Zhang Woods, Li Ge, Chen Yan-Ling
Department of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
Surg Laparosc Endosc Percutan Tech. 2017 Dec;27(6):415-423. doi: 10.1097/SLE.0000000000000472.
Laparoscopic common bile duct exploration (LCBDE) has been verified to be a comparatively effective treatment approach for uncomplicated choledocholithiasis, and it has been previously proposed that the primary duct closure (PDC) technique, in which the bile duct can directly be sutured in only 1 step compared with the T-tube drainage (TTD), can be deemed a choice after LCBDE; however, the conventional TTD performance is controversial in the minimally invasive surgery era. On the basis of the above-mentioned point, this meta-analysis was conducted to assess the different effects between TTD and PDC after LCBDE.
In PubMed, EMBASE, and the Cochrane Library, literature search was conducted to screen out randomized controlled trials (RCTs) to compare PDC with TTD. The analyzed outcome variables included overall morbidity, biliary-specific morbidity (retained stones, biliary leak, biliary peritonitis), other morbidities, operating time, postoperative hospital stay, reintervention (surgery, endoscopy/radiology), and median hospital expenses.
In this meta-analysis, there are 4 RCTs qualifying for inclusion, including 396 patients in all (222 in PDC and 214 in TTD). With respect to postoperative overall morbidity (P<0.05), biliary peritonitis (P<0.05), surgery time (P<0.05), length of stay (P<0.05), and median hospital expenses (P<0.05), PDC presented remarkably better results than TTD (P<0.05). Statistically, no remarkable distinction was found between the 2 groups as to biliary-specific morbidity, retained stones, biliary leak, other morbidities, or reintervention (radiology/endoscopy, surgery).
In this meta-analysis, there was no evidence provided for clinical benefits of using TTD after LCBDE. Therefore, TTD should not routinely be performed after LCBDE. However, multicenter, large sample size, RCTs should be conducted to clarify this issue.
腹腔镜胆总管探查术（LCBDE）已被证实是治疗单纯性胆总管结石的一种相对有效的方法，并且此前有人提出，与T管引流术（TTD）相比，一期胆管缝合（PDC）技术可在一步操作中直接缝合胆管，可被视为LCBDE后的一种选择；然而，在微创手术时代，传统的TTD操作存在争议。基于上述观点，进行了这项荟萃分析，以评估LCBDE后TTD和PDC的不同效果。
在PubMed、EMBASE和Cochrane图书馆中进行文献检索，筛选出比较PDC与TTD的随机对照试验（RCT）。分析的结果变量包括总体发病率、胆道特异性发病率（残留结石、胆漏、胆汁性腹膜炎）、其他发病率、手术时间、术后住院时间、再次干预（手术、内镜检查/放射学检查）以及中位住院费用。
在这项荟萃分析中，有4项RCT符合纳入标准，共396例患者（PDC组222例，TTD组214例）。在术后总体发病率（P<0.05）、胆汁性腹膜炎（P<0.05）、手术时间（P<0.05）、住院时间（P<0.05）和中位住院费用（P<0.05）方面，PDC的结果明显优于TTD（P<0.05）。统计学上，两组在胆道特异性发病率、残留结石、胆漏、其他发病率或再次干预（放射学检查/内镜检查、手术）方面没有显著差异。
在这项荟萃分析中，没有证据表明LCBDE后使用TTD有临床益处。因此，LCBDE后不应常规进行TTD。然而，应开展多中心、大样本量的RCT来阐明这一问题。
