Our study proved that the use of spontaneously removable biliary stent drainage is relatively simple, is associated with shorter operation time and lower intraoperative blood loss. The spontaneous excretion of biliary stent decreased the time required for postoperative recovery of bowel function and hospital stay, as previous reported.^[22] We think the only clinically relevant difference is in operative time and postoperative hospital stay. Differences in intraoperative blood loss and intestinal function recovery time, even though statistically significant, are not of much clinical significance.

We consider that the using of T-tube after LCBDE will lead to loss of bile, affect the absorption function of bowel, and slow down the intestinal peristalsis. However, with the spontaneously removed biliary stent, the biliary pressure is reduced without loss of bile, and this may help decrease postoperative complications.^[23] In fact, in our study, none of the cases showed any biliary leakage.

A key advantage with use of biliary stents is their spontaneous removal without the need for a second procedure, which reduces the risk of complications and treatment expenses.^[24] The biliary decompression surgery should not be ignored in consideration of the potential for temporary obstruction at the lower end of the CBD in the first few days after manipulations to extract duct calculi or retained stones. In our study, the average retention time of the biliary stent drainage tube was 6.6 days, which effectively prevented this complication.

However, the possibility of retention of biliary stent is a shortcoming that may necessitate endoscopic procedures with the associated risk of biliary atresia and cholangitis caused by the migration of stent, and remnant stones after surgery may not be removed readily. In our study, the biliary stent was not removed spontaneously in one case and an additional duodenum endoscopic procedure was performed one month after surgery. We consider that the time of spontaneous removal of stent is associated with the postoperative mental state of patient, activity, diet, and gastric motility. Moreover, previous studies have shown that in patients with intestinal adhesion or intestinal diverticulum, intestinal perforation occurs due to stent migration.^[25] Therefore, use of stent drainage for patients with intestinal adhesion or intestinal diverticulum should be avoided.

Around 8% to 15% of patients with cholecystitis develop choledocholithiasis with in the first year after surgery.^[7] If choledocholithiasis is not treated in time, it would progress to obstructive jaundice, acute cholangitis, pancreatitis thus increasing morbidity, and mortality.^[8] Endoscopic and laparoscopic treatments of CBD stones are the well-known minimally invasive treatment options. However, endoscopic retrograde cholangiopancreatography is associated with serious complications such as pancreatitis, hemorrhage, duodenal perforation (5%–11%), and mortality of up to 1%.^[9] LCBDE has the advantage of managing CBD stones associated with gallbladder stones in a single-stage procedure and avoids the need for endoscopic retrograde cholangiopancreatography and all its attendant complications.^[10] LCBDE by choledochotomy provides unrestricted access to CBD and common hepatic duct, thus enabling access to difficult stones.^[11] The LCBDE approach avoids Oddi sphincter manipulation, which can be particularly important in young patients.^[12] At present, LCBDE has become one of the preferred treatment options for patients with choledocholithiasis.^[1,2,13]

Traditionally, T-tube insertion has been applied most widely because of the advantage of decompressing the bile duct efficiently as well as for assessing and removing remnant CBD stones.^[14] However, this method is not only more difficult, but also prone to bile leakage, bleeding, and a series of complications.^[14–16] T-tube drainage could lead to excessive bile and electrolyte loss, affect the patient's recovery, prolong hospital stay, and increase treatment costs.^[17,18] The use of minimally invasive techniques could reduce surgical trauma, hasten recovery, and reduce length of hospital stay. Indeed, the traditional T-tube drainage seems to negate the benefits of laparoscopic surgery at this time.

Primary closure of the CBD without biliary drainage has been performed for several years.^[3,11] Although primary closure may avoid complications associated with T-tube placement, there is no conclusive data favoring one technique over the other.^[19,20] Furthermore, secondary to instrumentation of the CBD and maneuvers for stone extraction, papilla could develop edema and increase biliary tree pressure, and the associated risk of bile leakage.^[21] Insertion of a spontaneously removable biliary stent may be an alternative that can satisfy both conditions.

Despite the results and their statistical significance, the single-center scope of this study is a limitation. Large-scale randomized controlled trials are required to provide robust data on efficacy and safety of use of bile stent drainage in the future.