Primary closure with self-disengaging biliary stent following laparoscopic CBD exploration in normal-diameter ducts: a propensity score matching study

Abstract

Laparoscopic Common Bile Duct Exploration (LCBDE) is highly effective for treating common bile duct stones (CBDS). This study aims to evaluate the safety and feasibility of primary closure with a self-disengaging biliary stent during LCBDE in patients with normal-diameter CBDs (≤ 8 mm) and to compare perioperative outcomes and complications with those in dilated CBDs (> 8 mm). From May 2022 to May 2024, patients with CBDSs who underwent LCBDE with primary closure and a self-disengaging biliary stent were retrospectively analyzed. Patients were stratified into two subgroups based on CBD diameter (normal: ≤8 mm vs. dilated: >8 mm). Propensity score matching (PSM) was adjusted for baseline differences between normal and dilated CBD groups, and perioperative indicators and postoperative complications were compared. Multivariate analysis identified risk factors for postoperative bile leakage. Of 491 patients, 343 underwent primary closure with a self-disengaging biliary stent during LCBDE. The mean operation time was 85 (IQR 70-110) min, with blood loss of 20 (IQR 15-20) ml. The postoperative hospital stay was 8 (IQR 8-10) days, and the hospitalization cost was CNY 28,143 (IQR 25,522-32,809). The overall complication rate was 32 (9.3%), with 25 (7.3%) experiencing bile leakage. The Charlson Comorbidity Index (CCI) score was an independent risk factor for bile leakage (OR 2.587; 95% CI 1.729-3.873, P < 0.001). PSM of dilated (> 8 mm, n = 225) and normal (≤ 8 mm, n = 118) CBD groups resulted in 114 matched pairs. No significant differences were observed in operative time, blood loss, hospital stay, costs, or complications between the groups. Primary closure with a self-disengaging biliary stent following LCBDE is equally safe and effective in patients with normal-diameter CBDs as in those with dilated ducts. CBD diameter should not be a contraindication for this technique. The CCI score is a critical predictor of bile leakage and should be considered in perioperative risk assessment.

Keywords: Bile leakage; Common bile duct stones (CBDSs); Laparoscopic common bile duct exploration (LCBDE); Primary closure; Self-disengaging biliary stent.

Fig. 1

Study design with a flow diagram: Out of 491 consecutive patients diagnosed with CBDSs and treated between May 2022 and May 2024 at a single medical center, 343 were selected for the study. These patients were divided into two groups based on CBD diameter (8 mm): the normal group and the dilated group. Propensity score matching was conducted to match the two groups, aiming to reduce confounding factors such as age, gender, BMI, CCI score, ASA classification, history of abdominal surgery, preoperative hypoproteinemia, acute cholangitis, and obstructive jaundice.

Fig. 2

The self-disengaging biliary stent-making and fixing procedure. a–c A 6-Fr double J tube was trimmed to approximately 15 cm in length. A terminal coil was fashioned at one end using 4-0 coated Vicryl^® (polyglactin 910) sutures; d Following stone removal, a guidewire was first positioned through the working channel of the choledochoscope under direct endoscopic visualization. The choledochoscope was then carefully withdrawn while maintaining stable guidewire access. Finally, the self-disengaging stent was advanced over the guidewire into position; e Confirm the stent is positioned under choledochoscopy, passing through the papilla into the duodenum; f Perform the primary closure of the CBD and temporarily fix the stent by looping the coil at the end of the stent into the suture line.

Fig. 3

General procedure for dilated CBD. a Explore Calot’s triangle and make a longitudinal incision on the anterior wall of the CBD; b Bluntly dilate the incision on the bile duct; c Explore the CBD with a choledochoscope and remove all stones; d Place the stent under the guidance of the choledochoscope; e Use 4-0 PDS sutures for interrupted suturing and temporarily fix the stent; f After complete suturing, check the CBD for the absence of stenosis and bile leakage.

Fig. 4

CBD micro-incision process. a Dissect the Calot’s triangle and clamp the cystic duct; b make a longitudinal incision at the junction of the cystic and CBD, and make a small incision on the side wall of the CBD; c bluntly dilate the incision on the bile duct; d explore the CBD with a choledochoscope and remove all stones; e perform interrupted suturing of the small incision on the CBD, reconstruct the cystic duct, and temporarily fix the stent tube. f After complete suturing, check the CBD for the absence of stenosis and bile leakage.