Laparoscopic Transcystic Common Bile Duct Exploration and Laparoscopic Transductal Common Bile Duct Exploration in Elderly Patients with Cholecystolithiasis Combined with Choledocholithiasis
Minimally invasive surgical techniques have revolutionized the management of cholecystolithiasis combined with choledocholithiasis. Among these, laparoscopic transcystic common bile duct exploration (LTCBDE) with laparoscopic cholecystectomy (LC) has emerged as a preferred approach. This study compares the outcomes of LTCBDE+LC and laparoscopic transductal common bile duct exploration (LTDBDE)+LC in elderly patients, focusing on efficacy, safety, recovery parameters, and cost-effectiveness.
Patient Characteristics and Study Design
The study included 300 elderly patients diagnosed with both cholecystolithiasis and choledocholithiasis. These patients were divided into two groups: 150 underwent LTCBDE+LC, and 150 underwent LTDBDE+LC. The groups were comparable in baseline characteristics, ensuring a valid comparison. All participants provided informed consent.
Surgical Outcomes and Operative Parameters
Both techniques demonstrated similar intraoperative outcomes. The mean blood loss was comparable between the LTCBDE+LC and LTDBDE+LC groups (38.3 ± 8.0 mL vs. 37.3 ± 8.1 mL; t = 0.89, P = 0.282). Operative time also showed no significant difference (111.9 ± 10.2 minutes vs. 113.8 ± 11.2 minutes; t = 1.63, P = 0.132). The success rates were high in both groups (141/150 [94%] for LTCBDE+LC vs. 146/150 [97.3%] for LTDBDE+LC; χ² = 2.01, P = 0.101), with transcystic success further enhanced to 93.3% using microincisions and electrohydraulic lithotripsy.
Postoperative Recovery and Hospital Stay
The LTCBDE+LC group exhibited superior recovery metrics. Hospital stays were significantly shorter (4.31 ± 0.69 days vs. 4.73 ± 1.26 days; t = 2.28, P < 0.001), and patients resumed work earlier (5.13 ± 1.05 days vs. 6.39 ± 1.15 days; t = 3.82, P < 0.001). Recovery milestones such as first anal aerofluxus (1.2 ± 0.4 days vs. 2.3 ± 0.5 days; t = 3.65, P < 0.001), oral liquid diet resumption (1.2 ± 0.4 days vs. 2.1 ± 0.4 days; t = 2.43, P < 0.001), and drain tube removal (2.49 ± 2.31 days vs. 3.85 ± 2.77 days; t = 2.18, P < 0.001) were all achieved faster in the LTCBDE+LC group.
Pain Management and Cost Analysis
Pain scores at 8 hours post-surgery favored the LTDBDE+LC group (2.25 ± 1.09 vs. 3.30 ± 1.06; t = 1.86, P < 0.001). However, LTCBDE+LC was more cost-effective, with total hospitalization costs significantly lower (16,173 ± 558.5 Chinese Yuan vs. 19,852 ± 1,481.3 Chinese Yuan; t = 4.11, P < 0.001).
Complications and Safety Profile
The LTCBDE+LC group had a lower overall complication rate (12% [18/150] vs. 22.7% [34/150]; χ² = 6.17, P = 0.015). Specific complications, such as bile leakage, were less frequent in the LTCBDE+LC group (3.3% [5/150] vs. 9.3% [14/150]; χ² = 4.89, P = 0.033). Other complications, including retained common bile duct stones, deep venous thrombosis (DVT), acute cholangitis, pancreatitis, hemobilia, and hernia recurrence, showed no statistically significant differences between groups (Table 1).
Technical Advantages of LTCBDE
The transcystic approach avoids choledochotomy or sphincterotomy, eliminating risks associated with T-tube placement or endoscopic retrograde cholangiopancreatography (ERCP). This reduces complications like bile duct strictures or pancreatitis. The use of electrohydraulic lithotripsy and microincisions enhances stone clearance rates while preserving biliary anatomy.
Clinical Implications and Comparison to ERCP
The study highlights that both LTCBDE+LC and LTDBDE+LC are superior to ERCP in terms of hospital stay and cost. ERCP, though minimally invasive, carries risks of post-procedural pancreatitis, bleeding, and perforation. Laparoscopic approaches offer definitive treatment in a single stage, reducing the need for multiple interventions.
Limitations and Future Directions
While the study demonstrates the benefits of LTCBDE+LC, it is limited by its single-center design and lack of long-term follow-up. Future multicenter studies with extended observation periods are needed to validate these findings and assess durability of outcomes.
Conclusion
In elderly patients with cholecystolithiasis and choledocholithiasis, LTCBDE+LC offers advantages over LTDBDE+LC, including shorter hospitalization, faster recovery, lower costs, and reduced complications. These findings support its adoption as a first-line surgical strategy in this population.
doi.org/10.1097/CM9.0000000000000323
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