Postoperative T-tube tract choledochoscopy.

One hundred twenty-six patients underwent postoperative fiberoptic T-tube tract choledochoscopy for the management of retained biliary calculi as demonstrated by T-tube cholangiography. Extraction was successful in 94% of patients with retained stones. Thirty-nine patients had more than 1 stone, 20 patients had heptic duct stones, and 14 patients had large stones requiring electrohydraulic lithotripsy or laser fragmentation. Stone removal was not possible in six patients, secondary to either slippage of the T-tube with obliteration of the tract, inability to remove the stones with available instruments, a tortuous tract, or choledochoscope malfunction. Minor complications, most commonly transient fever, occurred in 12 patients. No serious complications or deaths occurred. The advantages of T-tube tract choledochoscopy include direct visualization of the biliary tree, avoidance of radiation exposure, and easy access to hepatic duct stones. This is the preferred method for treating retained biliary calculi in patients with a T-tube in situ.     

Endoscopic management of retained bile stones with an indwelling T-tube

Background Endoscopic sphincterotomy (ES) is widely used for the treatment of residual bile duct stones in patients who had common bile duct (CBD) exploration and T-tube insertions. Methods In a 4-year period 45 patients were referred for endoscopic removal of residual bile duct stones. All patients had been operated 7–15 days earlier for choledocholithiasis and had a T-tube in the common bile duct (CBD). Results Four patients were excluded. Three patients had a periampullary carcinoma and the fourth patient had no residual stone seen at cholangiography. All patients had a successful ES, conventional in 34, precut-knife in 3, and with the rendezvous technique in 4 patients. In 24 patients, all having stones distal to the T-tube, complete clearance of the CBD was achieved during one session and the T-tube was removed after 48 h. In the remaining 17 patients (15 having stones proximal to the T-tube), the T-tube had to be removed first and following stone extraction, a plastic stent was inserted in the CBD. Complete bile duct clearance and stent removal was achieved in a second session 3–4 weeks later. There were no serious complications or biliary related symptoms after the procedures and after a mean follow-up period of 18 months. Conclusion The endoscopic technique is safe and efficient for the treatment of residual stones after CBD exploration with a T-tube insertion, offering immediate cure compared to the percutaneous techniques. It is also an ideal method for the diagnosis of periampullary carcinomas. Online publication: 24 August 2004     

腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆总管巨大结石的临床分析

目的:探讨腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆道巨大结石的疗效。方法:回顾分析2005年1月至2013年11月84例因梗阻性黄疸、胆总管巨大结石行腹腔镜下胆道镜联合液电碎石经胆囊管取石患者的临床资料。结果:80例成功完成手术。1例因胆道出血中转开腹行胆总管切开止血、取石+T管引流术;1例患者怀疑胆道下段肿瘤中转开腹探查并行胰十二指肠切除术,术中冰冻病理证实为胆管癌;1例患者经胆囊管取石毕发现乳头下端狭窄,术中行内镜逆行胰胆管造影及乳头肌切开后胆汁流出通畅;1例患者因Mirizzi综合征导致胆囊三角区粘连紧密从而中转开腹行胆总管切开取石、T管引流术。术后均无出血、胆漏、胆总管损伤等并发症发生,术后住院7~11 d。结论:腹腔镜下胆道镜联合液电碎石经胆囊管取石术治疗胆总管巨大结石安全、可靠,手术微创,结石清除率高,并发症少;对于胆囊管粗短直、入口较大的患者,可直接置入胆道镜探查取石,损伤小,优点突出,值得临床应用。     

Management of gallstones in a district general hospital

This survey reviews 815 consecutive patients undergoing surgery for benign biliary disease. There were no deaths following elective operations and the overall mortality was 0.7 per cent. One-third of patients had one or more complications. The mortality in patients having common bile duct exploration (n = 160) by one or more methods was 2.5 per cent (4 patients) with 46 per cent of these patients having complications. Of 95 patients undergoing duct exploration and postoperative T-tube cholangiography, 7 had unexpected residual calculi after initial cholecystectomy. Five have had further surgery to clear the duct. All patients having duct surgery alone for retained stones (n = 24) had previously had cholecystectomy with or without supraduodenal duct exploration. Of all patients undergoing choledochoduodenostomy or transduodenal sphincter exploration only one has returned with evidence of retained calculi. Patients with choledocholithiasis were examined in an attempt to identify a high risk group. These were found to be elderly patients, having emergency surgery for sepsis and on whom more than one duct procedure was performed (mortality 10 per cent).     

Endoscopic sphincterotomy in the treatment of common bile duct benign lesions (experience with 100 cases)

The authors present the experience of the first 100 endoscopic sphincterotomy performed in Caritas Hospital, Surgery Department between 1997 and 2000 for CBD benign lesions treatment. The patients to whom we performed this procedure had a biliary syndrome associated mostly to obstructive jaundice of unknown etiology previously diagnosed echographically or by ERCP. The etiology was in 72% of the cases represented by migrated, residual or primary common bile duct stones. The aim of the procedure was the removal of the stones. We performed endoscopic sphincterotomy either before or after laparoscopic or open surgery. The morbidity was 8% and the related mortality was 0%. Endoscopic sphincterotomy is an efficient procedure for the treatment of the benign obstruction of the common bile duct and not only. Our results were similar to those published by other authors.     

Early endoscopic sphincterotomy for retained bile duct stones after gallbladder surgery.

Endoscopic sphincterotomy (ES) was performed in 36 patients (age range 33-88 years; median 63 years) with retained bile duct stones after cholecystectomy (32 patients) or cholecystostomy (4 patients). The median time interval between surgery and ES was 28 days (range 10-216 days). At the time of ES, 23 patients had a T-tube in situ. Clearance of the bile duct was achieved by T-tube irrigation in 15 patients, and by basket or balloon extraction in seven patients. Spontaneous clearance of the duct after ES occurred in 12 patients, while two patients required widening of the sphincterotomy to allow successful basket extraction. Complications occurred in four patients (11%). Two patients sustained significant haemorrhage from the ES site and subsequently died. One patient developed mild acute pancreatitis while another had persisting cholangitis before and after ES. Both of these patients recovered with conservative management. While ES performed soon after gallbladder surgery allows for early bile duct clearance, the small but significant risk of potentially lethal haemorrhage suggests that its use should be reserved for patients in whom other non-operative methods have failed or are inappropriate.     

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures.

OBJECTIVE: To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates. SUMMARY BACKGROUND DATA: For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed. METHODS: Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE. RESULTS: Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients. CONCLUSIONS: Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.     

Nonsurgical treatment of common-bile-duct stones

Exploration of the common bile duct, the traditional treatment for choledocholithiasis, can often be replaced by nonsurgical procedures. Since 1976, 147 patients have been treated nonsurgically with an overall success rate of 84%. Three groups are reported. In group 1, 80 patients had stone extraction under radiologic control through the T-tube tract alone. Stones were successfully removed from the common bile duct in 52 of 59 patients and from the intrahepatic ducts in 12 of 21 patients. The overall success rate of extraction through the T tube was 80%. Group 2 comprised 58 patients who underwent endoscopic sphincterotomy and stone extraction only with 86% success. The nine patients in group 3 required a combination of radiologic and endoscopic intervention. Six had stones "pushed" by the radiologist through a previously sphincterotomized ampulla of Vater and in two the radiologist introduced stone crushers transhepatically into the common duct to break up large stones to a size capable of passing through the sphincterotomy site (100% success). One elderly patient had a cholecystostomy under local anesthesia for suppurative cholecystitis, and subsequently multiple common-bile-duct stones were removed by the radiologist through the gallbladder and cystic duct and by the endoscopist through the endoscopic sphincterotomy site. All procedures were carried out under local anesthesia, and most required a hospital stay of 1 day or less. Complications were minimal and there were no deaths. T-tube extraction and endoscopic sphincterotomy are effective, relatively safe, nonsurgical procedures for the removal of common-duct stones.     

肝移植术后胆道并发症的内镜治疗

目的:探讨内镜下逆行胰胆管造影术(ERCP)在治疗肝移植术后胆道并发症方面的临床疗效.方法:回顾性分析2002年8月-2012年12月采用ERCP治疗8例肝移植术后胆道并发症患者的临床资料,其中胆道狭窄5例(吻合口狭窄4例,肝内型胆道狭窄1例),胆瘘1例,胆石和胆泥形成2例.8例患者共行ERCP治疗21次,对胆道狭窄患者行括约肌切开、胆管扩张、鼻胆管引流和内支架置放术等治疗;对胆瘘患者行鼻胆管引流及塑料内支架置放术等治疗;对结石患者行括约肌切开、鼻胆管冲洗引流术及取石网篮取石等治疗.结果:ERCP手术成功率为100％ (21/21);4例吻合口狭窄、1例胆瘘和2例结石患者均治愈,1例肝内型胆道狭窄治疗未成功,建议再次肝移植;术后胆道感染的发生率为14.3％(3/21),胰腺炎发生率为19.0％ (4/21),经对症治疗后均痊愈.结论:ERCP是治疗肝移植术后胆道并发症微创、安全和有效的方法.     

有上腹部手术史者腹腔镜联合纤维胆道镜胆总管探查62例分析

目的探讨对有上腹部手术史者行腹腔镜联合纤维胆道镜胆总管探查的可行性及临床疗效。方法 2002年3月～2008年11月对62例有上腹部手术史的胆总管结石采用腹腔镜胆总管切开探查取石、术中胆道镜取石、T管引流术或胆总管一期缝合术。结果手术成功60例;中转开腹2例:1例为胆总管下段狭窄,胆道镜无法进入十二指肠;另1例为术中胆道镜活检证实为胆总管下段癌伴结石嵌顿。28例取石后T管引流,22例取石后一期缝合胆总管,10例经胆囊管行胆总管胆道镜探查取石。无出血、胆漏、腹腔感染等并发症。60例随访6～34个月,平均21个月,无结石残留、胆管狭窄及胆管炎发生。结论对有上腹部手术史者施行腹腔镜联合纤维胆道镜胆总管探查安全、可行,上腹部手术史不是腹腔镜胆总管探查手术的绝对禁忌证。     

Treatment of residual and recurrent biliary calculi: the surgical option

Retained and recurrent bile duct stones can be treated with a variety of non-surgical methods. The list includes endoscopic papillotomy, chemical dissolution, by T-tube extraction, percutaneous or extracorporeal lithotripsy. The various attempts at non-surgical therapy are described in two patients with retained bile duct stones before biliary clearance was achieved by re-operation. The failure of oral dissolution using biliary acids, endoscopic papillotomy and by T-tube extraction, led to a delay of 6 and 8 months respectively in the elimination of the retained stones in each patient. Surgical re-exploration proved relatively simple due to the long interval after the first operation, and the stones were removed without particular difficulties. The paper underlines the importance of the choice of treatment for use in cases of secondary common bile duct calculi, evaluated on the basis of a correct assessment of the cost/benefit, risk/benefit ratios.     

Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period

We report on thirty-nine patients who underwent endoscopic sphincterotomy (ES) and stone extraction for retained common bile duct calculi with a T-tube in situ. Sixteen of the patients had undergone unsuccessful attempts at removal by flushing or dissolution by cholesterol solvents. A total of 76 stones were present: 53 distal to the T-tube and 23 proximal to the T-tube. ES and clearance of the common bile duct was achieved in 37 patients (95 per cent) and complications occurred in three patients (7.7 per cent). This method is an effective and relatively safe method in the early postoperative period allowing rapid treatment during the same admission as for the original operation and early hospital discharge.     

Endoscopic retrograde sphincterotomy in the treatment of biliary tract disease

Endoscopic retrograde sphincterotomy (E.R.S.) is rapidly becoming popular. In the past 5 years, E.R.S. was technically successful in 124 of 130 patients (95%) in whom it was attempted. One hundred twenty four had choledocholithiasis, and six had papillary stenosis after cholecystectomy. Urgent E.R.S. was performed for septic cholangitis in 12 patients and biliary pancreatitis in four. There were six patients with choledocholithiasis in whom sphincterotomy was not possible. Of the 118 patients with successful papillotomy for choledocholithiasis, spontaneous passage of calculi after E.R.S. occurred in 28 cases (24%), and instrumental extraction of stones was possible in 81 (69%). Duct clearance failed in nine patients (8%), mostly due to the large size of the retained stones. The largest stone extracted was 26 mm in diameter. The overall success rate of removing common bile duct stones was 109 in 118 cases (88%). In patients with papillary stenosis, E.R.S. was successful in relieving symptoms and biochemical cholestasis in six of six cases (100%). Complications occurred in only two patients. The complications were pancreatitis in one and hemorrhage in one. None of these patients required surgical treatment of the complication. Endoscopic retrograde sphincterotomy is effective for the removal of stones of the common bile duct, and at relieving the symptoms of papillary stenosis. It is safe in experienced hands and has led to only rare complications.     

Endoscopic Management of Early Postoperative Biliary Ascariasis in Patients with Biliary Tract Surgery

Bile leak and residual stones are well known complications of biliary tract surgery. In endemic areas of ascariasis, invasion of the biliary tract by roundworms during the early postoperative period is an infrequent but serious complication. The present study describes the endoscopic management of postoperative biliary ascariasis in 19 consecutive patients. There were 5 men and 14 women with a mean age of 33.3 ± 6.3 years. All patients had undergone cholecystectomy, with choledocholithotomy and placement of a T-tube in 13 (68.4%) patients. Eight (42.1%) patients including two with T-tubes were acutely sick at referral. Altogether, 16 (84.2%) patients had widened papillae due to previous endoscopic sphincterotomy (3 patients) or recent dilatation of the sphincter of Oddi by Bakes dilators (13 patients). All patients with a T-tube in situ had undergone unsuccessful attempts to remove the worms by flushing saline through the T-tube. Endoscopic retrograde cholangiopancreatography was performed 4 to 16 days after biliary tract surgery and revealed roundworms in the common bile duct in 10 patients, in the hepatic ducts in 2, or in both ducts in 7. Three patients had coexisting biliary leakage: from the cystic duct stump in two and from a T-tube track in one. Endoscopic treatment consisted of extracting the worms from the biliary tree and placing stents in those with coexisting leakage. Endoscopic success was defined as complete worm extraction and resolution of biliary leakage and was achieved in all patients. Complications occurred in one (5.3%) patient. We concluded that endoscopic management is an effective, safe approach for extracting ascarids from the biliary tree during the early postoperative period. It reduces the hospital stay, avoids T-tube-related complications, and permits a postoperative complication to be treated using a nonsurgical method.     

应用胆胰管内窥镜经胆囊管胆道探查21例临床分析

目的探讨应用胆胰管内窥镜经胆囊管行胆道探查的临床应用价值。方法 2011年1月～2012年1月,对21例急、慢性结石性胆囊炎合并或可疑合并肝内外胆管结石者,在开腹胆囊切除术中应用德国PolyDiagnost公司组合式、软性、可旋转纤维内窥镜（外径F8）经胆囊管行胆道探查、取石。结果 2例肝内胆管结石,用套石篮顺利取出。胆总管结石14例,其中6例经胆囊管顺利取出,4例钬激光击碎结石取出,2例行胆囊管汇入胆总管处微切开取石,未成功2例,行传统胆总管切开取石T管引流。5例未见明显结石及十二指肠乳头狭窄。术后胆漏1例,无胆道残余结石等并发症发生。术后随访6～18个月,平均13个月,无结石复发。结论应用胆胰管内窥镜经胆囊管进行肝内外胆管探查,避免了胆总管切开和放置T管,提高了胆道结石诊断的准确率,是一种安全简便、创伤小、恢复快的方法。     

The urgency of diagnosis and surgical treatment of acute suppurative cholangitis.

Twenty patients with suppurative cholangitis were seen at the Massachusetts General Hospital over a nine year period. Fifteen patients had acute obstructive suppurative cholangitis due to complete obstruction of the common duct, many with coma, hypotension, and positive blood cultures. Sixty per cent of patients were older than seventy years, and most had a history of biliary tract disease. Although most had jaundice, abdominal pain, and fever, clinical symptoms were variable. The diagnosis of cholangitis was made in only 30 per cent of patients before autopsy or surgery. Eighteen patients had calculi in the common duct, and two had primary fibrosis of the ampulla. Patients explored less than 24 hours after admission or deterioration died less often than those operated on after some delay. Most patients underwent common duct exploration and four had a concomitant sphincterotomy. In one instance, cholecystostomy only was performed and this patient died because of ongoing sepsis. The overall mortality was 40 per cent; of those subjected to operation, 25 per cent died in the hospital. Recovery was dramatic among most survivors, and calculous disease did not recur, except for two patients with retained stones. Prophylactic cholecystectomy is recommended to prevent the occurrence of this subtle and highly dangerous syndrome.     

Laparoscopic exploration of the common bile duct

Since the first laparoscopic common bile duct exploration in Hungary published in 1999 the authors use the technique themselves. We review and analyse our activity between 1 June 1999 and 31 August 2003. The minimally invasive approach was selected in twelve patients with obstructive jaundice for suspected bile duct stones. Eight of these patients underwent preoperative endoscopy, but either the number and/or size of stones or various complications prevented successful endoscopic stone extraction; five sphincterotomies--two followed by stenting--were performed. The four other patients did not consent to endoscopy. During surgery the biliary tract was visualised by choledochoscope (a bile duct endoscope with video connection) in four cases via the distended cystic duct and in eight cases via longitudinal choledochotomy. In one case there was no occlusion at all, in another one dilatation was performed because of a structure. In nine patients stones were removed either through the choledochotomy/cystic duct or by passing them into the duodenum. In one patient we converted to open procedure due to a stone impacted in the papilla of Vater. After choledochotomy intracorporal suturing and knot tying techniques were used to close the incision. On six occasions a cystic drain, three occasions a T-tube and on three occasions primary closure was used. Two bile leaks were treated by endoscopic stenting and in one patient a laparotomy was needed. There was no mortality. We believe that laparoscopic common bile duct exploration can be successful even in complicated situations.     

Early postoperative endoscopic sphincterotomy for retained common duct stones

The results of endoscopic sphincterotomy in 30 patients with retained common bile duct stones and a T-tube in situ following surgical exploration of the common bile duct are presented. Successful stone extraction was achieved in 27 cases (90%). There was one death, which was not procedure related. Early postoperative T-tube cholangiography is advocated and if necessary sphincterotomy can be safely performed 1 week following surgery. This approach has advantages in shortening hospital stay and minimising patient discomfort.     

COMMON BILE DUCT CALCULI AT LAPAROSCOPIC CHOLECYSTECTOMY: A TECHNIQUE FOR MANAGEMENT

Laparoscopic cholecystectomy was attempted in 150 unselected patients. The use of routine intra-operative cholangiography prevented serious bile duct injury in one patient. It also showed 75% of patients suspected pre-operatively of having common duct stones, had passed them by the time of cholecystectomy. Eight of 12 diagnosed duct stones (5 suspected, 7 unsuspected) were removed laparoscopically. A technique is described using inexpensive and readily available equipment that allows the transcystic duct treatment of the majority of common duct stones. The development and use of such techniques to laparoscopically treat duct stones will once more allow surgeons to treat all biliary calculi at the one procedure and reduce unnecessary dependence on endoscopic retrograde cholangiopancreatography/sphincterotomy.     

Large bile duct stones treated by endoscopic biliary drainage

One hundred five patients with obstructive jaundice and cholangitis (49 patients), referred for diagnostic endoscopy, were found to have inextractable bile duct stones. Median age was 76 years and three quarters were more than 72 years of age. Insertion of an endoprosthesis with or without a sphincterotomy relieved jaundice in 94% and settled cholangitis in 90%. Antibiotic cover during the procedure seems essential inasmuch as pyrexia and septicemia occurred in 6 of 57 cases where it was not given. One case was lethal. Another patient died of acute pancreatitis. The patients were old. One quarter died before the follow-up, 1 to 5 years after the initial intervention. The results indicate that the combination of endoscopic sphincterotomy, insertion of an endoprosthesis, and, if feasible, stone extraction on a later occasion when the acute phase of the illness had subsided brought the disease sufficiently under control among three quarters of the patients with large common duct stones or stenoses in the biliary tract. One quarter of the patients were treated surgically. This was accomplished without mortality, but morbidity was not negligible. A policy with a surgical approach restricted to selected cases with persistent symptoms in spite of sufficient endoscopic drainage is recommended.