Clinical outcomes after laparoscopic left hemihepatectomy with and without biliary duct exploration

Clinical outcomes after laparoscopic left hemihepatectomy with and without biliary duct exploration | 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 Research Article Clinical outcomes after laparoscopic left hemihepatectomy with and without biliary duct exploration Zhen Wan, Lei Wu, Xiang Liu, Renhua Wan, Xuzhen Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6883130/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Nov, 2025 Read the published version in BMC Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Background: The operative procedures of laparoscopic left hemihepatectomy (LLH) with and without common bile duct (CBD) exploration are largely different. However, the two procedures are frequently included in the same category. The present study aimed to evaluate the impact of CBD exploration on clinical outcome in patients undergoing LLH, especially postoperative liver function and biliary leakage. Methods: The retrospective study included patients with left-sided intrahepatic bile duct stones at the First Affiliated Hospital of Nanchang University from January 2020 to June 2024. Patients were divided into simple LLH group and LLH with CBD exploration (LLHCBDE) group. Perioperative outcomes and stone recurrence between the two groups were evaluated. Moreover, we performed multivariable linear regression to analyze peak postoperative levels of alanine transaminase (ALT) and aspartate transaminase (AST) and logistic regression to analyze the occurrence of biliary leakage. Results: This study enrolled 176 patients, with 36 and 140 patients in the LLH and LLHCBDE groups, respectively. The LLHCBDE group demonstrated significantly longer operation time, longer hospital stays, higher peak postoperative transaminase levels, and a higher stone recurrence rate compared to the LLH group. However, there were no significant differences in the incidence of major complications and biliary leakage between the two groups. Multivariate stepwise linear regression analysis revealed that CBD exploration was an independent predictor of peak postoperative levels of alanine transaminase (β = 0.313, P < 0.001) and aspartate transaminase (β = 0.359, P < 0.001). Furthermore, period of less than 1 month between LLH and the latest episode of acute cholangitis (OR 4.362, 95%CI 1.126-16.904, P =0.033) and intraoperative blood loss (OR 1.022, 95%CI 1.013-1.031, P <0.001) were independent risk factors for postoperative biliary leakage. Conclusions: LLH with CBD exploration should be considered as a different procedure from LLH. CBD exploration is significantly associated with higher peak postoperative levels of ALT and AST, but not with an increased risk of biliary leakage. Laparoscopic left hemihepatectomy Common bile duct exploration Left-sided intrahepatic bile duct stones Post-hepatectomy liver function Biliary leakage Figures Figure 1 Figure 2 Introduction Laparoscopic left hemihepatectomy (LLH) [1] with common bile duct (CBD) exploration [2] is usually performed for left-sided intrahepatic bile duct stones combined with choledocholithiasis. This procedure is markedly different from simple LLH without CBD exploration regarding the operative invasiveness and the incidence of postoperative complications. However, the two operative procedures may be classified in the same category [3–4] . To our knowledge, there are no previous studies comparing the surgical outcomes after LLH with and without CBD exploration. CBD exploration following LLH usually involves several operative steps including choledochotomy, choledochoscopic stone extraction and CBD closure. The impact of these procedures on postoperative liver function after LLH has not been well studied. Moreover, biliary leakage is still a major postoperative complication after both hepatectomy [5] and CBD exploration [6] . Whether concomitant CBD exploration increases the incidence of biliary leakage in patients undergoing LLH remains poorly characterized. This retrospective study aims to compare the clinical outcome including perioperative data and follow-up results between the two operative procedures, LLH with and without CBD exploration. Only patients with left-sided intrahepatic bile duct stones were enrolled in the LLH group to balance the baseline characteristics between the two groups. We further evaluate the impact of CBD exploration on postoperative liver function and the incidence of biliary leakage after LLH. Methods Patients Selection The retrospective study included patients with left-sided intrahepatic bile duct stones who underwent simple LLH or LLH with CBD exploration at the First affiliated hospital of Nanchang University from January 2020 to June 2024. All patients received preoperative abdominal magnetic resonance imaging (MRI) or computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP). Inclusion criteria were as follows: (1) left-sided intrahepatic bile duct stones and LLH; (2) presence or absence of stones within CBD; (3) Child-Pugh class A or B liver function. Exclusion criteria were as follows: (1) Child-Pugh class C liver function; (2) presence of biliary tumor; (3) suffering from acute cholangitis or severe obstructive jaundice; (4) need to undergo bilioenteric anastomosis; (5) lack of complete case data. This study was approved by the ethics committee of the First affiliated hospital of Nanchang University. Surgical Procedures Based on stone location and distribution in bile ducts, enrolled patients were classified into two groups: LLH group and LLH with CBD exploration (LLHCBDE) group. LLH group exhibited stones exclusively within the left intrahepatic bile ducts, whereas LLHCBDE group presented with concomitant intrahepatic and CBD stones (Fig. 1 ). Under general anesthesia, patients were placed in a supine position, with the two legs separating. CO 2 pneumoperitoneum pressure was maintained at 12–14 mmHg. Five trocars were placed: one 10 mm trocar was inserted through the umbilicus for telescope; two 12 mm trocars were located at the right and left midclavicular line; two 5 mm trocars were situated at the right and left subcostal. The round ligament, falciform ligament, left triangular ligament, and left coronary ligament were sequentially dissected. The left branch of the portal vein and left hepatic artery were dissected and divided. Alternatively, the left glissonian pedicle as en bloc was isolated from the liver parenchyma and transected using an endovascular stapler (Fig. 2 ) [7] . The ischemic demarcation line was marked on the liver surface using an electrocautery hook. An occlusion band was placed at the first hepatic portal for Pringle maneuver (15 min occlusion followed by 5 min reperfusion). Liver parenchyma was transected along the ischemic line from the foot to the head. The surgeon clamped and squeezed the liver parenchyma using a harmonic scalpel while the assistant used the aspirator to gently push the hepatic parenchyma to dissect blood vessels and bile ducts. Blood vessels or bile ducts were clipped with Hem-o-lok clips and cut off. When the root of the left hepatic vein (LHV) was exposed, the trunk of LHV and the remaining hepatic parenchyma was removed with an endovascular stapler. For patients combined with CBD stones, choledochotomy and stone extraction was performed. A longitudinal CBD incision was made and choledochoscope was inserted to examine the common bile duct. Under the guidance of choledochoscope, common bile duct stones were removed using a retrieval basket as possible. If stones were impacted, electrohydraulic lithotripsy in combination with repeated saline irrigation was necessary. After complete removal of CBD stone, T-tube drainage was routinely performed. Clinical Outcomes Operation time, Pringle maneuver time, intraoperative blood loss and conversion rate to open surgery were recorded. Perioperative outcomes included duration of oral intake and postoperative hospital stay, reoperation rate and 30-day mortality. Postoperative complications such as intra-abdominal hemorrhage and biliary leakage were documented. Biliary leakage was defined as elevated bilirubin level in drainage fluid on or after postoperative day 3 or requiring radiologic or operative intervention for biliary peritonitis [8] . The Clavien-Dindo system was used to classify postoperative complications and the major complications were defined as Clavien-Dindo classification Ⅲ, Ⅳ and ⅴ [9] . Laboratory parameters, including peak postoperative values of white blood cell (WBC), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (t-Bil) and prothrombin time-international normalized ratio (PT-INR) were measured. Patients were followed up at clinics every 3 months for the first 2 years and every 6 months in the following years. Routine blood examination, liver function test, abdominal ultrasound and MRCP were performed to evaluate the recurrence of bile duct stone. Stone recurrence was defined as detection of bile duct stones by CT/MRI at least 6 months after LLH. Statistical Analysis Data were analyzed using SPSS 29.0 (Chicago, IL, USA). Normally and non-normally distributed continuous variables were expressed as mean ± standard deviation (SD) and median (interquartile range, IQR) respectively, and were compared using t -test and Mann-Whitney U test. Categorical data were presented as numbers (percentages) and were analyzed with chi-square test and Fisher’s exact test. A correlation between two variables was evaluated using a Spearman rank correlation test. Multivariable linear regression models incorporating preoperative clinical data and intraoperative variables were performed to identify independent predictors of peak postoperative ALT/AST levels. Multivariate logistic regression analysis was performed to identify independent risk factors for development of biliary leakage. All tests were two-sided and a P value less than 0.05 was considered statistically significant. In addition, odds ratio (OR) with 95% confidence intervals (CI) were calculated to describe the uncertainty of the estimation. Results Patients’ characteristics The study included a total of 176 patients with left-sided intrahepatic bile duct stones, of which 36 patients were in the LLH group and 140 patients were in the LLHCBDE group. Baseline characteristics, including age, sex, BMI, Child-Pugh classification, ASA score [10] , comorbidities, history of prior upper abdominal surgery and a period of less than 1 month between LLH and the latest episode of acute cholangitis are detailed in Table 1 . Only history of prior upper abdominal surgery was found to be significantly different between the two groups. Table 1 Patients’ characteristics LLH group (n = 36) LLHBE group (n = 140) P value Sex (n(%)) 0.929 Male 9 (25%) 34 (24.3%) Female 27 (75%) 106 (75.7%) Age(years) (mean ± SD) 56.39 ± 6.21 58.19 ± 5.73 0.1 BMI (kg/m 2 ) (mean ± SD) 24.61 ± 1.27 24.81 ± 1.19 0.376 Child-A disease n(%) 36 (100%) 140 (100%) 1.000 ASA class n(%) 0.474 Ⅰ 13 (36.1%) 41 (29.3%) Ⅱ 21 (58.3%) 91 (65%) Ⅲ 2 (5.6%) 8 (5.7%) Presence of comorbidity n(%) Diabetes mellitus 4 (11.1%) 12 (8.6%) 0.883 Hypertension 8 (22.2%) 28 (20%) 0.768 Cardiac disease 3 (8.3%) 8 (5.7%) 0.847 Previous upper abdominal surgery n(%) 2 (5.6%) 30 (21.4%) 0.028 A period of less than 1 month between LLH and the latest episode of acute cholangitis n(%) 7 (19.4%) 36 (25.7%) 0.435 BMI, body mass index; ASA, American society of anesthesiologists. Perioperative outcomes As shown in Table 2 , the LLHCBDE group had longer operative time (190 (180–200) vs. 165 (151.25–170) min, P < 0.001) and prolonged duration of Pringle maneuver (30 (26–32) vs. 28 (26–30) min, P = 0.047) compared to the LLH group. No differences were observed with respect to intraoperative blood loss, blood transfusion rate, or rate of conversion to laparotomy. The LLHCBDE group had longer time to oral intake (2 (2–3) vs. 2 (2–2) days, P < 0.001) and prolonged postoperative hospital stays (8 (7.25–9) vs. 7 (6–7) days, P < 0.001). Strikingly, the LLHCBDE group did not demonstrate higher rate of biliary leakage (8.6% vs. 8.3%, OR 1.031, 95% CI 0.275–3.867, P = 1.000) compared to the LLH group. There were also no significant differences in the incidences of intra-abdominal hemorrhage and major complication between the two groups. No significant differences in reoperation rate and hospital mortality were observed between the two groups. Table 2 Perioperative and follow-up outcomes between the two groups LLH (n = 36) LLHBE (n = 140) P value OR (95% CI) Operating time(min) (median, IQR) 165 (151.25,170) 190 (180,200) < 0.001 Duration of Pringle maneuver (min) (median, IQR) 28 (26,30) 30 (26,32) 0.047 Intraoperative blood loss(ml) (median, IQR) 200 (165,245) 200 (200,250) 0.169 Intraoperative transfusion n(%) 2 (5.6%) 8 (5.7%) 1.000 Conversion n(%) 1 (2.8%) 6 (4.3%) 1.000 Time to oral intake (d) (median, IQR) 2 (2,2) 2 (2,3) < 0.001 Postoperative hospital stay (d) (median, IQR) 7 (6,7) 8 (7.25,9) < 0.001 Major complications n(%) 2 (5.6%) 5 (3.6%) 0.948 0.630 (0.117–3.386) Bile leakage n(%) 3 (8.3%) 12 (8.6%) 1.000 1.031 (0.275–3.867) Intra-abdominal hemorrhage n(%) 1 (2.8%) 3 (2.1%) 1.000 0.766 (0.077–7.594) Reoperation n(%) 0 (0.0%) 1 (0.7%) 1.000 - Hospital mortality n(%) 0 (0.0%) 1 (0.7%) 1.000 - Stone recurrence n(%) 2 (5.6%) 25 (17.9%) 0.045 3.696 (0.833–16.402) IQR, interquartile range. Follow-Up outcomes All patients were followed up for at least 6 months. The LLHCBDE group had higher stone recurrence rates (17.9% vs. 5.6%, OR 3.696, 95% CI 0.833–16.402, P = 0.045) compared to the LLH group. Laboratory Data The two groups showed no differences in the preoperative levels of WBC, ALT, AST, t-Bil and PT-INR, or peak postoperative values of WBC, t-Bil and PT-INR (Table 3 ). However, the LLHCBDE group had significantly higher peak postoperative levels of ALT (267.7 (235.1–328.7) vs. 201.6 (186.3–250.0) U/L, P < 0.001) and AST (307.1 (256.8–354.4) vs. 188.3 (176.8–234.7) U/L, P < 0.001). Further Spearman rank correlation tests revealed no significant correlations between peak ALT and peak WBC (rs = 0.009, P = 0.902) or preoperative ALT (rs = 0.04, P = 0.595). Likewise, no correlation between peak AST and peak WBC (rs = 0.041, P = 0.589) or preoperative AST (rs = 0.112, P = 0.140) was identified. Table 3 Preoperative and postoperative laboratory data LLH (n = 36) LLHBE (n = 140) P value Pre-op Hb (g/L) (mean ± SD) 123.94 ± 7.62 125.06 ± 7.48 0.429 Pre-op WBC count (/µL) (median, IQR) 4665 (4298,5275) 4860 (4560,5350) 0.060 Pre-op ALT (U/L) (median, IQR) 17.3 (12.7,29.7) 18.7 (15.8,25.0) 0.757 Pre-op AST (U/L) (median, IQR) 20.2 (16.1,26.6) 23.6 (17.6,28.4) 0.103 Pre-op t-bil (µmol/L) (median, IQR) 8.75 (7.8,10.0) 8.9 (7.6,11.0) 0.444 Pre-op PT-INR (median, IQR) 0.98 (0.94,1.01) 0.98 (0.96,1.01) 0.213 Peak postoperative WBC count (/mL) (median, IQR) 10680 (10120,11355) 11015 (10435,11443) 0.102 Peak postoperative ALT level (U/L) (median, IQR) 201.6 (186.3,250.0) 267.7 (235.1,328.7) < 0.001 Peak postoperative AST level (U/L) (median, IQR) 188.3 (176.8,234.7) 307.1 (256.8,354.4) < 0.001 Peak postoperative t-bil level (µmol/L) (median, IQR) 21.4 (18.4,26.7) 20.6 (15.6,25.6) 0.136 Peak postoperative PT-INR level (median, IQR) 1.095 (1.05,1.15) 1.11 (1.08,1.14) 0.151 Hb, Hemoglobin; WBC, white blood count; Pre-op, pre-operative; ALT, alanine aminotransferase; AST aspartate aminotransferase; t-bil, total bilirubin; PT-INR, prothrombin time-international normalized ratio. Multivariate linear regression analyses for peak postoperative ALT/AST values Six clinical variables were used in the multivariate linear regression analysis for peak postoperative ALT value (forward stepwise method). The contributions of all significant factors in the final model are shown in Table 4 . Apart from period of less than 1 month between operative time and the latest episode of acute cholangitis, history of prior upper abdominal surgery and duration of Pringle maneuver, the procedure of CBD exploration (β = 0.313, P < 0.001) was significantly associated with peak postoperative ALT value. Similarly, the procedure of CBD exploration was also confirmed to be associated with peak postoperative AST value (β = 0.359, P < 0.001). Table 4 Multivariable linear regression of peak postoperative transaminase levels Peak ALT Peak AST β P Adj.R 2 β P Adj.R 2 Age 0.096 0.065 0.544 Age 0.054 0.332 0.490 Previous upper abdominal surgery 0.149 0.007 Previous upper abdominal surgery -0.208 < 0.001 period of less than 1 month between LLH time and the latest episode of acute cholangitis 0.435 < 0.001 period of less than 1 month between LLH time and the latest episode of acute cholangitis -0.313 < 0.001 LLHCBDE 0.313 < 0.001 LLHCBDE 0.359 < 0.001 Duration of Pringle maneuver 0.361 < 0.001 Duration of Pringle maneuver 0.353 < 0.001 Intraoperative blood loss 0.054 0.319 LLHCBDE: laparoscopic left hemihepatectomy with common bile duct exploration. Univariate and multivariate analyses for biliary leakage In the univariate analysis, we found that only intraoperative blood loss had statistical significance. In the multivariate analysis that included the factors with a P value < 0.200 in the univariate analysis, a period of less than 1 month between LLH and the latest episode of acute cholangitis (OR 4.362, 95%CI 1.126–16.904, P = 0.033) and intraoperative blood loss (OR 1.022, 95%CI 1.013–1.031, P < 0.001) were identified to be independent risk factors for biliary leakage (Table 5 ). Table 5 Univariate and multivariate analysis for risk factors of bile leakage Variables Bile leakage (n = 15) No bile leakage (n = 161) Univariable Multivariable P value OR (95%CI) P value Sex (Male/female) 2/13 41/120 0.464 Age(years) (mean ± SD) 57.78 ± 5.89 58.27 ± 5.73 0.761 BMI (mean ± SD) 24.78 ± 1.18 24.74 ± 1.45 0.901 Previous upper abdominal surgery 4/11 28/133 0.589 period of less than 1 month between LLH time and the latest episode of acute cholangitis 7/8 36/125 0.075 4.362 (1.126–16.904) 0.033 Pre-op AST (U/L) (median, IQR) 23.6 (17.6,26.7) 23.4 (16.9,28.0) 0.994 Pre-op ALT (U/L) (median, IQR) 27.6 (14.3,36.8) 18.6 (15.7,24.9) 0.052 0.090 Pre-op WBC (/µL) (median, IQR) 4660 (4415,5105) 4860 (4550,5350) 0.292 LLH/LLHCBDE 3/12 33/128 1.000 Operating time (min) (median, IQR) 180 (170,185) 185 (170,200) 0.470 Intraoperative blood loss (ml) (median, IQR) 350 (250,400) 200 (180,250) < 0.001 1.022 (1.013–1.031) < 0.001 LLH: laparoscopic left hemihepatectomy. Discussion LLH with CBD exploration is a standard treatment modality for patients with left-sided intrahepatic bile duct stones and choledocholithiasis. In general, CBD exploration after LLH consists of several operative steps such as choledochotomy, choledochoscopic stone extraction and CBD closure. CBD stones were removed using a retrieval basket as possible. If large impacted stones in common bile duct were difficult to extract, electrohydraulic lithotripsy were used [11] . CBD exploration will prolong the surgical duration and increase the complexity of the operation. Moreover, choledochoscopic stone extraction and bile spillage during surgery may trigger an excessive intrahepatic cytokine release and systemic endotoxemia, contributing to impaired postoperative recovery [12–13] . Therefore, CBD exploration may have a major adverse effect on perioperative outcomes after LLH. However, the two operative procedures (LLH vs. LLHCBDE) were sometimes classified into the same category in previous studies [3–4,14] . The current study demonstrated for the first time that LLHCBDE group exhibited significantly prolonged operative time, longer time to oral intake, increased postoperative hospital stays and higher stone recurrence rate compared to the LLH group. These results suggest that LLH with CBD exploration is fundamentally distinct from LLH. The type of disease for simple LLH in this study was limited to left-sided intrahepatic bile duct stones. The patients included in the LLHCBDE group had concomitant intrahepatic and CBD stones. To ensure comparable baseline characteristics, we excluded patients with hepatocellular carcinoma, colorectal liver metastases, or hemangioma from the simple LLH group. Additionally, patients with perihilar cholangiocarcinoma were also excluded as extrahepatic bile duct resection and subsequent choledocho-jejunostomy was required. Extrahepatic bile duct resection and choledocho-jejunostomy aggravated post-operative liver injury and perturbed the liver regeneration process [15] . The number of patients with exclusive left-sided intrahepatic bile duct stones is relatively small compared to that of patients with concomitant left-sided intrahepatic bile duct stones and choledocholithiasis in most institutions. As the author’s institution is a high volume center for left-sided intrahepatic bile duct stones and has large number of cases of LLH without CBD exploration, the surgical outcomes could be compared between the two groups within our single institution. Peak postoperative values of ALT and AST reflect the extent of surgical liver injury following hepatectomy [16] . The study revealed significantly higher peak postoperative levels of ALT and AST in the LLHCBDE group than in the LLH group. The observed difference can not be simply attributed to the procedure of CBD exploration, as history of prior upper abdominal surgery and intraoperative factors including operative time, duration of Pringle maneuver and volume of intraoperative blood loss differed significantly between the two groups. In the multivariate stepwise linear regression model adjusted for potential confounding factors, CBD exploration was independently associated with higher peak postoperative levels of ALT and AST. We further evaluated the systemic inflammatory response via measuring peak postoperative WBC counts. The peak postoperative WBC counts were not significantly different between the two groups. In addition, no significant correlation between peak ALT and peak WBC counts was observed in the present study. Consequently, these data demonstrated that CBD exploration significantly exacerbated post-hepatectomy liver injury, which was not associated with systemic inflammatory response. We inferred that CBD exploration may induce an excessive local inflammatory response in the remnant liver, which contributed to the aggravated post-hepatectomy liver injury [17] . However, it is difficult to obtain liver tissue samples for histological and inflammatory cytokines analysis in the clinical setting. Accordingly, the future animal studies exploring the underlying mechanisms are warranted. In contrast to the significant elevation of peak postoperative transaminase levels in LLHCBDE group, peak postoperative levels of t-Bil and PT-INR demonstrated no statistically significant differences between the two groups. As alterations in t-Bil and PT-INR are considered to significantly impact liver regeneration capacity [18] , it appeared that CBD exploration did not adversely affect the regeneration potential after LLH. It should be noted, however, that the current conclusion remains preliminary. The rate of liver regeneration after left hemihepatectomy was significantly lower than that after right hemihepatectomy [19] . Thus, it may be speculated that serum t-Bil and PT-INR failed to demonstrate the intergroup disparities in regenerative potential post-left hemihepatectomy in the current study. Futhermore, volumetric analysis was not feasible due to incomplete imaging series in this retrospective cohort [20] . The overall biliary leakage rate in our study was 8%, with 8.3% in the LLH group and 8.6% in the LLHCBDE group, which is well controlled when compared with previous studies [21–22] . The incidence of biliary leakage showed no statistically significant differences between the two groups, suggesting CBD exploration did not increase the rate of biliary leakage after LLH. In fact, the most common site of biliary leakage after LLH was the liver section, irrespective of CBD exploration [23–24] . In this study, we identified only one case of biliary leakage originating from the choledochotomy site in the LLHCBDE group. Further multivariate logistic regression analysis revealed that period of less than 1 month between operative time and the latest episode of acute cholangitis and intraoperative blood loss were two independent risk factors for the development of postoperative biliary leakage. A shorter interval (< 1 month) between LLH and the latest episode of acute cholangitis was associated with a significantly higher incidence of postoperative biliary leakage, which was consistent with the results of a study by Li SQ et al [25] . Left-sided intrahepatic bile duct stones may induce repeated attacks of segmental cholangitis. During the acute phase, edema and abscesses within the liver parenchyma and intrahepatic bile ducts inhibit healing of the inflamed bile duct stump at the raw surface after LLH. Subsequently, necrosis developing in these bile duct stumps may lead to biliary leakage. Thus, in patients with acute cholangitis, LLH should be deferred for a minimum of 1 month after resolution of infection. There are some limitations to this study. First, this study was based on a retrospective review of patients at a single institution. Second, the number of simple LLH cases was relatively small, but this study included the maximum sample size of LLH in patients with left-sided intrahepatic bile duct stones. In conclusion, this study reveals significant differences in clinical outcomes after LLH with and without CBD exploration, emphasizing the need to classify the two procedures into different surgical categories. When performing LLH concomitant with CBD exploration, surgeons must pay more attention to preventing postoperative liver injury. Declarations Acknowledgments We would like to thank Dr Zeng Liang for his help in preparing figures. Author contributions ZW and XW designed the study and wrote the manuscript. LW and XL collected the data. RW analyzed the data. All authors read and approved the final manuscript. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The study was approved by the Ethics Committee of First affiliated hospital of Nanchang University (approval number 2024CDYFYYLK(12-114)), and it satisfies the Declaration of Helsinki standard. Informed consent was obtained from all participants. Clinical trial number Not applicable. Funding This work was supported by the grants from National Nature Science Foundation of China (No.82160127), Science and Technology Development Program of Jiangxi Provincial Health Commission (No.202210407), Key Research and Development Program of Jiangxi Province (No. 20203BBGL73142) and Natural science foundation of Jiangxi Province (No.20202BAB206016). Consent for publication Not applicable. Disclosure The authors have no conflicts of interest or financial ties to disclose. References Chen XP, Zhang WJ, Cheng B, Yu YL, Peng JL, Bao SH, Tong CG, Zhao J. Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study. Int J Surg. 2024;110(4):1896-903. Das S, Jha AK, Kumar M. Laparoscopic common bile duct exploration in cases of common bile duct stones: can LCBDE replace ERCP as first line treatment. Am J Surg. 2023;226(2):290. Jin RA, Wang Y, Yu H, Liang X, Cai XJ. Total laparoscopic left hepatectomy for primary hepatolithiasis: eight-year experience in a single center. Surgery. 2016; 159(3):834-41. Liao KX, Chen L, Ma L, Cao L, Shu J, Sun TG, Li XS, Wang XJ, Li JW, Chen J, et al. Laparoscopic middle-hepatic vein-guided anatomical hemihepatectomy in the treatment of hepatolithiasis: a 10-year case study. Surg Endosc. 2022;36(2):881-8. Spetzler VN, Schepers M, Pinnschmidt HO, Fischer L, Nashan B, Li J. The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications, preoperative chemotherapy, and surgical procedures. Hepatobiliary Surg Nutr. 2019;8(2):101-10. Wan Z, Wang XZ, Fu NT, Li Y, Xiao WD, Zheng DH. Primary closure versus T-tube drainage following laparoscopic common bile duct exploration in patients with previous biliary surgery. Am Surg. 2021;87(1):50-5. Cho SC, Kim JH. Laparoscopic left hemihepatectomy using the hilar plate-first approach. World J Surg. 2022;46(10):2454-8. Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, Fan ST, Yokoyama Y, Crawford M, Makuuchi M, et al. Biliary leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the international study group of liver surgery. Surgery. 2011;149(5):680-8. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, Santibanes ED, Pekolj J, Slankamenac KS, Bassi C, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-96. Li G, Walco JP, Mueller DA, Wanderer JP, Freundlich RE. Reliability of the ASA physical status classification system in predicting surgical morbidity: a retrospective analysis. J Med Syst. 2021;45(9):83. Ma ZL, Zhou J, Yao L, Dai YX, Xie WC, Song GD, Meng HB, Xu B, Zhang T, Zhou B, et al. 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. 2022;36(1):718-27. Li Y, Wu TX, Wang JY. Comparison of laparoscopic cholecystectomy outcome with laparoscopic versus endoscopic bile duct exploration in elderly patients with cholecystolithiasis and choledocholithiasis. J Coll Physicians Surg Pak. 2025;35(5):562-7. Fu XT, Tang Z, Chen JF, Shi YH, Liu WR, Gao Q, Ding GY, Song K, Wang YX, Zhou J, et al. Laparoscopic hepatectomy enhances recovery for small hepatocellular carcinoma with liver cirrhosis by postoperative inflammatory response attenuation: a propensity score matching analysis with a conventional open approach. Surg Endosc. 2021;35(2):910-20. Fang YT, Huang J, Xu LZ, Xu Q, Tang XG, Zheng KP, Hu W, Liu JH, Wang JY, Liu TD, et al. Laparoscopic anatomical left hemihepatectomy guided by middle hepatic vein in the treatment of left hepatolithiasis with a history of upper abdominal surgery. Surg Endosc. 2023;37(12):9116-24. Takagi T, Yokoyama Y, Kokuryo T, Ebata T, Ando M, Nagino M. A clear difference between the outcomes after a major hepatectomy with and without an extrahepatic bile duct resection. World J Surg. 2017;41(2):508-15. Matsumi J, Sato T. Protective effect propofol compared with sevoflurane on liver function after hepatectomy with pringle maneuver: a randomized clinical trial. PLOS One. 2023;18(8):e0290327. Takagi T, Yokoyama Y, Kokuryo T, Yamaguchi J, Nagino M. Perturbation of liver regeneration following major hepatectomy with choledochojejunostomy. Br J Surg. 2015;102(11):1410-7. Nomura Y, Akiba J, Yano H, Akagi Y, Hisaka T. Fatty liver does not increase the risk of postoperative liver damage following hepatectomy. Anticancer Res 2022;42(8):4159-64. Hamm A, Hidding S, Mokry T, Radeleff B, Mehrabi A, Buchler MW, Schneider M, Schmidt T. Postoperative liver regeneration does not elicit recurrence of colorectal cancer liver metastases after major hepatectomy. Surg Oncol. 2020;35:24-33. Bednarsch J, Bluthner E, Malinowski M, Seehofer D, Pratschke J, Stockmann M. Regeneration of liver function capacity after partial liver resection is impaired in case of postoperative bile leakage. World J Surg. 2016;40(9):2221-8. Huang L, Lai JL, Liao CY, Wang DF, Wang YD, Tian YF, Chen S. Classification of left-side hepatolithiasis for laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy. Surg Endosc. 2023;37(7):5737-51. Pan SB, Wu CL, Zhou DC, Xiong QR, Geng XP, Hou H. Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: study protocol for a randomized controlled trial. Trials. 2024; 25(1):137. Liao CY, Wang DF, Huang L, Bai YN, Yan ML, Zhou SQ, Qiu FN, Lai ZD, Wang YD, Tian YF, et al. A new strategy of laparoscopic anatomical hemihepatectomy guidided by the middle hepatic vein combined with trashepatic duct lithotomy for complex hemihepatolithiasis: a propensity score matching study. Surgery 2021;170(1):18-29. Nagano Y, Togo S, Tanaka K, Masui H, Endo I, Sekido H, Nagahori K, Shimada H. Risk factors and management of bile leakage after hepatic resection. World J Surg. 2003;27(6):695-8. Li SQ, Liang LJ, Peng BG, Lu MD, Lai JM, Li DM. Biliary leakage after hepatectomy for hepatolithiasis: risk factors and management. Surgery 2007;141:340-5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Nov, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 06 Oct, 2025 Reviews received at journal 05 Oct, 2025 Reviews received at journal 01 Oct, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviews received at journal 06 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers invited by journal 24 Jul, 2025 Editor invited by journal 17 Jul, 2025 Editor assigned by journal 21 Jun, 2025 Submission checks completed at journal 21 Jun, 2025 First submitted to journal 12 Jun, 2025 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. 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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-6883130","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":490347351,"identity":"9b807ecf-2240-42d5-9747-64a7a2649b32","order_by":0,"name":"Zhen Wan","email":"","orcid":"","institution":"the First Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Wan","suffix":""},{"id":490347352,"identity":"be083189-fa0a-4c36-aa0c-492ef00075af","order_by":1,"name":"Lei Wu","email":"","orcid":"","institution":"the First Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Wu","suffix":""},{"id":490347353,"identity":"1c2205b4-c891-4ea3-9a84-010bd6e23671","order_by":2,"name":"Xiang Liu","email":"","orcid":"","institution":"the First Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Liu","suffix":""},{"id":490347354,"identity":"354ae9fc-5aae-4a05-ac9e-bbdff980bd6a","order_by":3,"name":"Renhua Wan","email":"","orcid":"","institution":"the First Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Renhua","middleName":"","lastName":"Wan","suffix":""},{"id":490347357,"identity":"0394b010-2823-4777-b97b-0894f617406c","order_by":4,"name":"Xuzhen Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBACPmYEm/EAkJBjY28+gFcLG1hLAoQDVGpgzMdzLAG/FgY0LYnzJHIU8Gth5zF8XPnjnrw5/9kDB37u+JPexpDDwPCjYhseh/EYG55JKDbcOSMv4WDvGYPcNoazBxh7ztzGo4UtTbIhIYFxww0egwO8bUAtjH0JzIxteLWk/wRqsd9w/ozBwb9tBulAew0IaGE+xgjUkrjhQI7BYaAtCWxshLUclmxIS0jecCMv4bBsm7FhGw9bwkF8fuHnP9j4scEmwXbD+bMHH75tk5OXn//44IMfFbi1IAEeBPMAMepRtYyCUTAKRsEoQAYAWjVUbjJwPYIAAAAASUVORK5CYII=","orcid":"","institution":"the First Affiliated Hospital of Nanchang University","correspondingAuthor":true,"prefix":"","firstName":"Xuzhen","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-06-12 20:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6883130/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6883130/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03321-w","type":"published","date":"2025-11-28T15:58:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87801764,"identity":"44aa4a14-6787-4622-a3fa-4ba5f72e7686","added_by":"auto","created_at":"2025-07-29 07:54:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":118144,"visible":true,"origin":"","legend":"\u003cp\u003eLeft-sided intrahepatic bile duct stones with and without choledocholithiasis. A The stones are located primarily in the left intrahepatic bile duct; B Besides the stones located in the left intrahepatic bile duct, some stones are also found in CBD. LHB, left hepatic bile duct; CBD, common bile duct.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6883130/v1/47fd449d3665b91d956fa737.jpg"},{"id":87801757,"identity":"95fd294c-d770-4ca9-8941-c1b1fec95cd2","added_by":"auto","created_at":"2025-07-29 07:54:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79407,"visible":true,"origin":"","legend":"\u003cp\u003eSimple LLH for left-sided intrahepatic bile duct stones without choledocholithiasis. A An obvious stone (arrow) was observed above the main trunk of LHB; B Three-dimensional visualization of biliary tree demonstrated clearly the stone above the main trunk of LHB and the dilated left intrahepatic bile duct; C Glissonean pedicle transection.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6883130/v1/41bca4ffb85ea524f00af4eb.jpg"},{"id":97179402,"identity":"53173e73-d68b-4ac6-8d3e-6d478e8df0ec","added_by":"auto","created_at":"2025-12-01 16:15:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1008249,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6883130/v1/41295a62-1cd6-4893-a058-795a62811c7e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical outcomes after laparoscopic left hemihepatectomy with and without biliary duct exploration","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLaparoscopic left hemihepatectomy (LLH)\u003csup\u003e[1]\u003c/sup\u003e with common bile duct (CBD) exploration\u003csup\u003e[2]\u003c/sup\u003e is usually performed for left-sided intrahepatic bile duct stones combined with choledocholithiasis. This procedure is markedly different from simple LLH without CBD exploration regarding the operative invasiveness and the incidence of postoperative complications. However, the two operative procedures may be classified in the same category\u003csup\u003e[3\u0026ndash;4]\u003c/sup\u003e. To our knowledge, there are no previous studies comparing the surgical outcomes after LLH with and without CBD exploration.\u003c/p\u003e\u003cp\u003eCBD exploration following LLH usually involves several operative steps including choledochotomy, choledochoscopic stone extraction and CBD closure. The impact of these procedures on postoperative liver function after LLH has not been well studied. Moreover, biliary leakage is still a major postoperative complication after both hepatectomy\u003csup\u003e[5]\u003c/sup\u003e and CBD exploration\u003csup\u003e[6]\u003c/sup\u003e. Whether concomitant CBD exploration increases the incidence of biliary leakage in patients undergoing LLH remains poorly characterized.\u003c/p\u003e\u003cp\u003eThis retrospective study aims to compare the clinical outcome including perioperative data and follow-up results between the two operative procedures, LLH with and without CBD exploration. Only patients with left-sided intrahepatic bile duct stones were enrolled in the LLH group to balance the baseline characteristics between the two groups. We further evaluate the impact of CBD exploration on postoperative liver function and the incidence of biliary leakage after LLH.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients Selection\u003c/h2\u003e\u003cp\u003eThe retrospective study included patients with left-sided intrahepatic bile duct stones who underwent simple LLH or LLH with CBD exploration at the First affiliated hospital of Nanchang University from January 2020 to June 2024. All patients received preoperative abdominal magnetic resonance imaging (MRI) or computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP). Inclusion criteria were as follows: (1) left-sided intrahepatic bile duct stones and LLH; (2) presence or absence of stones within CBD; (3) Child-Pugh class A or B liver function. Exclusion criteria were as follows: (1) Child-Pugh class C liver function; (2) presence of biliary tumor; (3) suffering from acute cholangitis or severe obstructive jaundice; (4) need to undergo bilioenteric anastomosis; (5) lack of complete case data. This study was approved by the ethics committee of the First affiliated hospital of Nanchang University.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Procedures\u003c/h3\u003e\n\u003cp\u003eBased on stone location and distribution in bile ducts, enrolled patients were classified into two groups: LLH group and LLH with CBD exploration (LLHCBDE) group. LLH group exhibited stones exclusively within the left intrahepatic bile ducts, whereas LLHCBDE group presented with concomitant intrahepatic and CBD stones (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eUnder general anesthesia, patients were placed in a supine position, with the two legs separating. CO\u003csub\u003e2\u003c/sub\u003e pneumoperitoneum pressure was maintained at 12\u0026ndash;14 mmHg. Five trocars were placed: one 10 mm trocar was inserted through the umbilicus for telescope; two 12 mm trocars were located at the right and left midclavicular line; two 5 mm trocars were situated at the right and left subcostal. The round ligament, falciform ligament, left triangular ligament, and left coronary ligament were sequentially dissected. The left branch of the portal vein and left hepatic artery were dissected and divided. Alternatively, the left glissonian pedicle as en bloc was isolated from the liver parenchyma and transected using an endovascular stapler (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003csup\u003e[7]\u003c/sup\u003e. The ischemic demarcation line was marked on the liver surface using an electrocautery hook. An occlusion band was placed at the first hepatic portal for Pringle maneuver (15 min occlusion followed by 5 min reperfusion). Liver parenchyma was transected along the ischemic line from the foot to the head. The surgeon clamped and squeezed the liver parenchyma using a harmonic scalpel while the assistant used the aspirator to gently push the hepatic parenchyma to dissect blood vessels and bile ducts. Blood vessels or bile ducts were clipped with Hem-o-lok clips and cut off. When the root of the left hepatic vein (LHV) was exposed, the trunk of LHV and the remaining hepatic parenchyma was removed with an endovascular stapler.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFor patients combined with CBD stones, choledochotomy and stone extraction was performed. A longitudinal CBD incision was made and choledochoscope was inserted to examine the common bile duct. Under the guidance of choledochoscope, common bile duct stones were removed using a retrieval basket as possible. If stones were impacted, electrohydraulic lithotripsy in combination with repeated saline irrigation was necessary. After complete removal of CBD stone, T-tube drainage was routinely performed.\u003c/p\u003e\n\u003ch3\u003eClinical Outcomes\u003c/h3\u003e\n\u003cp\u003eOperation time, Pringle maneuver time, intraoperative blood loss and conversion rate to open surgery were recorded. Perioperative outcomes included duration of oral intake and postoperative hospital stay, reoperation rate and 30-day mortality. Postoperative complications such as intra-abdominal hemorrhage and biliary leakage were documented. Biliary leakage was defined as elevated bilirubin level in drainage fluid on or after postoperative day 3 or requiring radiologic or operative intervention for biliary peritonitis\u003csup\u003e[8]\u003c/sup\u003e. The Clavien-Dindo system was used to classify postoperative complications and the major complications were defined as Clavien-Dindo classification Ⅲ, Ⅳ and ⅴ\u003csup\u003e[9]\u003c/sup\u003e. Laboratory parameters, including peak postoperative values of white blood cell (WBC), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (t-Bil) and prothrombin time-international normalized ratio (PT-INR) were measured.\u003c/p\u003e\u003cp\u003ePatients were followed up at clinics every 3 months for the first 2 years and every 6 months in the following years. Routine blood examination, liver function test, abdominal ultrasound and MRCP were performed to evaluate the recurrence of bile duct stone. Stone recurrence was defined as detection of bile duct stones by CT/MRI at least 6 months after LLH.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS 29.0 (Chicago, IL, USA). Normally and non-normally distributed continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and median (interquartile range, IQR) respectively, and were compared using \u003cem\u003et\u003c/em\u003e-test and Mann-Whitney \u003cem\u003eU\u003c/em\u003e test. Categorical data were presented as numbers (percentages) and were analyzed with chi-square test and Fisher\u0026rsquo;s exact test. A correlation between two variables was evaluated using a Spearman rank correlation test. Multivariable linear regression models incorporating preoperative clinical data and intraoperative variables were performed to identify independent predictors of peak postoperative ALT/AST levels. Multivariate logistic regression analysis was performed to identify independent risk factors for development of biliary leakage. All tests were two-sided and a \u003cem\u003eP\u003c/em\u003e value less than 0.05 was considered statistically significant. In addition, odds ratio (OR) with 95% confidence intervals (CI) were calculated to describe the uncertainty of the estimation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u0026rsquo; characteristics\u003c/h2\u003e\u003cp\u003eThe study included a total of 176 patients with left-sided intrahepatic bile duct stones, of which 36 patients were in the LLH group and 140 patients were in the LLHCBDE group. Baseline characteristics, including age, sex, BMI, Child-Pugh classification, ASA score\u003csup\u003e[10]\u003c/sup\u003e, comorbidities, history of prior upper abdominal surgery and a period of less than 1 month between LLH and the latest episode of acute cholangitis are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Only history of prior upper abdominal surgery was found to be significantly different between the two groups.\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\u003ePatients\u0026rsquo; characteristics\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLLH group (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLLHBE group (n\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (n(%))\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.929\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (24.3%)\u003c/p\u003e\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\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106 (75.7%)\u003c/p\u003e\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\u003eAge(years) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.39\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.19\u0026thinsp;\u0026plusmn;\u0026thinsp;5.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.1\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) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.376\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChild-A disease n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e140 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA class n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.474\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅠ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (36.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (29.3%)\u003c/p\u003e\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\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (58.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91 (65%)\u003c/p\u003e\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\u003eⅢ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (5.7%)\u003c/p\u003e\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\u003ePresence of comorbidity n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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\u003eDiabetes mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.883\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\u003e8 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.768\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCardiac disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (8.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.847\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious upper abdominal surgery n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (21.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA period of less than 1 month between LLH and the latest episode of acute cholangitis n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (19.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (25.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.435\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\u003eBMI, body mass index; ASA, American society of anesthesiologists.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePerioperative outcomes\u003c/h3\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the LLHCBDE group had longer operative time (190 (180\u0026ndash;200) vs. 165 (151.25\u0026ndash;170) min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and prolonged duration of Pringle maneuver (30 (26\u0026ndash;32) vs. 28 (26\u0026ndash;30) min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047) compared to the LLH group. No differences were observed with respect to intraoperative blood loss, blood transfusion rate, or rate of conversion to laparotomy.\u003c/p\u003e\u003cp\u003eThe LLHCBDE group had longer time to oral intake (2 (2\u0026ndash;3) vs. 2 (2\u0026ndash;2) days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and prolonged postoperative hospital stays (8 (7.25\u0026ndash;9) vs. 7 (6\u0026ndash;7) days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Strikingly, the LLHCBDE group did not demonstrate higher rate of biliary leakage (8.6% vs. 8.3%, OR 1.031, 95% CI 0.275\u0026ndash;3.867, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000) compared to the LLH group. There were also no significant differences in the incidences of intra-abdominal hemorrhage and major complication between the two groups. No significant differences in reoperation rate and hospital mortality were observed between the two groups.\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\u003ePerioperative and follow-up outcomes between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLLH\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLLHBE (n\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating time(min) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e165 (151.25,170)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e190 (180,200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of Pringle maneuver (min) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (26,30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (26,32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative blood loss(ml) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e200 (165,245)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200 (200,250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative transfusion n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime to oral intake (d) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (2,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2,3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative hospital stay (d) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (6,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (7.25,9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMajor complications n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (3.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.948\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.630 (0.117\u0026ndash;3.386)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBile leakage n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (8.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.031 (0.275\u0026ndash;3.867)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntra-abdominal hemorrhage n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.766 (0.077\u0026ndash;7.594)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReoperation n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital mortality n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\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\u003e2 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (17.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.696 (0.833\u0026ndash;16.402)\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\u003eIQR, interquartile range.\u003c/p\u003e\n\u003ch3\u003eFollow-Up outcomes\u003c/h3\u003e\n\u003cp\u003eAll patients were followed up for at least 6 months. The LLHCBDE group had higher stone recurrence rates (17.9% vs. 5.6%, OR 3.696, 95% CI 0.833\u0026ndash;16.402, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) compared to the LLH group.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLaboratory Data\u003c/h2\u003e\u003cp\u003eThe two groups showed no differences in the preoperative levels of WBC, ALT, AST, t-Bil and PT-INR, or peak postoperative values of WBC, t-Bil and PT-INR (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, the LLHCBDE group had significantly higher peak postoperative levels of ALT (267.7 (235.1\u0026ndash;328.7) vs. 201.6 (186.3\u0026ndash;250.0) U/L, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and AST (307.1 (256.8\u0026ndash;354.4) vs. 188.3 (176.8\u0026ndash;234.7) U/L, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Further Spearman rank correlation tests revealed no significant correlations between peak ALT and peak WBC (rs\u0026thinsp;=\u0026thinsp;0.009, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.902) or preoperative ALT (rs\u0026thinsp;=\u0026thinsp;0.04, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.595). Likewise, no correlation between peak AST and peak WBC (rs\u0026thinsp;=\u0026thinsp;0.041, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.589) or preoperative AST (rs\u0026thinsp;=\u0026thinsp;0.112, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.140) was identified.\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\u003ePreoperative and postoperative laboratory data\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLLH (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLLHBE (n\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op Hb (g/L) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e123.94\u0026thinsp;\u0026plusmn;\u0026thinsp;7.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125.06\u0026thinsp;\u0026plusmn;\u0026thinsp;7.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.429\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op WBC count (/\u0026micro;L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4665 (4298,5275)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4860 (4560,5350)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op ALT (U/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.3 (12.7,29.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.7 (15.8,25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.757\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op AST (U/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.2 (16.1,26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.6 (17.6,28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op t-bil (\u0026micro;mol/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.75 (7.8,10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.9 (7.6,11.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.444\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op PT-INR (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.98 (0.94,1.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.98 (0.96,1.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.213\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak postoperative WBC count (/mL) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10680 (10120,11355)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11015 (10435,11443)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak postoperative ALT level (U/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e201.6 (186.3,250.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e267.7 (235.1,328.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak postoperative AST level (U/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e188.3 (176.8,234.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e307.1 (256.8,354.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak postoperative t-bil level (\u0026micro;mol/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.4 (18.4,26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.6 (15.6,25.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak postoperative PT-INR level (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.095 (1.05,1.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.11 (1.08,1.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.151\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\u003eHb, Hemoglobin; WBC, white blood count; Pre-op, pre-operative; ALT, alanine aminotransferase; AST aspartate aminotransferase; t-bil, total bilirubin; PT-INR, prothrombin time-international normalized ratio.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMultivariate linear regression analyses for peak postoperative ALT/AST values\u003c/h2\u003e\u003cp\u003eSix clinical variables were used in the multivariate linear regression analysis for peak postoperative ALT value (forward stepwise method). The contributions of all significant factors in the final model are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Apart from period of less than 1 month between operative time and the latest episode of acute cholangitis, history of prior upper abdominal surgery and duration of Pringle maneuver, the procedure of CBD exploration (β\u0026thinsp;=\u0026thinsp;0.313, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was significantly associated with peak postoperative ALT value. Similarly, the procedure of CBD exploration was also confirmed to be associated with peak postoperative AST value (β\u0026thinsp;=\u0026thinsp;0.359, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\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\u003eMultivariable linear regression of peak postoperative transaminase levels\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak ALT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePeak AST\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdj.R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eAdj.R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.490\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious upper abdominal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrevious upper abdominal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eperiod of less than 1 month between LLH time and the latest episode of acute cholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eperiod of less than 1 month between LLH time and the latest episode of acute cholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLLHCBDE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLLHCBDE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of Pringle maneuver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.361\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDuration of Pringle maneuver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative blood loss\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.319\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLLHCBDE: laparoscopic left hemihepatectomy with common bile duct exploration.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eUnivariate and multivariate analyses for biliary leakage\u003c/h2\u003e\u003cp\u003eIn the univariate analysis, we found that only intraoperative blood loss had statistical significance. In the multivariate analysis that included the factors with a \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.200 in the univariate analysis, a period of less than 1 month between LLH and the latest episode of acute cholangitis (OR 4.362, 95%CI 1.126\u0026ndash;16.904, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033) and intraoperative blood loss (OR 1.022, 95%CI 1.013\u0026ndash;1.031, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were identified to be independent risk factors for biliary leakage (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\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\u003eUnivariate and multivariate analysis for risk factors of bile leakage\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBile leakage\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo bile leakage (n\u0026thinsp;=\u0026thinsp;161)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUnivariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMultivariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR (95%CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male/female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41/120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.464\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.761\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.901\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious upper abdominal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4/11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28/133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.589\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eperiod of less than 1 month between LLH time and the latest episode of acute cholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7/8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36/125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.075\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.362 (1.126\u0026ndash;16.904)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op AST (U/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.6 (17.6,26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.4 (16.9,28.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.994\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op ALT (U/L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.6 (14.3,36.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.6 (15.7,24.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.090\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-op WBC (/\u0026micro;L) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4660 (4415,5105)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4860 (4550,5350)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.292\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLLH/LLHCBDE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33/128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating time (min) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e180 (170,185)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e185 (170,200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.470\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative blood loss (ml) (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e350 (250,400)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200 (180,250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.022 (1.013\u0026ndash;1.031)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003eLLH: laparoscopic left hemihepatectomy.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLLH with CBD exploration is a standard treatment modality for patients with left-sided intrahepatic bile duct stones and choledocholithiasis. In general, CBD exploration after LLH consists of several operative steps such as choledochotomy, choledochoscopic stone extraction and CBD closure. CBD stones were removed using a retrieval basket as possible. If large impacted stones in common bile duct were difficult to extract, electrohydraulic lithotripsy were used\u003csup\u003e[11]\u003c/sup\u003e. CBD exploration will prolong the surgical duration and increase the complexity of the operation. Moreover, choledochoscopic stone extraction and bile spillage during surgery may trigger an excessive intrahepatic cytokine release and systemic endotoxemia, contributing to impaired postoperative recovery\u003csup\u003e[12\u0026ndash;13]\u003c/sup\u003e. Therefore, CBD exploration may have a major adverse effect on perioperative outcomes after LLH. However, the two operative procedures (LLH vs. LLHCBDE) were sometimes classified into the same category in previous studies\u003csup\u003e[3\u0026ndash;4,14]\u003c/sup\u003e. The current study demonstrated for the first time that LLHCBDE group exhibited significantly prolonged operative time, longer time to oral intake, increased postoperative hospital stays and higher stone recurrence rate compared to the LLH group. These results suggest that LLH with CBD exploration is fundamentally distinct from LLH.\u003c/p\u003e\u003cp\u003eThe type of disease for simple LLH in this study was limited to left-sided intrahepatic bile duct stones. The patients included in the LLHCBDE group had concomitant intrahepatic and CBD stones. To ensure comparable baseline characteristics, we excluded patients with hepatocellular carcinoma, colorectal liver metastases, or hemangioma from the simple LLH group. Additionally, patients with perihilar cholangiocarcinoma were also excluded as extrahepatic bile duct resection and subsequent choledocho-jejunostomy was required. Extrahepatic bile duct resection and choledocho-jejunostomy aggravated post-operative liver injury and perturbed the liver regeneration process\u003csup\u003e[15]\u003c/sup\u003e. The number of patients with exclusive left-sided intrahepatic bile duct stones is relatively small compared to that of patients with concomitant left-sided intrahepatic bile duct stones and choledocholithiasis in most institutions. As the author\u0026rsquo;s institution is a high volume center for left-sided intrahepatic bile duct stones and has large number of cases of LLH without CBD exploration, the surgical outcomes could be compared between the two groups within our single institution.\u003c/p\u003e\u003cp\u003ePeak postoperative values of ALT and AST reflect the extent of surgical liver injury following hepatectomy\u003csup\u003e[16]\u003c/sup\u003e. The study revealed significantly higher peak postoperative levels of ALT and AST in the LLHCBDE group than in the LLH group. The observed difference can not be simply attributed to the procedure of CBD exploration, as history of prior upper abdominal surgery and intraoperative factors including operative time, duration of Pringle maneuver and volume of intraoperative blood loss differed significantly between the two groups. In the multivariate stepwise linear regression model adjusted for potential confounding factors, CBD exploration was independently associated with higher peak postoperative levels of ALT and AST. We further evaluated the systemic inflammatory response via measuring peak postoperative WBC counts. The peak postoperative WBC counts were not significantly different between the two groups. In addition, no significant correlation between peak ALT and peak WBC counts was observed in the present study. Consequently, these data demonstrated that CBD exploration significantly exacerbated post-hepatectomy liver injury, which was not associated with systemic inflammatory response. We inferred that CBD exploration may induce an excessive local inflammatory response in the remnant liver, which contributed to the aggravated post-hepatectomy liver injury\u003csup\u003e[17]\u003c/sup\u003e. However, it is difficult to obtain liver tissue samples for histological and inflammatory cytokines analysis in the clinical setting. Accordingly, the future animal studies exploring the underlying mechanisms are warranted.\u003c/p\u003e\u003cp\u003eIn contrast to the significant elevation of peak postoperative transaminase levels in LLHCBDE group, peak postoperative levels of t-Bil and PT-INR demonstrated no statistically significant differences between the two groups. As alterations in t-Bil and PT-INR are considered to significantly impact liver regeneration capacity\u003csup\u003e[18]\u003c/sup\u003e, it appeared that CBD exploration did not adversely affect the regeneration potential after LLH. It should be noted, however, that the current conclusion remains preliminary. The rate of liver regeneration after left hemihepatectomy was significantly lower than that after right hemihepatectomy\u003csup\u003e[19]\u003c/sup\u003e. Thus, it may be speculated that serum t-Bil and PT-INR failed to demonstrate the intergroup disparities in regenerative potential post-left hemihepatectomy in the current study. Futhermore, volumetric analysis was not feasible due to incomplete imaging series in this retrospective cohort\u003csup\u003e[20]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe overall biliary leakage rate in our study was 8%, with 8.3% in the LLH group and 8.6% in the LLHCBDE group, which is well controlled when compared with previous studies\u003csup\u003e[21\u0026ndash;22]\u003c/sup\u003e. The incidence of biliary leakage showed no statistically significant differences between the two groups, suggesting CBD exploration did not increase the rate of biliary leakage after LLH. In fact, the most common site of biliary leakage after LLH was the liver section, irrespective of CBD exploration\u003csup\u003e[23\u0026ndash;24]\u003c/sup\u003e. In this study, we identified only one case of biliary leakage originating from the choledochotomy site in the LLHCBDE group. Further multivariate logistic regression analysis revealed that period of less than 1 month between operative time and the latest episode of acute cholangitis and intraoperative blood loss were two independent risk factors for the development of postoperative biliary leakage.\u003c/p\u003e\u003cp\u003eA shorter interval (\u0026lt;\u0026thinsp;1 month) between LLH and the latest episode of acute cholangitis was associated with a significantly higher incidence of postoperative biliary leakage, which was consistent with the results of a study by Li SQ et al\u003csup\u003e[25]\u003c/sup\u003e. Left-sided intrahepatic bile duct stones may induce repeated attacks of segmental cholangitis. During the acute phase, edema and abscesses within the liver parenchyma and intrahepatic bile ducts inhibit healing of the inflamed bile duct stump at the raw surface after LLH. Subsequently, necrosis developing in these bile duct stumps may lead to biliary leakage. Thus, in patients with acute cholangitis, LLH should be deferred for a minimum of 1 month after resolution of infection.\u003c/p\u003e\u003cp\u003eThere are some limitations to this study. First, this study was based on a retrospective review of patients at a single institution. Second, the number of simple LLH cases was relatively small, but this study included the maximum sample size of LLH in patients with left-sided intrahepatic bile duct stones.\u003c/p\u003e\u003cp\u003eIn conclusion, this study reveals significant differences in clinical outcomes after LLH with and without CBD exploration, emphasizing the need to classify the two procedures into different surgical categories. When performing LLH concomitant with CBD exploration, surgeons must pay more attention to preventing postoperative liver injury.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Dr Zeng Liang for his help in preparing figures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZW and XW designed the study and\u0026nbsp;wrote the manuscript. LW and XL collected the data. RW analyzed the data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of First affiliated hospital of Nanchang University (approval number\u0026nbsp;2024CDYFYYLK(12-114)), and it satisfies the Declaration of Helsinki standard. Informed consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the grants from National Nature Science Foundation of China (No.82160127), Science and Technology Development Program of Jiangxi Provincial Health Commission (No.202210407), Key Research and Development Program of Jiangxi Province (No. 20203BBGL73142) and Natural science foundation of Jiangxi Province (No.20202BAB206016).\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\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest or financial ties to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChen XP, Zhang WJ, Cheng B, Yu YL, Peng JL, Bao SH, Tong CG, Zhao J. Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study. Int J Surg. 2024;110(4):1896-903.\u003c/li\u003e\n\u003cli\u003eDas S, Jha AK, Kumar M. Laparoscopic common bile duct exploration in cases of common bile duct stones: can LCBDE replace ERCP as first line treatment. Am J Surg. 2023;226(2):290.\u003c/li\u003e\n\u003cli\u003eJin RA, Wang Y, Yu H, Liang X, Cai XJ. Total laparoscopic left hepatectomy for primary hepatolithiasis: eight-year experience in a single center. Surgery. 2016; 159(3):834-41.\u003c/li\u003e\n\u003cli\u003eLiao KX, Chen L, Ma L, Cao L, Shu J, Sun TG, Li XS, Wang XJ, Li JW, Chen J, et al. Laparoscopic middle-hepatic vein-guided anatomical hemihepatectomy in the treatment of hepatolithiasis: a 10-year case study. Surg Endosc. 2022;36(2):881-8.\u003c/li\u003e\n\u003cli\u003eSpetzler VN, Schepers M, Pinnschmidt HO, Fischer L, Nashan B, Li J. The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications, preoperative chemotherapy, and surgical procedures. Hepatobiliary Surg Nutr. 2019;8(2):101-10.\u003c/li\u003e\n\u003cli\u003eWan Z, Wang XZ, Fu NT, Li Y, Xiao WD, Zheng DH. Primary closure versus T-tube drainage following laparoscopic common bile duct exploration in patients with previous biliary surgery. Am Surg. 2021;87(1):50-5.\u003c/li\u003e\n\u003cli\u003eCho SC, Kim JH. Laparoscopic left hemihepatectomy using the hilar plate-first approach. World J Surg. 2022;46(10):2454-8.\u003c/li\u003e\n\u003cli\u003eKoch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, Fan ST, Yokoyama Y, Crawford M, Makuuchi M, et al. Biliary leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the international study group of liver surgery. Surgery. 2011;149(5):680-8.\u003c/li\u003e\n\u003cli\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, Santibanes ED, Pekolj J, Slankamenac KS, Bassi C, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-96.\u003c/li\u003e\n\u003cli\u003eLi G, Walco JP, Mueller DA, Wanderer JP, Freundlich RE. Reliability of the ASA physical status classification system in predicting surgical morbidity: a retrospective analysis. J Med Syst. 2021;45(9):83.\u003c/li\u003e\n\u003cli\u003eMa ZL, Zhou J, Yao L, Dai YX, Xie WC, Song GD, Meng HB, Xu B, Zhang T, Zhou B, et al. 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. 2022;36(1):718-27.\u003c/li\u003e\n\u003cli\u003eLi Y, Wu TX, Wang JY. Comparison of laparoscopic cholecystectomy outcome with laparoscopic versus endoscopic bile duct exploration in elderly patients with cholecystolithiasis and choledocholithiasis. J Coll Physicians Surg Pak. 2025;35(5):562-7.\u003c/li\u003e\n\u003cli\u003eFu XT, Tang Z, Chen JF, Shi YH, Liu WR, Gao Q, Ding GY, Song K, Wang YX, Zhou J, et al. Laparoscopic hepatectomy enhances recovery for small hepatocellular carcinoma with liver cirrhosis by postoperative inflammatory response attenuation: a propensity score matching analysis with a conventional open approach. Surg Endosc. 2021;35(2):910-20.\u003c/li\u003e\n\u003cli\u003eFang YT, Huang J, Xu LZ, Xu Q, Tang XG, Zheng KP, Hu W, Liu JH, Wang JY, Liu TD, et al. Laparoscopic anatomical left hemihepatectomy guided by middle hepatic vein in the treatment of left hepatolithiasis with a history of upper abdominal surgery. Surg Endosc. 2023;37(12):9116-24.\u003c/li\u003e\n\u003cli\u003eTakagi T, Yokoyama Y, Kokuryo T, Ebata T, Ando M, Nagino M. A clear difference between the outcomes after a major hepatectomy with and without an extrahepatic bile duct resection. World J Surg. 2017;41(2):508-15.\u003c/li\u003e\n\u003cli\u003eMatsumi J, Sato T. Protective effect propofol compared with sevoflurane on liver function after hepatectomy with pringle maneuver: a randomized clinical trial. PLOS One. 2023;18(8):e0290327.\u003c/li\u003e\n\u003cli\u003eTakagi T, Yokoyama Y, Kokuryo T, Yamaguchi J, Nagino M. Perturbation of liver regeneration following major hepatectomy with choledochojejunostomy. Br J Surg. 2015;102(11):1410-7.\u003c/li\u003e\n\u003cli\u003eNomura Y, Akiba J, Yano H, Akagi Y, Hisaka T. Fatty liver does not increase the risk of postoperative liver damage following hepatectomy. Anticancer Res 2022;42(8):4159-64.\u003c/li\u003e\n\u003cli\u003eHamm A, Hidding S, Mokry T, Radeleff B, Mehrabi A, Buchler MW, Schneider M, Schmidt T. Postoperative liver regeneration does not elicit recurrence of colorectal cancer liver metastases after major hepatectomy. Surg Oncol. 2020;35:24-33.\u003c/li\u003e\n\u003cli\u003eBednarsch J, Bluthner E, Malinowski M, Seehofer D, Pratschke J, Stockmann M. Regeneration of liver function capacity after partial liver resection is impaired in case of postoperative bile leakage. World J Surg. 2016;40(9):2221-8.\u003c/li\u003e\n\u003cli\u003eHuang L, Lai JL, Liao CY, Wang DF, Wang YD, Tian YF, Chen S. Classification of left-side hepatolithiasis for laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy. Surg Endosc. 2023;37(7):5737-51.\u003c/li\u003e\n\u003cli\u003ePan SB, Wu CL, Zhou DC, Xiong QR, Geng XP, Hou H. Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: study protocol for a randomized controlled trial. Trials. 2024; 25(1):137.\u003c/li\u003e\n\u003cli\u003eLiao CY, Wang DF, Huang L, Bai YN, Yan ML, Zhou SQ, Qiu FN, Lai ZD, Wang YD, Tian YF, et al. A new strategy of laparoscopic anatomical hemihepatectomy guidided by the middle hepatic vein combined with trashepatic duct lithotomy for complex hemihepatolithiasis: a propensity score matching study. Surgery 2021;170(1):18-29.\u003c/li\u003e\n\u003cli\u003eNagano Y, Togo S, Tanaka K, Masui H, Endo I, Sekido H, Nagahori K, Shimada H. Risk factors and management of bile leakage after hepatic resection. World J Surg. 2003;27(6):695-8.\u003c/li\u003e\n\u003cli\u003eLi SQ, Liang LJ, Peng BG, Lu MD, Lai JM, Li DM. Biliary leakage after hepatectomy for hepatolithiasis: risk factors and management. Surgery 2007;141:340-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic left hemihepatectomy, Common bile duct exploration, Left-sided intrahepatic bile duct stones, Post-hepatectomy liver function, Biliary leakage","lastPublishedDoi":"10.21203/rs.3.rs-6883130/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6883130/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The operative procedures of laparoscopic left hemihepatectomy (LLH) with and without common bile duct (CBD) exploration are largely different. However, the two procedures are frequently included in the same category. The present study aimed to evaluate the impact of CBD exploration on clinical outcome in patients undergoing LLH, especially postoperative liver function and biliary leakage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The retrospective study included patients with left-sided intrahepatic bile duct stones at the First Affiliated Hospital of Nanchang University from January 2020 to June 2024. Patients were divided into simple LLH group and LLH with CBD exploration (LLHCBDE) group. Perioperative outcomes and stone recurrence between the two groups were evaluated. Moreover, we performed multivariable linear regression to analyze peak postoperative levels of alanine transaminase (ALT) and aspartate transaminase (AST) and logistic regression to analyze the occurrence of biliary leakage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e This study enrolled 176 patients, with 36 and 140 patients in the LLH and LLHCBDE groups, respectively. The LLHCBDE group demonstrated significantly longer operation time, longer hospital stays, higher peak postoperative transaminase levels, and a higher stone recurrence rate compared to the LLH group. However, there were no significant differences in the incidence of major complications and biliary leakage between the two groups. Multivariate stepwise linear regression analysis revealed that CBD exploration was an independent predictor of peak postoperative levels of alanine transaminase (β = 0.313, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and aspartate transaminase (β = 0.359, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Furthermore, period of less than 1 month between LLH and the latest episode of acute cholangitis (OR 4.362, 95%CI 1.126-16.904, \u003cem\u003eP\u003c/em\u003e=0.033) and intraoperative blood loss (OR 1.022, 95%CI 1.013-1.031, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) were independent risk factors for postoperative biliary leakage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e LLH with CBD exploration should be considered as a different procedure from LLH. CBD exploration is significantly associated with higher peak postoperative levels of ALT and AST, but not with an increased risk of biliary leakage.\u003c/p\u003e","manuscriptTitle":"Clinical outcomes after laparoscopic left hemihepatectomy with and without biliary duct exploration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 07:53:51","doi":"10.21203/rs.3.rs-6883130/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-06T11:00:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T05:49:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T05:28:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295219947726341937254963688940262422888","date":"2025-09-23T12:25:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322078067563033365577418729848381520281","date":"2025-09-22T10:19:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177371005220310109171617255571133565515","date":"2025-09-21T09:01:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284166875998698668733100966957774873353","date":"2025-08-21T18:28:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-06T09:13:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158981698206696313157494558625204586865","date":"2025-08-03T22:08:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-24T13:07:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-17T04:52:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-21T04:24:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-21T04:24:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-06-12T20:49:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c4066335-e938-4f4f-90a1-88d56ffec887","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:11:01+00:00","versionOfRecord":{"articleIdentity":"rs-6883130","link":"https://doi.org/10.1186/s12893-025-03321-w","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2025-11-28 15:58:16","publishedOnDateReadable":"November 28th, 2025"},"versionCreatedAt":"2025-07-29 07:53:51","video":"","vorDoi":"10.1186/s12893-025-03321-w","vorDoiUrl":"https://doi.org/10.1186/s12893-025-03321-w","workflowStages":[]},"version":"v1","identity":"rs-6883130","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6883130","identity":"rs-6883130","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}