Objective To study the advantages of laparoscopic primary suturing of common bile duct plus transabdominal nasobiliary drainage in reducing the rate of bile leakage.Methods The clinical data of laparoscopic primary suturing of common bile duct with or without nasal bile duct drainage in Second People's Hospital of Chengdu were analyzed retrospectively.Results During laparoscopic common bile duct exploration,286 patients were treated by primary suturing without nasobiliary drainage (group without drainage),including 32 (11.2％) patients with bile leakage;350 patients were treated by primary suturing with transabdominal nasobihary drainage (group with drainage),including 11 (3.1％) patients with bile leakage.The incidences of bile leakage of the two groups were significantly different (P ＜ 0.05).When the diameter of the common bile duct was less than 11.0 mm,the incidence of bile leakage in the non-drainage group and the drainage group were 18.5％ (20/108) and 2.1％ (3/143),respectively.The incidence in the drainage group was significantly lower than that in the non-drainage group,and the difference was statistically significant (P ＜ 0.05).When the diameter of common bile duct was larger than 11.0 mm,there was no significant difference in the incidences of bile leakage between the two groups (P ＞ 0.05).Conclusions The choice after laparoscopic primary suturing of common bile duct between with or without nasobiliary drainage should be determined according to the diameter of common bile duct.When a common bile duct diameter of less than 11.0 mm,nasobiliary drainage is recommended to reduce the rate of bile leakage.

Objective To analyze our experience in primary closure of common bile duct after laparoscopic bile duct exploration.Methods From June 1992 to March 2018,2 740 patients underwent primary closure of common bile duct after laparoscopic common bile duct exploration in the Second People's Hospital of Chengdu.Results The operations were successfully carried out in 2 534 (92.4％) out of 2 740 patients,of whom 15 patients (0.6％) were converted to open common bile duct exploration.Bile leakage occurred in 113 patients (4.1％).Residual stones were found in 29 patients (1.1％).One patient (0.1％) who had a pancreatic carcinoma died on postoperation day 15.48 patients (1.8％) developed other complications.The total postoperative complication rate was 7.0％ (191/2 740).Conclusion In suitable patients,laparoscopic bile duct exploration with primary closure was feasible,safe and effective.

Objective To investigate the clinical efficacy of primary closure in laparoscopic common bile duct exploration (LCBDE).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 2 429 patients who underwent primary closure in LCBDE in the Second Hospital of Chengdu City from March 1992 to December 2017 were collected.Patients underwent laparoscopic cholecystectomy (LC) + stone extraction using LCBDE or extracorporeal shock wave lithotripsy (ESWL),laparoscopic endoscopic sphincteropapillotomy (LEST) was performed selectively,then underwent laparoscopic endoscopic nasobiliary drainage (LENBD) or laparoscopic transabdominal antegrade-guide common bile duct stent implantation,finally underwent primary closure of common bile duct.Observation indicators:(1) surgical situations;(2) postoperative recovery;(3) postoperative short-term complications;(4) follow-up situation.Follow-up using outpatient examination and telephone interview was performed to observe long-term surgical complications once every 3 months up to 1 year postoperatively.Measurement data with normal distribution were represented as (x) ± s.Measurement data with skewed distribution were described as M (range).Results (1) Surgical situations:of 2 429 patients,2 251 underwent successful stone extraction using LCBDE,relief of the obstruction and primary closure of common bile duct,with depletion of stones;15 underwent stone extraction using conversion to open surgery,with depletion of stones;163 had residual stones or surgery-related complications.Of 2 429 patients,1 144,898,223,110 and 54 were respectively detected in grade N or 0,1,2,3 and 4 of laparoscopic distal of the common bile duct smooth classification (LDSC);599 underwent LEST,367 underwent LENBD,207 indwelled urinary catheter through cystic duct stump,125 underwent laparoscopic transabdominal antegrade-guide common bile duct stent implantation and 1 131 underwent primary closure in LCBDE only.Number of removing the stones,diameter of common bile duct,volume of intraoperative blood loss and operation time was (2.5±0.2)per case,(0.7±0.4)cm,(22.4±2.6)mL and (100±12) minutes,respectively.(2) Postoperative recovery:time of postoperative gastrointestinal function recovery,duration of hospital stay and treatment expenses were respectively (2.5±0.5) days,(7.3± 1.2) days and (2.7±0.3) × 104 yuan.Of 2 429 patients,367 removed nasobiliary catheter at 3-7 days postoperatively,207 removed urinary catheter at 3-6 weeks postoperatively,and 125 removed common bile duct stent through duodenoscope port at 1-4 months postoperatively.(3) Postoperative short-term complications:incidence of postoperative short-term complications in 2 429 patients was 6.711％ (163/2 429).① Ninety-four patients with bile leakage were cured after drainage and symptomatic and supportive treatment.② Of 29 patients with residual stones:25 with residual stones of common bile duct were cured by stone extraction using endoscopic sphincterotomy of duodenal papilla,and 4 with residual stones of intrahepatic bile duct didn't receive treatment.③ One patient died at 15 days after surgery for pancreatic cancer.④ Of 39 with postoperative other complications:2 with postoperative hemorrhage were cured by laparoscopic reoperation;12,19 and 3 were respectively complicated with postoperative inflammatory stenosis of duodenal papilla induced to short-term obstructive jaundice,mild acute pancreatitis and stress ulcer bleeding of upper digestive tract,and they were improved by endoscopy or non-operation treatment;2 with stenosis of bile duct didn't receive treatment;1 had a miss ligation at bending section of front zone of nasobiliary catheter,and ligation was removed by endoscopic retrograde cannulation of the pancreatic at 19 days postoperatively.(4) Follow-up situation:of 2 429 patients,1 749 were followed up for 3-12 months,with a median time of 6 months.During the follow-up,of 1 749 patients,2 had mild stenosis in the primary closure area of common bile duct incision and 1 had stenosis of duodenal papilla,they were not treated,and other patients didn't have related complications.Conclusion Controlling strictly the operative indication,primary closure of common bile duct in LCBDE is safe and feasible,with satisfactory clinical outcomes.

To explore the operation methods and indications of the duodenoscopic papillotomy (IEST) with endoscopic nasobiliary drainage (IENBD) for the treatment of duodenal papilla stenosis during the course of common bile duct operation.The clinical data of 219 cases of cholecystolithiasis with choledocholith and the stenosis of papillary underwent endoscopic sphincterotomy (IEST) plus endoscopic nasobiliary drainage (IENBD) in the Second People's Hospital of Chengdu were retrospectively analyzed.It was successful in 198 cases who had the gallbladder and common bile duct stones removed,and endoscopic papillary dissection was performed and the nasobiliary tube was successfully inserted.Nasobiliary drainage was successful in 186 cases (93.9％) of 198 cases.No liquid outflow was observed in nasobiliary drainage in 7 cases (3.5％).Nasal bile duct slipped early in 5 case (2.5％).Primary closure of bile duct incision was completed in 198 cases.It failed in 4 cases (2.0％) who had the bile leakage with primary closure of duct incision.Mild pancreatitis after operation occurred in 3 cases (1.5％).Nose bile duct ligation was performed in 1 case (0.5％).The overall postoperative complication rate was 4.0％ (8/198).IEST + IENBD in open laparotomy was successful in 21 cases.No perforation of intestine and bile duct,bleeding,severe pancreatitis and other complications and death were detected postoperatively in two groups.During the course of laparoscopy and open laparotomy,IEST + IENBD in treating cholecystolithiasis with choledocholith and the stenosis of papillary and primary closure of duct incision after the endoscopic nasobiliary drainage is safe and effective.

Objective To compare using the transabdominal route versus the transoral route in establishing naso-biliary drainage in laparoscopic surgery.Methods The combined use of laparoscopy with choledochoscopy and duodenoscopy to establish naso-biliary drainage was carried out in 204 patients with gallbladder and common bile duct calculi.In 162 patients,the naso-biliary drainage was established transabdominally and in 42 patients it was established transorally.The success and the complication rates in the two groups were compared.Results Of 162 patients using the transabdominal route,4 patients failed.There were 6 patients (3.7％) who had no output from the nasobiliary drain.There were 3 patients (1.8％) who had only intestinal juice outflow from the nasobiliary drain.Primary closure failed in 3 patients (1.8％),all resulting in bile leak.Pancreatitis occurred in 2 patients (1.2％) after the operation.There was 1 patient (0.6％) whose nasobiliary drain was wrongly ligated.Of 42 patients with nasobiliary drainage using the transoral route,6 patients failed.There was 1 patient (2.4％) who had no output from the nasobiliary drain.There was 1 patient (2.4％) who had intestinal juice output from the nasobiliary drain.Primary closure failed in 1 patient (2.4％) with resultant bile leakage.Pancreatitis occurred in 4 patients (9.5％) after the operation.The success rate of establishing a nasobiliary drainage in the transabdominal group was significantly higher than that in the transoral group,but the complications were less.Conclusions Nasobiliary drainage established through the transabdominal route in laparoscopy surgery for patients with gallbladder and common bile duct calculi was technically easier and had a high success rate.It had less complications.

Objective To explore the effect of laparoscopic bile duct exploration,balloon dilation,and catheter drainage in the treatment of postoperative recurrent choledocholithiasis.Method The data of 61 patients with postoperative recurrent bile duct stones from August 1999 to August 2009 were retrospectively analyzed.The patients received laparoscopic bile duct exploration (LCDE),laparoscopic papillary balloon dilation (LPBD),and laparoscopic papillary balloon dilation endoprosthesis (LPBDE).ResultSatisfactory outcome was achieved in all the 61 patients.Among the 61 patients,20 patients received LPBD and primary suturing,36 patients received LPBDE and primary suturing,and 5 patients received LPBDE and T-tube drainage.There was no residual stone.There was no perioperative mortality or serious complications including biliary leak and hemobilia.On follow up for 1 to 9.5 years in 56 patients,there was no recurrent choledocholithiasis.ConclusionThe procedures were feasible and safe,and they prevent recurrence of choledocholithiasis.

Objective To explore the operative methods and indications of duodenoscopic papillotomy during the course of operation(IEPT)for cholelithiasis.Methods Cholecystectomy was firstly conducted under the condition of laparoscopy or open laparotomy.For the gross choledochus,the common bile duct was cut open to clear the stones.The ureteric catheter and zebra guidewire were inserted into the common bile duct and duodenum.Then they were inserted via duodenoscopy into thepapillum of duodenum.The papillary stenosis was removed with electro-knife by pin-head-like and arch-like to track along the ureteric catheter and zebra guidewire.For the tiny choledochus,the ureterie catheter and zebra guidewire were inserted via the cholecystic duct remnant into the common bile duct and duodenum.Then they were inserted via duodenoscopy to perform papillotomy to clear the stones of the common bile duct with the reticulation and the balloon of duodenoscopy.Results Forthe gross choledochus,IEPT in laparoscopy was successful in 45 cases and the other 2 received other operation.IEPT in open laparotomy was successful in 5 cases.For the tiny choledochus,IEPT in laparoscopy was successful in 73 cases and the other 1 underwent other operation.IEPT in open laparotomy was successfulin 2 cases.Conclusion If patients are suitable,IEPT is safe and effective in the hands of skilled endoscopiests for laparoscopy and open laparotomy.

Objective To evaluate combination of cholcdochoscopy or duodenoscopy with therapeutic laparoscopy (LCDCS) in treatment of detail choledochus stones. Methods Laparoscopic cholecystectomy was firstly performed and followed by choledochoscopy or duodenoscopy. Procedures of therapeutic choledochoscopy were as follows: choledochoscopic exploration via cystic duct remnant, choledochotomy, electrohydralic lithothipsy, drainage of bile duct with ureteral catheter via cystic duct remnant, T-tube drainage, or the suture of duct incision. Procedures of therapeutic duodenoscopy were as follows: access to the common bile duct and duodenum through ureteric catheter and zebra guidewire via cholecystic duct remnant, duodenoscopy via oral cavity into the duodenum papilla, papillotomy with needle-knife or arch-like electro-knife along the ureteric catheter or zebra guidewire, and stone clearance in the common bile duct with the reticulation and balloon of duodenescopy. Results Combination therapy were given to 191 cholelithiasis patients with detail choledochus stones. Combined choledochoscopy were performed in 117 patients. Stones were completely removed and average operation time was 114 min. Bile leakage occurred in 7 cases, but was cured with drainage. Postoperative imaging showed 2 cases of bile duct stenosis at primary closure of duct incision. Combined duodenescopic procedures were performed in 74 patients. Papillotomy and stone clearance were successfully performed in 68 patients, 5 others of whom underwent successful papillotomy only, and another underwent other operations. Average operation time was 97 min. Post-operation mild acut pancreatitis developed in 6 patients. No perforation of intestine or bile duct, bleeding, severe pancreatitis, or death was observed in each group. Conclusion LCDCS was safe and effective with appropriate indications.

Objective To report our clinical experience on laparoscopic common bile duct exploration and primary suture.Methods From March 1992 to December 2006,669 cases of laparoscopic common bile duct exploration and primary suture were carried out in our hospital.Cholangioscopic lithotomy,electrohydraulic lithotripsy,biliary dilation,bile duct drainage,or biliary stenting were performed on the patients.Results The surgeries were completed successfully in 643 of the 669 cases(96.1%).Biliary leakage was observed in 17(2.5%) cases after the operations,and was cured by nasobiliary and intra-abdominal drainage.2(0.3%) patients developed mild stenosis of the bile duct without showing any symptoms.4(0.5%) had residual stones and were cured by a second laparoscopic surgery.The fine duct fell off in 2 cases(0.3%),and was re-fixed by a re-operation.581 of the cases achieved a 6- to 48-month follow-up(mean,25.6 months),during the period,no patient developed biliary leak,and stenosis or hemorrhage of the common bile duct.Conclusion Laparoscopic common bile duct exploration and primary suture is safe and effective.