The effect of the laparoscopic primary suture of the common bile duct in elderly patients: a retrospective study

Traditional surgery treatment strategies for elderly patients who were diagnosed as choledocholithiasis combined with cholecystolithiasis include laparoscopic choledocholithotomy, cholecystectomy, and T-tube drainage. However, long-term indwelling T-tube drainage will cause pain and other complications. This study was designed to compare the primary suture of the common bile duct and the T-tube drainage after laparoscopic choledochotomy to study the merits and demerits between primary suture and T-tube drainage in elderly patients. Eighty-five patients were screened from All patients were Fifty-six cases were the primary suture group (n=56). Twenty-nine cases were the T-tube group (n=29). Preoperative baseline characteristics, intraoperative and postoperative characteristics of the two groups were compared.


Abstract Background
Traditional surgery treatment strategies for elderly patients who were diagnosed as choledocholithiasis combined with cholecystolithiasis include laparoscopic choledocholithotomy, cholecystectomy, and T-tube drainage. However, long-term indwelling T-tube drainage will cause pain and other complications. This study was designed to compare the primary suture of the common bile duct and the T-tube drainage after laparoscopic choledochotomy to study the merits and demerits between primary suture and T-tube drainage in elderly patients.

Methods
Eighty-five patients were screened from January 2017 to January 2018. All patients were performed laparoscopic surgery. Fifty-six cases were the primary suture group (n=56). Twenty-nine cases were the T-tube group (n=29). Preoperative baseline characteristics, intraoperative and postoperative characteristics of the two groups were compared.

Results
There were no differences of baseline characteristics in both groups (P>0.05).
Compared with the T-tube group, the postoperative total drainage volume on the first day and patients of residual stones were fewer, and all drainage tube indwelling time was shorter in the primary suture group(P 0.05). And there were statistically significant differences in postoperative total drainage volume on the first day, all drainage tube indwelling time, postoperative total bilirubin and residual stones between the two groups (P<0.05). There were no statistically significant differences of the other intraoperative and postoperative characteristics(P>0.05). There were no pressure sores, hypostatic pneumonia, deep vein thrombosis, serious complications of heart, lung and brain and even death in both groups.

Conclusions
With accurate preoperative risk assessment and strict treatment of basic diseases in elderly patients, and the stones were removed in laparoscopic surgery, the primary suture in elderly patients is feasible, safe, and valid.

Background
Cholelithiasis is a common disease in biliary system of elderly patients 1 . Most of the elderly patients don't pay too much attention to their cholelithiasis until finding in physical examination 2,3 . Then the acute inflammation caused by choledocholithiasis often aggravated their condition 4,5 . Elderly patients are often accompanied by many basic diseases, such as cardiovascular diseases and respiratory diseases [6][7][8] . Those diseases increase the risk of surgery and affect patients' prognosis, and even lead to death during perioperative period 9 . Surgery treatment strategies for elderly patients who are diagnosed with choledocholithiasis combined with cholecystolithiasis include laparoscopic choledocholithotomy, cholecystectomy, and T-tube drainage, or endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy 10 . Although laparoscopic surgery is less invasive, Ttube drainage for biliary tract can still cause pain and other complications of elderly patients 11 . Due to poor self-care ability of elderly patients, long-term T-tube drainage not only makes their life inconvenient but also causes dyspepsia, fluid, and electrolyte imbalance 12 . After cleaning the stones in the common bile duct, primary suture of the common bile duct can save the patient from long-term T-tube drainage 12 . Previous studies have shown that many medical centers have carried out studies on the primary suture of common bile duct and have reported the curative effect [13][14][15] . In order to improve the postoperative living quality of the elderly patients, we tried to perform primary suture of the common bile duct after cleaned the stones.

Material
According to the inclusion criteria, eighty-five patients were screened from the department of hepatobiliary and pancreatic surgery, Chengdu second people's hospital from January 2017 to January 2018. All patients were performed laparoscopic surgery. Fifty-six cases were performed laparoscopic choledocholithotomy, cholecystectomy and primary suture of the common bile duct, they were the primary suture group (n = 56). Twenty-nine cases were performed laparoscopic choledocholithotomy, cholecystectomy, and T-tube drainage, they were the T-tube group (n = 29). The baseline characteristics of screened patients were shown in Table 1.

Surgery Technique
Primary suture group: Four-hole laparoscopic method was performed. Establish the laparoscopic surgery holes: The surgery hole near the navel which inserted a 10mm laparoscopic trocar was used to construct pneumoperitoneum. A 10mm laparoscopic trocar was inserted near the xiphoid as the main surgery hole. Two 5mm laparoscopic trocars were inserted along the costal margin as the auxiliary surgery holes. Cholecystectomy: The Calot's triangle was dissected, and then the gallbladder artery was separated and severed. The free gallbladder duct was closed with absorbable clips. After the gallbladder duct was severed, the gallbladder was  Postoperative complications: bile leakage and residual stones ( Table 2)..

Follow-up
All patients were followed up by outpatient service and telephone for 6 months.
Patients in the T-tube drainage group were followed up for 1-3 months and received an outpatient T-tube cholangiogram.

Statistical analysis
All data were analyzed by SPSS20.0 software (SPSS 12.0.1for Windows; SPSS, Chicago, IL). A Chi-Square Test was adopted for the enumeration data, and Fisher's Exact Test was used when the frequency was less than 5. The Rank-Sum Test was adopted for two independent samples, shown as M (P25, P75) (M = Median, P = Percentiles). P 0.05 was statistical significance. There were no pressure sores, hypostatic pneumonia, deep vein thrombosis, serious complications of heart, lung and brain and even death in both groups.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Thanks to professor Gang Zhang for his support of this research.   Choledochoscopy for stone removal Figure 3 The primary suture of the common bile duct