+BDE achieved a significantly higher success rate than that achieved in patients treated through LC+ESE (93.3% versus 82.5%; P  < .05). Specifically, the LC+BDE with primary closure procedure failed in patients with impacted stones located at the end of the common bile duct (CBD) and in those with stenosis of the sphincter of Oddi. The only variable that differed significantly between these two treatment groups was stone location. Variables other than stone location, CBD size, and stone size did not differ significantly between the two groups. However, the LC+BDE treatment was associated with significant reductions in patient operating time, morbidity, hospital day duration, and biliary reflux of duodenal contents relative to the LC+ESE treatment. Conclusions: We found that LC+BDE with primary closure was a safer and more effective means of treated CCBDS patients than was the LC+ESE procedure and that it was not associated with risks of sphincterotomy of duodenal papilla (EST)- or T-tube-related complications. However, our data also clearly indicate that LC+BDE cannot replace LC+ESE in all patients, and that as such both approaches should be considered as being complementary to one another, with their relative advantages in a given patient being defined based upon local resource availability and expertise. In addition, when the LC+ESE procedure fails then the LC+BDE treatment can be safely employed as a salvage approach.