Transcystic management of choledocholithiasis: Outcomes, factors associated with bile duct injury and implications for surgical practice.

BACKGROUNDS/AIMS: Choledocholithiasis with gallbladder in situ presents a complex surgical challenge. The transcystic approach offers a minimally invasive alternative to choledochotomy; however, its adoption remains limited. This study assessed the safety, efficacy, and reproducibility of this method.

METHODS

This retrospective study involved 71 patients diagnosed with choledocholithiasis and gallbladder in situ, all of whom underwent transcystic bile duct exploration at a primary care hospital. Demographic, clinical, and intraoperative variables were analyzed to determine predictors of bile duct injury.

RESULTS

Transcystic exploration achieved successful completion in 92.9% of cases and a duct clearance rate of 94%. The most common complication was bile duct injury, showing a significant association with previous endoscopic or percutaneous procedures (p = 0.031), increased preoperative leukocyte count (p = 0.050), and advanced age (median 72.7 vs. 60.4 years; p = 0.031). Conversion to choledochotomy elevated the risk of injury, and incomplete duct clearance correlated with higher complication rates. No specific intraoperative techniques or devices exhibited a significant impact on outcomes. Imaging at six months demonstrated no persistent strictures, supporting the likelihood of transient inflammatory changes.

CONCLUSIONS

The transcystic approach is a safe, effective, and reproducible first-line intervention for choledocholithiasis with gallbladder in situ. Patient-specific and disease-related factors primarily determine bile duct injury risk, rather than the surgical technique itself. Further prospective randomized studies are needed to confirm these findings.