Discussion

On Perioperative Safety
• In this meta-analysis, researchers have observed the superiority of
LCBDE + LC on perioperative safety in in terms of:
• Perioperative complications
• Conversion rate to other procedure
• Operative time
• In terms of perioperative complications, LCBDE + LC was noted to
have significantly lower rate (7.6%) compare to pre-EST (12%)

• In terms of conversion rate, LCBDE + LC has found to have lesser rate

at 4.1% compare to 7.1% in the pre-EST + LC group
Analysis of Perioperative complications
• In the subgroup analysis of perioperative complications, bile leaks was
significantly higher in LCBDE + LC group (3.5% vs 0.7%)
• Postoperative pancreatitis was significantly higher in the pre-EST + LC
group (0.7% vs 4.4%)
 Zhu et. Al.
• Bile leaks in LCBDE + LC were controllable and transient in the
majority of patients without any intervention
On Postoperative Efficacy
• In this meta-analysis, researchers have observed the superiority of
LCBDE + LC on postoperative efficacy in in terms of:
• CBD Stone clearance rate
• Retained stones
• Hospital stay
• Recurrence of stones
• Hospitalization cost
 Zhao et. Al. (2017)
• The study concluded that LCBDE + LC is more suitable approach to
reduce the recurrence od CBD stones in comparison with pre-EST + LC
• One reason for explaining the higher stone recurrence rate in pre-EST
+ LC was that EST leads to sphincter of Oddi disruption, causing
permanent loss of barrier function of the sphincter that prevents
duodenobiliary reflux
• Reflux from the duodenum into the bile is closely related to an
increased incidence of bacterobilia and further results in CBD stones
formation
 Ding et. Al
• Study conducted a follow up of 8-10 years after original surgery and
found out that recurrent CBD stones were observed more often in
pre-EST + LC group (9.5%) compare to LCBDE + LC group (2.1%)
 Zhu et al. (2015
• This study compared LCBDE + LC vs. pre-EST + LC

• Conclusions:
• CBD stone clearance rate was markedly higher in LCBDE + LC
group. (94.1% vs 90.1%)
• Conversion rate and complications were similar between two
groups.
Limitations of the study
• Half of the included studies were nonrandomized comparisons, which
increase the risk of potential selection and publication bias
• The treatment within the group was a little different. Whether
primary duct closure or T-tube drainage was used after LCBDE was
not uniform in the LCBDE + LC group while the time interval between
pre-EST and LC was not uniform in the Pre-EST + LC group all of which
have an effect on final results to some extent
• Most of the included studies lacked results of follow up. Therefore,
there was no way to assess long term outcome except lithiasis
occurrence
Conclusions
• LCBDE + LC is the preferred method of surgery for management of
concomitant gallstones and CBD stones
• In terms of perioperative safety and post operative efficacy, LCBDE +
LC is safer compared to pre-EST + LC
• Due to the development and popularization of laparoscopy, LCBDE
has become more effective and less costly compare to ERCP
Conclusions
• Main drawback of LCBDE is the use of T-tube increasing the patients’
psychological pressure and difficulty in nursing after discharge.
However, the problems seems to have been solved after recent
studies reported that primary duct closure after LCBDE is safe and
effective and is even better compared with T-tube drainage
• There is no significant difference on the mortality or complication
rates between patients over and under 70 years old (Lee et. Al.)