Surg Endosc DOI 10.1007/s00464-013-3395-4
and Other Interventional Techniques
LETTER TO THE EDITOR
Laparoscopic choledochotomy followed by primary duct closure for choledocholithiasis Yunqiang Cai • Xubao Liu
Received: 10 November 2013 / Accepted: 12 December 2013 Ó Springer Science+Business Media New York 2014
Dear Editor, We read with interest the article by Khaled et al. [1]. We appreciate that they shared their experience in the setting of choledocholithiasis via laparoscopic choledochotomy followed by primary duct closure, however we have several concerns regarding their study. The average diameter of common bile duct in their series was 9.4 mm (range 3–30 mm). We have also carried out more than 50 cases of laparoscopic bile duct exploration in our institution. In our practice, it is technically challenging to perform laparoscopic choledochotomy and choledochoscopy (5 mm in diameter) for patients without dilated common bile duct. Furthermore, single-stage management is not suitable for poor-risk patients, including those with cholangitis, deep jaundice, coagulopathy, and severe pancreatitis [2]. The selection criteria for laparoscopic choledochotomy followed by primary duct closure for choledocholithiasis may be better defined. The authors stated that they carried out interrupted sutures for patients without a markedly dilated duct, and continuous sutures for a dilated duct. Is there any difference in terms of postoperative biliary leak or bile duct stricture caused by the different ways of suture? Three patients suffered from postoperative bile leak, one of whom had a retained stone. Two of these patients required re-laparoscopic surgery. It is much more difficult to perform resuturing of choledochotomy for patients with
Y. Cai X. Liu (&) Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu 610041, Sichuan, China e-mail: [email protected]
biliary leak. Two patients in our series also experienced biliary leak after laparoscopic choledochotomy followed by primary duct closure. We performed endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage for these patients. The biliary leak was stopped in several days. Endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage may be an alternative to re-operation for patients suffering from a biliary leak and retained stones [3, 4]. Overall, we agree with Khaled et al. that primary duct closure following laparoscopic common bile duct exploration can facilitate the treatment of cholecystolithiasis and choledocholithiasis at a single setting and can be a safe and feasible alternative to T-tube insertion. Furthermore, this procedure is also cost effective compared with other common approaches in the setting of choledocholithiasis [2]. However, the selection criteria for this technique should be better defined. Disclosures Drs. Yunqiang Cai and Xubao Liu have no conflicts of interest or financial ties to disclose.
References 1. Khaled YS, Malde DJ, de Souza C, Kalia A, Ammori BJ (2013) Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis. Surg Endosc 27:4164–4170 2. Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A et al (2013) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. doi:10.1007/s00464013-3237-4
123
Surg Endosc 3. Christoforidis E, Goulimaris I, Tsalis K, Kanellos I, Demetriades H, Betsis D (2002) The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy. Surg Endosc 16:843–846
123
4. Terajima H, Ikai I, Hatano E, Uesugi T, Yamamoto Y, Shimahara Y et al (2004) Effectiveness of endoscopic nasobiliary drainage for postoperative bile leakage after hepatic resection. World J Surg 28:782–786
and Other Interventional Techniques
LETTER TO THE EDITOR
Laparoscopic choledochotomy followed by primary duct closure for choledocholithiasis Yunqiang Cai • Xubao Liu
Received: 10 November 2013 / Accepted: 12 December 2013 Ó Springer Science+Business Media New York 2014
Dear Editor, We read with interest the article by Khaled et al. [1]. We appreciate that they shared their experience in the setting of choledocholithiasis via laparoscopic choledochotomy followed by primary duct closure, however we have several concerns regarding their study. The average diameter of common bile duct in their series was 9.4 mm (range 3–30 mm). We have also carried out more than 50 cases of laparoscopic bile duct exploration in our institution. In our practice, it is technically challenging to perform laparoscopic choledochotomy and choledochoscopy (5 mm in diameter) for patients without dilated common bile duct. Furthermore, single-stage management is not suitable for poor-risk patients, including those with cholangitis, deep jaundice, coagulopathy, and severe pancreatitis [2]. The selection criteria for laparoscopic choledochotomy followed by primary duct closure for choledocholithiasis may be better defined. The authors stated that they carried out interrupted sutures for patients without a markedly dilated duct, and continuous sutures for a dilated duct. Is there any difference in terms of postoperative biliary leak or bile duct stricture caused by the different ways of suture? Three patients suffered from postoperative bile leak, one of whom had a retained stone. Two of these patients required re-laparoscopic surgery. It is much more difficult to perform resuturing of choledochotomy for patients with
Y. Cai X. Liu (&) Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu 610041, Sichuan, China e-mail: [email protected]
biliary leak. Two patients in our series also experienced biliary leak after laparoscopic choledochotomy followed by primary duct closure. We performed endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage for these patients. The biliary leak was stopped in several days. Endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage may be an alternative to re-operation for patients suffering from a biliary leak and retained stones [3, 4]. Overall, we agree with Khaled et al. that primary duct closure following laparoscopic common bile duct exploration can facilitate the treatment of cholecystolithiasis and choledocholithiasis at a single setting and can be a safe and feasible alternative to T-tube insertion. Furthermore, this procedure is also cost effective compared with other common approaches in the setting of choledocholithiasis [2]. However, the selection criteria for this technique should be better defined. Disclosures Drs. Yunqiang Cai and Xubao Liu have no conflicts of interest or financial ties to disclose.
References 1. Khaled YS, Malde DJ, de Souza C, Kalia A, Ammori BJ (2013) Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis. Surg Endosc 27:4164–4170 2. Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A et al (2013) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. doi:10.1007/s00464013-3237-4
123
Surg Endosc 3. Christoforidis E, Goulimaris I, Tsalis K, Kanellos I, Demetriades H, Betsis D (2002) The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy. Surg Endosc 16:843–846
123
4. Terajima H, Ikai I, Hatano E, Uesugi T, Yamamoto Y, Shimahara Y et al (2004) Effectiveness of endoscopic nasobiliary drainage for postoperative bile leakage after hepatic resection. World J Surg 28:782–786
