Impact of acute cholangitis severity on the safety of laparoscopic common bile duct exploration with primary closure: a stratified retrospective study.

BACKGROUND: Laparoscopic common bile duct exploration and primary suture (LBEPS) offers advantages such as minimal invasiveness, shorter operative time, and faster postoperative recovery in the treatment of common bile duct stones coexisting with cholecystolithiasis and has been widely adopted in clinical practice. However, its application in patients with concomitant acute cholangitis (AC), particularly those with severe cholangitis, remains controversial in terms of safety. METHODS: A retrospective analysis was conducted on the clinical data of 226 patients with common bile duct stones who underwent LBEPS at our hospital between December 2018 and August 2025. Based on the presence and severity of concomitant AC, patients were divided into three groups: the non-AC group (n = 158), the mild/moderate AC group (n = 47), and the severe AC group (n = 21). Baseline characteristics, operative time, and the incidence of postoperative complications were compared among the three groups. RESULTS: Among the three groups, patients in the severe AC group were older and had lower serum protein and hemoglobin levels; the proportion of male patients increased with the severity of inflammation (P < 0.05). The mild/moderate AC group had a higher likelihood of concomitant acute pancreatitis, and operative time was significantly longer than that in the non-AC group (P < 0.05). No significant differences were observed among the three groups in biliary-specific complications such as postoperative bile leakage (3.8-4.8%), stone recurrence, bile duct strictures and cholangitis during follow-up (P > 0.05). However, the overall incidence of complications was significantly higher in the severe AC group than in the non-AC group (P < 0.05), primarily driven by an increase in systemic complications (e.g., upper gastrointestinal bleeding), rather than biliary-related complications. Regarding hospital stay and costs, the severe AC group had significantly longer total, preoperative, and postoperative hospital stays (P < 0.05), as well as the highest total hospitalization costs (P < 0.05). A breakdown of costs revealed that, in addition to surgical fees, laboratory fees, diagnostic imaging fees, consumables fees, and medication fees were all highest in the severe AC group (P < 0.05). CONCLUSION: LBEPS is safe and feasible in patients with mild-to-moderate acute cholangitis. In patients with severe acute cholangitis who undergo rigorous selection and adequate preoperative intervention, LBEPS does not significantly increase the risk of biliary complications; however, it is associated with a significant increase in systemic complications and hospitalization costs.