Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by lap...Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.展开更多
Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of pat...Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct （CBD） stones. CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans （CT）, and magnetic resonance cholangiopancreatography （MRCP）. Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability, of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is olden dictated by the clinical situation.展开更多
BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with ja...BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration. RESULTS:The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery.These 60 patients avoided any intervention to their CBD. CONCLUSIONS:CBD stones pass spontaneously in more than half of jaundiced patients.Surgical management(laparoscopic cholecystectomy and intra-operative cholangiogram,with willingness to perform CBD exploration if positive)allows the avoidance of CBD intervention in these patients.展开更多
BACKGROUND:Endoscopic palliation in malignant hilar biliary obstruction requires endoscopic retrograde cholangiopancreatography (ERCP),whereas contrast injection leads to cholangitis.Contrast-free metal stenting with ...BACKGROUND:Endoscopic palliation in malignant hilar biliary obstruction requires endoscopic retrograde cholangiopancreatography (ERCP),whereas contrast injection leads to cholangitis.Contrast-free metal stenting with or without magnetic resonance cholangiopancreatography (MRCP) has shown encouraging results,but MRCP and metal stents are costly.There have been no reports on the use of air cholangiography.METHODS:We prospectively evaluated the role of air cholangiography-assisted unilateral plastic stenting in 10 patients with type Ⅱ malignant hilar biliary obstruction.A retrospectively analysed group of 10 patients treated with contrast-free unilateral metal stenting served as historical controls.RESULTS:Ten patients with unresectable type Ⅱ malignant hilar biliary obstruction were studied.Air cholangiography detected type Ⅱ obstruction in all patients,similar to MRCP.The patients underwent unilateral stenting.Successful endoscopic drainage was achieved in all patients.The mean patency of the stent was 95.8±17.5 days in the study group and 143.9±115.1 days in the control group (P=0.20).The mean survival was 121.8±41.6 days in the study group and 154.9±122.5 days in the control group (P=0.42).KaplanMeier analysis showed an estimated median survival of 100:95% CI (65.9,134.1) days in the study group and 98:95% CI (84.1,111.9) days in the control group (P=0.62).Cholangitis occurred in none of the patients and there were no 30-day deaths nor major complications.Air cholangiographyassisted unilateral plastic stenting was cheaper than contrastfree unilateral metal stenting.CONCLUSION:Air cholangiography-assisted unilateral plastic stenting is as safe and effective as contrast-free unilateral metal stenting in type Ⅱ malignant hilar biliary obstruction for palliating patients,but it is cheaper.展开更多
Accessory gallbladder is a rare congenital anomaly occurring in 1 in 4000 births, that is not associated with any specific symptoms. Usually this cannot be diagnosed on ultrasonography and hence they are usually not d...Accessory gallbladder is a rare congenital anomaly occurring in 1 in 4000 births, that is not associated with any specific symptoms. Usually this cannot be diagnosed on ultrasonography and hence they are usually not diagnosed preoperatively. Removal of the accessory gallbladder is necessary to avoid recurrence of symptoms. H-type accessory gallbladder is a rare anomaly. Once identified intra-operatively during laparoscopic cholecystectomy, the surgery is usually converted to open. By using the main gallbladder for liver traction and doing a dome down technique for the accessory gallbladder, we were able to perform the double cholecystectomy with intra-operative cholangiogram laparoscopically. Laparoscopic cholecystectomy was performed in 27-year-old male for biliary colic. Prior imaging with computer tomography-scan and ultrasound did not show a duplicated gallbladder. Intraoperatively after ligation of cystic artery and duct an additional structure was seen on its medial aspect. Intraoperative cholangiogram confirmed the patency of intra-hepatic and extra-hepatic biliary ducts. Subsequent dissection around this structure revealed a second gallbladder with cystic duct(H-type). Pathological analysis confirmed the presence of two gallbladders with features of chronic cholecystitis. It is important to use cholangiogram to identify structural anomalies and avoid complications.展开更多
This case report describes the unusual presentation of a patient who had findings which were initially suggestive of a type Ⅳ choledochal cyst. Her liver biopsy demonstrated biliary cirrhosis. She was treated with en...This case report describes the unusual presentation of a patient who had findings which were initially suggestive of a type Ⅳ choledochal cyst. Her liver biopsy demonstrated biliary cirrhosis. She was treated with endoscopic retrograde cholangiopancreatography and biliary stent exchanges over one year. Her cholangiogram one year later demonstrated resolution of the biliary cystic dilation which led to her initial diagnosis, with beading and stricturing of the hepatic ducts consistent with primary sclerosing cholangitis. Liver-associated enzymes and physical findings also improved. A liver biopsy one year later demonstrated a marked improvement in hepatic fibrosis with no evidence of cirrhosis.展开更多
Background:Data of living-donor liver transplantation(LDLT)suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors.This retrospective study aimed to determ...Background:Data of living-donor liver transplantation(LDLT)suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors.This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in rightlobe LDLT(RLDLT)is related to donor biliary anatomy type.Methods:We analyzed our RLDLT recipients’clinical data and those of their graft donors.The recipients were divided into 2 groups:with and without postoperative biliary stricture.The 2 groups were compared.The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence;the secondary endpoints were 1-,3-and 5-year graft and patient survival rates.Results:Totally 127 patients were included in the study;25(19.7%)of them developed biliary anastomotic stricture.In these 25 patients,16 had type A biliary anatomy,3 had type B,2 had type C,3 had type D,and 1 had type E.In the 127 donors,96(75.6%)had type A biliary anatomy,13(10.2%)had type B,6(4.7%)had type C,10(7.9%)had type D,and 2(1.6%)had type E.Biliary stricture was seen in 2 donors,who had type A biliary anatomy.None of the recipients or donors developed bile leakage.No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found(P=0.527).Conclusions:The incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type.As postoperative complications were similar in whatever type of donor bile duct anatomy,donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.展开更多
本文收集已知原因胆管积气征20例,通过病因与 x 线征象对照分析,发现胆管积气原因不同,x 线表现亦不同,有一定特征性。1.胆总管全气相征是各种原因所致的胆总管括约肌关闭不全的 x 线表现。2.部分胆总管气相征与胆管——肠管间沟通征是...本文收集已知原因胆管积气征20例,通过病因与 x 线征象对照分析,发现胆管积气原因不同,x 线表现亦不同,有一定特征性。1.胆总管全气相征是各种原因所致的胆总管括约肌关闭不全的 x 线表现。2.部分胆总管气相征与胆管——肠管间沟通征是胆管——肠管间存在捷径的 x 线表现。如无其间的外科吻合手术史,可做为二者间存在内瘘的诊断依据。3.胆总管下段充盈征亦是二者间存在内瘘的 x 线表现。4.肝脓疡腔——胆管积气征是肝胆系统急性产气菌感染的 x 线表现。展开更多
文摘Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.
文摘Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct （CBD） stones. CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans （CT）, and magnetic resonance cholangiopancreatography （MRCP）. Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability, of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is olden dictated by the clinical situation.
文摘BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration. RESULTS:The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery.These 60 patients avoided any intervention to their CBD. CONCLUSIONS:CBD stones pass spontaneously in more than half of jaundiced patients.Surgical management(laparoscopic cholecystectomy and intra-operative cholangiogram,with willingness to perform CBD exploration if positive)allows the avoidance of CBD intervention in these patients.
文摘BACKGROUND:Endoscopic palliation in malignant hilar biliary obstruction requires endoscopic retrograde cholangiopancreatography (ERCP),whereas contrast injection leads to cholangitis.Contrast-free metal stenting with or without magnetic resonance cholangiopancreatography (MRCP) has shown encouraging results,but MRCP and metal stents are costly.There have been no reports on the use of air cholangiography.METHODS:We prospectively evaluated the role of air cholangiography-assisted unilateral plastic stenting in 10 patients with type Ⅱ malignant hilar biliary obstruction.A retrospectively analysed group of 10 patients treated with contrast-free unilateral metal stenting served as historical controls.RESULTS:Ten patients with unresectable type Ⅱ malignant hilar biliary obstruction were studied.Air cholangiography detected type Ⅱ obstruction in all patients,similar to MRCP.The patients underwent unilateral stenting.Successful endoscopic drainage was achieved in all patients.The mean patency of the stent was 95.8±17.5 days in the study group and 143.9±115.1 days in the control group (P=0.20).The mean survival was 121.8±41.6 days in the study group and 154.9±122.5 days in the control group (P=0.42).KaplanMeier analysis showed an estimated median survival of 100:95% CI (65.9,134.1) days in the study group and 98:95% CI (84.1,111.9) days in the control group (P=0.62).Cholangitis occurred in none of the patients and there were no 30-day deaths nor major complications.Air cholangiographyassisted unilateral plastic stenting was cheaper than contrastfree unilateral metal stenting.CONCLUSION:Air cholangiography-assisted unilateral plastic stenting is as safe and effective as contrast-free unilateral metal stenting in type Ⅱ malignant hilar biliary obstruction for palliating patients,but it is cheaper.
文摘Accessory gallbladder is a rare congenital anomaly occurring in 1 in 4000 births, that is not associated with any specific symptoms. Usually this cannot be diagnosed on ultrasonography and hence they are usually not diagnosed preoperatively. Removal of the accessory gallbladder is necessary to avoid recurrence of symptoms. H-type accessory gallbladder is a rare anomaly. Once identified intra-operatively during laparoscopic cholecystectomy, the surgery is usually converted to open. By using the main gallbladder for liver traction and doing a dome down technique for the accessory gallbladder, we were able to perform the double cholecystectomy with intra-operative cholangiogram laparoscopically. Laparoscopic cholecystectomy was performed in 27-year-old male for biliary colic. Prior imaging with computer tomography-scan and ultrasound did not show a duplicated gallbladder. Intraoperatively after ligation of cystic artery and duct an additional structure was seen on its medial aspect. Intraoperative cholangiogram confirmed the patency of intra-hepatic and extra-hepatic biliary ducts. Subsequent dissection around this structure revealed a second gallbladder with cystic duct(H-type). Pathological analysis confirmed the presence of two gallbladders with features of chronic cholecystitis. It is important to use cholangiogram to identify structural anomalies and avoid complications.
文摘This case report describes the unusual presentation of a patient who had findings which were initially suggestive of a type Ⅳ choledochal cyst. Her liver biopsy demonstrated biliary cirrhosis. She was treated with endoscopic retrograde cholangiopancreatography and biliary stent exchanges over one year. Her cholangiogram one year later demonstrated resolution of the biliary cystic dilation which led to her initial diagnosis, with beading and stricturing of the hepatic ducts consistent with primary sclerosing cholangitis. Liver-associated enzymes and physical findings also improved. A liver biopsy one year later demonstrated a marked improvement in hepatic fibrosis with no evidence of cirrhosis.
文摘Background:Data of living-donor liver transplantation(LDLT)suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors.This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in rightlobe LDLT(RLDLT)is related to donor biliary anatomy type.Methods:We analyzed our RLDLT recipients’clinical data and those of their graft donors.The recipients were divided into 2 groups:with and without postoperative biliary stricture.The 2 groups were compared.The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence;the secondary endpoints were 1-,3-and 5-year graft and patient survival rates.Results:Totally 127 patients were included in the study;25(19.7%)of them developed biliary anastomotic stricture.In these 25 patients,16 had type A biliary anatomy,3 had type B,2 had type C,3 had type D,and 1 had type E.In the 127 donors,96(75.6%)had type A biliary anatomy,13(10.2%)had type B,6(4.7%)had type C,10(7.9%)had type D,and 2(1.6%)had type E.Biliary stricture was seen in 2 donors,who had type A biliary anatomy.None of the recipients or donors developed bile leakage.No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found(P=0.527).Conclusions:The incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type.As postoperative complications were similar in whatever type of donor bile duct anatomy,donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.
文摘本文收集已知原因胆管积气征20例,通过病因与 x 线征象对照分析,发现胆管积气原因不同,x 线表现亦不同,有一定特征性。1.胆总管全气相征是各种原因所致的胆总管括约肌关闭不全的 x 线表现。2.部分胆总管气相征与胆管——肠管间沟通征是胆管——肠管间存在捷径的 x 线表现。如无其间的外科吻合手术史,可做为二者间存在内瘘的诊断依据。3.胆总管下段充盈征亦是二者间存在内瘘的 x 线表现。4.肝脓疡腔——胆管积气征是肝胆系统急性产气菌感染的 x 线表现。
