Primary closure with endoscopic nasobiliary drainage after laparoscopic common bile duct exploration: A safe and feasible strategy for nondilated common bile ducts

Primary closure with endoscopic nasobiliary drainage after laparoscopic common bile duct exploration: A safe and feasible strategy for nondilated common bile ducts | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Primary closure with endoscopic nasobiliary drainage after laparoscopic common bile duct exploration: A safe and feasible strategy for nondilated common bile ducts Lou-Zong Sun, Qing-Da Wang, Xiao-Zhou Zhang, Gui-Gang Qiu, Nan Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6379168/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose The preferred treatment for cholecystolithiasis combined with choledocholithiasis is laparoscopic cholecystectomy (LC)+laparoscopic common bile duct exploration (LCBDE)+primary closure (PC). However, the appropriateness of LC+LCBDE+PC in patients with nondilated common bile ducts (CBDs) remain unclear. This study aimed to investigate the feasibility and safety of LC+LCBDE+PC with intraoperative endoscopic nasobiliary drainage (IO-ENBD) for the treatment of choledocholithiasis with nondilated CBDs. Methods From May 2021 to January 2024, 257 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent LC+LCBDE in our institution were reviewed. The clinical and treatment outcomes of patients with nondilated CBDs (<8 mm) were retrospectively analyzed. Results Of these patients, 53 patients with nondilated CBDs successfully underwent LC+LCBDE+PC+IO-ENBD. The stone clearance rate was 100%, operation time was 142.66±29.20 minutes, intraoperative blood loss volume was 26.23±22.21 mL, postoperative hospital stay was 6.77±2.32 days. There was 1 case of postoperative bile leakage (1/53, 1.9%), which was resolved with conservative treatment. No reoperation or mortality occurred. During the median follow-up period of 24 months (range: 6–40 months), one patient (1/53, 1.9%) experienced stone recurrence 18 months after the operation. No residual stones or biliary stricture occurred. Conclusion LC+LCBDE+PC+IO-ENBD is a safe and effective single-stage strategy for the management of cholecystolithiasis combined with choledocholithiasis in patients with nondilated CBDs. Health sciences/Gastroenterology/Hepatology/Biliary tract Health sciences/Gastroenterology/Hepatology/Biliary tract disease Laparoscopic common bile duct exploration Primary closure Endoscopic nasobiliary drainage Nondilated common bile ducts Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Common bile duct (CBD) stones, or choledocholithiasis, are present in approximately 5–15% of patients with cholecystolithiasis [ 1 ]. Choledocholithiasis can cause serious complications, such as obstructive jaundice, cholangitis and acute pancreatitis [ 2 ]. The current treatment options for choledocholithiasis combined with cholecystolithiasis include laparoscopic cholecystectomy (LC) \(\:+\) preoperative endoscopic retrograde cholangiopancreatography (pre-ERCP) and LC \(\:+\) laparoscopic common bile duct exploration (LCBDE) [ 3 – 5 ]. However, LC \(\:+\) pre-ERCP is associated with postoperative complications such as pancreatitis, haemorrhage, duodenal perforation, and sphincter of Oddi dysfuction in 5–11% of patients [ 6 ]. With advancements in laparoscopic techniques and equipment, LC \(\:+\) LCBDE has gained popularity due to its ability to be performed in a single-stage procedure, shorter hospital stays, and reduced costs [ 7 – 9 ]. Following LCBDE, the management of the CBD traditionally involves either T-tube drainage or primary closure (PC). T-tube drainage has been used to support the CBD, decompress the biliary tree, and reduce the risk of bile leakage. It also provides percutaneous access for cholangiography and removal of retained stones [ 10 ]. However, T-tube drainage is associated with a high postoperative complication rate of approximately 15%, including bile leakage, peritonitis, and reoperation due to planned or accidental early removal of the T-tube [ 11 ]. Additionally, the discomfort caused by prolonged T-tube placement contradicts the principles of minimally invasive surgery and Enhanced Recovery After Surgery (ERAS). Several studies have shown that PC without bile drainage is superior to T-tube drainage, offering shorter hospital stays and comparable rates of bile leakage and stone recurrence [ 12 ]. PC is also associated with reduced operative time and faster recovery [ 13 ]. However, most studies suggest that PC after LCBDE is safer in patients with CBD diameters \(\:\ge\:\) 8 mm, while its application in nondilated CBDs may increase the risk of bile leakage and biliary stricture [ 7 , 14 , 15 ]. The feasibility and safety of PC after LCBDE via choledochotomy in patients with nondilated CBDs remain unclear, and limited research has addressed this issue. This study aimed to evaluate the feasibility and safety of LC \(\:+\) LCBDE \(\:+\) PC via choledochotomy combined with intraoperative endoscopic nasobiliary drainage (IO-ENBD) for the treatment of choledocholithiasis in patients with nondilated CBDs. Methods Patients The diagnosis of choledocholithiasis was confirmed preoperatively using ultrasonography, magnetic resonance cholangiopancreatography (MRCP), or computed tomography (CT) scans. The CBD diameter was measured via preoperative CT or MRCP. The diagnosis and severity of acute cholangitis were assessed according to the Tokyo Guidelines 2018 (TG18), based on clinical features, laboratory data, and imaging findings [ 16 ]. The inclusion criteria were as follows: (1) age \(\:\ge\:\) 14 years; (2) patients with cholecystolithiasis combined with choledocholithiasis underwent LC \(\:+\) LCBDE. The exclusion criteria were as follows: (1) LC \(\:+\) LCBDE \(\:+\) T-tube drainage; (2) CBD exploration performed through the cystic duct; (3) patients with a CBD diameter \(\:\ge\:\) 8 mm. From May 2021 to January 2024, a total of 257 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent LC \(\:+\) LCBDE in our institution. Among these, 14 patients with T-tube drainage and 3 patients via transcystic approach were excluded. Additionally, 187 patients with CBD diameters \(\:\ge\:\) 8 mm were excluded. A flow chart of patient enrollment is presented in Fig. 1 . The study protocol was approved by the Ethics Committee of Zigong First People's Hospital (Approval No. 2023 − 121), and written informed consent was obtained from all participants. Surgical procedures All surgeries were performed by experienced laparoscopic biliary surgeons. The standard four-port approach was used for LC \(\:+\) LCBDE. The procedure began with the dissection of Calot’s triangle. The cystic artery and cystic duct were identified, ligated with absorbable clips, and divided. The gallbladder was then dissected from the liver bed. A supraduodenal choledochotomy was conducted on the anterior wall of the CBD in two layers. First, the serosal layer of the CBD was longitudinally incised using electrocautery in situ (Fig. 2 A). Subsequently, a longitudinal incision of approximately 5–8 mm was made along the anterior wall of the CBD, according to the size of the stones as determined by preoperative CT or MRCP (Fig. 2 B). Under choledochoscopic vision, CBD stones were extracted using a stone basket and saline irrigation. For larger or impacted stones, biliary laser lithotripsy was performed. After all the visible stones had been removed, choledochoscopy was conducted to confirm the clearance of the intrahepatic and extrahepatic bile ducts and to assess the condition of the sphincter of Oddi. A half-opened basket was passed through the ampulla to exclude small impacted stones and distal CBD stricture. For IO-ENBD, a zebra guidewire was inserted anterogradely through the choledochoscope into the distal CBD and advanced into the descending duodenum. The guidewire was then retrieved using an endoscopic snare (Fig. 3 A). A 7-Fr nasobiliary drainage tube was inserted retrograde along the guidewire into the left or right hepatic duct (Fig. 3 B). The tube was led out through the oral-nasal route under duodenoscopic visualization. All patients underwent a two-layered, small-bite closure of the CBD. The first layer was closed intermittently using 5–0 or 6–0 absorbable Vicryl sutures with small bites ( \(\:<\) 1 mm) (Fig. 4 A). After completing the first layer, sterile saline was injected to test for bile leakage, and additional sutures were performed where needed. In the second layer, the serosa of the anterior wall of the CBD was closed from the caudal to cranial end in a continuous fashion with 5–0 Vicryl sutures (Fig. 4 B). A nonsuction drain was placed near the foramen of Winslow, and a suction drain was positioned anterior to the CBD incision. The drains were removed 72–96 hours postoperatively if no bile leakage was observed. The nasobiliary drainage tube was clamped 48 hours after surgery and removed 48–72 hours after a negative nasal cholangiogram (Fig. 5 A). Follow-up Postoperative follow-up was conducted at 1, 6, 12, and 24 months after surgery to evaluate the clinical status of the patients. At each visit, liver function tests and abdominal ultrasonography were performed. MRCP was additionally performed at 6 months postoperatively (Fig. 5 B). Data collection Data extracted from patient records included demographic information, operative time, number and size of stones identified intraoperatively, postoperative hospital stay, and operative and postoperative complications (e.g., acute pancreatitis, bile leakage, retained stones, hemorrhage, reoperation, and in-hospital mortality). Follow-up data (up to September 2024) were also collected, including readmission rates and reintervention for biliary stricture or stone recurrence. Observation index and standard Operative time was defined as the interval from the initial skin incision to the final skin closure. Postoperative hospital stay was calculated as the duration from the end of surgery to discharge. The severity of postoperative complications was classified according to the Clavien-Dindo classification system [ 17 ]. Bile leakage was defined based on the criteria established by the International Study Group of Liver Surgery [ 18 ]. Post-ENBD pancreatitis was defined and graded in accordance with the European Society of Gastrointestinal Endoscopy guidelines [ 19 ]. Liver function tests, abdominal ultrasonography, and nasal cholangiography or MRCP were performed to assess for bile duct stricture or stone recurrence. Statistical analysis Statistical analyses were performed using SPSS 19.0 software (SPSS, Chicago, IL, USA). Continuous variables are presented as mean \(\:\pm\:\) standard deviation or median (range), while categorical variables are expressed as frequencies. Results Patient characteristics From May 2021 to January 2024, 53 patients with nondilated CBDs who underwent LC \(\:+\) LCBDE \(\:+\) PC \(\:+\) IO-ENBD were evaluated. The demographic characteristics and clinical details of these patients are presented in Table 1 . The most common presenting symptoms were abdominal pain (92.5%), obstructive jaundice (30.2%), fever (15.1%), pancreatitis (15.1%), and cholangitis (7.5%). The mean preoperative CBD diameter was 6.39 \(\:\pm\:\) 0.75 mm. Table 1 Characteristics of the patients Characteristics Patients (n \(\:=\) 53) Age (years) 52.08 \(\:\pm\:\) 13.61 Sex (female/male) 32/21 BMI (kg/m 2 ) 23.23 \(\:\pm\:\) 3.08 ASA (I/II/III) 3/48/2 Presentation, n (%) Abdominal pain 49 (92.5) Obstructive jaundice 16 (30.2) Fever 8 (15.1) Acute pancreatitis 8 (15.1) Acute cholangitis 4 (7.5) Preoperative liver function test Total bilirubin (µmol/L) 26.78 \(\:\pm\:\) 21.16 Direct bilirubin (µmol/L) 14.83 \(\:\pm\:\) 14.49 ALT (U/L) 161.76 \(\:\pm\:\) 153.83 AST (U/L) 99.72 \(\:\pm\:\) 104.79 CBD diameter (mm) 6.39 \(\:\pm\:\) 0.75 Accompanied disease, n (%) Heart disease history 2 (3.8) Hypertension 4 (7.5) Diabetes mellitus 5 (9.4) BMI body mass index, ASA American Society of Anaesthesiologists, ALT alanine aminotransferase, AST aspartate aminotransferase, CBD common bile duct Intraoperative results The intraoperative outcomes are summarized in Table 2 . The median operative time was 142.66 \(\:\pm\:\) 29.20 minutes, and the mean intraoperative blood loss was 26.23 \(\:\pm\:\) 22.21 mL. Intraoperative choledochoscopy identified impacted biliary stones in 5 patients (9.4%). Laser lithotripsy was required in 2 patients (3.8%) whose stones could not be removed using a stone basket or saline irrigation. No perioperative bile duct bleeding occurred, and the stone clearance rate was 100%. These findings demonstrate that LC \(\:+\) LCBDE \(\:+\) PC \(\:+\) IO-ENBD is a safe and feasible approach in patients with nondilated CBDs. Table 2 Intraoperative outcomes Intraoperative outcomes Patients (n \(\:=\) 53) Operation time (min) 142.66 \(\:\pm\:\) 29.20 Estimated blood loss (mL) 26.23 \(\:\pm\:\) 22.21 Stone characteristics Number of stones 1.91 \(\:\pm\:\) 1.40 Stone size (mm) 5.42 \(\:\pm\:\) 1.24 Stone impaction, n (%) 5 (9.4) Laser lithotripsy, n (%) 2 (3.8) Complete bile duct clearance, n (%) 53 (100) Postoperative results The postoperative outcomes are summarized in Table 3 . The mean postoperative hospital stay was 6.77 \(\:\pm\:\) 2.32 days. The mean time to ENBD removal was 3.72 \(\:\pm\:\) 1.29 days, and the mean time to abdominal drain removal was 5.13 \(\:\pm\:\) 1.36 days. Additionally, the mean hospital cost was 25,945.10 \(\:\pm\:\) 5,143.67 yuan. Table 3 Postoperative outcomes Postoperative outcomes Patients (n \(\:=\) 53) Postoperative hospital stay (d) 6.77 \(\:\pm\:\) 2.32 ENBD removal (d) 3.72 \(\:\pm\:\) 1.29 Abdominal drainage time (d) 5.13 \(\:\pm\:\) 1.36 Liver function test Total bilirubin (µmol/L) 30.29 \(\:\pm\:\) 20.81 Direct bilirubin (µmol/L) 14.69 \(\:\pm\:\) 11.29 ALT 115.88 \(\:\pm\:\) 97.04 AST 53.54 \(\:\pm\:\) 39.48 Complications, n (%) 4 (7.5) Bile leakage 1 (1.9) Bleeding 0 Post-ENBD pancreatitis 1 (1.9) Respiratory tract infection 1 (1.9) Wound infection 1 (1.9) ENBD displacement, n (%) 2 (3.8) Residual stone (%) 0 Reoperation (%) 0 Mortality (%) 0 Hospitalization cost (yuan) 25,945.10 \(\:\pm\:\) 5,143.67 ENBD endoscopic nasobiliary drainage, ALT alanine aminotransferase, AST aspartate aminotransferase Postoperative complications occurred in 4 patients (7.5%; Table 4 ). One patient (1.9%) developed Grade A bile leakage; the CBD diameter in this patient was 5.6 mm, and accidental nasobiliary drainage tube detachment was observed after postoperative nasal cholangiography. The bile leakage was cured spontaneously with conservative management, and the peritoneal drain was removed 5 days postoperatively. One patient developed respiratory tract infection, which was successfully treated with intravenous antibiotics. One patient developed post-ENBD pancreatitis, which was successfully cured by treatment with octreotide and antacid. Another patient experienced wound infection that resolved after 6 days of surgical dressing changes. All patients underwent nasal cholangiography, which confirmed the absence of residual stones or biliary strictures. Two patients (3.8%) experienced accidental nasobiliary drainage tube detachment postoperatively, and abdominal ultrasound was subsequently used to rule out residual stones. There were no cases of postoperative mortality, reoperation, or residual stones. Table 4 Postoperative complications and their clinical management Clavien-Dindo classification a Number of patients Complication Management I 1 Bile leakage Conservative * II 1 Post-ENBD pancreatitis Octreotide and antacid 1 Respiratory tract infection Intravenous antibiotics 1 Wound infection Surgical dressing change IIIa 0 IIIb 0 IV 0 a Clavien-Dindo classification: Grade I: any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, or radiological interventions. Grade II: requiring pharmacological treatment with drugs other than those allowed for Grade I complications. Grade III: complications requiring surgical, endoscopic, or radiological intervention: IIIa, complications requiring intervention without the need for general anaesthesia; IIIb, complications requiring intervention under general anaesthesia. Grade IV: life-threatening complications requiring intensive care unit management. * Conservative management: no antibiotics or further action was needed, and the leakage site closed spontaneously Follow-up results All patients completed at least one follow-up visit by September 2024 (Table 5 ). The median follow-up duration was 24 months (range: 6–40 months). During follow-up period, one patient (1.9%) experienced stone recurrence 18 months postoperatively, which was successfully treated with ERCP. No cases of biliary stricture were observed. Table 5 Long-term outcomes Outcomes Patients (n \(\:=\) 53) Number of patients followed up, n (%) 53 (100) Median follow-up time (months) 24 (6–40) Bile duct stricture, n (%) 0 Stone recurrence, n (%) 0 Discussion This retrospective study aimed to evaluate the feasibility and safety of LCBDE \(\:+\) PC \(\:+\) IO-ENBD for treating choledocholithiasis in patients with nondilated CBDs. To our knowledge, this is the first reported series of patients undergoing LCBDE \(\:+\) PC for choledocholithiasis with nondilated CBDs. Our results demonstrated a 100% duct clearance rate, a 1.9% bile leakage rate, and no biliary strictures during follow-up, which are comparable to the outcomes of dilated CBDs reported in other studies [ 11 , 12 , 25 ]. With the rapid advancement of minimally invasive surgical techniques, LC \(\:+\) LCBDE has become a widely accepted single-stage treatment for cholecystolithiasis and choledocholithiasis [ 20 ]. Numerous studies have demonstrated that PC without bile drainage offers advantages over T-tube drainage or stent placement, including shorter hospital stays and fewer postoperative complications [ 12 , 13 , 21 ]. However, existing evidence suggests that PC after LCBDE is safer in patients with CBD diameters \(\:\ge\:\) 8 mm [ 7 , 14 , 15 ]. For instance, Liu et al. [ 22 ] reported a significantly higher incidence of bile leakage in patients with thinner CBD diameters ( \(\:<\) 1 cm vs. \(\:\ge\:\) 1 cm: 31.6% vs. 7.0%, P \(\:=\) 0.04). Similarly, Hua et al. [ 23 ] found that the risk of bile leakage in patients with CBD diameters \(\:<\) 8 mm was 17.75 times higher than in those with diameters \(\:\ge\:\) 8 mm. These findings indicate that PC after LCBDE in patients with nondilated CBDs may increase the risk of postoperative complications, necessitating further investigation into its safety and feasibility. In this study, 53 patients with choledocholithiasis and nondilated CBDs underwent LC \(\:+\) LCBDE \(\:+\) PC \(\:+\) IO-ENBD. The outcomes, including a postoperative complication rate of 7.5% (4/53), a mean operative time of 142.66 \(\:\pm\:\) 29.20 minutes, and a mean postoperative hospital stay of 6.77 \(\:\pm\:\) 2.32 days, were comparable to those reported in patients with dilated CBDs [ 24 – 26 ]. These results suggest that LC \(\:+\) LCBDE \(\:+\) PC \(\:+\) IO-ENBD is a safe and effective approach for managing choledocholithiasis in patients with nondilated CBDs. Previous studies have identified bile leakage and biliary stricture as the main postoperative complications of LCBDE \(\:+\) PC [ 22 , 23 ]. Clinicians should remain vigilant in monitoring and managing these complications. Bile leakage following PC is a critical indicator of the safety of this procedure. Currently, several strategies have been proposed to reduce the incidence of postoperative bile leakage in LCBDE \(\:+\) PC: (1) LCBDE combined with nasobiliary drainage or stent insertion. Zhang et al. [ 24 ] reported no cases of postoperative bile leakage in patients undergoing LC \(\:+\) LCBDE \(\:+\) IO-ENBD \(\:+\) PC, whereas 4 cases (5.6%) of bile leakage occurred in the absence of IO-ENBD. Similarly, Lyon et al. [ 21 ] demonstrated that the use of a biliary stent during LCBDE significantly reduces the risk of postoperative bile leakage; (2) In a previous study, our team reported no cases of bile leakage in patients who underwent two-layered closure of the CBD, compared to 5 cases in the traditional primary closure group [ 27 ]; (3) The use of human fibrin sealant at the CBD suture site has been shown to reduce postoperative bile leakage [ 28 ]. Despite these advancements, no method can completely eliminate the risk of bile leakage, either theoretically or practically. In our study, bile leakage occurred in one patient (1.9%), consistent with the outcomes of dilated CBDs reported in previous studies [ 25 , 26 ]. Several previous studies have identified surgeon experience, nondilated CBD, and stone clearance failure as significant risk factors for bile leakage following LCBDE [ 22 , 29 , 30 ]. However, our findings demonstrate that LCBDE \(\:+\) PC in patients with nondilated CBDs did not increase the incidence of postoperative bile leakage. This discrepancy may be attributable to the following factors: (1) In most previous studies, PC was performed using 3–0 or 4–0 sutures [ 29 , 30 ], whereas we employed finer 5–0 or 6–0 absorbable Vicryl sutures. The use of finer needles may reduce the risk of bile leakage from needle puncture sites, particularly in thin CBD wall; (2) All procedures in this study were performed by surgeons with over 10 years of experience in hepatobiliary and laparoscopic surgery. Their advanced laparoscopic suturing skills likely contributed to the lower bile leakage rate; (3) The CBD incision was closed using a two-layered technique. The first layer involved complete closure of the CBD wall, ensuring that the suture extended beyond the edges of the incision. When the second serosal layer was sutured, a small portion of the outer CBD wall was also sutured to strengthen the incision; (4) Rapid changes in Oddi sphincter dynamics and increased CBD pressure following cholecystectomy may contribute to bile leakage after LC \(\:+\) LCBDE \(\:+\) PC [ 31 , 32 ]. IO-ENBD may reduce the pressure in the CBD and promote healing at the suture site. Although biliary stricture is a rare complication following LCBDE, it represents a serious adverse event associated with PC. Biliary stricture can lead to bile duct obstruction, jaundice, and even liver failure, which seriously affects patient health and often requires surgical intervention, such as ERCP or biliary duct reconstruction [ 33 – 35 ]. Martin et al. [ 36 ] reported one case of biliary stricture (1.6%) among 61 patients who underwent conversion from laparoscopic to open choledochotomy with T-tube placement in a 5-mm duct; the stricture was managed with Roux-en-Y choledochojejunostomy 6 months postoperatively. Similarly, Zhan et al. [ 37 ] observed one case of biliary stricture (0.25%) in 408 patients with a bile duct diameter of 6 mm, which was treated with choledochojejunostomy 6 months after LCBDE. Based on our experience and previous studies [ 36 , 37 ], the primary risk factors for biliary stricture include nondilated CBDs and suboptimal suturing techniques. Therefore, we strongly recommend that LCBDE \(\:+\) PC for nondilated CBDs be performed by experienced surgeons. In our series, the mean CBD diameter was 6.39 \(\:\pm\:\) 0.75 mm. Postoperative nasocholangiography revealed no stenosis at the CBD suture site in 51 of 53 patients, another two patients failed to perform nasocholangiography due to accidental nasobiliary drainage tube detachment. No biliary strictures were observed during the median follow-up period of 24 months. These favorable outcomes may be attributed to our meticulous small-bite suture technique, in which the margin of the CBD wall closure was controlled within 1 mm. This approach minimized the reduction in CBD circumference ( \(\:<\) 2mm) and diameter ( \(\:<\) 1 mm), thereby preventing stenosis at the suture site. Retained stones following LCBDE remain a significant complication, with reported rates as high as 10% [ 38 – 40 ]. However, the use of choledochoscopy and laser lithotripsy has significantly reduced the incidence of retained stones to approximately 2% [ 41 , 42 ]. In our study, the meticulous use of choledochoscopy likely contributed to the absence of retained stones. Additionally, the cystic duct was dissected close to the CBD, ensuring a residual cystic duct length of less than 3 mm. This approach effectively reduced the risk of retained stones in the cystic duct. During the median follow-up period of 24 months (range: 6–40 months), no cases of stone recurrence were identified. Although this study offers preliminary evidence supporting the safety and efficacy of LCBDE \(\:+\) PC \(\:+\) IO-ENBD for treating cholecystolithiasis with nondilated CBDs, several limitations should be acknowledged. The retrospective, single-center design and relatively small sample size (n \(\:=\) 53) may introduce selection bias and limit the generalizability of the findings. Consequently, these results require validation through well-designed, multicenter prospective studies with larger patient cohorts. Furthermore, the technical complexity and prolonged operative time associated with nasobiliary drainage placement present significant practical challenges for widespread clinical application. Although postoperative MRCP demonstrated the absence of biliary strictures in all cases, the safety and feasibility of LC \(\:+\) LCBDE \(\:+\) PC without biliary drainage in this specific patient population necessitate further investigation. Conclusion LC \(\:+\) LCBDE \(\:+\) PC \(\:+\) IO-ENBD is a safe and effective single-stage strategy for the management of cholecystolithiasis combined with choledocholithiasis in patients with nondilated CBDs. This technique expands the indications for PC, and promotes enhanced recovery after surgery. Declarations Acknowledgment We appreciate the contributions of all authors. Funding 2023 Zigong Research Fund Project (2023YLWS19). Conflict of Interest The authors declare no conflict of interest. Ethical Approval The study protocol was approved by the Ethics Committee of Zigong First People's Hospital (Approval No. 2023-121). Contributions LZ. S and QD. W conceptualized and designed the study and drafted the initial manuscript. LZ. S and XZ. Z collected the data and carried out the initial analyses. N. Y and GG. Q critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. Human Ethics and Consent to Participate declarations This study was approved by the Ethics Committee of Zigong First People’s Hospital and was performed in accordance with the Declaration of Helsinki. All patients provided their informed consent on the use of anonymous data through an opt-out methodology. Data Availability declaration The data are available from the corresponding author on reasonable request. Consent for publication Not applicable. 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Ann Surg 240(2):205-13. https://doi.org/10.1097/01.sla.0000133083.54934.ae. Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, Fan ST, Yokoyama Y, Crawford M, Makuuchi M, Christophi C, Banting S, Brooke-Smith M, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Nimura Y, Figueras J, DeMatteo RP, Büchler MW, Weitz J (2011) Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 149(5):680-8. https://doi.org/10.1016/j.surg.2010.12.002. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE (2020) ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 52(2):127-149. https://doi.org/10.1055/a-1075-4080. Epub 2019 Dec 20. Zerey M, Haggerty S, Richardson W, Santos B, Fanelli R, Brunt LM, Stefanidis D (2018) Laparoscopic common bile duct exploration. Surg Endosc 32(6):2603-2612. https://doi.org/10.1007/s00464-017-5991-1. Epub 2017 Dec 22. Lyon M, Menon S, Jain A, Kumar H (2015) Use of biliary stent in laparoscopic common bile duct exploration. Surg Endosc 29(5):1094-8. https://doi.org/10.1007/s00464-014-3797-y. Liu D, Cao F, Liu J, Xu D, Wang Y, Li F (2017) Risk factors for bile leakage after primary closure following laparoscopic common bile duct exploration: a retrospective cohort study. BMC Surg 17(1):1. https://doi.org/10.1186/s12893-016-0201-y. Hua J, Lin S, Qian D, He Z, Zhang T, Song Z (2015) Primary closure and rate of bile leak following laparoscopic common bile duct exploration via choledochotomy. Dig Surg 32(1):1-8. https://doi.org/10.1159/000368326. Zhang Z, Shao G, Li Y, Li K, Zhai G, Dang X, Guo Z, Shi Z, Zou R, Liu L, Zhu H, Tang B, Wei D, Wang L, Ge J (2023) Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis. Surg Endosc 37(3):1700-1709. https://doi.org/10.1007/s00464-022-09601-3. Adler DG, Papachristou GI, Taylor LJ, McVay T, Birch M, Francis G, Zabolotsky A, Laique SN, Hayat U, Zhan T, Das R, Slivka A, Rabinovitz M, Munigala S, Siddiqui AA (2017) Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: a large multicenter study. Gastrointest Endosc 85(4):766-772. https://doi.org/10.1016/j.gie.2016.08.018. Guo T, Wang L, Xie P, Zhang Z, Huang X, Yu Y (2022) Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years' experience of a single institution. Surg Endosc 36(7):4903-4911. https://doi.org/10.1007/s00464-021-08843-x. Wang Q, Zhang X, Sun L, Yang N (2021) Primary Two-Layered Closure of the Common Bile Duct Reduces Postoperative Bile Leakage After Laparoscopic Common Bile Duct Exploration. J Laparoendosc Adv Surg Tech A 31(11):1274-1278. https://doi.org/10.1089/lap.2020.0768. Zhang X, Zhang L, Yu Y, Sun S, Sun T, Sun Y (2019) Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis. J Minim Access Surg 15(4):320-324. https://doi.org/10.4103/jmas.JMAS_129_18. Hua J, Meng H, Yao L, Gong J, Xu B, Yang T, Sun W, Wang Y, Mao Y, Zhang T, Zhou B, Song Z (2017) Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution. Surg Endosc 31(9):3581-3589. https://doi.org/10.1007/s00464-016-5388-6. Khaled YS, Malde DJ, de Souza C, Kalia A, Ammori BJ (2013) Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis. Surg Endosc 27(11):4164-70. https://doi.org/10.1007/s00464-013-3015-3. Tanaka M, Ikeda S, Nakayama F. Change in bile duct pressure responses after cholecystectomy: loss of gallbladder as a pressure reservoir. Gastroenterology. 1984 Nov;87(5):1154-9. Isherwood J, Oakland K, Khanna A (2019) A systematic review of the aetiology and management of post cholecystectomy syndrome. Surgeon 17(1):33-42. https://doi.org/10.1016/j.surge.2018.04.001. Parsi MA. Common controversies in management of biliary strictures. World J Gastroenterol. 2017 Feb 21;23(7):1119-1124. https://doi.org/10.3748/wjg.v23.i7.1119. Rahman S, Krokidis M, Paraskevopoulos I (2019) Transcholecystic approach for distal common bile duct stricture in a non-dilated biliary system: an alternative route. BMJ Case Rep 12(12):e231153. https://doi.org/10.1136/bcr-2019-231153. Fernández-Simon A, Díaz-Gonzalez A, Thuluvath PJ, Cárdenas A (2014) Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation. Clin Liver Dis 18(4):913-26. https://doi.org/10.1016/j.cld.2014.07.009. Martin IJ, Bailey IS, Rhodes M, O'Rourke N, Nathanson L, Fielding G (1998) Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg 228(1):29-34. https://doi.org/10.1097/00000658-199807000-00005. Zhan Z, Han H, Zhao D, Song G, Hua J, Xu B, Song Z (2020) Primary closure after laparoscopic common bile duct exploration is feasible for elderly patients: 5-Year experience at a single institution. Asian J Surg 43(1):110-115. https://doi.org/10.1016/j.asjsur.2019.04.009. Tan KK, Shelat VG, Liau KH, Chan CY, Ho CK (2010) Laparoscopic common bile duct exploration: our first 50 cases. Ann Acad Med Singap 39(2):136-42. Tumer AR, Yüksek YN, Yasti AC, Gözalan U, Kama NA (2005) Dropped gallstones during laparoscopic cholecystectomy: the consequences. World J Surg 29(4):437-40. https://doi.org/10.1007/s00268-004-7588-9. Taylor CJ, Kong J, Ghusn M, White S, Crampton N, Layani L (2007) Laparoscopic bile duct exploration: results of 160 consecutive cases with 2-year follow up. ANZ J Surg 77(6):440-5. https://doi.org/10.1111/j.1445-2197.2007.04091.x. Ma Z, Zhou J, Yao L, Dai Y, Xie W, Song G, Meng H, Xu B, Zhang T, Zhou B, Yang T, Song Z (2022) Safety and efficacy of laparoscopic common bile duct exploration for the patients with difficult biliary stones: 8 years of experiences at a single institution and literature review. Surg Endosc 36(1):718-727. https://doi.org/10.1007/s00464-021-08340-1. Yin P, Wang M, Qin R, Zhang J, Xiao G, Yu H, Ding Z, Yu Y (2017) Intraoperative endoscopic nasobiliary drainage over primary closure of the common bile duct for choledocholithiasis combined with cholecystolithiasis: a cohort study of 211 cases. Surg Endosc 31(8):3219-3226. https://doi.org/ 10.1007/s00464-016-5348-1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6379168","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":490802545,"identity":"b65c464a-fd3b-403d-a9f8-e0fb50ffc7ad","order_by":0,"name":"Lou-Zong Sun","email":"","orcid":"","institution":"Zigong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lou-Zong","middleName":"","lastName":"Sun","suffix":""},{"id":490802546,"identity":"4c509279-d186-41d4-b77a-bb2960d7f3a0","order_by":1,"name":"Qing-Da Wang","email":"","orcid":"","institution":"Zigong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qing-Da","middleName":"","lastName":"Wang","suffix":""},{"id":490802547,"identity":"7ac97e53-d603-4841-af2e-5cfd57b5ef3f","order_by":2,"name":"Xiao-Zhou Zhang","email":"","orcid":"","institution":"Zigong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiao-Zhou","middleName":"","lastName":"Zhang","suffix":""},{"id":490802548,"identity":"e88f86c5-1c60-4a33-b885-782eaa1572e3","order_by":3,"name":"Gui-Gang Qiu","email":"","orcid":"","institution":"Zigong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gui-Gang","middleName":"","lastName":"Qiu","suffix":""},{"id":490802549,"identity":"45fc54ce-b815-4713-822b-3d09024f3760","order_by":4,"name":"Nan Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYFACxsYHCRUSckAWG7FamJsNHpyxMIZpkSBCC3ub5MOWisQGorUY3G5sNkhskEjfcLz52QPGHTZ1hLXcOdj4IHGHRO6GM8fMDRjPpBFhy41EoC1ngFpuJJhJMLYdJkpLmwQQpRvcf/4NqOU/8VoSDG7wgGw5QFiLJMhhCWckDGeeySkD6k2WbCCkhe9G+sOHPyrq5PmOH98m8bHNjp+gLQoHkBkJBNUDgXwDOmMUjIJRMApGAToAAGJeRHb3dQL4AAAAAElFTkSuQmCC","orcid":"","institution":"Zigong First People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Nan","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2025-04-05 00:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6379168/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6379168/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87883764,"identity":"e34cbb81-ab9c-4e8c-a70b-48ed28943d00","added_by":"auto","created_at":"2025-07-30 04:54:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46299,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patient enrollment. \u003cem\u003eLC\u003c/em\u003e laparoscopic cholecystectomy, \u003cem\u003eLCBDE \u003c/em\u003elaparoscopic common bile duct exploration, \u003cem\u003ePC \u003c/em\u003eprimary closure, \u003cem\u003eIO-ENBD \u003c/em\u003eintraoperative endoscopic nasobiliary drainage\u003cem\u003e, CBD \u003c/em\u003ecommon bile duct.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6379168/v1/a5cb7ca72e6824d4a29cea12.png"},{"id":87883766,"identity":"7445d53b-b4cd-4346-ab0b-1609236f525c","added_by":"auto","created_at":"2025-07-30 04:54:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":245891,"visible":true,"origin":"","legend":"\u003cp\u003eThe CBD wall was incised in two layers. A Incision of the serous layer of CBD. B Incision of the whole layer of CBD. \u003cem\u003eCBD\u003c/em\u003e common bile duct.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6379168/v1/ac7bf925402f38c636970c6c.png"},{"id":87884884,"identity":"a040e620-aa1c-4da4-ad55-07b2c9267b52","added_by":"auto","created_at":"2025-07-30 05:02:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":187524,"visible":true,"origin":"","legend":"\u003cp\u003eIO-ENBD procedure. A The zebra guidewire was inserted anterogradely into the CBD and advanced into the duodenum, then pulled out of the duodenoscope with an \u003ca href=\"https://www.hujiang.com/ciku/endoscopic_snare/\"\u003eendoscopic snare\u003c/a\u003e. B The nasobiliary drainage tube was intubated retrogradely into the left or right hepatic duct along the guidewire. \u003cem\u003eIO-ENBD \u003c/em\u003eintraoperative endoscopic nasobiliary drainage\u003cem\u003e, CBD \u003c/em\u003ecommon bile duct\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6379168/v1/297029a0133a00a1e587ddd7.png"},{"id":87883775,"identity":"2f1845dd-1b16-41d6-87c4-8141e1850534","added_by":"auto","created_at":"2025-07-30 04:54:27","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":261829,"visible":true,"origin":"","legend":"\u003cp\u003eSuture method of the two-layered closure of CBD. A The first layer of CBD is sutured. B The serous layer of CBD is sutured. \u003cem\u003eCBD\u003c/em\u003e common bile duct.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6379168/v1/79daf795bc396942376fac28.png"},{"id":87883776,"identity":"68bcc3c5-382e-4daf-9056-755ae95cb9df","added_by":"auto","created_at":"2025-07-30 04:54:28","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":206355,"visible":true,"origin":"","legend":"\u003cp\u003eThe postoperative cholangiogram. A Nasal cholangiography. B Magnetic resonance cholangiopancreatography.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6379168/v1/37aee862597c9b75107cf248.png"},{"id":90672342,"identity":"a00bc5fc-daf5-4793-a5a3-71bda276e01c","added_by":"auto","created_at":"2025-09-05 13:47:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2033002,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6379168/v1/e5179d9a-d54a-4ff0-81cb-b0283ebcf493.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Primary closure with endoscopic nasobiliary drainage after laparoscopic common bile duct exploration: A safe and feasible strategy for nondilated common bile ducts","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCommon bile duct (CBD) stones, or choledocholithiasis, are present in approximately 5\u0026ndash;15% of patients with cholecystolithiasis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Choledocholithiasis can cause serious complications, such as obstructive jaundice, cholangitis and acute pancreatitis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe current treatment options for choledocholithiasis combined with cholecystolithiasis include laparoscopic cholecystectomy (LC)\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003epreoperative endoscopic retrograde cholangiopancreatography (pre-ERCP) and LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003elaparoscopic common bile duct exploration (LCBDE) [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003epre-ERCP is associated with postoperative complications such as pancreatitis, haemorrhage, duodenal perforation, and sphincter of Oddi dysfuction in 5\u0026ndash;11% of patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With advancements in laparoscopic techniques and equipment, LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE has gained popularity due to its ability to be performed in a single-stage procedure, shorter hospital stays, and reduced costs [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Following LCBDE, the management of the CBD traditionally involves either T-tube drainage or primary closure (PC). T-tube drainage has been used to support the CBD, decompress the biliary tree, and reduce the risk of bile leakage. It also provides percutaneous access for cholangiography and removal of retained stones [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, T-tube drainage is associated with a high postoperative complication rate of approximately 15%, including bile leakage, peritonitis, and reoperation due to planned or accidental early removal of the T-tube [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, the discomfort caused by prolonged T-tube placement contradicts the principles of minimally invasive surgery and Enhanced Recovery After Surgery (ERAS).\u003c/p\u003e\u003cp\u003eSeveral studies have shown that PC without bile drainage is superior to T-tube drainage, offering shorter hospital stays and comparable rates of bile leakage and stone recurrence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. PC is also associated with reduced operative time and faster recovery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, most studies suggest that PC after LCBDE is safer in patients with CBD diameters\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e8 mm, while its application in nondilated CBDs may increase the risk of bile leakage and biliary stricture [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The feasibility and safety of PC after LCBDE via choledochotomy in patients with nondilated CBDs remain unclear, and limited research has addressed this issue.\u003c/p\u003e\u003cp\u003eThis study aimed to evaluate the feasibility and safety of LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC via choledochotomy combined with intraoperative endoscopic nasobiliary drainage (IO-ENBD) for the treatment of choledocholithiasis in patients with nondilated CBDs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eThe diagnosis of choledocholithiasis was confirmed preoperatively using ultrasonography, magnetic resonance cholangiopancreatography (MRCP), or computed tomography (CT) scans. The CBD diameter was measured via preoperative CT or MRCP. The diagnosis and severity of acute cholangitis were assessed according to the Tokyo Guidelines 2018 (TG18), based on clinical features, laboratory data, and imaging findings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The inclusion criteria were as follows: (1) age\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e14 years; (2) patients with cholecystolithiasis combined with choledocholithiasis underwent LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE. The exclusion criteria were as follows: (1) LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eT-tube drainage; (2) CBD exploration performed through the cystic duct; (3) patients with a CBD diameter\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e8 mm. From May 2021 to January 2024, a total of 257 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE in our institution. Among these, 14 patients with T-tube drainage and 3 patients via transcystic approach were excluded. Additionally, 187 patients with CBD diameters\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e8 mm were excluded. A flow chart of patient enrollment is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The study protocol was approved by the Ethics Committee of Zigong First People's Hospital (Approval No. 2023\u0026thinsp;\u0026minus;\u0026thinsp;121), and written informed consent was obtained from all participants.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical procedures\u003c/h3\u003e\n\u003cp\u003eAll surgeries were performed by experienced laparoscopic biliary surgeons. The standard four-port approach was used for LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE. The procedure began with the dissection of Calot\u0026rsquo;s triangle. The cystic artery and cystic duct were identified, ligated with absorbable clips, and divided. The gallbladder was then dissected from the liver bed. A supraduodenal choledochotomy was conducted on the anterior wall of the CBD in two layers. First, the serosal layer of the CBD was longitudinally incised using electrocautery in situ (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Subsequently, a longitudinal incision of approximately 5\u0026ndash;8 mm was made along the anterior wall of the CBD, according to the size of the stones as determined by preoperative CT or MRCP (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Under choledochoscopic vision, CBD stones were extracted using a stone basket and saline irrigation. For larger or impacted stones, biliary laser lithotripsy was performed. After all the visible stones had been removed, choledochoscopy was conducted to confirm the clearance of the intrahepatic and extrahepatic bile ducts and to assess the condition of the sphincter of Oddi. A half-opened basket was passed through the ampulla to exclude small impacted stones and distal CBD stricture.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFor IO-ENBD, a zebra guidewire was inserted anterogradely through the choledochoscope into the distal CBD and advanced into the descending duodenum. The guidewire was then retrieved using an endoscopic snare (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). A 7-Fr nasobiliary drainage tube was inserted retrograde along the guidewire into the left or right hepatic duct (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The tube was led out through the oral-nasal route under duodenoscopic visualization.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAll patients underwent a two-layered, small-bite closure of the CBD. The first layer was closed intermittently using 5\u0026ndash;0 or 6\u0026ndash;0 absorbable Vicryl sutures with small bites (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026lt;\\)\u003c/span\u003e\u003c/span\u003e1 mm) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). After completing the first layer, sterile saline was injected to test for bile leakage, and additional sutures were performed where needed. In the second layer, the serosa of the anterior wall of the CBD was closed from the caudal to cranial end in a continuous fashion with 5\u0026ndash;0 Vicryl sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB). A nonsuction drain was placed near the foramen of Winslow, and a suction drain was positioned anterior to the CBD incision. The drains were removed 72\u0026ndash;96 hours postoperatively if no bile leakage was observed. The nasobiliary drainage tube was clamped 48 hours after surgery and removed 48\u0026ndash;72 hours after a negative nasal cholangiogram (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eFollow-up\u003c/h3\u003e\n\u003cp\u003ePostoperative follow-up was conducted at 1, 6, 12, and 24 months after surgery to evaluate the clinical status of the patients. At each visit, liver function tests and abdominal ultrasonography were performed. MRCP was additionally performed at 6 months postoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB).\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData extracted from patient records included demographic information, operative time, number and size of stones identified intraoperatively, postoperative hospital stay, and operative and postoperative complications (e.g., acute pancreatitis, bile leakage, retained stones, hemorrhage, reoperation, and in-hospital mortality). Follow-up data (up to September 2024) were also collected, including readmission rates and reintervention for biliary stricture or stone recurrence.\u003c/p\u003e\n\u003ch3\u003eObservation index and standard\u003c/h3\u003e\n\u003cp\u003eOperative time was defined as the interval from the initial skin incision to the final skin closure. Postoperative hospital stay was calculated as the duration from the end of surgery to discharge. The severity of postoperative complications was classified according to the Clavien-Dindo classification system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Bile leakage was defined based on the criteria established by the International Study Group of Liver Surgery [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Post-ENBD pancreatitis was defined and graded in accordance with the European Society of Gastrointestinal Endoscopy guidelines [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Liver function tests, abdominal ultrasonography, and nasal cholangiography or MRCP were performed to assess for bile duct stricture or stone recurrence.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using SPSS 19.0 software (SPSS, Chicago, IL, USA). Continuous variables are presented as mean\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003estandard deviation or median (range), while categorical variables are expressed as frequencies.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003ePatient characteristics\u003c/h2\u003e\u003cp\u003eFrom May 2021 to January 2024, 53 patients with nondilated CBDs who underwent LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD were evaluated. The demographic characteristics and clinical details of these patients are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The most common presenting symptoms were abdominal pain (92.5%), obstructive jaundice (30.2%), fever (15.1%), pancreatitis (15.1%), and cholangitis (7.5%). The mean preoperative CBD diameter was 6.39\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e0.75 mm.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients (n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\)\u003c/span\u003e\u003c/span\u003e53)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.08\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e13.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (female/male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32/21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.23\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e3.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA (I/II/III)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3/48/2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresentation, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49 (92.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstructive jaundice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (30.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute cholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative liver function test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal bilirubin (\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.78\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e21.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect bilirubin (\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.83\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e14.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALT (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e161.76\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e153.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAST (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99.72\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e104.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCBD diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.39\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccompanied disease, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart disease history\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (3.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (9.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index, \u003cem\u003eASA\u003c/em\u003e American Society of Anaesthesiologists, \u003cem\u003eALT\u003c/em\u003e alanine aminotransferase, \u003cem\u003eAST\u003c/em\u003e aspartate aminotransferase, \u003cem\u003eCBD\u003c/em\u003e common bile duct\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eIntraoperative results\u003c/h2\u003e\u003cp\u003eThe intraoperative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median operative time was 142.66\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e29.20 minutes, and the mean intraoperative blood loss was 26.23\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e22.21 mL. Intraoperative choledochoscopy identified impacted biliary stones in 5 patients (9.4%). Laser lithotripsy was required in 2 patients (3.8%) whose stones could not be removed using a stone basket or saline irrigation. No perioperative bile duct bleeding occurred, and the stone clearance rate was 100%. These findings demonstrate that LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD is a safe and feasible approach in patients with nondilated CBDs.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntraoperative outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative outcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients (n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\)\u003c/span\u003e\u003c/span\u003e53)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e142.66\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e29.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.23\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e22.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStone characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of stones\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.91\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e1.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStone size (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.42\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e1.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStone impaction, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (9.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLaser lithotripsy, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (3.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplete bile duct clearance, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePostoperative results\u003c/h2\u003e\u003cp\u003eThe postoperative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean postoperative hospital stay was 6.77\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e2.32 days. The mean time to ENBD removal was 3.72\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e1.29 days, and the mean time to abdominal drain removal was 5.13\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e1.36 days. Additionally, the mean hospital cost was 25,945.10\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e5,143.67 yuan.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative outcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients (n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\)\u003c/span\u003e\u003c/span\u003e53)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative hospital stay (d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.77\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e2.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eENBD removal (d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.72\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal drainage time (d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.13\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e1.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiver function test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal bilirubin (\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.29\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e20.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect bilirubin (\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.69\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e11.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115.88\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e97.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAST\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.54\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e39.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBile leakage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBleeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-ENBD pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespiratory tract infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWound infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eENBD displacement, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (3.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidual stone (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReoperation (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMortality (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospitalization cost (yuan)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25,945.10\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e5,143.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eENBD\u003c/em\u003e endoscopic nasobiliary drainage, \u003cem\u003eALT\u003c/em\u003e alanine aminotransferase, \u003cem\u003eAST\u003c/em\u003e aspartate aminotransferase\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePostoperative complications occurred in 4 patients (7.5%; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). One patient (1.9%) developed Grade A bile leakage; the CBD diameter in this patient was 5.6 mm, and accidental nasobiliary drainage tube detachment was observed after postoperative nasal cholangiography. The bile leakage was cured spontaneously with conservative management, and the peritoneal drain was removed 5 days postoperatively. One patient developed respiratory tract infection, which was successfully treated with intravenous antibiotics. One patient developed post-ENBD pancreatitis, which was successfully cured by treatment with octreotide and antacid. Another patient experienced wound infection that resolved after 6 days of surgical dressing changes. All patients underwent nasal cholangiography, which confirmed the absence of residual stones or biliary strictures. Two patients (3.8%) experienced accidental nasobiliary drainage tube detachment postoperatively, and abdominal ultrasound was subsequently used to rule out residual stones. There were no cases of postoperative mortality, reoperation, or residual stones.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative complications and their clinical management\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClavien-Dindo classification\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of\u003c/p\u003e\u003cp\u003epatients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eManagement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBile leakage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConservative\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-ENBD pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOctreotide and antacid\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRespiratory tract infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntravenous antibiotics\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWound infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSurgical dressing change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIIa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIIb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eClavien-Dindo classification: Grade I: any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, or radiological interventions. Grade II: requiring pharmacological treatment with drugs other than those allowed for Grade I complications. Grade III: complications requiring surgical, endoscopic, or radiological intervention: IIIa, complications requiring intervention without the need for general anaesthesia; IIIb, complications requiring intervention under general anaesthesia. Grade IV: life-threatening complications requiring intensive care unit management.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e*\u003c/sup\u003eConservative management: no antibiotics or further action was needed, and the leakage site closed spontaneously\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eFollow-up results\u003c/h2\u003e\u003cp\u003eAll patients completed at least one follow-up visit by September 2024 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The median follow-up duration was 24 months (range: 6\u0026ndash;40 months). During follow-up period, one patient (1.9%) experienced stone recurrence 18 months postoperatively, which was successfully treated with ERCP. No cases of biliary stricture were observed.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLong-term outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients (n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\)\u003c/span\u003e\u003c/span\u003e53)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients followed up, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian follow-up time (months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (6\u0026ndash;40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBile duct stricture, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStone recurrence, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective study aimed to evaluate the feasibility and safety of LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD for treating choledocholithiasis in patients with nondilated CBDs. To our knowledge, this is the first reported series of patients undergoing LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC for choledocholithiasis with nondilated CBDs. Our results demonstrated a 100% duct clearance rate, a 1.9% bile leakage rate, and no biliary strictures during follow-up, which are comparable to the outcomes of dilated CBDs reported in other studies [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWith the rapid advancement of minimally invasive surgical techniques, LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE has become a widely accepted single-stage treatment for cholecystolithiasis and choledocholithiasis [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Numerous studies have demonstrated that PC without bile drainage offers advantages over T-tube drainage or stent placement, including shorter hospital stays and fewer postoperative complications [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, existing evidence suggests that PC after LCBDE is safer in patients with CBD diameters\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e8 mm [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. For instance, Liu et al. [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] reported a significantly higher incidence of bile leakage in patients with thinner CBD diameters (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026lt;\\)\u003c/span\u003e\u003c/span\u003e1 cm vs. \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e1 cm: 31.6% vs. 7.0%, P\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\)\u003c/span\u003e\u003c/span\u003e0.04). Similarly, Hua et al. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] found that the risk of bile leakage in patients with CBD diameters\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026lt;\\)\u003c/span\u003e\u003c/span\u003e8 mm was 17.75 times higher than in those with diameters\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e8 mm. These findings indicate that PC after LCBDE in patients with nondilated CBDs may increase the risk of postoperative complications, necessitating further investigation into its safety and feasibility. In this study, 53 patients with choledocholithiasis and nondilated CBDs underwent LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD. The outcomes, including a postoperative complication rate of 7.5% (4/53), a mean operative time of 142.66\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e29.20 minutes, and a mean postoperative hospital stay of 6.77\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e2.32 days, were comparable to those reported in patients with dilated CBDs [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. These results suggest that LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD is a safe and effective approach for managing choledocholithiasis in patients with nondilated CBDs.\u003c/p\u003e\n\u003cp\u003ePrevious studies have identified bile leakage and biliary stricture as the main postoperative complications of LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Clinicians should remain vigilant in monitoring and managing these complications. Bile leakage following PC is a critical indicator of the safety of this procedure. Currently, several strategies have been proposed to reduce the incidence of postoperative bile leakage in LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC: (1) LCBDE combined with nasobiliary drainage or stent insertion. Zhang et al. [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] reported no cases of postoperative bile leakage in patients undergoing LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC, whereas 4 cases (5.6%) of bile leakage occurred in the absence of IO-ENBD. Similarly, Lyon et al. [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] demonstrated that the use of a biliary stent during LCBDE significantly reduces the risk of postoperative bile leakage; (2) In a previous study, our team reported no cases of bile leakage in patients who underwent two-layered closure of the CBD, compared to 5 cases in the traditional primary closure group [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]; (3) The use of human fibrin sealant at the CBD suture site has been shown to reduce postoperative bile leakage [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. Despite these advancements, no method can completely eliminate the risk of bile leakage, either theoretically or practically. In our study, bile leakage occurred in one patient (1.9%), consistent with the outcomes of dilated CBDs reported in previous studies [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eSeveral previous studies have identified surgeon experience, nondilated CBD, and stone clearance failure as significant risk factors for bile leakage following LCBDE [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, our findings demonstrate that LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC in patients with nondilated CBDs did not increase the incidence of postoperative bile leakage. This discrepancy may be attributable to the following factors: (1) In most previous studies, PC was performed using 3\u0026ndash;0 or 4\u0026ndash;0 sutures [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e], whereas we employed finer 5\u0026ndash;0 or 6\u0026ndash;0 absorbable Vicryl sutures. The use of finer needles may reduce the risk of bile leakage from needle puncture sites, particularly in thin CBD wall; (2) All procedures in this study were performed by surgeons with over 10 years of experience in hepatobiliary and laparoscopic surgery. Their advanced laparoscopic suturing skills likely contributed to the lower bile leakage rate; (3) The CBD incision was closed using a two-layered technique. The first layer involved complete closure of the CBD wall, ensuring that the suture extended beyond the edges of the incision. When the second serosal layer was sutured, a small portion of the outer CBD wall was also sutured to strengthen the incision; (4) Rapid changes in Oddi sphincter dynamics and increased CBD pressure following cholecystectomy may contribute to bile leakage after LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. IO-ENBD may reduce the pressure in the CBD and promote healing at the suture site.\u003c/p\u003e\n\u003cp\u003eAlthough biliary stricture is a rare complication following LCBDE, it represents a serious adverse event associated with PC. Biliary stricture can lead to bile duct obstruction, jaundice, and even liver failure, which seriously affects patient health and often requires surgical intervention, such as ERCP or biliary duct reconstruction [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. Martin et al. [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] reported one case of biliary stricture (1.6%) among 61 patients who underwent conversion from laparoscopic to open choledochotomy with T-tube placement in a 5-mm duct; the stricture was managed with Roux-en-Y choledochojejunostomy 6 months postoperatively. Similarly, Zhan et al. [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e] observed one case of biliary stricture (0.25%) in 408 patients with a bile duct diameter of 6 mm, which was treated with choledochojejunostomy 6 months after LCBDE.\u003c/p\u003e\n\u003cp\u003eBased on our experience and previous studies [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e], the primary risk factors for biliary stricture include nondilated CBDs and suboptimal suturing techniques. Therefore, we strongly recommend that LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC for nondilated CBDs be performed by experienced surgeons. In our series, the mean CBD diameter was 6.39\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\)\u003c/span\u003e\u003c/span\u003e0.75 mm. Postoperative nasocholangiography revealed no stenosis at the CBD suture site in 51 of 53 patients, another two patients failed to perform nasocholangiography due to accidental nasobiliary drainage tube detachment. No biliary strictures were observed during the median follow-up period of 24 months. These favorable outcomes may be attributed to our meticulous small-bite suture technique, in which the margin of the CBD wall closure was controlled within 1 mm. This approach minimized the reduction in CBD circumference (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026lt;\\)\u003c/span\u003e\u003c/span\u003e2mm) and diameter (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026lt;\\)\u003c/span\u003e\u003c/span\u003e1 mm), thereby preventing stenosis at the suture site.\u003c/p\u003e\n\u003cp\u003eRetained stones following LCBDE remain a significant complication, with reported rates as high as 10% [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, the use of choledochoscopy and laser lithotripsy has significantly reduced the incidence of retained stones to approximately 2% [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. In our study, the meticulous use of choledochoscopy likely contributed to the absence of retained stones. Additionally, the cystic duct was dissected close to the CBD, ensuring a residual cystic duct length of less than 3 mm. This approach effectively reduced the risk of retained stones in the cystic duct. During the median follow-up period of 24 months (range: 6\u0026ndash;40 months), no cases of stone recurrence were identified.\u003c/p\u003e\n\u003cp\u003eAlthough this study offers preliminary evidence supporting the safety and efficacy of LCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD for treating cholecystolithiasis with nondilated CBDs, several limitations should be acknowledged. The retrospective, single-center design and relatively small sample size (n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\)\u003c/span\u003e\u003c/span\u003e53) may introduce selection bias and limit the generalizability of the findings. Consequently, these results require validation through well-designed, multicenter prospective studies with larger patient cohorts. Furthermore, the technical complexity and prolonged operative time associated with nasobiliary drainage placement present significant practical challenges for widespread clinical application. Although postoperative MRCP demonstrated the absence of biliary strictures in all cases, the safety and feasibility of LC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC without biliary drainage in this specific patient population necessitate further investigation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eLCBDE\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003ePC\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:+\\)\u003c/span\u003e\u003c/span\u003eIO-ENBD is a safe and effective single-stage strategy for the management of cholecystolithiasis combined with choledocholithiasis in patients with nondilated CBDs. This technique expands the indications for PC, and promotes enhanced recovery after surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the contributions of all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e2023 Zigong Research Fund Project\u0026nbsp;(2023YLWS19).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Zigong First People\u0026apos;s Hospital (Approval No. 2023-121).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLZ. S and QD. W conceptualized and designed the study and drafted the initial manuscript. LZ. S and XZ. Z collected the data and carried out the initial analyses. N. Y and GG. Q critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Zigong First People\u0026rsquo;s Hospital and was performed in accordance with the Declaration of Helsinki. All patients provided their informed consent on the use of anonymous data through an opt-out methodology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\nPermissions\nAll the figures and tables are created by ourselves, no permission is required.\n"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKo CW, Lee SP (2002) Epidemiology and natural history of common bile duct stones and prediction of disease. 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ANZ J Surg 77(6):440-5. https://doi.org/10.1111/j.1445-2197.2007.04091.x.\u003c/li\u003e\n \u003cli\u003eMa Z, Zhou J, Yao L, Dai Y, Xie W, Song G, Meng H, Xu B, Zhang T, Zhou B, Yang T, Song Z (2022) Safety and efficacy of laparoscopic common bile duct exploration for the patients with difficult biliary stones: 8 years of experiences at a single institution and literature review. Surg Endosc 36(1):718-727. https://doi.org/10.1007/s00464-021-08340-1.\u003c/li\u003e\n \u003cli\u003eYin P, Wang M, Qin R, Zhang J, Xiao G, Yu H, Ding Z, Yu Y (2017) Intraoperative endoscopic nasobiliary drainage over primary closure of the common bile duct for choledocholithiasis combined with cholecystolithiasis: a cohort study of 211 cases. Surg Endosc 31(8):3219-3226. https://doi.org/ 10.1007/s00464-016-5348-1.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic common bile duct exploration, Primary closure, Endoscopic nasobiliary drainage, Nondilated common bile ducts","lastPublishedDoi":"10.21203/rs.3.rs-6379168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6379168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose The preferred treatment for cholecystolithiasis combined with choledocholithiasis is laparoscopic cholecystectomy (LC)+laparoscopic common bile duct exploration (LCBDE)+primary closure (PC). However, the appropriateness of LC+LCBDE+PC in patients with nondilated common bile ducts (CBDs) remain unclear. This study aimed to investigate the feasibility and safety of LC+LCBDE+PC with intraoperative endoscopic nasobiliary drainage (IO-ENBD) for the treatment of choledocholithiasis with nondilated CBDs.\u003c/p\u003e\n\u003cp\u003eMethods From May 2021 to January 2024, 257 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent LC+LCBDE in our institution were reviewed. The clinical and treatment outcomes of patients with nondilated CBDs (\u0026lt;8 mm) were retrospectively analyzed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults Of these patients, 53 patients with nondilated CBDs successfully underwent LC+LCBDE+PC+IO-ENBD. The stone clearance rate was 100%, operation time was 142.66±29.20 minutes, intraoperative blood loss volume was 26.23±22.21 mL, postoperative hospital stay was 6.77±2.32 days. There was 1 case of postoperative bile leakage (1/53, 1.9%), which was resolved with conservative treatment. No reoperation or mortality occurred. During the median follow-up period of 24 months (range: 6–40 months), one patient (1/53, 1.9%) experienced stone recurrence 18 months after the operation. No residual stones or biliary stricture occurred.\u003c/p\u003e\n\u003cp\u003eConclusion LC+LCBDE+PC+IO-ENBD is a safe and effective single-stage strategy for the management of cholecystolithiasis combined with choledocholithiasis in patients with nondilated CBDs.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Primary closure with endoscopic nasobiliary drainage after laparoscopic common bile duct exploration: A safe and feasible strategy for nondilated common bile ducts","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-30 04:54:22","doi":"10.21203/rs.3.rs-6379168/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d48444b-1fe3-40ad-9d56-36aec769bf62","owner":[],"postedDate":"July 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52116014,"name":"Health sciences/Gastroenterology/Hepatology/Biliary tract"},{"id":52116015,"name":"Health sciences/Gastroenterology/Hepatology/Biliary tract disease"}],"tags":[],"updatedAt":"2025-10-03T13:38:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-30 04:54:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6379168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6379168","identity":"rs-6379168","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}