Laparoscopic Common Bile Duct Exploration Versus Open Approach in Cirrhotic Patients with Choledocholithiasis: A Retrospective Study

Abstract

Objective:

To evaluate the safety and benefits of laparoscopic common bile duct exploration (LCBDE) compared with open approach (OCBDE) in cirrhotic patients.

Materials and Methods:

Between January 2009 and December 2012, a total of 113 cirrhotic patients with choledocholithiasis underwent common bile duct (CBD) explorations in our department. There were two groups of patients: A:LCBDE (n = 61) and B:OCBDE (n = 52). Patients' demographic characteristics, surgical data, postoperative outcomes, and long-term results were retrospectively collected and analyzed.

Results:

There were no significant differences between the two groups in the demographic characteristics or preoperative status. The transcystic approach was successfully performed in 52 (46.0%) patients (group A:34, group B:20), whereas choledochotomy was successful in 59 (54.0%) patients (group A:27, group B:32). The differences between group A and group B in terms of surgical time (124.9 ± 34.2 minutes versus 132.6 ± 48.6 minutes, P = .323), stone clearance rate (93.4% versus 94.2%, P > .05), short-term complication rate (9.8% versus 13.4%, P = .547), and recurrent stone rate (6.6% versus 5.8%, P > .05) were not statistically significant. However, group A suffered less blood loss [95 (60–200) mL versus 200 (90–450) mL, P < .001] and shorter length of hospital stay (4.7 ± 2.5 days versus 11.3 ± 3.1 days, P < .001) than group B. In the LCBDE group, 4 (6.6%) patients were converted due to heavy inflammation and severe adhesions. No mortality, biliary injury, or stricture occurred during follow-up.

Conclusion:

LCBDE can be safely performed in patients with Child-Pugh A or B cirrhosis and choledocholithiasis, with considerable efficiency, minimal short-term complications, and acceptable long-term outcomes. LCBDE has the advantages over open CBD exploration of less bleeding and reduced length of hospital stay.

Introduction

Gallstone incidence in cirrhotic patients is ∼30%, at least two times higher than that in the noncirrhotic population.^1,2 It was reported that choledocholithiasis occurred in 10%–18% of patients undergoing laparoscopic cholecystectomy for cholecystolithiasis.³ Common bile duct (CBD) stone complications include obstructive jaundice, acute cholangitis, or pancreatitis, especially in cirrhotic patients.^4,5

The traditional approach of open common bile duct exploration (OCBDE) always represents excessive invasiveness regarding blood loss, wound pain, and complications associated (incisional hernia, wound infection, seroma, abscesses). In the laparoscopy era, minimally invasive procedures have been tried and preferred instead of traditional open surgery, which include endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE).⁶

Since ERCP introduction in 1974, it has been accepted and developed to treat CBD stones.⁷ However, ERCP is related to severe complications such as pancreatitis, bleeding, and duodenal perforation.⁸ Long-term complications secondary to sphincterotomy (recurrent ductal stones, papillary stricture, and potential of bile duct cancer) were reported in up to 12%.⁹

Quite a few publications have shown that LCBDE is a safe and feasible treatment for CBD stones in the general population with the advantage of being a single-stage procedure^10,11; however, the safety and benefits of LCBDE in cirrhotic patients have not been well documented. The aim of the present study is to evaluate the safety and benefits of LCBDE in patients with liver cirrhosis and choledocholithiasis compared with the open approach.

Materials and Methods

Patients and data collection

The study was approved by the Ethics Committee of Shanghai Ninth People's Hospital, Shanghai Jiao Tong University. Between January 2009 and December 2012, a total of 113 cirrhotic patients (57 males and 56 females; age range: 37–81 years) with choledocholithiasis underwent CBD explorations in our department. They were divided in two groups: group A-LCBDE (n = 61) and group B-OCBDE (n = 52). The demographic characteristics, surgical information (including surgical time, estimated blood loss, conversion rate, and stone clearance), postoperative information (including length of hospital stay, time to resume liquid diet, short-term complications, and hematology tests on the third day after surgery), and long-term results (including recurrent stone rate, time to recurrence, and biliary injury or stricture) were, retrospectively, collected and analyzed.

Preoperative assessment and preparation

Each patient underwent a physical examination; hematological examination (including blood count, clotting times, liver function, and hepatitis test); and abdominal imaging tests (including ultrasonography [USG] and MRI). Choledocholithiasis was diagnosed from clinical symptoms and abdominal imaging tests. Magnetic Resonance Cholangiopancreatography was indispensable when there was uncertainty. Diagnosis of liver cirrhosis was based on medical history, abdominal USG, intraoperative findings of small liver nodules, and further liver biopsy confirmation.

Surgical technique of LCBDE

Intraoperative cholangiography was performed at first to confirm CBD stone diagnosis, the number, size, position of stones, and the anatomy of cystic duct. Laparoscopic transcystic common bile duct exploration (LTCBDE) was adopted when all the following conditions were met: (1) appropriate location of all stones (below the confluence part of CBD and cystic duct); (2) number of stones <5; (3) small stones (maximum diameter 6 mm); and (4) a relatively dilated cystic duct (diameter >5 mm). Direct choledochotomy was used when LTCBDE was not applicable and failed to remove the stones.

Laparoscopic transcystic common bile duct exploration

All patients received general anesthesia and were placed in the supine position. The camera was introduced through a transumbilical 10-mm port. Another two trocars (5 mm) were placed in subxiphoid and right anterior axillary line, respectively. The fourth trocar (10 mm) was inserted at the right midclavicular line just below the subcostal margin for choledochoscope insertion. As the first step of the procedure, a small longitudinal incision (1/2–2/3 circumference) on the cystic duct (∼0.5 cm away from the confluence part of CBD and cystic duct) was made. Then, the insertion of fiber choledochoscope into CBD through the cystic duct was performed to find stones. Under direct vision of the choledochoscope, small CBD stones were extracted by means of basket and saline irrigation; impacted stones were removed after electrohydraulic lithotripsy. After clearing out the CBD stones, a completion cholangiography was necessary for confirming whether there was residual stone in the intrahepatic duct and extrahepatic duct. If no residual stone was found, the cystic duct was closed with clips or suture.

Direct choledochotomy

The anterior surface of the CBD was clearly exposed by careful dissection, where a longitudinal incision was made. Afterward, a fiber choledochoscope was introduced into the CBD to find and clean stones. After clearance of the intrahepatic duct and CBD was checked with a completion cholangiography, primary closure of the CBD was performed. In the condition of acute jaundice or cholangitis, residual stones, and numerous stones, a T-tube was placed into the CBD.

Each patient received a subhepatic drain. The subhepatic drain was removed when daily drain amount from it was < 20 mL. The T-tube was removed on postoperative day 21 if no remnant stone was observed with T-tube cholangiogram.

Open common bile duct exploration

The open approach was used in some cases because our study was retrospective and includes all cases in the mentioned time period. Other reasons for this inclusion were (1) laparoscopic surgery has not been fully carried out in the early period of this study; (2) in some cases, the surgeon decided to perform open surgery at first; and (3) a few patients with poor cardiorespiratory function did not meet indications for LCBDE.

Follow-up

Physical examination and laboratory tests were carried out in each patient, with 3 or 6 months of follow-up. If there were abnormities, further examination such as ultrasonography and computed tomography were required.

SPSS 20.0 software was used to perform all statistical analyses. Continuous variables were presented as mean ± standard deviation or median (range) and compared using Student's t-test or nonparametric Mann–Whitney U. Categorical data were expressed as a proportion (%) and compared using chi-square test or Fisher's exact test. P < .05 was considered statistically significant.

Results

Patient demographics and short-term results

The demographic and clinical characteristics of all 113 patients are presented in Table 1. There were no significant differences between both groups in terms of sex, age, ASA classification, Child-Pugh classes, diagnoses, and the proportion of preoperative ERCP.

Table 1.

Demographic and Clinical Characteristics

Variable	A	B	P
Cases (n)	61	52
Age (years)	54.2 ± 10.2	56.3 ± 10.4	.287
Sex (m/f)	32/29	25/27	.642
ASA classification (n)			.990
I	30	24
II	21	19
III	8	7
IV	2	2
Child-Pugh class (n)			.637
A	39	31
B	22	21
Diagnoses			.952
Posthepatitic cirrhosis	56	48
Alcoholic cirrhosis	3	2
Schistosomiasis cirrhosis	2	2
Preoperative ERCP [n (%)]	9 (14.8)	6 (11.5)	.616

ERCP, endoscopic retrograde cholangiopancreatography; F, female; M, male.

Intraoperative characteristics are demonstrated in Table 2. There was no significant difference between the two groups in surgical time (124.9 + 34.2 minutes versus 132.6 + 48.6 minutes, P = .323). The estimated blood loss was significantly less in the laparoscopic group than open group [95 (60–200) mL versus 200 (90–450) mL, P < .001]. In group A, 4 (6.6%) patients were converted to open surgery due to heavy inflammation (3.3%) and severe adhesions (3.3%). Retained stones occurred in 4 (6.5%) patients in group A, whereas 3 (5.8%) patients had retained stones in group B.

Table 2.

Surgical Characteristics

Variable	A	B	P
Surgical time (min)	124.9 ± 34.2	132.6 ± 48.6	.323
Estimated blood loss (mL)	95 (60–200)	200 (90–450)	<.001
Open conversion [n (%)]	4 (6.6)	/
Choledochotomy repair			.100
T-tube drainage [n (%)]	33 (54.1)	36 (69.2)
Primary closure [n (%)]	28 (45.9)	16 (30.8)
Stone clearance [n (%)]	57 (93.4)	49 (94.2)	>.05
Approach to choledocholithiasis			.067
Transcystic [n (%)]	34 (57.4)	20 (38.4)
Direct choledochotomy [n (%)]	27 (42.6)	32 (61.6)

Table 3 details the postoperative information. The length of postoperative hospital stay was significantly shorter in group A than that in group B (4.7 ± 2.5 days versus 11.3 ± 3.1 days, P < .001). Compared with group A, longer time was required for the patients in group B to recover to liquid diet (3.3 ± 1.0 days versus 1.2 ± 0.4 days, P < .001). Postoperative hematology tests on the third day after surgery did not differ obviously between the two groups, despite there being relative increases in terms of bilirubin and alanine aminotransferase (ALT) in the open group.

Table 3.

Postoperative Information

Variable	A	B	P
Postoperative hospital stay (d)	4.7 ± 2.5	11.3 ± 3.1	<.001
Recovery to liquid diet (d)	1.2 ± 0.4	3.3 ± 1.0	<.001
Postoperative hematology test
Hb (g/L)	131.0 (86.0–157.0)	131.0 (86.0–169.0)	>.05
Albumin (g/L)	35.4 (25.3–45.6)	34.3 (25.5–44.6)	>.05
Bilirubin (μmol/L)	17.2 (9.5–63.2)	19.5 (6.7–72.3)	>.05
ALT (IU/L)	45.0 (14–120)	47.5 (14.0–142.0)	>.05
AST (IU/L)	51.0 (24.0–150.0)	50.0 (23.0–140.0)	>.05
Prothrombin time (sec)	12.3 (10.0–16.9)	12.2 (9.7–17.8)	>.05
Short-term complications [n (%)]	6 (9.8)	7 (13.4)	.547
Bile leak	1 (1.6)	1 (1.9)	>.05
Ascites	2 (3.3)	2 (3.8)	>.05
Pulmonary inflammation	1 (1.6)	0	>.05
Wound infection	0	2 (3.8)	>.05
Pancreatitis	1 (1.6)	1 (1.9)	>.05
Bleeding	1 (1.6)	1 (1.9)	>.05

ALT, alanine aminotransferase; AST, aspartate transaminase; Hb, hemoglobin.

No mortality occurred in both groups, fortunately. Concerning short-term surgical complications, no statistically significant difference was found between two groups (9.8% versus 13.4%, P = .547). One patient each in groups LCBDE and OCBDE had mild bile leak and both patients recovered after 5–7 days of primitive drainage. Postoperative bleeding occurred in 1 (1.6%) patient in group A and 1 (1.9%) patient in group B, which was controlled conservatively with erythrocyte and hemostatic transfusions. In addition, the incidence of ascites, pulmonary inflammation, wound infection, and pancreatitis between two groups had no significant difference.

Long-term results

In a mean follow-up period of 41.7 months, 7 (6.2%) of 113 patients suffered from recurrent CBD stones (Table 4). Comparisons of groups A and B manifested no differences in recurrent stone rate (6.6% versus 5.8%, P > .05). CBD stones relapsed in 2 (3.3%) patients in the LCBDE group and 1 (2.0%) patient in the OCBDE group after 24 months of the operation. ERCP was performed to deal with recurrent CBD stones in five patients and hepaticojejunostomy was used in three patients. None of the patients developed any indication of biliary injury or stricture during the follow-up period.

Table 4.

Comparison of the Long-Term Result Between LCBDE and OCBDE

Variable	A	B	P
Mean follow-up period (months)	41.3 ± 18.5	42.1 ± 18.9	.808
Recurrent CBD stone [n (%)]	4 (6.6)	3 (5.8)	>.05
Time to recurrence [n (%)]			>.05
Within 24 months	2 (3.3)	2 (3.8)
After 24 months	2 (3.3)	1 (2.0)
Biliary injury or stricture	0	0

CBD, common bile duct; LCBDE, laparoscopic common bile duct exploration; OCBDE, open common bile duct exploration.

Discussion

Choleocholithiasis is a common disease worldwide, but a consensus regarding the optimal treatment for choledocholithiasis has not been reached so far. Traditional open CBD exploration¹² and minimally invasive approach (laparoscopic CBD exploration and ERCP) are primary treatment options for symptomatic CBD stones. In the era of minimally invasive surgery, traditional surgery is gradually being replaced by laparoscopic CBD exploration¹³ and ERCP.^7,14 During the past two decades, ERCP has become a standard procedure for most CBD stones. However, ERCP may increase patient morbidity and is related to a relatively high failure rate (10%–25%).^8,14,15 Furthermore, it was reported that ERCP was impossible in 3%–10% of patients.^16,17

With advancing laparoscopic equipment and accumulating experience in laparoscopic operation, LCBDE is widely accepted by surgeons at a multitude of medical centers.^13,18 Many researches of LCBDE for general patients have shown that LCBDE is a safe and efficient procedure with reduced hospital stay and postoperative pain.^16,19,20 However, the safety and efficacy of LCBDE for cirrhotic patients have not been investigated thoroughly, and little research has been performed on the benefits and long-term results of this procedure. Therefore, we carried on a research to make comparisons between LCBDE and OCBDE for choledocholithiasis in patients with liver cirrhosis in both short-term and long-term outcomes. Generally speaking, significantly less estimated blood loss and shorter postoperative hospital stay were found in the LCBDE group. Comparisons between groups demonstrated no significant differences with respect to surgical time, postoperative complications, and long-term outcomes (including recurrent CBD stones and bile duct stricture).

Both transcystic approach and direct choledochotomy can be used to perform bile duct exploration. Priority is usually given to transcystic approach, because it is less invasive and cheaper than direct choledochotomy.⁴ If stones are successfully removed through the transcystic approach, there is no need to place external biliary drainage. However, the transcystic approach has limitations associated with the size, number, position of CBD stones, and cystic duct anatomy.²¹ When faced with numerous impacted stones and failure of the transcystic approach, choledochotomy is applied in spite of the fact that it may increase the morbidity rate and length of hospital stay. In this study, the transcystic approach was successfully performed in 54 patients (LCBDE:34, OCBDE:20), whereas choledochotomy was successful in 59 patients (LCBDE:27, OCBDE:32).

Conventionally, T-tube drainage is employed to decompress the biliary tree, to reduce the risk of bile leak as much as possible, to provide a tract for cholangiography, and to remove the retained stones after open CBD exploration and laparoscopic CBD exploration through choledochotomy. Previous studies have shown that the postoperative complication rate associated with T-tube was 10.5%–20%.^22,23 Moreover, it has also been found that T-tube drainage could not prevent bile leak.²⁴ Many recent studies showed that primary closure after LCBDE was a safe and feasible alternative to T-tube drainage, with the advantages of shorter hospital stay and higher life quality.^25,26 Our retrospective research found that the differences in terms of surgical-related complications and residual stone rate between the primary closure group and T-tube drainage group were not significant. In the present study, primary closure was used in 45.9% of patients in group LCBDE and only 30.8% in group OCBDE, which may be explained by a higher success rate of transcystic approach in the laparoscopic group compared with the open group (57.4% versus 38.4%, P > .05). In addition, an outstanding visualization and exact suturing supported by laparoscopic technology also may be another reason for the difference in the proportion of primary closure between group A and group B.

To make a comparison in efficiency of LCBDE and OCBDE, we conducted a retrospective study of 113 patients (A:61, B:52). In the current study, the rate of stone clearance in group A was 93.4%, which compares favorably with previous researches in noncirrhotic patients with choledocholithiasis.^27,28 A retrospective study by Grubnik et al. suggested that choledochoscopy and cholangiography may be necessary to minimize the risk of retained stones after LCBDE.¹⁰ There was no significant difference in the stone clearance rate between two groups (93.4% versus 94.2%, P > .05), whereas the postoperative complication rate in group A was equal to that in group B (A:9.8% versus B:13.4%, P > .05). On the basis of a retrospective study conducted on a total of 132 cirrhotic patients who underwent LCBDE, the stone clearance rate was 91.7% and complication rate was 10.6%, which were similar to our findings in the present.²⁹

To date, there were only a small quantity of studies dealing with late complications of LCBDE in general patients, even little about late complications was known in cirrhotic patients after LCBDE. In a study of LCBDE using choledochotomy with 157 general patients, the recurrent CBD stones occurred in 5.9% of patients and no CBD stricture was found in the mean follow-up of 51.9 months.¹¹ Another study by Paganini et al. showed that with a median follow-up of 72.3 months, the recurrent CBD stones occurred in 5.9% of patients and no CBD stricture was found.³⁰ In this study, the recurrent CBD stone rate between the laparoscopic group and open group was not significantly different (6.6% versus 5.8%, P > .05), and no CBD stricture was found in both groups during a mean follow-up period of 42.2 months. Abovementioned results all manifest the safety and efficiency of LCBDE for cirrhotic patients even with respect to the long-term outcomes.

As expected, estimated blood loss in group A was obviously less than that in group B by means of avoiding a subcostal incision and magnification of the surgical field, but higher than other studies of LCBDE in noncirrhotic patients.^11,29 Coagulopathy, hypersplenism, and portal hypertension greatly increase the risk of bleeding in patients with cirrhosis. Surgeons should pay attention to intraoperative bleeding from the liver bed and arteries. Controlled low central venous pressure and low pressure of pneumoperitoneum (about 10 mmHg, 1 mmHg = 0.133 kPa) have been proved to be beneficial for reducing intraoperative bleeding in cirrhotic patients.^31,32 To minimize the surgical risk, individual preparation should be performed to optimize the cirrhotic patients with the basis of patient's Child-Pugh classification. As usual, special measures (including hepatic function protection, alleviation of ascites, correction of coagulopathy, and reduction of portal vein pressure) are needed to improve and maintain the liver function for patients with Child-Pugh B cirrhosis, whereas special measures are not required for patients with Child-Pugh A.³³

In conclusion, LCBDE can be performed in selected patients with Child-Pugh A and B cirrhosis, with considerable efficiency, minimal short-term complications, and acceptable long-term outcomes. Hence, LCBDE is a safe, feasible, and effective treatment in cirrhotic patients. LCBDE has the advantages over open CBD exploration of less bleeding and reduced postoperative hospital stay. Our study was retrospective; however, a prospective and randomized study is indispensable for further research.

Footnotes

Acknowledgment

This study was financially supported by the Science and Technology Commission of Baoshan District, Shanghai (No. 13-E-4).

Disclosure Statement

No competing financial interests exist.

References

Morino

, Cavuoti

, Miglietta

, et al. Laparoscopic cholecystectomy in cirrhosis: Contraindication or privileged indication?. Surg Laparosc Endosc Percutan Tech, 2000; 10:360–363.

Silva

, Wong

. Gallstones in chronic liver disease. J Gastrointest Surg, 2005; 9:739–746.

Dasari

, Tan

, Gurusamy

, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev, 2013; 12:CD003327.

Verbesey

, Birkett

. Common bile duct exploration for choledocholithiasis. Surg Clin North Am, 2008; 88:1315–1328, ix.

Sugiyama

, Atomi

, Kuroda

, et al. Treatment of choledocholithiasis in patients with liver cirrhosis. Surgical treatment or endoscopic sphincterotomy?. Ann Surg, 1993; 218:68–73.

Tranter

, Thompson

. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg, 2002; 89:1495–1504.

, Li

, Wang

, et al. Early percutaneous transhepatic gallbladder drainage compared with endoscopic retrograde cholangiopancreatography and papillotomy treatment for severe gallstone associated acute pancreatitis. Postgrad Med J, 2007; 83:187–191.

Wang

, Li

, Liu

, et al. Risk factors for ERCP-related complications: A prospective multicenter study. Am J Gastroenterol, 2009; 104:31–40.

Saito

, Tsuyuguchi

, Yamaguchi

, et al. Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis. Gastrointest Endosc, 2000; 51:540–545.

10.

Grubnik

, Tkachenko

, Ilyashenko

, et al. Laparoscopic common bile duct exploration versus open surgery: Comparative prospective randomized trial. Surg Endosc, 2012; 26:2165–2171.

11.

Lee

, Min

, Lee

. Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis: 15-year experience from a single center. Ann Surg Treat Res, 2014; 86:1–6.

12.

Kusano

, Isa

, Shimoji

, et al. Results of retrograde transhepatic biliary drainage after a common bile duct exploration for choledocholithiasis. Hepatogastroenterology, 1999; 46:2776–2780.

13.

, Wang

, Huang

, et al. Laparoscopic common bile duct exploration in patients with complicated cholecystitis: A safety and feasibility study. World J Surg, 2012; 36:2455–2460.

14.

Nathanson

, O'Rourke

, Martin

, et al. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: A randomized trial. Ann Surg, 2005; 242:188–192.

15.

Chen

, Tay

, Hoe

, et al. Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit. ANZ J Surg, 2005; 75:1070–1072.

16.

Topal

, Aerts

, Penninckx

. Laparoscopic common bile duct stone clearance with flexible choledochoscopy. Surg Endosc, 2007; 21:2317–2321.

17.

Zidi

, Prat

, Le Guen

, et al. Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: Prospective comparison with a reference imaging method. Gut, 1999; 44:118–122.

18.

Paik

, Kim

. Laparoscopic common bile duct exploration after unsuccessful endoscopic stone removal. J Laparoendosc Adv Surg Tech A, 2013; 23:137–140.

19.

Chander

, Vindal

, Lal

, et al. Laparoscopic management of CBD stones: An Indian experience. Surg Endosc, 2011; 25:172–181.

20.

Hanif

, Ahmed

, Samie

, et al. Laparoscopic transcystic bile duct exploration: The treatment of first choice for common bile duct stones. Surg Endosc, 2010; 24:1552–1556.

21.

Lyass

, Phillips

. Laparoscopic transcystic duct common bile duct exploration. Surg Endosc, 2006; 20 Suppl 2:S441–S445.

22.

Seale

, Ledet

Jr.

Primary common bile duct closure. Arch Surg, 1999; 134:22–24.

23.

Sorensen

, Buck

, Chung

, et al. Primary common bile duct closure following exploration: An effective alternative to routine biliary drainage. Am Surg, 1994; 60:451–454.

24.

Wills

, Gibson

, Karihaloot

, et al. Complications of biliary T-tubes after choledochotomy. ANZ J Surg, 2002; 72:177–180.

25.

Yin

, Xu

, Sun

, et al. Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming? A systematic review and meta-analysis. Ann Surg, 2013; 257:54–66.

26.

Zhang

, Chen

, Wu

, et al. Laparoscopic common bile duct exploration with primary closure for management of choledocholithiasis: A retrospective analysis and comparison with conventional T-tube drainage. Am Surg, 2014; 80:178–181.

27.

Berthou

, Dron

, Charbonneau

, et al. Evaluation of laparoscopic treatment of common bile duct stones in a prospective series of 505 patients: Indications and results. Surg Endosc, 2007; 21:1970–1974.

28.

Moreaux

. Traditional surgical management of common bile duct stones: A prospective study during a 20-year experience. Am J Surg, 1995; 169:220–226.

29.

Qiu

, Yuan

, Chen

, et al. Laparoscopic common bile duct exploration in cirrhotic patients with choledocholithiasis. J Clin Gastroenterol, 2015; 49:132–136.

30.

Paganini

, Guerrieri

, Sarnari

, et al. Long-term results after laparoscopic transverse choledochotomy for common bile duct stones. Surg Endosc, 2005; 19:705–709.

31.

Jarnagin

, Gonen

, Fong

, et al. Improvement in perioperative outcome after hepatic resection: Analysis of 1,803 consecutive cases over the past decade. Ann Surg, 2002; 236:397–406; discussion 406–397.

32.

Curro

, Iapichino

, Melita

, et al. Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. JSLS, 2005; 9:311–315.

33.

Leandros

, Albanopoulos

, Tsigris

, et al. Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease. ANZ J Surg, 2008; 78:363–365.