Predictors of Failed Transcystic Laparoscopic Common Bile Duct Exploration: Analysis of Multicenter Integrated Health System Database.

BACKGROUND: The aim of this study is to report our experience with laparoscopic common bile duct exploration (LCBDE) and validate the experts' opinion about anatomical predictors of failed transcystic LCBDE (TLCBDE) approach. METHODS: Patients undergoing LCBDE at Kaiser Permanente Southern California hospitals (2005-2015) were included. Predictors of failed TLCBDE were identified using bivariate analysis. RESULTS: Of 115 LCBDE, 89.6% were TLCBDE and 10.4% through choledochotomy. Success rate, morbidity, and length of hospital stay were 83.5%, 6.1%, and 3.8 days respectively. Only stone size:cystic duct ratio >1 (35% versus 63%, P = .044) was associated with failure of TLCBDE. In accordance with experts' opinion, there was a suggestive association of stone size ≥6 mm, cystic duct ≤4 mm, multiple stones, and proximal stone location with failure; however, these did not reach statistical significance. CONCLUSION: LCBDE is an effective and safe mean of clearing common bile duct stones at community hospitals of an integrated health system. Previously cited contraindications for TLCBDE are not absolute, but rather predictors of failure.

Laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography for choledocholithiasis found at time of laparoscopic cholecystectomy: Analysis of a large integrated health care system database.

BACKGROUND: We compared endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) for managing choledocholithiasis found at time of cholecystectomy. METHODS: One hundred and five LCBDE (2005-2015) were compared to 195 LC/ERCP (2014-2015) from the Southern California Kaiser Permanente database. RESULTS: LC/ERCP was more effective at clearing the CBD (98% vs. 88.6%, p = 0.01); but required more procedures per patient (mean ± standard deviation, 1.1 ± 0.4 vs. 2.0 ± 0.12, p < 0.001). Morbidity, hospital length of stay and readmission were not different (P > 0.05). Four patients failed ERCP, while 12 patients failed LCBDE and had subsequent ERCP (10) or CBD exploration (2). All patients with RYGB had successful LCBDE. CONCLUSION: LC/ERCP is better than LCBDE in clearing CBD stones, but has similar morbidity and is an effective alternative for patients with RYGB.

Endostapler versus Hem-O-Lok clip to secure the appendiceal stump and mesoappendix during laparoscopic appendectomy.

BACKGROUND: Our study evaluates the safety and cost of using the Hem-O-Lok (HOL) clip in laparoscopic appendectomy (LA). METHOD: We prospectively compared 30-day postoperative outcomes and cost between HOL clip and endoscopic stapler (ES) in LA at a single institution. RESULTS: HOL clip was used in 45 out of 92 LA. Perforated appendicitis (29.8% vs. 11.1%, P = 0.027) and postoperative complications were more common in the ES group (19.2% vs. 2.2%, p = 0.009). In multivariate analysis, HOL clip was associated with lower complications rate (OR = 0.05, 95% CI 0.003-0.744; p = 0.030). In propensity score matched cohort, complications were not different (p > 0.05). In patients with non-perforated appendicitis, HOL use increased operative time by 10 min on average (p = 0.004). Minimum ES cost per single appendectomy was $273.13, while HOL clip cost was $32.14. CONCLUSION: The use of HOL clip in LA is safe and it reduced the costs of the procedure in comparison to the use of ES.