title: Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis.
abstract: BACKGROUND
  With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis.
  
  
  METHODS
  A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications.
  
  
  RESULTS
  Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001).
  
  
  CONCLUSIONS
  This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.
authors.affiliation: HPB and UpperGI Surgery Unit, Ninewells Hospital and Medical School, Ward 11, Dundee, DD1 9SY, UK. mauropodda@ymail.com.
authors.forename: Mauro
authors.identifier: http://orcid.org/0000-0001-9941-0883
authors.initials: M
authors.lastname: Podda
authors.affiliation: HPB and UpperGI Surgery Unit, Ninewells Hospital and Medical School, Ward 11, Dundee, DD1 9SY, UK. f.polignano@nhs.net.
authors.forename: Francesco Maria
authors.initials: FM
authors.lastname: Polignano
authors.affiliation: HPB and UpperGI Surgery Unit, Ninewells Hospital and Medical School, Ward 11, Dundee, DD1 9SY, UK. andreasluhmann@nhs.net.
authors.forename: Andreas
authors.initials: A
authors.lastname: Luhmann
authors.affiliation: HPB and UpperGI Surgery Unit, Ninewells Hospital and Medical School, Ward 11, Dundee, DD1 9SY, UK. michael.wilson@nhs.net.
authors.forename: Michael Samuel James
authors.initials: MS
authors.lastname: Wilson
authors.affiliation: HPB and UpperGI Surgery Unit, Ninewells Hospital and Medical School, Ward 11, Dundee, DD1 9SY, UK. christoph.kulli@nhs.net.
authors.forename: Christoph
authors.initials: C
authors.lastname: Kulli
authors.affiliation: HPB and UpperGI Surgery Unit, Ninewells Hospital and Medical School, Ward 11, Dundee, DD1 9SY, UK. i.z.tait@dundee.ac.uk.
authors.forename: Iain Stephen
authors.initials: IS
authors.lastname: Tait
mesh_terms: D042883:Choledocholithiasis / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery*; D004322:Drainage / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay; D061646:Operative Time; D011183:Postoperative Complications; D013536:Suture Techniques
keywords: Choledochotomy; Cholelithiasis; Common bile duct exploration; Laparoscopy; Primary duct closure; T-tube