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T-tube drainage versus primary closure after laparoscopic common bile duct exploration

  1. Kurinchi Selvan Gurusamy*,
  2. Rahul Koti,
  3. Brian R Davidson

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 21 JUN 2013

Assessed as up-to-date: 10 APR 2013

DOI: 10.1002/14651858.CD005641.pub3


How to Cite

Gurusamy KS, Koti R, Davidson BR. T-tube drainage versus primary closure after laparoscopic common bile duct exploration. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD005641. DOI: 10.1002/14651858.CD005641.pub3.

Author Information

  1. Royal Free Campus, UCL Medical School, Department of Surgery, London, UK

*Kurinchi Selvan Gurusamy, Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital,, Rowland Hill Street, London, NW3 2PF, UK. kurinchi2k@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 21 JUN 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

 
Summary of findings for the main comparison. T-tube drainage compared to primary closure after laparoscopic common bile duct exploration

T-tube drainage compared to primary closure after laparoscopic common bile duct exploration

Patient or population: laparoscopic common bile duct exploration.
Settings: secondary or tertiary hospital.
Intervention: T-tube drainage.
Comparison: primary closure.

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)

Assumed riskCorresponding risk

Primary closureT-tube drainage

Serious morbidity (rate)61 per 100097 per 1000
(40 to 233)
Rate ratio 1.59
(0.66 to 3.83)
295
(3 studies)
⊕⊝⊝⊝
very low1,2,3,4

Serious morbidity (proportion of patients)61 per 1000113 per 1000
(53 to 241)
RR 1.86
(0.87 to 3.96)
295
(3 studies)
⊕⊝⊝⊝
very low1,2,3,4

Operating time
(minutes)
The mean operating time in the control groups was
106.48 minutes
The mean operating time in the intervention groups was
21.22 minutes higher
(12.44 to 30 higher)
295
(3 studies)
⊕⊝⊝⊝
very low1,2

Hospital stay
(days)
The mean hospital stay in the control groups was
3.93 days
The mean hospital stay in the intervention groups was
3.26 days higher
(2.49 to 4.04 higher)
295
(3 studies)
⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk is the overall control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 All the trials were at high risk of bias.
2 There were few trials included in this review and reporting bias could not be assessed.
3 There was moderate heterogeneity.
4 The confidence intervals include 1 and either 0.75 or 1.25 or both.

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

About 5% to 25% of the adult western population have gallstones (GREPCO 1984; GREPCO 1988; Bates 1992; Halldestam 2004). The annual incidence of gallstones is about 1 in 200 people (NIH 1992). Only 2% to 4% of people with gallstones become symptomatic with biliary colic (pain), acute cholecystitis (inflammation), obstructive jaundice, or gallstone pancreatitis in a year (Attili 1995; Halldestam 2004). Cholecystectomy (removal of gallstones) is the preferred option in the treatment of symptomatic gallstones (Strasberg 1993) and every year, 1.5 million cholecystectomies are performed in the United States and 60,000 in the United Kingdom (Dolan 2009; HES 2011). Approximately 80% of the cholecystectomies are performed laparoscopically (key-hole) (Ballal 2009). The reported proportion of patients with common bile duct stones at the time of cholecystectomy varies between 5% (Kama 2001; Hemli 2004) and 11% (Pitluk 1979; Duensing 2000). Laparoscopic cholecystectomy is currently preferred over open cholecystectomy for elective cholecystectomy (Livingston 2004; Ballal 2009). If stones are found in the common bile duct prior to laparoscopic cholecystectomy, the options include pre-operative or intra-operative endoscopic sphincterotomy (Gurusamy 2011) or laparoscopic common bile duct exploration. If stones are found in the common bile duct for the first time during the laparoscopic cholecystectomy (because of the per-operative cholangiogram), the options include laparoscopic cholecystectomy followed by endoscopic sphincterotomy (Ng 1999), conversion to open procedure (Sarli 2003), or laparoscopic common bile duct exploration (Hyser 1999; Rojas-Ortega 2003; Waage 2003; Ebner 2004). Laparoscopic common bile duct exploration can be either transcystic (Thompson 2002; Rojas-Ortega 2003; Waage 2003) or performed through a choledochotomy (Thompson 2002; Waage 2003) depending upon the size and location of the stones (Jacobs 1991; Memon 2000). Some surgeons use T-tube drainage routinely after choledochotomy and not after successful transcystic common bile duct exploration (Thompson 2002; Rojas-Ortega 2003). Laparoscopic common bile duct exploration can be performed successfully in the majority of the patients (Snow 1999; Thompson 2002; Rojas-Ortega 2003; Hemli 2004).

After the common bile duct exploration is performed, the choice lies between T-tube drainage, primary duct closure with no drainage (Decker 2003), or primary duct closure with biliary stent insertion (Isla 2004; Kim 2004; Griniatsos 2005). T-tube drainage of the common bile duct is performed for the following reasons (Williams 1994):

  • Prevent extravasation of bile from the common bile duct.
  • Post-operative visualization of common bile duct.
  • Availability of T-tube tract extraction of common bile duct with a Burhenne steerable catheter (Burhenne 1973).

T-tube drainage may lead to biliary infection resulting in increased mortality and morbidity in open common bile duct stone exploration (Lygidakis 1983; Wills 2002). Migration of the tube causing common bile duct obstruction (Bernstein 1994) and bile leaks following removal of T-tube have also been reported (Kacker 1995).

This is an update of our previous review (Gurusamy 2007) with revisions in the methodology of the review and interpretation of information according to the current Cochrane Handbook (Higgins 2011).

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

To assess the benefits and harms of T-tube drainage versus primary closure after laparoscopic common bile duct stone exploration.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included all randomised clinical trials examining the effects of T-tube drainage versus primary closure after laparoscopic common bile duct stone exploration irrespective of language, blinding, or publication status.

Quasi-randomised trials (where the method of allocating participants to a treatment are not strictly random, eg, date of birth, hospital record number, alternation) were not included in this review. However, we did include reports of harmful effects from quasi-randomised trials and observational studies.

 

Types of participants

Participants who were about to undergo laparoscopic exploration of the common bile duct for possible common bile duct stones.

 

Types of interventions

Any form of T-tube drainage versus primary duct closure without biliary stent insertion after laparoscopic operative exploration of the common bile duct.

 

Types of outcome measures

 

Primary outcomes

  1. Mortality.
    1. Mortality at maximal follow-up, usually assessed by hazard ratios.
    2. Mortality within 30 days (procedure or operative mortality).
  2. Serious morbidity, corresponding to Grade 3 or Grade 4 Clavien-Dindo classification (Dindo 2004; Clavien 2009) or as classified by the authors. The Clavien-Dindo classification approximately corresponds to the definition of serious adverse events by the International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use - Good Clinical Practice (ICH-GCP) (ICH-GCP 1997).
  3. Quality of life.

 

Secondary outcomes

  1. Operating time.
  2. Length of hospital stay.
  3. Return to work.
  4. Recurrent or retained common bile duct stones at maximal follow-up.

The summary of findings were reported for all the outcomes reported by at least one trial in a  Summary of findings for the main comparison using GRADEpro 3.6 (http://ims.cochrane.org/revman/other-resources/gradepro).

 

Search methods for identification of studies

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (Royle 2003) until April 2013. We also searched the International Clinical Trials Registry Platform (ICTRP) by World Health Organization (http://apps.who.int/trialsearch/Default.aspx). This search portal allows the search of ClinicalTrials.gov and ISRCTN trial registers among various other trial registers. We have given the search strategies with the time spans for the searches in Appendix 1. References of the identified studies were also searched for further trials.

 

Data collection and analysis

KSG and RK, independently of each other, identified the trials for inclusion. KSG and RK have also listed the excluded studies with the reasons for the exclusion. BRD adjudicated any differences in opinion.

Both authors independently extracted the following data.

  1. Year and language of publication.
  2. Country.
  3. Year of conduct of the trial.
  4. Inclusion and exclusion criteria.
  5. Sample size.
  6. Population characteristics such as age and sex ratio.
  7. Antibiotic prophylaxis.
  8. Abdominal drain use.
  9. Duration of T-tube drainage.
  10. Whether routine cholangiogram was performed.
  11. Outcomes (mentioned above).
  12. Risk of bias (described below).

We sought any unclear or missing information by contacting the authors of the individual trials. If there was any doubt whether the trials shared the same participants - completely or partially (by identifying common authors and centres), we planned to contact the authors of the trials to clarify whether the trial report had been duplicated.

We resolved any differences in opinion through discussion. BRD adjudicated any differences in opinion.

 

Assessment of risk of bias

The authors assessed the risk of bias in the trials independently, without masking of the trial names, and following the instructions in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and the Cochrane Hepato-Biliary Group Module (Gluud 2013). Due to the risk of overestimation of intervention effects in randomised trials with high risk of bias (Schulz 1995; Moher 1998; Kjaergard 2001; Wood 2008; Lundh 2012; Savovic 2012), we assessed the influence of risk of bias on the trial results using the following domains.

 

Allocation sequence generation

  • Low risk of bias: sequence generation was achieved using computer random number generation or a random number table. Drawing lots, tossing a coin, shuffling cards, and throwing dice are adequate if performed by an independent adjudicator.
  • Uncertain risk of bias: the trial was described as randomised, but the method of sequence generation was not specified.
  • High risk of bias: the sequence generation method was not, or might not be, random. Quasi-randomised studies, those using dates, names, or admittance numbers in order to allocate patients were inadequate and were excluded for the assessment of benefits but not for assessing harms.

 

Allocation concealment

  • Low risk of bias: allocation was controlled by a central and independent randomisation unit, sequentially numbered, opaque and sealed envelopes or similar, so that intervention allocations could not have been foreseen in advance of, or during, enrolment.
  • Uncertain risk of bias: the trial was described as randomised, but the method used to conceal the allocation was not described so that intervention allocations might have been foreseen in advance of, or during, enrolment.
  • High risk of bias: if the allocation sequence was known to the investigators who assigned participants, or if the study was quasi-randomised. Quasi-randomised studies were excluded for the assessment of benefits but not for assessing harms.

 

Blinding of participants and personnel

  • Low risk of bias: blinding was performed adequately, or the outcome measurement was not likely to be influenced by lack of blinding.
  • Uncertain risk of bias: there was insufficient information to assess whether the type of blinding used was likely to induce bias on the estimate of effect.
  • High risk of bias: no blinding or incomplete blinding, and the outcome or the outcome measurement was likely to be influenced by lack of blinding.

 

Blinding of outcome assessors

  • Low risk of bias: blinding was performed adequately, or the outcome measurement was not likely to be influenced by lack of blinding.
  • Uncertain risk of bias: there was insufficient information to assess whether the type of blinding used was likely to induce bias on the estimate of effect.
  • High risk of bias: no blinding or incomplete blinding, and the outcome or the outcome measurement was likely to be influenced by lack of blinding.

 

Incomplete outcome data

  • Low risk of bias: the underlying reasons for missing data were unlikely to make treatment effects depart from plausible values, or proper methods had been employed to handle missing data.
  • Uncertain risk of bias: there was insufficient information to assess whether the missing data mechanism in combination with the method used to handle missing data were likely to induce bias on the estimate of effect.
  • High risk of bias: the crude estimate of effects (eg, complete case estimate) were clearly biased due to the underlying reasons for missing data, and the methods used to handle missing data were unsatisfactory.

 

Selective outcome reporting

  • Low risk of bias: pre-defined, or clinically relevant and reasonably expected outcomes were reported on.
  • Uncertain risk of bias: not all pre-defined or clinically relevant and reasonably expected outcomes were reported on, or were not reported fully, or it was unclear whether data on these outcomes were recorded or not.
  • High risk of bias: one or more clinically relevant and reasonably expected outcomes were not reported on; data on these outcomes were likely to have been recorded.

 

Vested interest bias

  • Low risk of bias: the trial was conducted by a party without any vested interest in the outcome of the trial.
  • Uncertain risk of bias: it was not clear if the trial was conducted by a party with a vested interest in the outcome of the trial.
  • High risk of bias: the trial was conducted by a party with one or more vested interests in the outcome of the trial (such as a T-tube manufacturer).

We considered trials to be of low risk of bias if we assessed all the above domains being of low risk of bias. In all other cases, the trials were considered having high risk of bias.

 

Statistical methods

We performed the meta-analyses according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and the Cochrane Hepato-Biliary Group Module (Gluud 2013). We used the software package Review Manager 5 for all statistical analyses (RevMan 2012). For dichotomous variables, we calculated the risk ratio (RR) with 95% confidence intervals (CI) if there were two or more trials for an outcome. For continuous outcomes we calculated the mean difference (MD) and the standardised mean difference (SMD) if different assessment scales were used with 95% confidence intervals. For serious morbidity, we calculated the proportion of patients with serious morbidity and the number of serious morbidities ('serious morbidity rate') in each group. While the proportion of patients with serious morbidity is a binary outcome, the serious morbidity rate is a count data outcome. For count data outcomes such as serious adverse events, the rate ratio was calculated using the methods shown in section 9.4.8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). For such a calculation, one needs the time that the patients were exposed to the risk of serious morbidity in each of the groups. We considered that both groups were exposed to the risk of serious morbidity for the same time period, which is a reasonable assumption considering that the patients were followed up for the same time in both groups.

We used a random-effects model (DerSimonian 1986) and a fixed-effect model (DeMets 1987) for meta-analysis in the presence of two or more trials included under the outcomes. In case of discrepancy between the two models, we have reported both results; otherwise we have reported the results of the fixed-effect model. Heterogeneity was explored by a chi-squared test with significance set at P value 0.10, and the quantity of heterogeneity was measured by I2 (Higgins 2002; Higgins 2011).

The analyses were performed on an intention-to-treat basis (Newell 1992) whenever possible. Otherwise, we adopted the 'available-patient analysis' (Higgins 2011). We did not impute any data for the post-randomisation drop-outs for any of the continuous outcomes. In the absence of summary information such as mean and standard deviation for continuous outcomes, we used the median for the meta-analysis when the mean was not available and imputed the standard deviation from P values according to the instructions given in the Cochrane Handbook for Systematic Reviews of Intervention (Higgins 2011) (See Sensitivity analysis below). If it was not possible to calculate the standard deviation from the P value or the confidence intervals, we imputed the standard deviation as the highest standard deviation in the other trials included under that outcome, fully recognising that this form of imputation would decrease the weight of the study for calculation of mean differences and bias the effect estimate to no effect in case of standardised mean difference (Higgins 2011).

 

Reporting bias

We planned to use a funnel plot to explore reporting bias (Egger 1997; Macaskill 2001) in the presence of at least 10 trials. We planned to use asymmetry in funnel plot of study size against treatment effect to identify bias. We also planned to perform linear regression approach described by Egger (Egger 1997) to determine the funnel plot asymmetry.

 

Subgroup analysis

We planned to perform the following subgroup analyses:

  • Trials at low risk of bias compared to those at high risk of bias.
  • Trials in which routine antibiotic prophylaxis was used compared to those in which routine antibiotic prophylaxis was not used.
  • Trials in which patients underwent laparoscopic common bile duct exploration in the presence of acute cholecystitis compared to those in which patients underwent laparoscopic common bile duct exploration in the absence of acute cholecystitis.

We planned to use the test for subgroup differences available through RevMan.

 

Sensitivity analysis

We planned to perform a sensitivity analysis by imputing the outcomes for binary outcomes under different scenarios, namely best-best analysis, worst-worst analysis, best-worst analysis, and worst-best analysis (Gurusamy 2009; Gluud 2013) for any significant binary outcomes. We performed a sensitivity analysis by excluding the trials in which median or standard deviation was imputed for continuous outcomes. Both these sensitivity analyses were planned a priori (Gurusamy 2007). We also performed post-hoc sensitivity analyses by considering the complications for which the severity could not be determined as 'mild' complications (best-best scenario) and then we considered these 'mild' complications as severe complications (worst-worst scenario). For example, bile leaks are post-operative complications some of which resolve spontaneously without any prolongation of hospital stay and hence were categorised as 'mild' adverse events. Other bile leaks need radiological or endoscopic interventions and hence were classified as 'serious' adverse events. If the trial authors did not report the way the bile leaks were treated, it was not possible to determine their severity. So, we performed two analyses - one, excluding the bile leaks which resolved spontaneously and those, for which the treatment was not reported, and another analysis including the bile leaks for which the treatment was not reported.

 

Trial sequential analysis

Trial sequential analysis was applied because cumulative meta-analyses are at risk of producing random errors due to sparse data and repetitive testing of the accumulating data (CTU 2011; Thorlund 2011). To minimise random errors, we calculated the required information size (ie, the number of participants needed in a meta-analysis to detect or reject a certain intervention effect). The required information size calculation should also account for the heterogeneity or diversity present in the meta-analysis. The underlying assumption of trial sequential analysis is that testing for significance may be performed each time a new trial is added to the meta-analysis. We added the trials according to the year of publication, and if more than one trial was published in a year, the trials were added alphabetically according to the last name of the first author. On the basis of the required information size, trial sequential monitoring boundaries were constructed. These boundaries determine the statistical inference one may draw regarding the cumulative meta-analysis that has not reached the required information size; if the trial sequential monitoring boundary is crossed before the required information size is reached, firm evidence may perhaps be established and further trials may turn out to be superfluous. On the other hand, if the boundary is not surpassed, it is most probably necessary to continue doing trials in order to detect or reject a certain intervention effect.   

We performed trial sequential analysis for binary outcomes and continuous outcomes in which at least two trials were present to determine if further trials are necessary on the topic (CTU 2011; Thorlund 2011). We performed the trial sequential analysis using an alpha error of 5%, beta error of 20%, control event proportion obtained from the results, and a relative risk reduction of 20% for binary outcomes (Brok 2008; Wetterslev 2008; Brok 2009; Thorlund 2009; Wetterslev 2009; Thorlund 2010). For continuous outcomes, we conducted the trial sequential analysis using alpha error of 5%, beta error of 20%, the variance of the included trials, and a minimal clinically important difference of one day for hospital stay and 15 minutes for operating time.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of studies

We identified a total of 1752 references through electronic searches of Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (n = 179), MEDLINE (n = 759), EMBASE (n = 369), and Science Citation Index Expanded (n = 445). We excluded 542 duplicates and 1203 clearly irrelevant references through reading abstracts. Seven references were retrieved for further assessment. No trials were identified from the ICTRP portal or through scanning reference lists of the identified randomised trials. Of the seven references, we excluded three because of the reasons listed in the table 'Characteristics of excluded studies'. In total, four references of three randomised trials fulfilled the inclusion criteria (Leida 2008; Zhang 2009; El-Geidie 2010). The reference flow is shown in Figure 1. Details of the trials are shown in the table 'Characteristics of included studies'.

 FigureFigure 1. Study flow diagram.

 

Included trials

A total of 295 participants who underwent laparoscopic common bile duct exploration were randomised in three trials (Leida 2008; Zhang 2009; El-Geidie 2010). The number of participants in each trial ranged from 80 to 122. The average age in all the three trials was about 50 years. The proportion of females in the trials was about 60% (Characteristics of included studies).

Antibiotic use was not reported in any of the trials. Intra-abdominal drains were used in all three trials. The timing of removal of the T-tube and whether a T-tube cholangiogram was performed are described in the Characteristics of included studies table.

 

Risk of bias in included studies

All the trials were assessed as having high risk of bias (Figure 2; Figure 3).

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Effects of interventions

See:  Summary of findings for the main comparison T-tube drainage compared to primary closure after laparoscopic common bile duct exploration

The results are summarised in  Summary of findings for the main comparison.

 

Mortality

 

Mortality at maximal follow-up

None of the trials reported long-term outcomes.

 

Mortality within 30 days (procedure or operative mortality)

All three trials reported this outcome. There was no peri-operative mortality in either group ( Analysis 1.1).

 

Serious morbidity (serious complications)

All three trials provided results on serious complications, although the severity of the complications was not available for two participants in the T-tube group in one of the trials (Zhang 2009). We performed an analysis considering that the morbidity in these two patients were not severe (best-best scenario) ( Analysis 1.2;  Analysis 1.4) and another analysis considering that the morbidity in these patients were severe (worst-worst scenario) ( Analysis 1.3;  Analysis 1.5). In the best-best scenario, there was no significant difference in the serious morbidity rates (rate ratio 1.59; 95% CI 0.66 to 3.83; P = 0.30; I2 = 50%) ( Analysis 1.2) or in the proportion of patients who developed serious morbidity (RR 1.86; 95% CI 0.87 to 3.96; P = 0.11; I2 = 55%) ( Analysis 1.4). The results were not altered sufficiently to change the interpretation by performing the worst-worst scenario ( Analysis 1.3;  Analysis 1.5).

 

Trial sequential analysis

The information fraction was only 1.03%, and so, the trial sequential monitoring boundaries and the required information size (n = 28,572 patients) were not drawn (Figure 4).

 FigureFigure 4. Trial sequential analysis of serious morbidity
The diversity-adjusted required information size (DARIS) was calculated to 28,572 patients, based on the proportion of patients in the control group with the outcome of 6.1%, a relative risk reduction of 20%, an alpha of 5%, a beta of 20%, and a diversity of 61.69%. After accruing 295 patients in the three trials, we have only reached 1.03% of the DARIS. Accordingly, the trial sequential analysis does not show the required information size and the trial sequential monitoring boundaries. As shown, the conventional boundaries have also not been crossed.

 

Quality of life

None of the included trials reported on quality of life.

 

Operating time

All three trials reported this outcome. The mean value of the operating time was missing in one trial and was imputed from the median (Leida 2008).The standard deviation was not reported in two trials (Leida 2008; El-Geidie 2010). The standard deviation was calculated using the P value in one trial (El-Geidie 2010) and from the inter-quartile range in another trial (Leida 2008). The meta-analysis showed that the operating time was significantly longer in the T-tube group than in the primary closure group (MD 21.22 minutes; 95% CI 12.44 to 30.00; P < 0.00001; I2 = 0%) ( Analysis 1.6). The results were not changed by excluding the trials in which means or standard deviations were imputed.

 

Trial sequential analysis

The trial sequential analysis of operating time shows that the accumulative Z-curve crosses the trial sequential monitoring boundary after the second trial favouring primary closure. The diversity-adjusted required information size (DARIS) was 414 patients based on a minimal relevant difference (MIRD) of 15 minutes, a variance (VAR) of 2962, an alpha (a) of 5%, a beta (b) of 20%, and a diversity (D2) of 0%. The results are compatible with significant reduction of operation time favouring the primary closure group without risk of random errors (Figure 5).

 FigureFigure 5. Trial sequential analysis of operating time
This figure shows that the accumulative Z-curve crosses the trial sequential monitoring boundary during the second trial (see the dashed line). The diversity-adjusted required information size (DARIS) was 414 patients based on a minimal relevant difference (MIRD) of 15 minutes, a variance (VAR) of 2962, an alpha (a) of 5%, a beta (b) of 20%, and a diversity (D2) of 0%. The results are compatible with significant reduction of operation time favouring the primary closure group without risk of random errors.

 

Hospital stay

All three trials reported this outcome. As in the case of operating time, the standard deviation was imputed from P value in one trial (El-Geidie 2010) and from the inter-quartile range in another trial (Leida 2008). The mean was imputed from the median in one trial (Leida 2008). The hospital stay was significantly longer in the T-tube group than in the primary closure group (MD 3.26 days; 95% CI 2.49 to 4.04; P < 0.00001; I2 = 0%) ( Analysis 1.7). The results did not change by excluding the trials in which mean or standard deviation were imputed.

 

Trial sequential analysis

The trial sequential analysis of hospital stay shows that the accumulative Z-curve does not cross the trial sequential monitoring boundary after the second trial. The diversity-adjusted required information size (DARIS) was 724 patients based on a minimal relevant difference (MIRD) of one day, a variance (VAR) of 23.04, an alpha (a) of 5%, a beta (b) of 20%, and a diversity (D2) of 0%. The results are compatible with significant reduction of hospital stay favouring the primary closure group without risk of random errors (Figure 6).

 FigureFigure 6. Trial sequential analysis of duration of hospital stay
This figure shows that the accumulative Z-curve crosses the trial sequential monitoring boundary during the second trial. The diversity-adjusted required information size (DARIS) was 724 patients based on a minimal relevant difference (MIRD) of one day, a variance (VAR) of 23.04, an alpha (a) of 5%, a beta (b) of 20%, and a diversity (D2) of 0%. The results are compatible with significant reduction of hospital stay favouring the primary closure group without risk of random errors.

 

Return to work

This outcome was reported in only one trial (Leida 2008). This trial reported only the median of number of days before returning to work and inter-quartile range. The participants in the T-tube group returned to work about eight days later than the participants in the primary closure group (P < 0.005) ( Analysis 1.8).

 

Recurrent or retained common bile duct stones at long-term follow-up

None of the trials reported this outcome.

 

Subgroup analysis

All the trials were of high risk of bias. None of the trials reported whether antibiotics were used and the trials did not report the outcomes for participants with acute cholecystitis separately. So the subgroup analyses were not performed.

 

Reporting bias

We did not perform a funnel plot because only three trials were included in this review.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Summary of main results

This systematic review shows that T-tube drainage might increase the operating time and hospital stay without any evidence of difference in serious complications. One of the reasons for considering the employment of T-tube drainage is to decompress the common bile duct if there is distal obstruction (Williams 1994). This is to avoid bile leak and bile peritonitis. In the three trials including 148 patients allocated to the primary closure group (Leida 2008; Zhang 2009; El-Geidie 2010), the biliary complications in the primary closure group included one patient with bile leak requiring endoscopic stent (Zhang 2009), one patient with bile leak requiring percutaneous drainage (Leida 2008), and another patient developing biliary pancreatitis requiring endoscopic stent (Leida 2008). In contrast, of the 147 patients belonging to the T-tube closure group in the three trials (Leida 2008; Zhang 2009; El-Geidie 2010), the biliary complications included seven patients who required open re-operations for bile peritonitis, T-tube dislodgement, or bleeding from the choledochotomy wound, three patients requiring percutaneous drainage for bile leak, and one patient developing acute pancreatitis which settled without any surgical, endoscopic, or radiological intervention (Leida 2008; Zhang 2009; El-Geidie 2010). Thus, there is no evidence that the T-tube is preventing bile leaks. There is also no evidence that the proportion of patients with serious morbidity or serious morbidity rates were different between the two groups. Long-term follow-up is necessary to detect any bile strictures and recurrence of common bile duct stones. There is no current evidence to suggest that these will be different between the groups.

Another reason for considering T-tube drainage is to extract any residual stones through the T-tube tract (Williams 1994). Even if patients develop symptomatic retained stones, endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy can be used for the treatment. Before the advent of endoscopic sphincterotomy, percutaneous transhepatic biliary drainage or open exploration were the only options available for the treatment of such patients. Although T-tube drainage to facilitate extraction of stones may have been appropriate in the past, this has become redundant with the currently available treatments.

The operating time was significantly longer in the T-tube group than in the primary closure group. This is expected because the T-tube involves additional steps during surgery.

The post-operative hospital stay was significantly longer in the T-tube group than for the primary closure group. The patients were discharged home with the T-tube in situ in all three trials included in this review (Leida 2008; Zhang 2009; El-Geidie 2010). So, the differences in the post-operative hospital stay cannot be explained by a delayed discharge for T-tube cholangiogram. While there was no significant difference in the serious morbidity rates between the two groups, this may be due to lack of evidence of effect rather than lack of effect. In the absence of any other explanation for the prolonged post-operative hospital stay, one has to conclude that the longer hospital stay in the T-tube group than primary closure group is due to higher morbidity.

The time taken to return to work was significantly longer in the T-tube group than for the primary closure group. This may be related to the presence of the T-tube itself which may discourage the patient to return to work or may be related to associated morbidity. As mentioned previously, lack of evidence of significant differences in serious morbidity should not be considered as evidence for lack of effect. The confidence intervals were wide and there is a possibility that this finding of lack of significant differences in serious morbidity rates could be because of lack of evidence of effect. Quality of life, another patient-oriented outcome, was not reported in any of the trials included in this review.

A longer post-operative hospital stay is neither beneficial to the patient (particularly in a private healthcare funding set-up) nor to the healthcare provider (particularly in a state-funded or insurance company funded healthcare funding set-up). In addition to the shorter hospital stay, the other cost-savings that can be made in the primary closure include the cost of the T-tube, increased operating time, the cost of T-tube cholangiogram, and the cost of removal of the T-tube. Unless these costs can be offset by decreased complications, the costs associated with the use of a T-tube cannot be justified. Based on the evidence from this review, this does not appear to be the case. Consequently, there appears to be little justification in the use of a T-tube after laparoscopic common bile duct exploration.

It appears that T-tube use has a significant potential to harm the patients and increase the costs for the healthcare funder without any notable benefit based on the information obtained from the trials included in this review. There is additional corroborative information. We identified three non-randomised studies comparing T-tube with primary closure (Ha 2004; Jameel 2008; Noh 2009) from the search strategy. None of the studies reported any biliary peritonitis (T-tube drainage: 0/26 (0%) (Ha 2004); 0/11 (0%) (Jameel 2008); 0/33 (0%) (Noh 2009) versus primary closure: 0/12 (0%) (Ha 2004); 0/48 (0%) (Jameel 2008); 0/30 (0%) (Noh 2009)). In addition, in another Cochrane review, which included 359 patients from six trials, we found that T-tube closure had longer operating time and hospital stay than primary closure of the common bile duct without stent after open common bile duct exploration, without affecting the serious morbidity rates significantly (Gurusamy 2013). In that Cochrane review of T-tube drainage versus primary closure in patients undergoing open common bile duct exploration, fewer patients developed biliary complications requiring intervention (not statistically significant) (Gurusamy 2013) as is the case with this review. The purpose of T-tube drainage is the same whether the patients undergo open or laparoscopic common bile duct exploration. Thus, there is a strong corroborative evidence that supports the findings of this review.

 

Overall completeness and applicability of evidence

This review is applicable in only patients undergoing laparoscopic common bile duct exploration for common bile duct stones and without distal obstruction to the flow of bile.

 

Quality of the evidence

Although the risk of bias in the included trials was high and the overall quality of evidence was very low, one has to put this into perspective. This is currently the best available evidence. The previous routine use of T-tube was based on clinical opinion and the fact that a significant proportion of the patients had to undergo major re-operations where stones were left in the bile duct. The advent of endoscopic sphincterotomy appears to have made the use of the T-tube redundant. The trials were at high risk of bias (for example, outcomes such as hospital stay and return to work can be biased because of lack of blinding and absence of any criteria for discharge from hospital or return to work, and a surgeon favouring primary closure might have discharged the patient from hospital earlier or might have advised the patient that he or she could return to work earlier) and new trials are necessary to assess whether T-tube drainage is better than primary closure after laparoscopic common bile duct exploration, as shown by the trial sequential analysis. Until such new trials with low risk of bias show that T-tube use is safe and effective, the use of T-tube after laparoscopic common bile duct exploration should be confined to randomised clinical trials. Such randomised trials should include quality of life and return to work as these outcomes are useful to determine whether T-tube is beneficial to the patient and whether it is cost-effective.

 

Potential biases in the review process

We have followed the Cochrane methodology for performing the review. One potential bias was that we imputed the mean and standard deviation from median and other measures such as P values or inter-quartile ranges. This may have introduced an error in the effect estimate. The sensitivity analysis by excluding the trials in which the imputation was performed did not change the results. The alternative to this imputation is to present the information as presented by the authors, but the interpretation of that information can be even more confusing.

 

Agreements and disagreements with other studies or reviews

In the previous version of this review, we stated that we could not make any conclusions because of the data available at that time (Gurusamy 2007). In this review, we advocate against the use of T-tube outside well-designed randomised clinical trials.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

 

Implications for practice

T-tube drainage appears to result in significantly longer operating time and hospital stay as compared to primary closure, without any evidence of benefit after laparoscopic common bile duct exploration. Based on currently available evidence, there is no justification for the routine use of T-tube drainage after laparoscopic common bile duct exploration in patients with common bile duct stones. T-tube drainage should not be used outside well-designed randomised clinical trials.

 
Implications for research

Further adequately powered trials of low risk of bias are necessary. Such trials ought to report in detail on mortality, adverse events, quality of life, and return to work as well as outcomes addressed in this systematic review. Furthermore, such trials should be designed according to the SPIRIT guidelines (Chan 2013) and reported according to the CONSORT guidelines (http://www.consort-statement.org).

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

To The Cochrane Hepato-Biliary Group who provided support and guidance.
To K Samraj who independently identified the trials and extracted the data for the first version of the review.

Peer reviewer for the first version of the review: PW Jorgensen, for suggesting improvements to the first version of the review.
Z Yu (China), who contributed to the background section of the protocol, which has been revised significantly.
M Wei, the Chinese Cochrane Centre, who helped with the translation of a Chinese paper for the first version of the review.

Peer reviewers: Kyeon Kook Lee, South Korea; Ahmed Abdel-Raouf El-Geidie, Egypt; Janus Jakobsen, Denmark.
Contact editors: Christian Gluud, Denmark; Ronald Koretz, USA.

This project was funded by the National Institute for Health Research (NIHR).

 

Disclaimer

Department of Health disclaimer: the views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS (National Health Service), or the UK Department of Health.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
Download statistical data

 
Comparison 1. T-tube drainage versus primary closure

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 MortalityOther dataNo numeric data

 2 Serious morbidity (best-best scenario)3295Rate Ratio (Fixed, 95% CI)1.59 [0.66, 3.83]

 3 Serious morbidity (worst-worst scenario)3295Rate Ratio (Fixed, 95% CI)1.80 [0.78, 4.11]

 4 Serious morbidity (best-best scenario)3295Risk Ratio (M-H, Fixed, 95% CI)1.86 [0.87, 3.96]

 5 Serious morbidity (worst-worst scenario)3295Risk Ratio (M-H, Fixed, 95% CI)2.07 [0.99, 4.34]

 6 Operating time3295Mean Difference (IV, Fixed, 95% CI)21.22 [12.44, 30.00]

 7 Hospital stay3295Mean Difference (IV, Fixed, 95% CI)3.26 [2.49, 4.04]

 8 Return to workOther dataNo numeric data

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Appendix 1. Search strategies for identification of studies


DatabaseTimespanSearch strategy

Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Wiley)Issue 3, 2013#1 MeSH descriptor Cholelithiasis explode all trees in MeSH products
#2 MeSH descriptor Gallstones explode all trees in MeSH products
#3 MeSH descriptor Common Bile Duct explode all trees in MeSH products
#4 MeSH descriptor Cholestasis explode all trees in MeSH products
#5 MeSH descriptor Jaundice, Obstructive explode all trees in MeSH products
#6 gall stone* or gallstone* or cholelithiasis or common bile duct* or cholecystolithiasis or cholestasis or choledocholithiasis or obstructive jaundice in All Fields in all products
#7 (#1 OR #2 OR #3 OR #4 OR #5 OR #6)
#8 MeSH descriptor Drainage explode all trees in MeSH products
#9 MeSH descriptor Decompression, Surgical explode all trees in MeSH products
#10 drain* or decompression in All Fields in all products
#11 (#8 OR #9 OR #10)
#12 (#7 AND #11)

MEDLINE (PubMed)1946 to April 2013 ("Cholelithiasis"[MeSH] OR "Gallstones"[MeSH] OR "Common Bile Duct"[MeSH] OR "Cholestasis"[MeSH] OR "Jaundice, Obstructive"[MeSH] OR gall*stone* or cholelithiasis or common bile duct* or cholecystolithiasis or cholestasis or choledocholithiasis or obstructive jaundice) AND (drain* or decompression OR "Drainage"[MeSH] OR "Decompression, Surgical"[MeSH]) AND ((randomised controlled trial [pt] OR controlled clinical trial [pt] OR randomised [tiab] OR placebo [tiab] OR drug therapy [sh] OR randomly [tiab] OR trial [tiab] OR groups [tiab]) NOT (animals [mh] NOT humans [mh]))

EMBASE (OvidSP)1947 to April 20131. exp cholelithiasis/ or exp cholestasis/ or exp obstructive jaundice/

2. (gallstone* or gall stone* or gall-stone* or cholelithiasis or common bile duct* or cholecystolithiasis or cholestasis or choledocholithiasis or obstructive jaundice).af.

3. 1 or 2

4. exp drain/

5. (drain* or decompression).af.

6. 4 or 5

7. 3 and 6

8. exp crossover-procedure/ or exp double-blind procedure/ or exp randomised controlled trial/ or single-blind procedure/

9. (random* or factorial* or crossover* or placebo*).af.

10. 8 or 9

11. 7 and 10

Science Citation Index Expanded (SCI Expanded)
(ISI Web of Knowledge)
1898 to April 2013#1 TS=(gall stone* or gallstone* or cholelithiasis or common bile duct* or cholecystolithiasis or cholestasis or choledocholithiasis or obstructive jaundice)
#2 TS=drain* or decompression
#3 #1 and #2
#4 TS=(random* OR blind* OR placebo* OR meta-analysis)
#5 #3 and #4

International Clinical Trials Registry Platform (http://apps.who.int/trialsearch/Default.aspx)April 2013common bile duct or choledocholithiasis



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Last assessed as up-to-date: 10 April 2013.


DateEventDescription

16 April 2013AmendedThe title has been revised since the T-tube drainage intervention has additional steps compared to primary closure.

10 April 2013New search has been performedThe search was updated, but no additional trials were found.

17 February 2012New search has been performedThe search was updated, and two new trials meeting the inclusion criteria were included.

Trial sequential analysis was performed.

17 February 2012New citation required and conclusions have changedThe methods were updated according to version 5.1 of the Cochrane Handbook (Higgins 2011). This involved changes of the outcomes so that they are now of relevance also to the patients and changes to the risk of bias domains. This resulted in a change in the findings and conclusions of the review.

The intervention 'primary closure with biliary stent' was considered to be very different from 'primary closure without biliary stent'. Hence the intervention 'primary closure with biliary stent' was excluded from the review. 'Primary closure with a biliary stent' should be the subject of another review.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

K Gurusamy identified trials, extracted data, analysed the data, and interpreted the data. R Koti independently identified trials and extracted data for the current version of the review. BR Davidson critically commented on the review.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Internal sources

  • University College London, UK.

 

External sources

  • National Institute of Health Research, UK.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

The protocol for the present review was published with the title 'T-tube drain in laparoscopic common bile duct stone exploration' (Gurusamy 2006). During the review preparation we felt that we would achieve greater clarity if we changed the review title into 'T-tube drainage versus primary closure after laparoscopic common bile duct exploration'.

 

Differences between previous version and current version

  • T-tube drainage was changed to intervention, and primary closure was changed to control. This is because T-tube drainage contains additional steps in surgery as compared to primary closure.
  • The methods were updated according to version 5.1 of the Cochrane Handbook (Higgins 2011). This involved changes of the outcomes and the risk of bias domains. This resulted in changes in the findings and conclusions of the review.
  • The intervention 'primary closure with biliary stent' was considered to be very different from 'primary closure without biliary stent'. Hence, the intervention 'primary closure with biliary stent' was excluded from the review. 'Primary closure with a biliary stent' should be considered in another review.
  • Trial sequential analysis was performed.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
  22. References to other published versions of this review
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  • El-Geidie AA. Is the use of T-tube necessary after laparoscopic choledochotomy?. Journal of Gastrointestinal Surgery 2010;14(5):844-8. [1873-4626: (Electronic)]
Leida 2008 {published data only}
  • Leida Z, Ping B, Shuguang W, Yu H. A randomized comparison of primary closure and T-tube drainage of the common bile duct after laparoscopic choledochotomy. Surgical Endoscopy 2008; Vol. 22, issue 7:1595-600. [1432-2218: (Electronic)]
  • Zhang LD, Bie P, Chen P, Wang SG, Ma KS, Dong JH. [Primary duct closure versus T-tube drainage following laparoscopic choledochotomy]. Zhonghua Wai Ke Za Zhi 2004;42(9):520-3.
Zhang 2009 {published data only}
  • Zhang WJ, Xu GF, Wu GZ, Li JM, Dong ZT, Mo XD. Laparoscopic exploration of common bile duct with primary closure versus T-tube drainage: a randomized clinical trial. Journal of Surgical Research 2009; Vol. 157, issue 1:e1-e5. [1095-8673: (Electronic)]

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
  22. References to other published versions of this review
Ha 2004 {published data only}
  • Ha JP, Tang CN, Siu WT, Chau CH, Li MK. Primary closure versus T-tube drainage after laparoscopic choledochotomy for common bile duct stones. Hepatogastroenterology 2004;51(60):1605-8.
Jameel 2008 {published data only}
Noh 2009 {published data only}
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  1. Top of page
  2. Abstract摘要Résumé
  3. Summary of findings
  4. Background
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  6. Methods
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  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
  22. References to other published versions of this review
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References to other published versions of this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
  22. References to other published versions of this review
Gurusamy 2006
Gurusamy 2007
  • Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after laparoscopic common bile duct stone exploration. Cochrane Database of Systematic Reviews 2007, Issue 1. [DOI: 10.1002/14651858.CD005641.pub2]