Author index,volume 140

Cholecystostomy retains a place in the general surgical armamentarium. In this series of 115 patients undergoing cholecystostomy between 1967 and 1977, 68 percent had acute cholecystitis, whereas in the remaining patients biliary drainage was undertaken as part of another procedure. The in-hospital mortality rate was 6 percent for the group with acute cholecystitis and 37 percent for the other patients. Forty-five patients subsequently had elective cholecystectomy, 29 of these for radiographically documented retained calculi. Thirty-four patients without retained calculi remained asymptomatic for more than 1 year. On the basis of this experience and the literature cited, we recommend that subsequent to cholecystostomy, cholecystectomy be performed if the patient is in good general health and has a long life expectancy. Conversely, in the aged, ill patient without evidence of retained stones, cholecystostomy may be a lifesaving and curative procedure and the only one needed.     

Recurrent biliary calculi: duodenal diverticula as a predisposing factor

Several studies indicate a causal relationship between duodenal diverticula and gallstone disease. The diverticula persist after biliary tract surgery, and it is therefore presumed that patients with diverticula have an increased disposition to develop new calculi in the bile ducts after cholecystectomy. To test this hypothesis, the occurrence of recurrent biliary calculi was studied in 101 patients who had cholecystectomy, all with an asymptomatic period of two years or more following the primary biliary surgery. All patients had symptoms, that indicated biliary tract or pancreatic diseases. The incidence of recurrent calculi in patients with diverticula was 87.5% (95% confidence interval, 66.9-95.8). In patients without diverticula, the incidence was 31.9% (95% confidence interval, 21.5-44.3). The difference is highly significant, and the results support the assumption tht diverticula in the area of the papilla of Vater dispose to gallstone disease.     

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain

Background: Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms. Methods: Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram. Results: Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic. Conclusion: Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder–cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.     

Cholecystocholangiography During Laparoscopic Cholecystectomy

The aim of this study was to assess the efficacy and safety of performing cholecystocholangiography through a central venous pressure catheter during laparoscopic cholecystectomy. Laparoscopic cholecystocholangiography was attempted during laparoscopic cholecystectomy for chronic calculous cholecystitis in 40 patients, and considered successful if the biliary anatomy was clearly defined. The procedure was evaluated as successful in 36 patients (90%). It added an average 13.5 min to the operating time. A unsuspected common bile duct stone was identified by cholecystocholangiography in one patient and there were no cholangiogram-related complications. We concluded that laparoscopic cholecystocholangiography is a safe, simple, and quick procedure that can be used as an alternative to cystic duct cholangiography to identify the biliary anatomy and detect any common bile duct calculi prior to laparoscopic dissection. Received: May 1, 2000 / Accepted: March 6, 2001     

Interval Laparoscopic Cholecystectomy in the Management of Acute Biliary Pancreatitis

The timing of laparoscopic cholecystectomy following an attack of acute biliary pancreatitis is controversial. The traditional approach of interval cholecystectomy has been challenged recently. The present study was designed to evaluate the benefits of interval laparoscopic cholecystectomy for patients with mild acute pancreatitis (Ranson less than 3). Nineteen patients with mild pancreatitis underwent ultrasonographic evaluation to confirm the biliary etiology. ERCP was performed in all patients on the first available endoscopy list, and endoscopic sphincterotomy was performed in two patients with calculi or dilated common bile duct on ultrasonographic examination. Medical treatment was administered and laparoscopic cholecystectomy was scheduled after 8–12 weeks to allow the inflammatory process to settle. There were no recurrent attacks of pancreatitis during this period. The degree of difficulty of the laparoscopic procedure was assessed by the presence of adhesions to the gallbladder area, difficulty of dissection in the Calot''s triangle, intraoperative bleeding and the need for a drain. Six patients (31.5%) had severe adhesions, difficult dissection of the cystic duct and artery, bleeding and prolonged operating time. In two of these patients (10.5%) the procedure was converted to open cholecystectomy. In conclusion, our results suggest that postponing laparoscopic cholecystectomy in acute pancreatitis patients is not advantageous surgically and does not justify the risk of further morbidity caused by the gallbladder disease.     

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.     

腹腔镜胆囊切除术中胆道造影的临床意义

目的:探讨术中胆道造影对行腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)患者的临床意义。方法:回顾性分析113例因胆囊结石行LC加术中胆道造影患者的情况。结果:113例患者中造影成功110例(成功率97%),发现胆总管结石5例,占4.5%(5/110)。结论:LC加术中胆道造影有利于防止胆道残余结石,对正确判断胆道解剖关系,减少胆道损伤有重要的临床意义。LC加术中胆道造影可常规使用。     

Comparison of magnetic resonance cholangiography and percutaneous transhepatic cholangiography in the evaluation of bile duct strictures after cholecystectomy

BACKGROUND: Percutaneous transhepatic cholangiography (PTC) has been the preferred investigation to delineate the anatomy of the biliary tract in a patient with a bile duct stricture after cholecystectomy. Recently magnetic resonance cholangiography (MRC) has been described to evaluate the obstructed biliary tract. This paper reports a comparison of MRC with PTC in evaluating patients with an iatrogenic bile duct stricture. METHODS: This was a prospective study of 26 patients who had surgery for a bile duct stricture after cholecystectomy. Before operation all patients underwent both MRC and PTC, the results of which were compared with the intraoperative findings. RESULTS: Both PTC and MRC were comparable with regard to image quality, detection of intrahepatic bile duct dilatation, assessment of the level of injury and detection of abnormalities such as intraduct calculi, cholangitic liver abscesses and atrophy of liver lobes. MRC provided additional information in four patients, including detection of associated fluid collections (n = 3) and portal hypertension (n = 1). In eight patients more than one puncture had to be performed during PTC to delineate the complete anatomy. CONCLUSION: MRC is an accurate and non-invasive imaging procedure for preoperative evaluation of patients with a bile duct injury after cholecystectomy, and is capable of providing additional information which may not be available with PTC.     

Management of complex biliary tract calculi with a holmium laser

The difficulty in managing complex biliary tract calculi is exemplified in patients with primary intrahepatic calculi. Standard surgical and endoscopic approaches often fail to clear calculi in these patients who have recurrent episodes of cholangitis. The success of the holmium laser for urologic calculi led us to adapt treatment strategies for primary and secondary biliary tract calculi where standard treatments had been unsuccessful. Our goals were to remove all calculi, prevent recurrent sepsis, and preserve hepatic parenchyma. Thirty-six patients with complex biliary calculi were treated. After sepsis was controlled and the extent of calculi was evaluated, appropriate access to and drainage of the biliary tract was achieved. Holmium laser lithotripsy was performed under video guidance using flexible choledochoscopes and a 200 μ laser fiber generating 0.6 to 1.0 joules at frequencies of 6 to 10 Hz. Lithotripsy procedures were repeated until cholangiography and cholangioscopy confirmed the clearance of calculi. Twenty-two patients of Asian descent with primary intrahepatic calculi and 14 patients with secondary intrahepatic calculi were treated. Access to the biliary tract could be accomplished through percutaneous catheter tracts, T-tube tracts, or the cystic duct during laparoscopic cholecystectomy. Biliary drainage was by biliary enteric anastomosis or endoscopic sphincterotomy. Complete stone clearance required an average of 3.9 procedures (range 1 to 15) for patients with primary intrahepatic calculi and 2.6 procedures (range 1 to 10) for patients with secondary intrahepatic calculi regardless of stone composition. No patient required hepatic resection and no complications or deaths were attributed to the holmium laser. Clearance of calculi can reliably and safely be achieved with a holmium laser regardless of stone composition or location while preserving hepatic parenchyma and preventing recurrent sepsis. Presented at the Fourth Americas Hepato-Pancreato-Biliary Association Congress, Miami Beach, Florida, February 27-March 2, 2003.     

The colecistectomy in primary sclerosing cholangitis: case report and review of literature

Primary sclerosing cholangitis (PSC) is an idiopathic chronic inflammatory condition affecting intra- and extra-hepatic biliary system. The aim of this study is to stress the importance of cholecystectomy in patients with PSC. Consideration should be given to performing a cholecystectomy in PSC patients with gallbladder adenomyomas or calculi, even asymptomatic; this happens in approximately 15% of cases.     

Role of biliary scintiscan in predicting the need for cholangiography

BACKGROUND: Currently used predictors for bile duct calculi in patients undergoing cholecystectomy have low specificity resulting in unnecessary cholangiograms being performed. The role of biliary scintiscan in predicting the presence of bile duct calculi was assessed. METHODS: Seventy-five patients with symptomatic gallstone disease were studied prospectively regard- ing the value of a history of jaundice or acute pancreatitis, raised serum bilirubin and serum alkaline phosphatase levels, and visualization of stones or presence of dilated bile ducts on ultrasonography (standard criteria) in detecting bile duct calculi. Results of biliary scintiscan were evaluated against a combination of standard criteria. The 'gold standard' for evaluation was endoscopic or peroperative cholangiography. RESULTS: Biliary scintiscan had a higher sensitivity and specificity (93 and 94 per cent) than a combination of the above standard and modified predictors for biliary calculi (89 and 71 per cent). A combination of ultrasonography and selective use of scintiscan, in the absence of bile duct dilatation only, had higher values (96 and 98 per cent). CONCLUSION: A combination of ultrasonography and biliary scintiscan can accurately predict bile duct calculi and could be used as a guide for selective cholangiography.     

Endoscopic sphincterotomy for common bile duct calculi

A series of 74 patients having endoscopic sphincterotomy for common bile duct calculi is reported. Complete stone extraction was achieved in 53 cases (72%). Seventeen of 21 patients with retained calculi following recent biliary surgery had successful extractions (80%). Of 30 patients having had a cholecystectomy, 21 (70%) were successful, but only 15 of 23 patients with obstructive jaundice and no previous biliary surgery had the ducts cleared of calculi. Failure was due to multiple stones in the duct, or calculi too large to pass through the sphincterotomy. Endoscopic sphincterotomy is advocated in patients with obstructive jaundice due to stones, moving to early surgery should it prove unsuccessful. The results in patients with a T-tube in situ are comparable to extraction of the calculi along the T-tube tract.     

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).     

腹腔镜、胆道镜联合液电碎石在胆总管结石中的应用

目的 探讨腹腔镜、胆道镜联合液电碎石在胆总管结石中的应用.方法 2009年1月至2013年12月应用腹腔镜、胆道镜联合液电碎石治疗173例胆道结石,其中男性102例,女性71例.年龄24～73岁,平均47.2岁.胆道结石合并胆囊结石者先行腹腔镜胆囊切除术,再通过胆道镜工作通道,应用液电碎石机治疗电极,在直视下接触结石,将胆总管及肝胆管结石击碎后用取石篮套出.结果 173例病人中,147例结石均一次性完全清除,余下病人留置T管后按疗程3～9周内清除结石.无胆管损伤、胆漏.162例术后随访3～30个月,平均15个月,腹部B超或磁共振胰胆管成像（magnetic resonance cholangiopancreatography,MRCP）检查未发现结石复发及残留,无胆道狭窄.结论 腹腔镜、胆道镜联合液电碎石机治疗胆道结石具有直观、准确、方便、疗效确切的特点,是治疗胆道结石的一种安全、有效的新手段.     

Laparoscopic Transcystic Treatment Biliary Calculi by Laser Lithotripsy

Methods:From August 2011 through September 2014, 89 patients at our hospital were treated for cholecystolithiasis with biliary calculi. Patients underwent laparoscopic cholecystectomy and exploration of the CBD via the cystic duct and the choledochoscope instrument channel. A dual-band, dual-pulse laser lithotripsy system was used to destroy the calculi. Two intermittent laser emissions (intensity, 0.12 J; pulse width 1.2 μs; and pulse frequency, 10 Hz) were applied during each contact with the calculi. The stones were washed out by water injection or removed by a stone-retrieval basket.Results:Biliary calculi were removed in 1 treatment in all 89 patients. No biliary tract injury or bile leakage was observed. Follow-up examination with type-B ultrasonography or magnetic resonance cholangiopancreatography 3 months after surgery revealed no instances of retained-calculi–related biliary tract stenosis.Conclusion:The combined use of laparoscopic transcystic CBD exploration by ultrathin choledochoscopy and dual-frequency laser lithotripsy offers an accurate, convenient, safe, effective method of treating biliary calculi.     

腹腔镜胆囊切除术后胆总管残留结石的转归

目的:研究腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)后胆总管残留结石的处理及转归。方法:回顾分析我院1992年4月至2006年6月15 000余例LC术后28例胆总管残留结石的原因、治疗及转归。结果:LC术后28例胆总管残留结石中结石自行排出3例,ERCP确诊25例,25例通过EST成功取石,其中1例为术后胆漏并发胆管结石。结论:通过加强术前检查、术中仔细操作和术后积极处理,可减少LC术后胆总管残留结石及其他严重并发症的发生。     

腹腔镜胆总管探查术161例分析

目的探讨腹腔镜联合胆道镜在胆总管探查、取石术中的应用价值。方法 2009年1月～2011年1月应用腹腔镜联合纤维胆道镜行腹腔镜胆囊切除术、胆总管切开取石、T管引流术治疗161例胆管结石。结果 161例腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE)均获成功,无中转开腹。术后3例发生胆漏,保守治疗4～6 d痊愈。术后住院7～12 d,平均9 d。术后6～8周拔除T管,4例胆管残余结石经T管窦道二期胆道镜取石成功。161随访1～17个月,平均6个月,B超或MRCP复查未发现肝外胆管狭窄,无黄疸、结石复发、胰腺炎等。结论腹腔镜联合纤维胆道镜胆总管探查取石术安全、有效。     

Reconstruction of the biliary tract

The history of biliary reconstruction is a record of almost 100 years of surgical advancement. A reasonable technique is now available and applies not only to reconstruction after injury in the course of cholecystectomy but also to reconstruction after resection of tumor or in the treatment of sclerosing cholangitis, choledochocyst, or biliary calculi. A successful technique requires a dissection that does not compromise blood supply to the proximal duct, the use of a single layer of interrupted sutures, the temporary placement of a stent, and the use of bowel at the hilus of the liver without tension. As in most operative procedures the actual performance of the reconstruction is relatively easy in slender, good surgical subjects, but operative decisions and the actual technique used in locating the proximal duct and in suturing deep in the right upper quadrant can make reconstruction a difficult procedure.     

腹腔镜超声辅助下复杂类型的腹腔镜胆囊切除术

目的：评估腹腔镜超声在复杂的腹腔镜胆囊切除（LC）术中避免胆道损伤及胆总管结石残留的作用。方法:104例LC因肝外胆系解剖变异,胆囊管真实性不确定,疑有胆总管结石或胆道损伤,三角区粘连或炎症,急性或萎缩性胆囊炎等被界定为复杂的LC患者,借助腹腔镜术中超声检查（LUS）显示的胆总管下端,肝外胆管与胆囊壶腹,胆囊管之间的解剖关系施行LC。结果：在LUS辅助下顺利完成复杂的LC85例,19例因LUS提示的潜在胆道损伤危险,胆总管下段结石,及疑有胆道损伤而中转开腹手术。结论：通过LUS显示的肝外胆管,并在术野中胆囊管,胆囊壶腹的参照下,可了解肝外胆系诸结构之间的解剖关系,由此避免胆道损伤,LUS还可发现隐匿的胆总管结石,LUS是复杂LC术中有效的辅助手段。     

Significance of preoperative ultrasound measurement of gallbladder wall thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.