Common bile duct stones on multidetector computed tomography:Attenuation patterns and detectability

AIM:To investigate the attenuation patterns and detectability of common bile duct(CBD) stones by multidetector computed tomography(MDCT).METHODS:Between March 2010 and February 2012,191 patients with suspicion of CBD stones undergoing both MDCT and endoscopic retrograde cholangiopancreatography(ERCP) were enrolled and reviewed retrospectively.The attenuation patterns of CBD stones on MDCT were classified as heavily calcified,radiopaque,less radiopaque,or undetectable.The association between the attenuation patterns of CBD stones on MDCT and stone type consisting of pure cholesterol,mixed cholesterol,brown pigment,and black pigment and the factors related to the detectability of CBD stones by MDCT were evaluated.RESULTS:MDCT showed CBD stones in 111 of 130 patients in whom the CBD stones were demonstrated by ERCP with 85.4% sensitivity.The attenuation patterns of CBD stones on MDCT were heavily calcified 34(26%),radiopaque 31(24%),less radiopaque 46(35%),and undetectable 19(15%).The radiopacity of CBD stones differed significantly according to stone type(P < 0.001).From the receiver operating characteristic curve,stone size was useful for the determination of CBD stone by MDCT(area under curve 0.779,P < 0.001) and appropriate cut-off stone size on MDCT was 5 mm.The factors related to detectability of CBD stones on MDCT were age,stone type,and stone size on multivariate analysis(P < 0.05).CONCLUSION:The radiopacity of CBD stones on MDCT differed according to stone type.Stone type and stone size were related to the detectability by MDCT,and appropriate cut-off stone size was 5 mm.     

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy.METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared.RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed before complete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions).CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.     

Extrahepatic bile duct angulation by T-tube: The elbow sign

The normal shape of the extrahepatic bile ducts approximates a straight line. The cholangiograms of 50 patients with indwelling T-tube catheters were retrospectively reviewed between 4 and 14 weeks postcholecystectomy. We observed a lateral distortion in the shape of the bile ducts in 35 patients (70%) such that an angle measured between the proximal and distal parts of the duct, centered at the site of T-tube insertion, decreased to between 60° and 158°. We have called this observation the elbow sign, which to our knowledge has not been previously described and appears to be of no clinical consequence.     

胆囊切除术中胆管造影对检出胆管结石的价值与指征

分析胆囊切除术时胆管造影检出胆管结石的价值和指征。病例和方法:1988年迄今共行胆囊切除646例。病例分三组,第一组304例兼行胆管造影和探查(造影组);第二组107例未行胆管造影而直接胆道探查(探查组);第三组235例行单纯胆囊切除。结果:第一组胆石检出率为94％;第二组胆石检出率为53％;第三组术后随访有残石2例。结论:术中胆管造影有助于:①降低术后胆道残石率;②避免不必要的胆道探查;③明确胆道解剖变异,有效地预防胆道损伤;④提高对Mirizzi综合征的识别率。     

New multipurpose endoknot device for laparoscopic surgery

Extracorporeal knot tying for the ligation and suture ligation of various structures is becoming more important with the increasing popularity of laparoscopic surgery, especially in complicated cholecystectomies with the need to do intraoperative cholangiography, and in other advanced procedures. We have designed a new multipurpose endoknot device that can be used to: (1) push the knot of a pre-tied loop, (2) facilitate the extracorporeal tying of square knots, and (3) facilitate the suturing of tissues, using either a slip knot or a square knot. The device consists of a simple stainless steel rod with a 3-mm lateral hole at its working end which connects to a 1-mm hole at the tip. The blunt tip lessens the chance of inadvertent injury to the liver and other organs during knot tying. We have used this instrument in laparoscopic cholecystectomy with intraoperative cholangiography, and in laparoscopic hernia repair, colon resection, and thoracoscopic esophagectomy, with great success and with no morbidity attributable to its use.     

Intraoperative cholangiography during laparoscopic cholecystectomy

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intra-operative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.     

Biliary complications after living donor adult liver transplantation.

The highest rate of complications characterizing the adult living donor liver transplantation (ALDLT) are due to biliary problems with a reported negative incidence of 22-64%. We performed 23 ALDLT grafting segments V-VIII without the middle hepatic vein from March 2001 to September 2005. Biliary anatomy was investigated using intraoperative cholangiography alone in the first five cases and magnetic resonance cholangiography in the remaining 18 cases. In 13 cases we found a single right biliary duct (56.5%) and in 10 we found multiple biliary ducts (43.7%). We performed single biliary anastomosis in 17 cases (73.91%) and double anastomosis in the remaining six (26%) cases. With a mean follow up of 644 days (8-1598 days), patient and graft survivals are 86.95% and 78.26%, respectively. The following biliary complications were observed: biliary leak from the cutting surface: three, anastomotic leak: two, late anastomotic strictures: five, early kinking of the choledochus: one. These 11 biliary complications (47.82%) occurred in eight patients (34.78%). Three of these patients developed two consecutive and different biliary complications. Biliary complications affected our series of ALDLT with a high percentage, but none of the grafts transplanted was lost because of biliary problems. Multiple biliary reconstructions are strongly related with a high risk of complication.     

Experience with three-port laparoscopic cholecystectomy

After considerable experience with laparoscopic cholecystectomy (LC) using four ports, we began using three-port LC in October 1993 and have performed 130 LCs with this procedure up to May 1996. The procedure was successful in 119 patients. In 6 patients fourth port was used, and in another 5, the procedure was converted to open laparo-tomy. Cooperative manipulation of the surgical instruments between the operator and assistant is very important for this procedure, for exposing Calot's triangle and dissecting the gallbladder from the gallbladder bed. The use of an ultrasonic aspiration system (Sumisonic ME 2400; Sumitomo Bakelite, Tokyo, Japan) made it easier to identify the cystic duct and artery, especially in patients with chronic inflammation or dense adhesions. We encountered no problems with cannulation into the cystic duct for intraoperative cholangiography, and there were no intra- and postoperative complications in this series. We achieved good results, similar to those achieved with the four-port technique. This technique is technically feasible and safe, and it has esthetic and cost advantages compared with the four-port technique. However, the operator who performs three-port LC should not hesitate to add another port, or to convert to open laparotomy, whenever any difficulties occur during this procedure, to prevent critical complications.     

Peritoneoscopic cholecystectomy has opened the door to minimally invasive surgery

In 1989 a new trend occurred in the surgical treatment of a diseased gall-bladder, laparoscopic cholecystectomy (LC). Laparoscopic surgery is now accepted world-wide as the choice of treatment with the advantages of less pain, good cosmesis, short hospital stay and early recovery. It is also a curative procedure for cholelithiasis as well as a cholecystectomy. The rate of conversion to open surgery is about 5% and the rates of bile duct injury are 0.1–0.6%. This new approach revives controversies concerning cholecystectomy; namely indication, use of intra-operative cholangiography, ductal calculi and pregnancy. There are new issues to consider, including use of a Veress needle for pneumoperitoneum, type of trocars, cardiovascular responses to pneumoperitoneum using carbon dioxide and so on. With increasing use, these difficulties will be overcome. Advances in technology are expected to make even more new types of surgery possible, even perhaps extending into robotic surgery.     

Gadoxetic acid-enhanced T1-weighted MR cholangiography in primary sclerosing cholangitis

Purpose:

To investigate the value of gadoxetic acid‐enhanced three‐dimensional T1‐weighted MR cholangiography (T1w‐MRC) in comparison to three‐dimensional T2‐weighted MR cholangiopancreaticography (T2w‐MRCP) in patients with primary sclerosing cholangitis (PSC).

Materials and Methods:

Thirty‐four MR exams in 29 patients (46.0 ± 16.1 years; 19 men, 10 women) scanned within a 14‐month period were retrospectively included. Two abdominal radiologists independently evaluated image quality regarding image contrast, image quality degradation due to artifacts, and visualization quality of ducts. The order of biliary tree branches that were visualized and reader preference toward each method were recorded. Helpfulness of T1w‐MRC was scored in consensus. Confirmatory endoscopic retrograde cholangiopancreaticography (ERCP) performed within 3 months of the MR examination was available in 8 patients.

Results:

Image quality of T1w‐MRC and T2w‐MRCP was graded good to excellent in all cases. There were advantages for both T1w‐MRC (functional information, less degradation due to artifacts) and T2w‐MRCP (higher order of visualized branches, better branch depiction). Both readers showed preference for T2w‐MRCP; however, both readers found gadoxetic acid–enhanced T1w‐MRC helpful in the majority of cases.

Conclusion:

Gadoxetic acid‐enhanced T1w‐MRC is complementary to, but should not replace, T2w‐MRCP. T1w‐MRC is a useful adjunct to T2w‐MRCP for morphologic evaluation and provides additional diagnostic information. J. Magn. Reson. Imaging 2012;36:632–640. © 2012 Wiley Periodicals, Inc.