Laparoscopic Transcystic Common Bile Duct Exploration in the Elderly is as Effective and Safe as in Younger Patients

Abstract

Background:

Choledocholithiasis represents a greater proportion of gallstone in the elderly. Elderly patients have more comorbidity, which could increase the operative risk and postoperative complications. However, no study has focused on the effect and safety of laparoscopic transcystic common bile duct exploration (LTCBDE) in elderly patients. The aim of this study was to investigate whether LTCBDE can be performed effectively and safely in elderly patients.

Methods:

This is a retrospective study of patients who underwent LTCBDE for choledocholithiasis performed from January 2010 to December 2012. Patients of age 70 or older were included in the elderly group. The rest integrated the younger group. Demographic data and perioperative parameters were compared between groups.

Results:

From January 2010 to December 2012, 171 patients admitted for choledocholithiasis and gallstone attempted a single-step treatment combining LTCBDE and laparoscopic cholecystectomy. There were 104 women (60.8%) and 67 men (39.2%) with a median age of 57 (range 24–87) years. Elderly patients had significantly more preoperative risk factors. However, there was no significant difference in the success rate of LTCBDE (96.9% versus 92.7%, P = .142) for the two groups. The operative time was a little longer in elderly group than in younger group: median 80 (60–110) minutes versus 70 (50–95) minutes, respectively (P < .001). Postoperative recovery was slower in elderly group than in younger group, as reflected by a longer median postoperative hospital stay (2 days versus 1 day, P < .001) and a higher rate of abdominal drain placed (17.1% versus 8.5%, P = .202). The rates of postoperative complications at discharge were similar between groups (3.0% versus 4.9%, P = .952).

Conclusion:

LTCBDE in the elderly patients is as effective and safe as in younger patients.

Introduction

Elderly patients have more comorbidity, which could increase the operative risk and postoperative complications.^1,2 Since minimal invasive surgery has replaced open surgery, the elderly have been reconsidered for surgical management of their diseases. Laparoscopic cholecystectomy (LC) has revealed to be safe in elderly patients although increased conversion rate and morbidity have been reported.^3,4 Choledocholithiasis represents a greater proportion of gallstone in the elderly.⁵ The treatment protocol involves a sequential approach consisting of endoscopic retrograde cholangiopancreatography (ERCP) followed by LC or a single procedure: LC with laparoscopic common bile duct exploration (LCBDE). Meta-analyses^6–10 have confirmed that LCBDE and ERCP have similar rates of stone clearance, morbidity, and mortality. However, LCBDE and LC used as a single-stage approach are associated with a shorter hospital stay and are likely to be more cost-effective than ERCP.^11,12 A systematic review¹³ was fixed on transcystic versus transductal stone extraction during LCBDE and concluded that there was no strong evidence to support one approach over the other. For elderly, there are many reports about the effect and safety of transductal approach of LCBDE.^14–17 However, there are few data about the effect and safety of laparoscopic transcystic common bile duct exploration (LTCBDE) in elderly patients.

The aim of this study was to investigate whether LTCBDE can be effectively and safely performed in elderly patients.

Patients and Methods

Patients and data collection

This is a retrospective study of 171 patients who underwent LTCBDE performed by the same surgeon from January 2010 to December 2012. Indications were gallstones and having symptoms or laboratory abnormalities consistent with choledocholithiasis, including obstructive jaundice, raised levels of alkaline phosphatase and/or γ-glutamyltransferase, common bile duct (CBD) diameter >8 mm, CBD stones diagnosed by magnetic resonance cholangiopancreatography (MRCP) or CT, repeated episodes of biliary colic and cholangitis, history of obstructive jaundice, and a history of biliary pancreatitis. Exclusion criteria were hepatolithiasis, Mirizzi syndrome diagnosed by MRCP, and suspected bile duct or gallbladder cancer. Patients of age 70 or older at the time of surgery were included in the elderly group. The rest of the patients integrated the younger group. We compared the data on sex, preoperative investigations, transcystic success rate, operative time, conversion to an open procedure, intraoperative and postoperative complications, and retained stones by groups.

Operative techniques

LTCBDE was performed under general anesthesia. A carbon dioxide pneumoperitoneum of 12 mmHg was created using a 10-mm port inserted at the umbilicus, and a 30° laparoscope was used.

The patient was positioned in a reverse Trendelenburg position tilted to the left. Three additional trocars were positioned at the epigastrium (10 mm) and two 5-mm ports in the right hypochondrium. A wide local dissection of Calot's triangle was performed, and the cystic artery was divided. After the bile duct had been clipped 1 cm upstream of the CBD, a transverse incision was made in the lateral wall of the cystic duct. After dilatation with the forceps' tip, one suture was used to expose the cystic duct. A 3- or 5-mm flexible choledochoscope (CHF-P20; Olympus, Tokyo, Japan) was inserted into the CBD. The stones were retrieved individually in a wire basket introduced through the choledochoscope. Saline flushing was used to remove multiple small stones in the CBD. To confirm duct clearance, two to three consecutive proximal and distal choledochoscopies were performed. LC was completed after the cystic duct had been clipped and divided. A drain was placed in the subhepatic space, if necessary, and was removed routinely on the first or second day after surgery if there was no bile leak.

For patients with abnormal anatomy of the cystic duct or when the diameter of stones was larger than the cyst duct, a microincision of the cystic duct was performed at the confluence with the CBD. The CBD was cut only for 3–5 mm at the lateral margin. After retrieval of the stones, the incision was closed with interrupted sutures, and the cystic duct ligated with two Hem-o-lok^® (Weck Surgical Instruments; Teleflex Medical, Durham, North Carolina) closures.

The failure of LTCBDE is defined as the failed inserting of choledochoscope into the CBD through the cystic duct or the failed extraction of CBD stone through the cystic duct. Transductal exploration was carried out if the microincision was not possible or failed. Conversion to open was the last choice for all the patients.

Statistical analysis

Statistical analysis was performed using SPSS 16.0 software (Chicago, IL). All reported P values are two tailed and P < .05 was taken as significant. The continuous variables were expressed as mean (s.d.) or median (i.q.r.). For the analysis of differences between groups, two-tailed t tests were used or nonparametric tests if the results were not distributed normally. χ² or Fisher's exact test was used for comparison of proportions.

Results

Between January 2010 and December 2012, 171 patients admitted for choledocholithiasis and gallstone attempted a single-step treatment combining LTCBDE and LC. There were 104 women (60.8%) and 67 men (39.2%) with a median age of 57 (range 24–87) years. Younger group included 130 patients with a median (i.q.r.) age of 53 (44–61) years, whereas elderly group included 41 patients with a median (i.q.r.) age of 76 (72–80) years (Table 1).

Table 1.

Baseline Characteristics of the Patients

	Younger group (n = 130)	Elderly group (n = 41)	P^a
Sex
Female	80 (61.5)	24 (58.5)	.731
Male	50 (38.5)	17 (41.5)
Comorbidity^b	51 (39.2)	25 (61.0)	.015
Hypertension	38 (29.2)	15 (36.6)
Diabetes mellitus	15 (11.5)	9 (22.0)
Cardiovascular disease	6 (4.6)	9 (22.0)
Preoperative abdominal surgery	24 (18.5)	4 (9.8)	.189
Preoperative ERCP+EST	13 (10.0)	5 (12.2)	.914
ASA grade			<.001
I	23 (17.7)	0 (0.0)
II	96 (73.8)	22 (53.7)
III	11 (8.5)	19 (46.3)

Values in parentheses are percentages. American Society of Anesthesiologists (ASA) grade I: healthy status; grade II, mild systemic disease; and grade III, severe systemic disease.

χ² test.

History of two and more coexistent systemic diseases was recorded in seven patients of each group.

CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy.

The elderly group had significantly more comorbidity than the younger group (61.0% versus 39.2%, P = .015). These accounted for a higher proportion of American society of anesthesiologists' grade in elderly group than that in younger group (P < .001).

There was no significant difference in the success rate of transcystic CBD exploration between younger and elderly groups (96.9% versus 92.7%, P = .142). The seven failed LTCBDEs (four in the younger group and three in the elderly group) were due to friable cystic ducts (four patients), long parallel cystic ducts (one patient), and severe adhesions at the triangle of Calot (two patients). The seven failed LTCBDEs were converted to the transductal approach of LCBDE (two in younger group and three in elderly group) and open surgery (two in younger group).

The operative time was significantly longer in elderly group than in younger group: median 80 (60–110) minutes versus 70 (50–95) minutes, respectively (P < .001). There was a significant increase in postoperative hospital stay between younger and elderly groups: median 1.0 (1.0–2.0) day versus 2.0 (1.0–3.0) days, respectively (P < .001). There were more patients discharged on the first day in younger group than elderly groups (63.1% versus 31.7%, P < .001) (Table 2).

Table 2.

Intraoperative Variables and Postoperative Outcomes

	Younger group (n = 130)	Elderly group (n = 41)	P^a
Transcystic CBD exploration	126 (96.9)	38 (92.7)	.142^b
Flushing	52 (40.0)	8 (19.5)	.075
Basket extraction	63 (48.5)	26 (63.4)
Microincision	11 (8.5)	4 (9.8)
Transductal CBD exploration	2 (1.5)	3 (7.3)
Conversion to open surgery	2 (1.5)	0 (0.0)
Operative time (min)^c	70 (50–95)	80 (60–110)	.017^d
Blood loss (mL)^c	10 (5–10)	10 (10–15)	.159^d
CBD diameter (cm)^c	0.9 (0.8–1.0)	1.0 (1.0–2.0)	.208^d
Drain placed	11 (8.5)	7 (17.1)	.202
Discharged on the first day	82 (63.1)	13 (31.7)	<.001
Postoperative hospital stay (days)^c	1.0 (1.0–2.0)	2.0 (1.0–3.0)	<.001^d

Values in parentheses are percentages unless indicated otherwise.

χ² test.

Fisher^'s exact test.

Values are median (i.q.r.).

Mann–Whitney test.

CBD, common bile duct.

The complication rates were similar in two groups (Table 3). Two patients in younger group were found to have retained CBD stones about 24 months postoperatively, which were successfully removed by ERCP. No mortality was recorded in this study.

Table 3.

Postoperative Complications by Age Groups

	Younger group (n = 130)	Elderly group (n = 41)	P
Acute cholangitis	0	1
Biliary stricture	1	0
Pancreatitis	0	1
Intra-abdominal hemorrhage	1	0
Retained CBD stones	2	0
Total	4 (3.0%)	2 (4.9%)	.952^a

χ² test.

CBD, common bile duct.

Discussion

This study would be helpful to facilitate the application of LTCBDE in elderly patients. First, an important difference between our study and the previous ones^14–17 is that the main method is transcystic exploration instead of transductal exploration. Without the assistive technology of microincision, the transcystic success rate was 88.5% in younger group and 82.9% in elderly group. Second, the microincision was given higher priority in the failed transcystic exploration. In our study, the transcystic exploration success rate increased in both groups (from 88.5% to 96.9% in younger group, from 82.9% to 92.7% in elderly group). Although some reports confirmed the safety and effect of the procedures,¹⁸ there are few reports focused on the role of microincision used in the failed LTCBDE.

The transcystic exploration is the least invasive and the quickest procedure and has the advantage of preservation of the biliary sphincter.¹⁹ Biliary sphincter plays an important role in preventing the regurgitation of duodenal contents into the biliary tract. Several studies^20,21 have reported that indicate reflux of duodenal contents up in the bile and pancreatic duct after endoscopic sphincterotomy. A prospective cohort study²² shows an increased incidence for pancreatitis and cholangitis after endoscopic sphincterotomy. Such reflux can be the explanation of increased inflammation of the bile and pancreatic duct,²³ which has been reported to play a causal role in the development of cancer.²⁴

Regardless of a patient's age, this study highlights the important fact that major operative complications and prolonged hospital stay still occur at reasonably high rates after LTCBDE. Elderly patients frequently suffer from significant comorbidities and limited cardiopulmonary reserves that may contribute to a longer hospital stay. Elderly patients needed more days to discharge from hospital for the worrying about possible complications caused by associated comorbidities, which are reported to increase the postoperative complications.^1,2 In this series, we have clearly demonstrated that the morbidity in elderly group is higher than that in younger group, but without significant difference. However, there is a significant increase in the postoperative hospital stay in elderly group compared with younger group.

In our study, a significant difference was observed in operative time between the younger and elderly groups. However, our operative time in elderly group was only 10 minutes longer than that in the younger group. To some degree, in the elderly group, the proportion of basket extraction in transcystic CBD exploration is higher than that in the younger group without significant difference. This also may result in the longer operative time.

As reported by other authors,²⁵ the most common major complication was retained stone, which occurred only in two cases (1.5%) in younger group and required ERCP within 2 years. To confirm duct clearance, we rely on two to three consecutive, proximal, and distal negative choledochoscopies. Although it was reported that intraoperative cholangiography could prevent common duct injury,²⁶ controversy exists regarding the effect of routine use in the prevention of common duct injury.^27,28 A recent study reported that there was no robust evidence to support or abandon the use of cholangiography to prevent retained CBD stones.²⁹ As to our hospital, the intraoperative cholangiography was performed only when the bile duct injury was suspected.

The limitation of this study is its retrospective nature. Therefore, case selection bias and treatment bias cannot be avoided. Furthermore, the application of LTCBDE is partly limited by the lack of expertise and facilities.

Conclusions

In our experience, LTCBDE for elderly patients can be performed safely and effectively similar to younger patients. The present study adds up to a growing body of literature confirming that LTCBDE for the management of CBD stones is a safe and effective procedure in elderly patients. Surgeons performing LC should be encouraged to use LTCBDE as a tool to manage elderly patients with CBD stones. Furthermore, randomized studies need to be completed to verify this conclusion.

Footnotes

Disclosure Statement

No competing financial interests exist.

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