Laparoscopic common bile duct exploration with primary closure could be safely performed among elderly patients with choledocholithiasis

doi:10.21203/rs.3.rs-2198941/v1

Background

For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of common bile duct (CBD) should be performed on completion of choledochotomy and corresponding indications for primary closure of common bile duct are still controversial topics. This study was accomplished to evaluate safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE.

Methods

Patients with choledocholithiasis who had undergone LCBDE with primary closure of CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (group A: ≥70 years and group B: <70 years) according to age. Group A was compared with Group B in terms of preoperative characteristics, intraoperative results and postoperative outcomes.

Results

The mean operative time for group A was 176.59 minutes (± 68.950) while the operative time for group B was 167.64 minutes (± 69.635 ) (P = 0.324). The mean hospital stay after surgery for group A was 8.43 days (± 4.440) while that for group B was 8.30 days (± 5.203) (P = 0.849). 3 patients in group A experienced bile leakage while bile leakage occurred to 10 patients in group B (3.8% VS 4.5%, P = 0.781). Group A was not significantly different from group B in terms of postoperative complications and 30-day mortality except pneumonia (P = 0.016), acute cardiovascular event (P = 0.005) and ICU observation (P = 0.037). After a median follow-up time of 60 months, 2 patients in group A and 2 ones in group B experienced stone recurrence (2.5% VS 0.9%, P = 0.612). 1 patient in group A experienced stenosis of CBD while stenosis of CBD occurred to 5 ones in group B (1.3% VS 2.2%, P = 0.937).

Conclusions

Simultaneous closure of CBD upon completion of LCBDE could be safely performed among patients ≥ 70 years.

Choledocholithiasis

Laparoscopic common bile duct exploration

Primary closure of CBD

Bile leakage

Elderly patients

Choledocholithiasis is the result of expelled stones from intrahepatic bile duct or gallbladder. Despite the fact that some stones can pass into the duodenum via major duodenal papilla, some stones may not pass through the CBD so smoothly due to large sizes and obstruction caused by large stones may subsequently lead to acute cholangitis or acute pancreatitis[1]. Among elderly patients, choledocholithiasis is quite commonly diagnosed. According to some previous studies, incidence of choledocholithiasis increased with age[2–4]. Increased incidence of choledocholithiasis means more hepatobiliary surgeries for patients with high risks.

Treatment choices for patients with choledocholithiasis vary significantly, including laparotomy, laparoscopic or robotic surgery, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous intervention[5]. For patients suffering from choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) could be safely performed[6–8]. Additionally, primary closure of CBD without inserting a T-tube drainage has been advocated as a feasible alternative to T tube insertion after LCBDE, which may further significantly reduce surgical trauma and remarkably increase quality of life after surgery[9–11]. Prevalence of comorbidity significantly increases with increasing age. Whereas, studies investigating feasibility and safety of primary closure of CBD among elderly patients with choledocholithiasis, are still needed. The present study was accomplished to further assess safety and feasibility of primary closure of CBD on completion of LCBDE among patients ≥ 70 years in comparison with those < 70 years.

Patients and ethical approval

Information of patients with choledocholithiasis who had undergone primary closure of CBD without inserting T drainage tube upon the completion of LCBDE at Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People^,s Hospital between July 2014 and December 2020 was retrospectively reviewed. Diagnoses of choledocholithiasis were made by combining symptoms, physical signs, and results of imaging examinations. Both magnetic resonance cholangiopancreatography (MRCP) and abdominal ultrasonography were routinely performed while computed tomography (CT) was performed as an alternative to MRCP for patients who could not undergo MRCP due to different contraindications. Diameter of CBD and characteristics of stones within CBD (number and diameter) were identified by the aforementioned imaging examinations. Informed consent in written form was acquired from each patient and the present study was approved by The Ethical Committee, Shenzhen People^,s Hospital. Patients were assigned into the elderly group (group A, ≥ 70 years) and the younger group (group B, < 70 years). All the procedures were accomplished under general anesthesia by two to three surgeons. Consistent with standards from some previous studies[2, 12–15], the following were our standards for primary closure of CBD: diameter of CBD ≥ 8mm, both stones in CBD and within intrahepatic bile duct thoroughly extracted, mild inflammation of CBD wall, expedite distal CBD and major duodenal papilla, well functional Oddi’s sphincter, and without severe injuries to supplying vessels of CBD.

Operational Procedures

Initially, laparoscopic cholecystectomy (LC) was accomplished by a three-port configuration. At first the subumbilical trocar for inserting camera was established. Then under direction vision, the epigastric port (10-mm) and the right midclavicular (5mm) were established. Then the gallbladder was removed using an electrotome or a harmonic dissector (Ultracision harmonic scalpel; Ethicon Endo-surgery, Cincinnati, OH, USA). After LC, another 5-mm trocar was established to serve as an assistive port. Distribution of the four trocars mentioned above was demonstrated in Fig. 1. For patients who had already undergone cholecystectomy, LCBDE would be directly performed using the four-port configuration described as above. For patients with a cystic duct less than 5mm, LCBDE was accomplished via the transcholedochal approach as described in some previous studies[2, 16]. The anterior surface of CBD was cut open longitudinally using surgical scissors or electric hooks and then according to sizes of stones, we performed choledochotomy via an incision between 8 and 12mm. Then we performed CBD exploration by inserting choledochoscope (Olympus, Tokyo, Japan). In most cases, choledochoscope could be inserted into the right and left hepatic duct and secondary intrahepatic bile ducts could be observed under choledochoscope. When the biliary system was remarkably dilated, the choledochoscope could even be inserted into secondary intrahepatic bile duct. Both stone in CBD and visible calculus within intrahepatic bile duct were extracted using suction, basket or electro-hydraulic lithotripsy. In addition to being used to extract stones, the choledochoscope was also adopted to observe patency of Oddi’s sphincter and distal CBD. Patency and status of Oddi’s sphincter and distal CBD were carefully inspected to confirm whether outlet of CBD was obstructed. Primary closure of CBD was not performed only if the following conditions were met: good contraction and favorable peristalsis of Oddi’s sphincter could be directly observed under choledochoscope and choledochoscope could be successfully inserted into duodenum without remarkable resistance; otherwise, a 5Fr ureteric catherter was inserted through the choledochoscope into the lower part of CBD and could smoothly enter duodenum via the Oddi’s sphincter. When the aforementioned conditions were fulfilled, the incision on CBD was continuously closed using a 5 − 0 polydioxanone suture. The representative image for LCBDE via CBD and primary closure were demonstrated in Fig. 2A.

For patients with cystic ducts larger than 5mm, a transcystic approach was adopted to accomplish LCBDE. Initially, the cystic duct was dilated using a balloon dilator. When dilating the cystic duct using a balloon dilator was impossible, we then made a longitudinal incision on the cystic duct. Then the choledochoscope was inserted into the CBD via the cystic duct. After extracting stones within bile ducts, we then closed the cystic duct using suture or clips. The representative images for LCBDE via cystic duct and primary closure were demonstrated in Fig. 2B.

After the completion of surgery, patients were transferred back to general ward or intensive care unit (ICU) considering vital signs during surgery, recovery of autonomous respiration and consciousness. For all patients, a rubber drainage tube was routinely put into the subhepatic area. Two to three days after surgery, we removed the drainage tube when less than 20ml/day was drained out. When the following standards were met, patients would be discharged: stable vital signs and normal laboratory tests, being able to autonomously accomplish off-bed activities, a good appetite and normal excretion, without surgical site infection or poorly healed incision.

Follow-up

Unless otherwise contraindicated, all the patients were instructed to attend a postoperative follow-up lasting 60 months every six months.

Statistical analysis

Continuous variables were presented as mean ± standard deviation (SD) while categorical ones were demonstrated as percentages. Comparisons of baseline characteristics, preoperative factors, operation-related variables and postoperative morbidity were accomplished by Student’s t-test, Fisher’s exact test or Chi-squared analysis when appropriate. Statistical Package for the Social Sciences (SPSS, version 22.0) was used to perform statistical analyses in this study. And comparisons with P values less than 0.05 were considered as statistically significant.

Baseline characteristics and co-morbidities

Two groups were compared regarding baseline characteristics including age, gender, body mass index (BMI), obstructive jaundice, acute cholangitis, history of pancreatitis, history of abdominal surgery, history of cholecystectomy, diameter of CBD, number of CBD stones, maximum diameter of stones, revealing that group A had more senior ages (P < 0.001) and more common history of cholecystectomy (P = 0.023) (Table 1). Additionally, group A was also compared with group B in terms of co-morbidities and ASA score, demonstrating that significantly more patients in group A had hypertension (P < 0.001), diabetes mellitus (P = 0.002), cardiovascular diseases (P < 0.001) and higher ASA scores (P < 0.001) (Table 2).

Table 1: Comparisons between Group A and Group B regarding demographics and clinical factors

Characteristics	No.	B	A	χ²/t	P
	(N=303)	(N=223)	(N=80)	Value	Value
Age	56.56±18.095	48.71±14.133	78.44±5.634	-26.150	0.000
Gender				0.175	0.676
Male	150(49.5%)	112(50.2%)	38(47.5%)
Female	153(50.5%)	111(49.8%)	42(52.5%)
BMI				1.440	0.696
≤18.4(kg/m²)	21(6.9%)	15(6.7%)	6(7.5%)
18.5-23.9(kg/m²)	161(53.1%)	116(52.0%)	45(56.3%)
24-27.9(kg/m²)	97(32.0%)	72(32.3%)	25(31.2%)
≥28(kg/m²)	24(8.0%)	20(9.0%)	4(5.0%)
Obstructive jaundice				2.103	0.147
No	75(24.8%)	60(26.9%)	15(18.8%)
Yes	228(75.2%)	163(73.1%)	65(81.2%)
Acute cholangitis				2.258	0.133
No	143(47.2%)	111(49.8%)	32(40.0%)
Yes	160(52.8%)	112(50.2%)	48(60.0%)
History of pancreatitis				0.001	0.972
No	273(90.0%)	201(90.1%)	72(90.0%)
Yes	30(10.0%)	22(9.9%)	8(10.0%)
History of abdominal surgery				0.371	0.542
No	231(76.2%)	172(77.1%)	59(73.8%)
Yes	72(23.8%)	51(22.9%)	21(26.2%)
History of cholecystectomy				5.161	0.023
No	286(94.4%)	215(96.4%)	71(88.8%)
Yes	17(5.6%)	8(3.6%)	9(11.2%)
Diameter of CBD				3.603	0.058
≤8mm	37(12.2%)	32(14.3%)	5(6.3%)
＞8mm	266(87.8%)	191(85.7%)	75(93.7%)
Solitary/multiple stones				3.661	0.056
Solitary	149(49.2%)	117(52.5%)	32(40.0%)
Multiple	154(50.8%)	106(47.5%)	48(60.0%)
Maximum diameter of stones (mm)	7.87±4.786	7.68±4.893	8.39±4.462	-1.132	0.258

Table 2

Comparisons between Group A and Group B regarding preoperative risk factors
Characteristics	No.	B	A	χ²/t	P
	(N = 303)	(N = 223)	(N = 80)	Value	Value
Hypertension				32.217	0.000
No	221(72.9%)	182(81.6%)	39(48.8%)
Yes	82(27.1%)	41(18.4%)	41(51.2%)
Diabetes mellitus				9.880	0.002
No	276(91.1%)	210(94.2%)	66(82.5%)
Yes	27(8.9%)	13(5.8%)	14(17.5%)
Cardiovascular disease				24.730	0.000
No	276(91.1%)	214(96.0%)	62(77.5%)
Yes	27(8.9%)	9(4.0%)	18(22.5%)
Pulmonary disease				1.273	0.259
No	295(97.4%)	219(98.2%)	76(95.0%)
Yes	8(2.6%)	4(1.8%)	4(5.0%)
Renal insufficiency
No	299(98.7%)	220(98.7%)	79(98.8%)	0.004	0.949
Yes	4(1.3%)	3(1.3%)	1(1.2%)
ASA score	1.50 ± 0.645	1.32 ± 0.540	2.00 ± 0.656	−9.071	0.000

Intraoperative Variables

8 patients in group A underwent transcystic exploration of CBD while 72 ones underwent transcholedochal surgery; for patients in group B, 17 ones underwent transcystic exploration of CBD while 206 ones underwent transcholedochal surgery (P = 0.507). Mean operative time for group A was 176.59 minutes (± 68.950) while the average operative time for group B was 167.64 minutes (± 69.635) (P = 0.324). Group A was not significantly different group B in terms of estimated blood loss (P = 0.075). 3 patients in group A needed blood transfusion while 1 in group B needed intraoperative blood transfusion (P = 0.099). 6 patients in group A were transferred to ICU for recovery and early postoperative care after surgery which occurred to 4 ones in group B (P = 0.037). The mean hospital stay after surgery for group A was 8.43 days (± 4.440) while that for group B was 8.30 days (± 5.203) (P = 0.849).

Postoperative Complications

Group A was not significantly different group B in terms of most postoperative complications except higher incidence of pneumonia (P = 0.016) and acute cardiovascular event (P = 0.005) for group A (Table 3). In group A, remnant stones occurred to 4 patients and 9 ones in group B experienced remnant stones (5.0% VS 4.0%, P = 0.965). Presentations of remnant stones were persistent upper abdominal pain and fever. Remnant stones were confirmed by MRCP. Remnant stones within CBD were extracted by endoscopic sphincterotomy (EST).

Table 3：Comparisons between Group A and Group B regarding postoperative results and follow-up outcomes

Characteristics	No.	B	A	χ²/t	P
	(N=303)	(N=223)	(N=80)	Value	Value
Operation type				0.439	0.507
Transcystic exploration	25(8.3%)	17(7.6%)	8(10%)
Transcholedochal exploration	278(91.7%)	206(92.4%)	72(90%)
Operative time (min)	170.00±69.453	167.64±69.635	176.59±68.950	-0.988	0.324
Estimated blood loss (mL)				3.168	0.075
＜100ml	273(90.1%)	205(91.9%)	68(85.0%)
≥100ml	30(9.9%)	18(8.1%)	12(15.0%)
Blood transfusion	4(1.3%)	1(0.4%)	3(3.8%)	2.718	0.099
ICU observation	10(3.3%)	4(1.8%)	6(7.5%)	4.352	0.037
Total hospital stay (d)	16.85±8.807	16.85±9.082	16.86±8.045	-0.013	0.990
Postoperative hospital stay	8.33±5.006	8.30±5.203	8.43±4.440	-0.191	0.849
Remnant stone	13(4.3%)	9(4.0%)	4(5.0%)	0.002	0.965
Recurrent stone	4(1.3%)	2(0.9%)	2(2.5%)	0.257	0.612
Bile leakage	13(4.3%)	10(4.5%)	3(3.8%)	0.077	0.781
CBD stricture	6(2.0%)	5(2.2%)	1(1.3%)	0.006	0.937
Pancreatitis	0(0.0%)	0(0.0%)	0(0.0%)	0	1.000
Pneumonia	9(3.0%)	3(1.3%)	6(7.5%)	5.750	0.016
Acute cardiovascular event	4(1.3%)	0(0.0%)	4(5.0%)	7.787	0.005
Intra-abdominal hemorrhage	4(1.3%)	2(0.9%)	2(2.5%)	0.257	0.612
Fever	20(6.6%)	12(5.4%)	8(10.0%)	2.037	0.153
Urinary retention	1(0.3%)	0(0.0%)	1(1.3%)	2.797	0.094
30-day mortality	1(0.3%)	0(0.0%)	1(1.3%)	2.797	0.094

In both groups, no patients experienced pancreatitis. 3 patients in group A had bile leakage while bile leakage occurred to 10 patients in group B (3.8% VS 4.5%, P = 0.781) (Table 3). All the patients experiencing bile leakage fully recovered after drainage and lavaging. None of these 13 patients underwent reoperation to treat bile leakage. Regarding urinary retention, no significant differences between two groups exited (1.3% VS 0.0%, P = 0.094) (Table 3). Intra-abdominal hemorrhage occurred to 2 patients from group A and 2 ones from group B (2.5% VS 0.9%, P = 0.612) (Table 3). 8 patients in group A and 12 patients in group B underwent postoperative fever (10.0% VS 5.4%, P = 0.153) (Table 3). 1 patient in group A experienced 30-day mortality while no patients from group B experienced 30-day mortality (1.3% vs 0.0%, P = 0.094) (Table 3).

Follow-up

During the subsequent follow-up, 2 patients from group A underwent recurrence of calculus while 2 ones from group B had recurrence of calculus (2.5% VS 0.9%, P = 0.612). 1 patient in group A and 5 ones in group B experienced stenosis of CBD (1.3% VS 2.2%, P = 0.937). For patients suffering from stenosis of CBD, a 10F biliary stent was planted into CBD immediately and three months after implantation, biliary stent was removed.

For patients with choledocholithiasis, LCBDE is one of minimal treatment choices[1, 2]. Laparoscopic cholecystectomy plus CBDE enables the surgeons to simultaneously solve two problems and allows patients to undergo general anesthesia only once with favorable results and low complication rate. Conventionally, a T drainage tube was placed into CBD for at least 2 weeks after surgery with the aim of decreasing pressure within CBD, reducing the possibility of postoperative bile leakage and offering backup percutaneous approach for cholangiography and extracting residual stones. However, a few complications related to T drainage tube have been proposed, such as biliary obstruction, fluid and electrolyte disturbances, bile leakage and chronic pain. Additionally, stenosis of CBD is also a complication after removal of T drainage tube[17]. And bile leakage was totally avoidable even in presence of T drainage tube. Additionally, living with T drainage tube for several weeks might lead to nonnegligible discomfort, more significant abdominal scar, and burdens on mind and finance. All these aforementioned troubles related to T drainage tube was likely to severely affect patients^, quality of life. In this new age of laparoscopy, treatment methods are becoming more and more minimally invasive in order to reduce surgery-related trauma, enhance recovery and shorten hospital stay. Thus, T drainage tube placement seems to compromise advantages of laparoscopic surgery.

Over the past few years, a series of studies comparing LCBDE with T drainage tube and LCBDE without T drainage tube have been published[2, 9–13, 16]. According to these studies, for carefully selected patients, primary closure of CBD was feasible, safe and effective in treating patients with choledocholithiasis [2, 9–13, 16]. Thus, we could say that the era of routine T drainage tube insertion has ended.

Choledocholithiasis is a quite common disease among elderly patients. However, senior age will bring some considerable challenges: high prevalence of comorbidity, such as pulmonary diseases, cardiovascular diseases, and diabetes mellitus; relatively poorer tolerance to surgical trauma and general anesthesia due to declined functional reserve of multiple organs; significantly slower recovery after surgery. Studies reporting the feasibility, safety and efficacy of LCBDE plus primary closure of the CBD among elderly patients are still not so abundant.

Thus, the present study was performed to further assess the feasibility, safety and efficacy of LCBDE plus primary closure of the CBD among elderly patients. In this study, elderly patients had a significantly higher incidence concurrent diseases, such as hypertension, diabetes, and cardiovascular diseases. Correspondingly, ASA scores of elderly patients were significantly higher, implying that compared with younger ones, elderly patients faced remarkably higher risks for cardiopulmonary complications after general anesthesia. As a matter of fact, elderly patients in our study did have a significantly incidence of pneumonia and acute cardiovascular event after laparoscopic surgery. Therefore, it was understandable that elderly patients were more likely to experience ICU stay. In terms of demographic and clinical variables, elderly patients were not significantly different from younger patients except age and history of cholecystectomy. Reassuringly, in this study, elderly patients were not significantly different from younger patients regarding operative time, estimated blood loss, blood transfusion, postoperative stay, 30-day mortality and most postoperative complications except higher incidence of pneumonia and acute cardiovascular events. Despite the fact that elderly patients were not significantly different from younger patients in terms of postoperative hospital stay, we tend to be more prudent when discharged elderly patients since they recovered more slowly than younger patients. Due to the progress made in anesthesiology and organ support technology, supervision and management of underlying diseases are getting more and more meticulous and efficient. For all the patients in this study, a comprehensive evaluation algorithm was adopted to fully assess physical status especially for elderly patients. For elderly patients, electrocardiogram, echocardiography, chest radiograph or CT, liver function and kidney function were routinely performed to fully evaluate tolerance of elderly patients to laparoscopic surgery and general anesthesia. Laparoscopic surgery was performed only if the premise that all the examinations mentioned above were at good levels. Therefore, both risks of organ dysfunction and incidences of postoperative complications were controllable and comparable to those of younger patients.

No significant differences regarding surgical technique-related results existed. These results included remnant stones, bile leakage, stenosis of CBD and stone recurrence. Remnant stones were detected among 4 elderly patients while 9 younger patients experienced remnant stones. All patients experiencing remnant stones suffered from multiple choledocholithiasis prior to surgery, which might explain their remnant stones. We speculated that small stones or smaller fragments of bigger stones were flushed into upstream intrahepatic bile ducts and located in blind spot of choledochoscope. These stones would migrate to the distal part of CBD with bile excretion and eventually caused abdominal pain. Difficulties during LCBDE with primary closure were not significantly affected by senior age. With the continuously increasing number of laparoscopic surgeries, surgeons at our center had gained much more experience in hepatobiliary surgeries, including more in-depth understanding of the anatomy of intrahepatic bile ducts, more reasonably selecting surgical approach, controlling bleeding and managing unexpected intraoperative situations, all of which enabled the surgeons to perform more standardized and proficient surgeries. Therefore, it was no surprise for us that senior age did not significantly affect results of patients after LCBDE with primary closure.

Despite the encouraging results of this study, studies opposing primary closure of CBD after LCBDE have been published. In a study by Cai et al, it was reported that primary closure of CBD after LCBDE should not be performed among patients suffering from acute obstructive suppurative cholangitis (AOSC) or those with outlet stenosis of CBD since these patients need continuous and long-term decompression and drainage[18]. In our study, 3 elderly patients and 10 younger patients experienced bile leakage after primary closure of CBD after LCBDE, statistical difference of which was, however, not significant. Thin wall thickness of CBD was likely to be one of the contributing factors to bile leakage. Apart from thickness of CBD, operation techniques and suturing are also factors affecting incidence of bile fistula. It has also been suggested that incision should be made at the point where CBD, cystic duct and common hepatic duct converge since there were significantly less vascular distributions at this point which could further reduce the incidence of injury to bile duct caused by electrocoagulation for the hemorrhagic spot. Upon the completion of closure of the incision on the bile duct by interrupted or continuous suture, we routinely accomplished interrupted sutures on the surface. This technique would help decrease tension of suture and could potentially reduce the risk of bile leakage. Additionally, patients suspected to be with malignant biliary tumor or those having undergone biliary surgeries were not recommended to undergone primary closure of CBD.

This study was not prospectively randomized, suggesting that direct comparisons between the elderly patients and younger patients were difficult to make. However, given the fact that the elderly patients were not significantly different from younger patients in terms of baseline characteristics, comparisons between these two groups were fair. We should also state that surgeons must be quite prudent when making surgical plans, especially for surgeons who are not quite experienced in grasping indications and contraindications. Thus, surgeons should try their best to better grasp indications and contraindications and improve their surgical skills after undergoing intensive training of laparoscopic skills. Surgeons should attach more importance to these aspects since it will potentially improve surgical outcomes of patients.

Therefore, considering all the aforementioned results of this study, we may conclude that for selected elderly patients, laparoscopic common bile duct exploration plus primary closure of CBD is feasible and could be safely performed. Senior age should not be considered as an absolute contraindication preventing surgical treatment.

LCBDE: laparoscopic common bile duct exploration

CBD: common bile duct (CBD)

ERCP: endoscopic retrograde cholangiopancreatography

MRCP:Magnetic resonance cholangiopancreatography

CT: computed tomography

LC: laparoscopic cholecystectomy

ICU: intensive care unit

SD: standard deviation

SPSS: Statistical Package for the Social Sciences

BMI: body mass index

ASA: American Society of Anesthesiologists

Ethics approval and consent to participate

This study was approved by the Ethical Committee, Shenzhen People^,s Hospital and each patient had given his or her informed consent in written form. Declaration of Helsinki was adhered to during the whole process of this study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The present study did not receive any financial supports.

Authors' contributions

L. F, T. A and L. L designed this study. L. L and T. A supervised this study. Y. W, M. W and T. W collected the data. L. F, Y. W and T. A accomplished statistical analyses in this study. L. F, T. A and M. W prepared the manuscript. Y. W, Y. W and T. A revised the manuscript. All the authors read and approved the final version of this study.

Acknowledgements

The authors really appreciated Xue Tang from Shenzhen People^,s Hospital for her help with revising our manuscript.

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No competing interests reported.

Laparoscopic common bile duct exploration with primary closure could be safely performed among elderly patients with choledocholithiasis

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Materials And Methods

Patients and ethical approval

Operational Procedures

Follow-up

Statistical analysis

Results

Baseline characteristics and co-morbidities

Intraoperative Variables

Postoperative Complications

Follow-up

Discussion

Conclusions

Abbreviations

Declarations

Consent for publication

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

Funding

Authors' contributions

References

Additional Declarations

Status:

Journal Publication

Version 1