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OBJECTIVE: To compare the safety and feasibility of T-tube drainage and primary suture after laparoscopy combined with choledochoscopy in the treatment of secondary choledocholithiasis. METHODS: The clinical data of patients who underwent laparoscopic choledochoscopy combined with choledochoscopic common bile duct exploration (LCBDE) for secondary choledocholithiasis from June 2015 to June 2020 were analyzed retrospectively. According to the different treatment method of common bile duct (CBD) incision, the patients were divided into a T-tube drainage group and a primary suture group. The preoperative clinical characteristics, results of preoperative liver function tests (LFTs), LFTs on the first day after the operation and the fourth day after the operation, operation time, intraoperative bleeding, postoperative complications, and times of postoperative hospital stay were compared between the two groups. RESULTS: There was no significant difference in preoperative clinical data, preoperative LFTs, and postoperative complications between the two groups (P > .05). However, primary suture demonstrated significant advantages (P

Background Residual and recurrent stones remain one of the most important challenges of hepatolithiasis and are reported in 20 to 50% of patients treated for this condition. To date, the two most common surgical procedures performed for hepatolithiasis are choledochojejunostomy and T-tube drainage for biliary drainage. The goal of the present study was to evaluate the therapeutic safety and perioperative and long-term outcomes of choledochojejunostomy versus T-tube drainage for hepatolithiasis patients with sphincter of Oddi laxity (SOL). Methods/design In total, 210 patients who met the following eligibility criteria were included and were randomized to the choledochojejunostomy arm or T-tube drainage arm in a 1:1 ratio: (1) diagnosed with hepatolithiasis with SOL during surgery; (2) underwent foci removal, stone extraction and stricture correction during the operation; (3) provided written informed consent; (4) was willing to complete a 3-year follow-up; and (5) aged between 18 and 70 years. The primary efficacy endpoint of the trial will be the incidence of biliary complications (stone recurrence, biliary stricture, cholangitis) during the 3 years after surgery. The secondary outcomes will be the surgical, perioperative and long-term follow-up outcomes. Discussion This is a prospective, single-centre and randomized controlled two-group parallel trial designed to demonstrate which drainage method (Roux-en-Y hepaticojejunostomy or T-tube drainage) can better reduce biliary complications (stone recurrence, biliary stricture, cholangitis) in hepatolithiasis patients with SOL. Trial registration Clinical Trials.gov: NCT04218669. Registered on 6 January 2020.

Introduction: One of the safe & feasible methods for the management of extra-hepatic bile duct calculi is laparoscopic bile duct exploration. Around 10-15% of the subjects who have surgery due to gallstone disease have choledocholithiasis associated with it. A standard procedure to prevent bile escape from the choledochotomy site is conventionally postoperative T-tube drainage following common bile duct exploration. Aims & Objectives: Comparative study of laproscopic common bile duct exploration using stent drainage versus t- tube drainage. Material & Methods: The study involved a total of 46 subjects with choledocholithiasis, who were categoryed in 2 categorys. Category I as a drainage category of stents and Category 2 as a drainage category of T-tubes. The subjects in both classes underwent LCBDE surgery. Of the 46 subjects operated, 23 were in category I (stent drainage category) and 23 were in category 2 (T-tube drainage category). Results: 23 subjects were categoryed in the stent drainage and T-tube drainage categories, respectively. In both classes, no perioperative or postoperative mortality was reported. Subjects had hypertension in stent drainage category 4 (17.39 percent) and 5 (21.73 percent) suffered from diabetes as a comorbid disease, while 2 (8.69 percent) subjects had jaundice. Four (17.39 percent) subjects with diabetes and three (13.04 percent) subjects with jaundice were found in T-tube drainage category 3 (13.04 percent) with hypertension. In both classes, no statistically significant difference was found. In terms of organisational results and outcomes, statistically significant variations were found in both categorys (Table 3). Mean operating time was 103± 22.4 in category I while 127±32.7 (P value < 0.005) in category II. In the Stent Drainage Category, blood loss during procedure was 22±3.7 ml, while in the T-tube drainage category it was 38±5.1 (P value < 0.005). Conclusion. After laparoscopic choledochotomy, primary closure of the bile duct with spontaneously reversible biliary stent placement is a viable and practicable process. With spontaneously removable biliary stents, less surgery time, less bleeding and less intestinal complications have been observed. Keywords: stent drainage, T- tube drainage, choledochotomy

The closure of common bile duct (CBD) after choledocholithotomy can be done over T-tube or primarily. The method of T-tube drainage comes with many complications and hence, nowadays, there is tendency to close CBD primarily which leads to less complications and shorter duration of stay at hospital. We conducted this study comparing primary closure of CBD with T-tube drainage following choledocholithotomy over a period of one year in 40 patients divided in two groups each of 20 i.e. Group A– primary closure and Group B- T-tube drainage. The results were compared in terms of operating time, duration of stay at hospital and complications such as leakage and wound infection. It was observed that primary closure group had less operating time, less duration of hospital stay and less complication rates as compared to T-tube group. Hence, we concluded in our study that primary closure can be recommended as safe alternative procedure after choledocholithotomy in selected patients of choledocholithiasis.

We compared the post-operative course and final outcome of primary duct closure combined with transcystic drainage with those of T-tube drainage.We retrospectively analysed 112 consecutive patients treated with laparoscopic choledochotomy for common bile duct stones between February 2014 and December 2017. Primary closure with transcystic drainage was performed in 59 patients (group A), and laparoscopic choledochotomy with T-tube drainage was performed in 53 (group B). The primary endpoints were morbidity, the bile drainage quantity, operative time, post-operative stay, time until return to work and post-operative complications.The operation was successfully completed in all patients. The return to work period in group A was significantly shorter than that in group B (7.25 ± 1.27 versus 46.47 ± 3.86 days, P 0.05). The average daily drainage was not significantly different between the two groups (P 0.05). There was no significant difference in the operation time (133.75 ± 14.51 versus 132.21 ± 12.71 min) and duration of hospital stay (5.15 ± 1.23 versus 5.94 ± 0.95 days) between the two groups (P 0.05). Bile leakage was seen in one T-tube removal patient. No complications were reported in group A. The patients were followed for 2 to 29 months (average: 10). Normal liver function and no stricture of the bile duct were detected with ultrasonography.Primary closure of choledochotomy and subsequent transcystic drainage is a simple and less invasive procedure than T-tube placement.

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

To investigate the feasibility and clinical effect of laparoscopic choledochotomy for primary suture of bile duct. Methods: There were 190 cases of cholecystolithiasis with choledocholithiasis. They were randomly divided into endoscopic group and open group. In the endoscopic group ,87 patients underwent laparoscopic choledocholithotomy and primary bile duct suture. A total of 103 patients in open group were treated with open bile duct incision and T tube drainage. The operative time, intraoperative blood loss, postoperative ventilation time, hospital stay and postoperative complications were compared between the two groups. Results: The length of hospital stay, the amount of bleeding during operation and the time of postoperative ventilation were less than those in open group. The operation time was longer than that in open group, P

Background: A recent meta-analysis showed that the primary closure (PC) of the biliary duct in the absence of T-tube (TT) drainage is a safe alternative for cholelithiasis after laparoscopic biliar...

Background: Residual and recurrent stones remain one of the most important challenges of hepatolithiasis and is reported in 20% to 50% of patients treated for this condition. To date, the two most common surgical procedures performed for hepatolithiasis are choledochojejunostomy and T-tube drainage for biliary drainage. The goal of the present study was to evaluate the therapeutic safety and perioperative and long-term outcomes of choledochojejunostomy versus T-tube drainage for hepatolithiasis patients with sphincter of Oddi laxity (SOL).Methods/Design: In total, 210 patients who met the following eligibility criteria were included and were randomized to the choledochojejunostomy arm or T-tube drainage arm in a 1:1 ratio: (1) diagnosed with hepatolithiasis with SOL during surgery, (2) underwent foci removal, stone extraction and stricture correction during the operation, (3) provided written informed consent, (4) was willing to complete a 3-year follow-up, and (5) aged between 18 and 70 years. The primary efficacy endpoint of the trial will be the incidence of biliary complications (stone recurrence; biliary stricture; cholangitis) during the 3 years after surgery. The secondary outcomes will be the surgical, perioperative and long-term follow-up outcomes.Discussion: This is a prospective, single-centre and randomized controlled two-group parallel trial designed to demonstrate which drainage method (Roux-en-Y hepaticojejunostomy or T-tube drainage) can better reduce biliary complications (stone recurrence; biliary stricture; cholangitis) in hepatolithiasis patients with SOL.Trial Registration: Clinical Trials.gov: NCT04218669; Registered January 6, 2020, https://clinicaltrials.gov/ct2/show/NCT04218669.

Özet Çalışmamızda, ERCP (endoskopik retrograd kolanjiopankreatografi) yapılamayan koledokolithiyazisli hastalarda açık olarak yapılan T-tüp drenaj prosedürünü değerlendirmek amaçlanmıştır. Hastaların yaş, cinsiyet, laboratuvar değerleri, hastanede yatış süresi, T-tüp çekilme zamanı ve tedaviye yanıtları elektronik kayıtlarından alındı. Preoperatif dönemde tüm hastalar MRCP (magnetik rezonans kolanjio pankreatigografi) ile değerlendirildi. Toplam 16 hastanın 11 (%68.8)’i kadın ve beşi (%31.2)’i erkekti. Hastaların yaş ortalaması 49.7±15 olarak bulundu. Koledok çapı (mm) 15±7.3’dü. Hastaların 8’inde (%50) intrahepatik safra yolları ileri derecede dilate iken, 8’inde (%50) hafif derecede dilatasyon mevcuttu. Biyokimyasal parametrelerinden bilirübin ve kolestaz enzimlerinin düzeyleri yüksek bulundu. Hastaların hastanede yatış süresi ve T-tüp çekilme süresi sırasıyla; 15.3±0.9 ve 13.7±1 olarak bulundu. Seçilmiş hasta grubunda koledokolithiyazis tedavisi için; açık koledok eksplorasyonu, taş ekstraksiyonu ve T-tüp drenajı ERCP’nin olmadığı yerlerde halen uygulanabilirliği olan bir yöntemdir. Abstract The aim of this study is to patients with choledocholithiasis who underwent open exploration with T-tube drainage that can’t undergo ERCP (endoscopic retrograde cholangiopancreatography). Materials and methods: Patient age, gender, laboratory workup, period of hospital stay, time of T-tube removal and treatment response were looked back into from the hospital database. All patients underwent MRCP (magnetic resonance Cholangio pancreatography) preoperatively. There were a total of 16 patients of which 11 (68.8%) were female and 5 (31.2%) were males. Mean age was 49.7±15. Common bile duct was 15±7.3 mm in diameter. 8 (50%) of the patients’ intra-hepatic bile ducts were moderately dilated, the rest 8 (50%) patients were minimally dilated. Bilirubin levels and cholestasis enzymes were elevated. Hospital stay period and T-tube removal time were 15.3±0.9 and 13.7±1 respectively. When ERCP is not available, open bile duct exploration, stone extraction and T-tube drainage can be used for choledocholithiasis treatment as feasible method in the selected patient groups., Endoskopik Retrograd Kolanjiopankreatografi (ERCP) Bulunmayan Somali'de Koledok Eksplorasyonu ve T-tüp Drenaj Prosedürü. [ High resolution figures, metrics, and more: http://lifemedsci.com/a/2022/1/oz/2.htm ] [ This article previously published as: "Somalia Turkey Journal of Medical Science 2020; 1(1): 1-5." Currently, Somalia Turkey Journal of Medical Science was merged with Life and Medical Sciences. ], {"references":["1. Beltran MA, Csendes A, Cruces KS. The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World journal of surgery. 2008; 32(10): 2237-43.","2. Costi R, Gnocchi A, Di Mario F, Sarli L. 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Zhang JF, Du ZQ, Lu Q, Liu XM, Lv Y, Zhang XF. Risk Factors Associated With Residual Stones in Common Bile Duct Via T Tube Cholangiography After Common Bile Duct Exploration. Medicine (Baltimore) 2015; 94(26): e1043.","8. Ozcan N, Kahriman G, Karabiyik O, Donmez H, Emek E. Percutaneous management of residual bile duct stones through T-tube tract after cholecystectomy: A retrospective analysis of 89 patients. Diagn Interv Imaging 2017; 98(2): 149-53.","9. Hakuta R, Kawahata S, Kogure H, Nakai Y, Saito K, Saito T, et al. Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity-matched analysis. Dig Endosc 2019; 31(1): 59-68.","10. Baiu I, Hawn MT. Choledocholithiasis. JAMA 2018; 320(14): 1506.","11. Corbett CR, Fyfe NC, Nicholls RJ, Jackson BT. Bile peritonitis after removal of T-tubes from the common bile duct. Br J Surg 1986; 73(8): 641-3.","12. 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Spontaneous perforation of the left intrahepatic bile duct is extremely rare, especially in adults. Here, we report on a case of a 64-year-old woman who had a complaint of right upper abdominal pain for 10 days, which gradually progressed to entire abdominal pain for 3 days, and was admitted to our hospital. Relevant examinations revealed she had a normal cardiac and lung workup, but an obvious abnormal abdominal computed tomography examination, which revealed an enlarged gallbladder, choledocholithiasis with dilatation of the common bile duct (1.8 cm) and intrahepatic bile duct, and a lot of encapsulated ascites. After being given adequate fluid resuscitation and active preoperative preparation, cholecystectomy and common bile duct exploration and perforation repair operation were then performed. The postoperative course was uneventful, and she was discharged with the T-tube in situ. A choledochoscopy examination at week 6 showed the conditions of the intrahepatic and extrahepatic bile duct were good. For these patients, early diagnosis and surgical treatment are essential for good prognosis. The goal of our surgery is to stop bile leakage, resolve choledocholithiasis and cholangitis, and reconstruct the bile duct.

Common Bile Duct (CBD) exploration for choledocholithiasis is usually closed after T-tube insertion. However, complications of T-tube insertion limit its use. In the present study, we wanted to compare outcomes between primary repair of choledochotomy and traditional T-tube insertion. Thirty patients with CBD stones admitted at Tangail Medical College Hospital, Tangail, from January 2010 to December 2015, were included in this study. The patients were randomly divided into two groups: T-tube drainage group and primary closure group. Intraoperative findings and postoperative complications were recorded and analyzed. There was no mortality and retained stones in both groups. Two of 15 patients in the Ttube group and four of 15 patients in primary closure group suffered from minor bile leakage. There was no major bile leakage in the T-tube group but one patient in the primary closure group had major bile leakage, which was treated conservatively without surgical or endoscopic intervention. Wound infection was seen in two patients in the T-tube group and one patient in the primary closure group. In follow up assessment, there was no intra-abdominal collection in both groups. Overall postoperative complications include biliary complications, wound infection and intraabdominal collections, were seen in four patients in the T-tube group and six patients in primary closure group; that was not statistically significant. Primary (Para) closure of CBD after open choledochotomy is feasible and is as safe as T-tube insertion. In effect, primary closure avoids T-tube insertion and disadvantages associated with the use of T-tube. Primary closure can be recommended for selected patients with choledocholithiasis.Medicine Today 2017 Vol.29(1): 15-18

Objective Primary closure of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) is a technical challenge. The present study was performed to evaluate the safety and effectiveness of this surgical method. Methods This retrospective study of surgical efficacy and safety involved 79 patients who underwent primary CBD closure with a knotless unidirectional barbed suture or traditional T-tube drainage after LCBDE for CBD stones. Results The average suturing time, operation time, and postoperative hospital stay were significantly shorter in the primary closure group than T-tube group. There were no significant differences in the mean diameter of the CBD, number of stones, or incidence of postoperative complications between the two groups. No patients developed recurrence of CBD stones during the median follow-up of 21.5 months. Conclusions After LCBDE and intraoperative choledochoscopy, primary closure with knotless unidirectional barbed sutures is a safe and effective therapeutic option for patients with cholelithiasis and concurrent CBD stones. This is especially true when the CBD is dilated more than 8 mm.

Background: T tube drainage following CBD exploration has been a gold standard for a long time now. This has its own set of problems, mainly prolonging hospital stay and leakage around T-tube. This study was designed to assess the outcome of primary repair of CBD in terms of operating time, duration of hospital stay and postoperative complications. Methods: We conducted a prospective randomized study of 60 patients divided into two groups, at our institute to see the effectiveness of primary closure and compared the results with those patients who had T tube drainage. Results: Our results indicate that the hospital stay is reduced to half in cases with primary closure and there were no significant complications resulted in primary closure cases. Conclusions: Primary closure of the common bile duct following CBD exploration is a safe and effective method and it helps to reduce the morbidity related to T-tube use. We strongly recommend the primary closure of CBD following its exploration.

Background Laparoscopic common bile duct exploration (LCBDE) offers good clinical outcomes in dealing with common bile duct stones. Surgeons experienced in laparoscopy can perform this procedure securely and efficiently. The goal of this study was to assess the security and possibility of primary repair as a substitute to usual T-tube drainage after LCBDE. Patients and methods This was a prospective study that included 40 successive patients who were subjected to LCBDE for common bile duct stones. After LCBDE, the choledochotomy was repaired either by primary repair (group A) in 20 patients or with T-tube insertion (group B) in 20 patients. The preoperative data, intraoperative details, and postoperative results of the two groups were assessed and evaluated with a mean follow-up of 12 months. Results The mean operation period was considerably lesser in group A than group B (101.1±27.7 min for group A vs 140.3±26 min for group B; P=0.000). Moreover, the hospital stay was considerably shorter in group A than in group B (2.8 days for group A vs 6.1 days for group B; P=0.017). Postoperative bile leakage occurred in two cases in each group. Conclusion Primary repair of choledochotomy is a secure alternate to usual T-tube insertion after LCBDE.

Objective. We are trying to investigate the possibility, safety, and benefits of replacing the role of T-tube by another more safe and effective procedure for biliary decompression in the case of common bile duct (CBD) exploration. Methods. Our present study includes fifty consecutive patients who underwent a traditional CBD exploration due to choledocholithiasis. Patients were divided into 2 equal groups. In the 1st group, a spontaneously expelled Nelaton tube is placed in the CBD to aid in bile drainage to the duodenum, while in the 2nd group, a conventional T-tube is placed to decompress the CBD in the early postoperative (PO) days to a drainage bag. Operative and PO data as well as PO hospital stay time were recorded. All data were collected and statistically analyzed. Results. The mean operative time and PO hospital stay days were significantly low (p value < 0.05) in the Nelaton tube drainage group compared with the T-tube drainage group. On the other hand, the mean time needed for the abdominal drain removal was significantly higher in the T-tube drainage group (p value < 0.05). Conclusion. Nelaton tube with internal biliary drainage is effective and safer than T-tube drainage and it helps in reduction of the PO hospital stay time. In addition, it avoids all short-term complications of T-tube.

Spontaneous perforation of the esophagus after forceful vomiting is known as Boerhaave syndrome, a rare and life-threatening condition associated with a high rate of mortality. The management of Boerhaave syndrome is challenging, especially when diagnosed late. Herein, we report the successful management of late-diagnosed Boerhaave syndrome with T-tube drainage in a 55-year-old man. The patient was transferred to our institution 8 days after the onset of symptoms, successfully managed by placing a T-tube, and was discharged on postoperative day 46 without complications.

Laparoscopic common bile duct exploration (LCBDE) had become one of the main options for management of choledocholithiasis. This retrospective comparative study aimed to evaluate on the feasibility and advantages of primary closure versus conventional T-tube drainage of the common bile duct (CBD) after laparoscopic choledochotomy. In this retrospective analysis, 100 patients (47 men and 53 women) with choledocholithiasis who underwent primary closure of the CBD (without T-tube drainage) after LCBDE (Group A) were compared with 92 patients who underwent LCBDE with T-tube drainage (Group B). Both groups were evaluated with regard to biliary complications, hospital stay, and recurrence of stones. The mean operation time was 104.12 minutes for Group A and 108.92 minutes for Group B ( P = 0.069). The hospital stay was significantly shorter in Group A than that in Group B (6.95 days and 12.05 days, respectively; P < 0.001). In Group A, bile leakage occurred in two patients on postoperative Day 2 and Day 3, respectively. In Group B, bile leakage noted in one patient after removal of the T-tube on Day 14 after operation ( P = 1.000). With a median follow-up time of 40 months for both groups, stone recurrence was noted in two patients in Group A and three patients in Group B ( P = 0.672). Primary closure of the CBD is safe and feasible in selected patients after laparoscopic choledochotomy. It results in shorter duration of hospital stay without the need for carrying/care of a T-tube in the postoperative period and similar stone recurrence as that of the conventional method.

Background: Residual or missed stones of common bile duct (CBD) and ascending cholangitis after CBD exploration are major biliary surgery problems. Repeated biliary tract interventions for correction of complications are catastrophic on both patients and surgeons.Methods: This is a prospective study of 83 patients which compares two methods for surgical management of CBD stones between June 2016 to May 2018. Group I included 43 patients who were managed by CBD exploration followed by insertion of T tube, the risk factors of the incidence of missed retained stone in CBD were multiple stones in CBD and hugely dilated CBD (>15 mm).The second method was choledochoduodenal anastomosis for patients having the same previous risk factors (Group II) which included 40 patients. Postoperative follow up was for 12 to 18 months.Results: In group I, 6 patients developed residual stones in CBD, reoperation was required for 3 of them and endoscopic retrograde cholangiopancreatography with sphincterotomy for another 3 patients, while in the other group (group II) 2 patients suffered from ascending cholangitis and are managed conservatively. No missed or residual CBD stones were developed and no patients need reoperation.Conclusions: With choledochoduodenostomy in patients with multiple CBD stones or markedly dilated CBD the incidence of missed or retained stones in CBD was reduced.

Common bile duct exploration (CBDE) is an operation that can be performed either laparoscopically or open in order to treat choledocholithiasis by removing stones from the common bile duct. CBDE can be performing via either a transcystic approach or a transcholedochal one, in which an incision (or choledochotomy) is made directly into the common bile duct in order to access the stones within it. Traditionally this cholecdochotomy have been closed around an external drain, or “T-tube”, at the end of CBDE operations, in order to drain the biliary system and allow access for future interventions should the need arise. However, recent data suggesting that primary closure of the choledochotomy may in fact be a superior technique have challenged the surgical dogma of routine T-tube placement after CBDE.

Summary Background Spontaneous perforation of the extrahepatic bile duct is very rare. We report a patient with a spontaneous perforation of the left hepatic bile duct who was diagnosed preoperatively. Case Report A 65-year-old woman was admitted to our hospital complaining of a right upper quadrant pain lasting for two days. She was diagnosed as having a perforated bile duct and peritonitis and underwent a laparotomy. After a cholecystectomy, T-tube drainage of the left hepatic duct was performed. The postoperative course was uneventful. The T tube was removed 25 days after the surgery. Conclusions A more noninvasive procedure, such as endoscopic treatment, should play a central role in the management of extra bile duct perforation. For this case, however, we chose to perform a laparotomy based on the patient’s general condition and the presence of peritonitis. T tube decompression is effective and a safe and reliable method. The goal of treatment is to stop the bile leakage, resolve the choledocholithiasis and cholangitis, and reconstruct the bile duct.

Background: Choledochotomy followed by T-tube drainage has been long the standard surgical treatment in many hospitals. However, the insertion of a T-tube is not without complications and the patients have to carry it for 2 weeks before removal. To avoid those complications associated with T-tube, we have performed primary closure of the common bile duct (CBD) after choledochotomy and removal of CBD stones. This study assesses the safety of primary closure of CBD and may help in its application in a wide scale. Objectives: To compare the clinical results of primary closure of (CBD) with T-tube drainage after open choledochotomy. Patients & methods: This comparative study was conducted at El-Demerdash Hospital & Ain Shams University Hospital from January 2008 to December 2008. Thirty patients were included in the study, 15 patients underwent primary closure and 15 patients underwent T-tube drainage. Results: There was no mortality in both groups. A T-tube was inserted in 15 patients and the CBD was closed primarily in 15 patients, there were no difference in the demographic characteristics or clinical presentations between the two groups. Compared with the T-tube group, the post-operative stay was significantly shorter, the hospital expenses significantly lower, and the incidences of overall postoperative complications and biliary complications were statistically and significantly lower in the primary closure group. Conclusion: Primary closure without external drainage after open choledochotomy is feasible and as safe as T-tube insertion.

Udgivelsesdato: 2008-null BACKGROUND/PURPOSE: We investigated the effect of T-tube drainage on the healing of choledocho-choledochostomies in pigs. METHODS: Twenty pigs with a median weight of 56 kg were used for the experiments. The pigs were randomized to two groups of ten. In all pigs the gallbladder was removed and the common bile duct was transected. In both groups continuity was re-established by standardized single-line, interrupted, and inverted sutures. In one group a T-tube for decompression was inserted. On postoperative day 6, a laparotomy was performed. Pigs were investigated for signs of cholascos, and an intraoperative cholangiography was performed. The excised anastomosis was examined for breaking strength and collagen content. Blood samples were drawn prior to the first and the final operations. RESULTS: In both groups standard liver parameters were unaffected by surgery, and cholangiography showed no signs of extrahepatic stenosis or intrahepatic dilatation. The T-tube-drained choledocho-choledochostomies showed a significantly higher breaking strength (P = 0.035) compared to the group which had no drainage. Collagen content per volume was unaffected by T-tube drainage. CONCLUSIONS: T-tube drainage had a significant stimulatory effect on the breaking strength of choledocho-choledochostomies in pigs on postoperative day 6, but was without effect on collagen content.

The late management of spontaneous esophageal perforation is the most challenging problem for the surgeon. In this paper, we present a case in whom a spontaneous esophageal perforation was successfully treated by T-tube drainage after unsuccessful conservative treatment. The patient, a 68-year-old male, was admitted to the hospital with sudden upper abdominal pain. After 2 days, esophageal perforation was diagnosed, and conservative management was begun. Thereafter, the subcutaneous emphysema disappeared, and the patient’s temperature decreased. However, on day 13, the patient’s temperature spiked above 38°C, and computed tomography showed a mediastinal abscess. An emergency left thoracotomy with laparotomy was performed. Since a 2-cm longitudinal perforation with severe inflammatory reactions was observed, the T-tube drainage method was performed. The patient was discharged without postoperative complications and has not experienced any gastrointestinal symptoms, such as gastroesophageal reflux or dysphagia. In conclusion, the T-tube drainage method appears to be a simple and effective method for the late management of esophageal perforation with severe inflammatory reaction.

症例は36歳の男性で, 胃潰瘍による幽門狭窄に対して, 近医で幽門側胃切除術(Billroth-II法再建)を施行された. 術翌日から血清総ビリルビン値とアミラーゼ値の上昇を認め, 腹部CTで肝内胆管の拡張および膵腫大, 膵周囲の液体貯留を認めた. 閉塞性黄疸および重症急性膵炎の診断で, 経皮経肝胆管ドレナージ施行後, 当科紹介入院となった. 膵周囲貯留液のアミラーゼ値は262,000IU/Lと異常高値を示しており, これを経皮的にドレナージした. その後の精査で, 術中の自動縫合器による十二指腸乳頭損傷が判明した. 経過中, 途絶した膵管と十二指腸断端の間に瘻孔が形成されたため, 同部にT-チューブを挿入し, 内外瘻の状態とした. T-チューブ挿入から約3か月後には炎症が沈静化し, 膵瘻管空腸吻合術(Lahey-Lium法)および胆管空腸吻合術を施行した. T-チューブは術後7か月後に抜去し, 患者は社会復帰を果たしている.

Complications related to the T tube drainage of the common bile duct are not uncommon. Some, like dislocations of the T tube out of the common bile duct, could be very serious, particularly if developed during the first few days after surgery, when the abdominal drain in the subhepatic space had been already removed. Then, an emergency reoperation might be necessary. The slip of the T tube upwards or downwards inside the common bile duct is not so rare. Fortunately, it is less dangerous and can usually be resolved without reoperation. It takes place several days after surgery, followed by the right subcostal pain, occasionally with temperature, rise of the bilirubin and with decrease or complete cessation of the bile drainage through the T tube. The diagnosis can be made only on the basis of T tube cholangiography. The re-establishment of the proper T tube position must be done under X-ray visualization. Seven cases of the T tube slip within the common bile duct, its clinical presentation, diagnosis and method of repositioning were presented. Possible mechanism of complication was described. As far as we know, the complications have not been described by other authors.

Various surgical procedures are described and practiced for operative management of uncomplicated meconium ileus. In our series, we have tried an approach of minimally invasive procedure to minimize the operative stress in already sick neonates. Ten cases of meconium ileus operated between 01/01/2003 to 21/06/2004 were screened. Three cases presented with complications like peritonitis (2) and volvulus (1) and so were not included in this study. Seven cases were uncomplicated. Out of them three were managed conservatively. Operative management by minilaparotomy - enterotomy and T-tube insertion was done in the remaining four cases, which did not resolve by conservative approach. In this group, patients passed stool by approximately seventh day (range - sixth to eight day). Oral feeds begun on approximately ninth day (range - eighth to tenth day). All four babies survived. This approach of minilaprotomy, T-tube insertion and N acetyl cysteine instillation, could be of significant benefit in an already sick neonate. Also, T- tube helps in post- operative bowel decompression, distal bowel wash and check dye study

Resume La perforation de l'œsophage est consideree comme la plus serieuse et la plus rapidement fatale de toutes les perforations du tractus digestif. Meme si cet evenement n'apparait que rarement, les etiologies sont de plus en plus nombreuses et le plus souvent iatrogenes. Le pronostic depend essentiellement de la rapidite du diagnostic et du choix du traitement instaure en premiere ligne. Cependant, les options therapeutiques sont variees et aucune ne fait l'unanimite. Meme si une approche non operatoire est admise dans des conditions bien definies, dans la majorite des cas, le traitement reste chirurgical. La suture simple evolue souvent vers l'echec surtout si le diagnostic est tardif et plusieurs alternatives sont proposees comme les lambeaux de renforcement de la suture ou la fistulisation dirigee. En cas d'affection œsophagienne sous-jacente, une resection emportant la lesion et la perforation est recommandee. Pour les cas desesperes ou les echecs d'une intervention initiale, le recours a l'exclusion œsophagienne reste quelquefois le seul moyen de controler une infection pleurale ou mediastinale persistante.

Controversy surrounds the indications for and effectiveness of the abdominal drain. There are a variety of factors which mitigate against formulating rigid guidelines for the indications of drains, but surgeons should understand the benefits and applications of drainage and the tissue responses to the constituent materials. Drains are not a substitute for meticulous surgical technique.

Background: Traditionally laparoscopic common bile duct exploration is followed by T-tube placement because of which patients suffer problems related to T-tube thereby increasing the morbidity of patients. Primary closure of CBD following laparoscopic choledocholithotomy is now being considered as an alternative superior to the traditional method. This study is designed to analyse the outcome of primary CBD repair in terms of mean operation time, duration of hospital stay and post-operative morbidity. Methods: A prospective randomized study was done in which 40 patients at our institute and associated hospitals were divided into two groups to compare the results of primary closure to T-tube placement following laparoscopic choledocholithotomy. Results: 40 patients were included in this study. The mean operating time was observed to be 65±14.05 mins in Group A (primary closure) patients while that in case of Group B (T-tube drainage) patients was 95.25±9.66 mins with a p-value 0.0001 which is considered statistically significant. The average duration of hospital stay in Group A (primary closure) was 8.2 days which was much shorter than that of Group B (T-tube drainage) patients which was of 15.7 days. The post-operative complication was observed in 1 patient of Group A (primary closure) while post-operative complication occurred in 3 patients of Group B (T-tube drainage). Conclusions: This study indicates that primary repair following laparoscopic choledocholithotomy is a safer and more effective method than T-tube drainage and we strongly recommend this procedure in clinical practice.

Background Common bile duct (CBD) stones are present in 10–18% of patients undergoing cholecystectomy for chronic calcular cholecystitis. Treatment of CBD stones is still controversial. However, CBD stones can be treated by cholecystectomy plus CBD exploration or by precholecystectomy or postcholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages. If CBD exploration is performed and biliary decompression is needed after stone removal, the placement of transpapillary stent (TS) shows promising results in avoiding T-tube–related complications. Aim We aimed to evaluate the efficacy and complications of two approaches used for the management of CBD stones: intraoperative transpapillary CBD stent and T-tube external biliary drainage. Patients and methods Between May 2015 and May 2016, 24 patients underwent CBD exploration for treatment of irretrievable CBD stones. Included patients were randomly subjected to either CBD TS or T-tube drainage for management of irretrievable CBD stones after failure of ERCP. Results CBD exploration and TS placement (15 patients) was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with a T-tube external biliary drainage (nine patients) had more surgery-related complications and a longer hospital stay. Postoperative ERCP to remove the CBD stent was successful in all cases. Conclusion Surgical transpapillary CBD stenting seems to be an effective method for management of irretrievable CBD stone with less surgical-related complications and less hospital stay and should be the first option in management of such patients.

BACKGROUND/AIM Although common bile duct stones are generally treated endoscopically, surgery is required if endoscopic removal is impossible. The aim of this study was to compare the surgical options in such patients. MATERIALS AND METHODS A total of 282 patients with common bile duct stones underwent open choledochotomy; primary closure was applied in 48 (17.0%), primary closure with T-tube drainage in 81 (28.7%), and choledochoduodenostomy in 153 (54.3%) patients. RESULTS Postoperative complications were seen in 8 (16.7%) patients in the primary closure, 33 (40.7%) patients in the primary closure with T-drainage, and 37 (24.2%) patients in the choledochoduodenostomy group. No significant differences were observed among the groups (P > 0.05). The mean postoperative hospital stays in the primary closure, primary closure with T-tube drainage, and choledochoduodenostomy groups were 5.5, 13.5, and 8.9 days, respectively. The mean postoperative hospitalization was significantly shorter in the primary closure group than in the other groups (P < 0.05). CONCLUSION Primary closure is a safe and feasible method in selected patients.

Twenty-nine patients undergoing primary closure (primary closure group) and seventy patients undergoing T tube drainage (T tube group) were compared clinically to elucidate the effectiveness and problems of the primary closure of the common bile duct for choledocholithiasis. The frequency of bile leakage after the operation was 24.1% in primary closure group. The frequency of localized peritonitis after removal of a T tube due to incomplete fistula formation was 8.6% in T tube group. Postoperative liver dysfunction was noted in 7.1% for primary closure group and in 14.3% for T tube group. The duration of hospital stay after the operation was 20.1 days in primary closure group, being significantly shorter than 38.8 days in T tube group. Recurrence of stones was observed in 1 patient for each group. Though the primary closure was predominantly performed for aged patients compared to T tube drainage group, primary closure group revealed less complications. In the primary closure group, shortening of duration of hospital stay after the operation and the same prognosis as that of T tube drainage group were obtained. We concluded that the primary closure of the common bile duct for choledocholithiasis is more effective than T tube drainage as long as the indications are kept.

The leaking anastomosis following total gastrectomy has been reported in a frequency from 6.1% to 15.2%, and that following distal gastrectomy from 1.6% to 3.5%. Mortality rate of anastomotic failure has been recently improved due to advances in nutrition supports and treatments for infections, but it is still serious complication. From January 1981 to December 1993, a total of 505 gastric cancer patients underwent gastrectomy in the First Department of Surgery at Jikei University School of Medicine. In 316 cases of distal gastrectomy, 8 patients (2.5%) incurred an anastomotic falure postoperatively. Of these, 4 cases were with major leakage. We performed T-tube drainage procedure to 3 of 4 cases. In this procedure, T-tube was inserted at the center of the anterior wall of resuturing line for purposes of decompression to anastomoses and prevention from anastomotic stenoses. Two of three cases recovered without anastomotic stenosis after the operation. The remaining one case incurred anastomotic falure after resuturing, but could safely undergo reoperation. This paper presents the T-tube drainage procedure for leaking gastrointestinal anastomosis, with a reveiw of the literature.

Background: The management of concomitant gallbladder and common bile duct (CBD) stones is controversial. We study the outcomes of laparoscopic management of common bile duct (CBD) stones with stent placement and primary closure against T-tube drainage. Patients and Methods: A series of 31 patients (17 females and 14 males) aged between 30 and 55 years, who underwent biliary decompression after laparoscopic CBD exploration to treat choledocholithiasis, was studied retrospectively from May 2009 to December 2015. The results in patients with stent (11) were compared with those who had T-tube drainage (20). Results: Stent placement and T-tube drainage was achieved in all cases by choledochotomy after adequate clearance of CBD. No mortality was reported in our series. Patients with T-tube drainage had more morbidity and complications compared to stented patients. Stents were successfully removed in all cases in the postoperative follow up by endoscopy. Conclusions: Laparoscopic CBD stenting is a safe method in the treatment of selected patients of CBD stones who need biliary decompression. Because of lower morbidity and shorter hospital stay compared with T-tube drainage, it should be considered as the first approach whenever biliary decompression is needed after LCBDE.

External drainage of the common bile duct by placement of a T-tube is a common practice after choledochotomy. This practice may result in the specific complication of bile peritonitis due to leakage after removal of the T-tube. This complication has multiple causes: some are patient-related (corticotherapy, chemotherapy, ascites), and others are due to technical factors (inappropriate suturing of the drain to the ductal wall, minimal inflammatory reaction related to some drain materials). The clinical presentation is quite variable depending on the amount and rapidity of intra-peritoneal spread of of bile leakage. Abdominal ultrasound (US), with US-guided needle aspiration and occasionally Technetium(99) scintigraphy are useful for diagnosis. Traditional therapy consists of surgical intervention including peritoneal lavage and re-intubation of the choledochal fistulous tract to allow for a further period of external drainage. When leakage is walled off and well-tolerated, a more nuanced and less invasive conservative therapy may combine percutaneous drainage with endoscopic placement of a trans-ampullary biliary drainage.

胆管結石症に対し, 胆管切開後, 逆行性経肝チューブを留置し, 胆管は1次的に縫合閉鎖した (RTBD-t法) 術式の臨床成績をTチューブ造設法 (T-t法) と比較した.1986年4月から1992年7月までに施行したRTBD-t法132例とこれまでのT-t法199例を対象に合併症を中心に比較検討し, RTBD-t法における1次縫合部の胆管径の変化率, 肝機能に及ぼす影響を検討した.RTBD-t法の重篤な合併症は瘻孔形成不全による胆汁性腹膜炎の開腹例1例 (0.8%) で, 従来のT-tube造設法8例 (4.0%) の再開腹率より低率であった.1次縫合後の胆管像より, 胆管径比が4分の3以上が87%, 4分の3以下2分の1までが13%で, 胆道減圧も良好で肝機能にも好影響を呈した.胆管結石症における胆管切開後のRTBD-t留置および1次縫合閉鎖術は, 臨床的に安全で推奨すべき術式である.

Background Traditionally, the common bile duct (CBD) is closed with T-tube drainage after choledochotomy and removal of CBD stones. However, the insertion of a T-tube is not without complication and the patients have to carry it for several weeks before removal. In the laparoscopic era, surgery is performed with minimally invasive techniques in order to reduce the trauma, hasten recovery, and reduce the hospital stay of patients. T-tube insertion seems to negate these benefits. This randomized study was designed to compare the two methods applied after LCBDE and to determine whether primary closure can be as safe as closure with T-tube drainage. Methods From May 2000 to January 2008, 93 consecutive patients with common bile duct stones (CBDS) and gallbladder in situ were enrolled in this randomized study to undergo laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE). Intraoperative findings, postoperative complications, postoperative stay, and hospital expenses were recorded and analyzed. Results There was no mortality in both groups. A T-tube was inserted in 46 patients and the CBD was closed primarily in 47. There were no differences in the demographic characteristics or clinical presentations between the two groups. Compared with the T-tube group, the operative time and postoperative stay were significantly shorter, the hospital expenses were significantly lower, and the incidences of overall postoperative complications and biliary complications were statistically and insignificantly lower in the primary closure group. Conclusion LCBDE with primary closure without external drainage after laparoscopic choledochotomy is feasible and as safe as T-tube insertion.

INTRODUCTION The aim of this study was the assessment of patient outcome, peri-operative complications, length of stay and duration of operation after laparoscopic primary closure of the common bile duct (CBD) compared with choledochotomy with T-tube drainage and trans-cystic exploration. PATIENTS AND METHODS Analysis of prospectively collected data on 71 explorations of the common bile duct between July 2001 and March 2006. RESULTS A total of 71 patients had exploration of the CBD. Within this group, 12 were referred after failed endoscopic retrograde cholangiopancreatography (ERCP). The methods of exploration included trans-cystic (9 cases), choledochotomy with Ttube (12), and choledochotomy with primary closure (50). CBD stones were found in 66 patients. In the remaining cases, we found a stricture in 1, debris in 2, and dilatation of the CBD without a stone in 2. There were 5 conversions to open technique and 3 patients required postoperative ERCP (1 with permanent stenting). Peri-operative complications included T-tube (3), primary closure group (9), and trans-cystic (0). There was no statistical significant difference (Chi-square test, P = 0.296) between the groups. There was a trend towards a shorter length of stay in the primary closure group as compared with the trans-cystic and T-tube groups of 4.16, 4.44, and 6.33 days, respectively. However, it did not reach statistical significance (one-way analysis of variance with Boneferroni correction, mean difference between groups 1.89, 0.28, 2,17, statistical significance at P < 0.05). The shortest operating time was in the primary closure group (95.92 min) which was statistically significant (P < 0.001). We did not use a biliary drain in the last 48 patients. CONCLUSIONS Primary laparoscopic closure of the CBD is safe and results in a reduction in operating time. Choledochoscopy ensures clearance of the CBD and eliminates the need for T-tube.