Clinical research of laparoscopic common bile duct exploration with primary suture and T tube drainage in the management of choledocholithiasis / 国际外科学杂志

ABSTRACT

Objective To investigate the short-term clinical efficacy of laparoscopic common bile duct exploration(LCBDE) with primary suture or T tube drainage in the management of choledocholithiasis.Methods The retrospective cohort study was conducted from January 2014 to December 2018 with the clinical data of patients with choledocholithiasis being analyzed.A total of 863 patients were enrolled in this study.There were 431 males and 432 females.The median age was 60 (range 11 to 94).These patients had received LCBDE with primary suture (n =287) and T tube drainage (n =576) in the Department of General Surgery,the First Affiliated Hospital of Nanjing Medical University.Observation indicators(1) Preoperative blood biochemistry,including blood serum levels of total bilirubin,direct bilirubin,ALT,AST,GGT.(2) Intraoperative conditions,including operation time,blood loss,diameter of common bile duct,number of common bile duct stone.(3) Short-term postoperativeconditions,including postoperative hospital stay,postoperative complications.Measurement data with non-normal distribution were described as M (P25,P75),and comparison between groups was done using Mann-Whitney U test.Comparison of count data between groups were analyzed using the chi-square test.Univariate analysis and subsequent multivariable logistic regression were used to investigated the factors affecting the selection of surgical methods.Results (1) Blood serum levels of total bilirubin and direct bilirubin in the T tube drainage group were 17.0(12.2,36.0) μmol/L,7.6 (4.9,19.0) μmol/L,which were significantly higher than those of the primary suture group[15.7 (11.8,29.7) μmol/L,6.7 (4.4,16.5) μmol/L)] (Z =-2.023,-2.468,P ＜ 0.05).Preoperative blood serum levels of ALT,AST and GGT in the T tube drainage group were 56.7 (26.6,128.8) U/L,38.0 (24.3,75.8) U/L and 179.7 (50.8,394.4) U/L,the primary suture group were [68.2 (24.8,165.3) U/L,35.5(22.8,96.9) U/L and 235.2(74.9,459.1) U/L],with no difference between the two groups (Z =-0.985,-0.437,-1.740,P ＞ 0.05).(2) The operation time of the primary suture group was 85 (70,100) min,which was significantly shorter than that of the T tube drainage group [97 (75,120) min] (Z =-5.532,P ＜ 0.05).The diameter of common bile duct in the primary suture and T tube drainage group were 1.0(0.8,1.2) cm and 1.0 (0.8,1.2) cm,respectively.Significant difference was observed between the two groups(Z =-2.071,P ＜ 0.05).The intraoperative blood loss in the primary suture and T tube drainage group were 20(10,50) ml and 20(20,50) ml,with no difference between the two groups (Z =-0.477,P ＞0.05).61.32％ (176/287) and 67.36％ (388/576) of patients in the primary suture group and T tube drainage group were found with multiple stones in the common bile duct,with no difference between the two groups (x2 =3.083,P ＞ 0.05).(3)The primary suture group showed shorter postoperative hospital stay compared with the T tube drainage group [4 (3,5) d vs 6 (5,6) d,Z =-12.057,P ＜ 0.05].The primary suture group showed more patients with bile leakage (2.09％) compared with that of the T tube drainage group (0.35％).Multivariable logistic regression showed that the number of common bile duct stone,diameter of common bile duct,time period of surgery,surgery group were significant factors affecting the selection of surgical methods (OR =1.687,2.423,0.587,4.632,95％CI1.152-2.470,1.519-3.865,0.511-0.675,3.698-5.802,P＜0.05).Conclusions Although different surgeons showed different opinions with the method of primary suture,laparoscopic common duct exploration with primary suture is safe and reliable in the management of choledocholithiasis with shorter operation time and faster postoperative recovery.T tube drainage is not absolutely necessary in the management of choledocholithiasis.Patients with multiple common bile duct stone or large diameter of common bile duct are likely to receive T tube drainage.