OGBN O03 Role of Antegrade Stenting in Common Bile Duct Exploration for Biliary Stone Disease; Systematic Review and Metanalysis

Abstract Background It's estimated that approximately 10–18% of patients who have gall bladder stones have stones in the common bile duct (CBD). CBD stones could be managed either endoscopically, using ERCP, or surgically, using common bile duct exploration (CBDE). Following CBDE, closure of the CBD could be done by either primary closure, closure over the T tube, or over the antegrade biliary stent. Primary closure alone is usually associated with concerns over a high-pressure biliary system risking a bile leak. In the past the T-tube was the method of choice for CBD decompression following CBDE, however, it causes complications in up to 10% of patients. Antegrade biliary stent use has emerged as a good alternative to the T-tube being placed through the choledochotomy prior to primary closure of the CBD and it is believed to be associated with fewer complications and avoiding the discomfort of the T-tube. This study aimed to review the published studies for the outcomes of antegrade stenting of the CBD in CBDE for gall stone disease in adult patients. Methods The literature search was performed by an expert Information Specialist, Royal College of Surgeons of England Library in the electronic databases of MEDLINE, Embase, and the Cochrane Library to retrieve literature in the English Language up to September 2020 including all related studies except case reports discussing the use of antegrade stenting during CBDE for gall stone disease in adults >18-year-old excluding age<18 years, malignant cases, non-human studies, and non-English language results. Following the PRISMA protocol, studies were identified, and data were extracted. The studies describing the closure method after CBDE were reviewed. Data were extracted regarding the closure method either over T tube, over the antegrade stent, or primary direct closure without T tube or CBD stent. The primary outcome was the incidence of bile leak. Other outcomes were evaluated including mean length of hospital stay, failure of cannulation rate, average operative time, the incidence of cholangitis, acute pancreatitis, readmission and reoperation rates, biliary stent retention or migration, and CBD stones recurrence, and incidence of biliary stenosis requiring intervention. Analysis was performed with Review Manager (RevMan) [Computer program]. Version 5.4.1. The Cochrane Collaboration, 2020. Results Twelve eligible studies were analyzed reporting outcomes following CBDE mainly using T tube or antegrade stenting. Only one study reported outcomes after primary direct closure. The bile leak was less common in stent group compared to T tube group with risk ratio (RR) of 0.78 [95% CI 0.41, 1.50] (P = 0.46). Although this finding is statistically insignificant, it has clinical significance in minimizing risk of bile leak in the stent group. One study reported less frequent bile leaks in the stent group compared to primary closure of 8.6% and 16.7% respectively. The mean length of hospital stay (LOS) was shorter in stent group compared to T tube group with RR of -3.05 [95% CI -4.03, -2.08] (P < 0.00001). A study reported mean LOS in stent group to be 8.9 days compared to 6.46 days after primary closure. Likewise, the risk of readmission and reoperation favours stent group over T tube group with RR of 0.41 [95% CI 0.15, 1.15] (P = 0.09) and 0.41 [0.15, 1.08] (P = 0.07) respectively. On the other hand, the risk of pancreatitis is higher in stent group compared to T tube group with RR of 1.64 [95% 0.54, 4.97] (P = 0.38). Conclusions The use of antegrade stenting after CBDE offers less frequent bile leaks, shorter hospital stays less risk of readmission and reoperation over T tube use. Despite pancreatitis being more frequent in the antegrade stenting group, they are of variant clinical significance mostly biochemical diagnosis, and can be managed conservatively in the majority of cases. Few literatures report outcomes of primary direct closure after CBDE compared to other techniques, identifying a gap of knowledge requiring further studies in the future.