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1.  Comparison of Laparoscopic Versus Open Left Hemihepatectomy for Left-Sided Hepatolithiasis 
PURPOSE: The purpose of this study was to evaluate and compare the perioperative and long-term outcomes of open versus laparoscopic left hemihepatectomy (OLH vs. LLH) for left-sided hepatolithiasis.
METHODS: Between October 2007 and June 2012, 149 patients with left-sided hepatolithiasis who underwent LLH (n = 37) or OLH (n = 112) were evaluated. The perioperative and long-term outcomes that were reviewed included the stone clearance rate, operative morbidity and mortality, and the stone recurrence rate.
RESULTS: The mean operative time of the LLH group was significantly longer than that of the OLH group (257±50.4 minutes vs. 237±75.5 minutes, p = 0.022), but the mean hospital stay was significantly shorter (8.8±4.10 vs. 14.1±4.98 days, p < 0.001). Postoperative complications were noted in four and twenty cases among LLH and OLH patients, respectively (p = 0.982). The initial clearance rate of intrahepatic duct (IHD) stones was 100% and 96.4% in the LLH and OLH groups, respectively, but all remnant stones (n = 4, OLH group) were resolved postoperatively. There were two cases of recurrence of IHD stones in OLH patients, but none in LLH patients (p = 0.281).
CONCLUSIONS: In left-sided hepatolithiasis, LLH was safe and effective: it resulted in low postoperative morbidity, no mortality and a high stone clearance rate, and there were no incidences of recurrence in our study. The potential benefits of LLH include a shorter hospital stay and a faster return to oral intake. If consideration is given to the appropriate indication criteria, including the extent of hepatectomy and the location and distribution of lesions, LLH may be an excellent choice for treatment of left-sided hepatolithiasis.
PMCID: PMC3894396  PMID: 24465157
Laparoscopic left hemihepatectomy; intrahepatic duct stone; open left hemihepatectomy; left-sided hepatolithiasis; minimal invasive surgery
2.  Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis 
AIM: To investigate the feasibility, efficacy and safety of laparoscopic hepaticoplasty using gallbladder as subcutaneous tunnel and sphincter-of-Oddi preservation for hepatolithiasis.
METHODS: From January 2010 to July 2013, six patients with hepatolithiasis were treated at our institution. All the patients underwent laparoscopic surgery. The procedures included common hepatic duct exploration, stone clearance by fiberoptic choledochoscopy, hilar bile duct hepaticoplasty with preservation of the sphincter of Oddi, anastomosis between the hilar bile duct and neck of the gallbladder, and establishment of a subcutaneous tunnel with the gallbladder. Two patients underwent left lateral hepatectomy simultaneously. Clinical data including operation time, intraoperative blood loss, operative morbidity, hospital mortality, stone clearance, and recurrence rate were analyzed.
RESULTS: All patients successfully completed laparoscopic surgery. The mean length of hospital stay was 4.5 ± 0.9 d (range: 3-6 d). The mean blood loss of the hepatectomy was 450 mL (range: 200-700 mL), and the blood loss of the other four was 137 ± 151 mL (range: 50-400 mL). The mean operative time was 318 ± 68 min (range: 236-450 min). The operative morbidity and hospital mortality were zero. The immediate stone clearance rate was 100%. All patients were followed up for an average of 17 mo (range: 7-36 mo). One of the six patients had abdominal mass with pain, and subcutaneous tunnel cholangiography showed severe gallbladder-biliary anastomotic stricture at 4 mo postoperatively. There was no stone recurrence and no cholangitis during follow-up.
CONCLUSION: Laparoscopic hepaticoplasty using gallbladder with a subcutaneous tunnel and preserving the sphincter of Oddi is feasible, safe and effective for hepatholithiasis.
PMCID: PMC3964406
Hepatolithiasis; Laparoscopy; Hepaticoplasty; Minimally invasive surgery; Subcutaneous tunnel
3.  A decade of washing out common bile duct stones with papillary balloon dilatation as a one-stage procedure during laparoscopic cholecystectomy 
Surgical Endoscopy  2010;24(9):2226-2230.
Laparoscopic cholecystectomy is the treatment of choice for the management of cholecystolithiasis. For the management of choledocholithiasis, a number of options exist. The effectiveness of washing out common bile duct stones with laparoscopic transcystic papillary balloon dilatation (LTPBD) in patients undergoing laparoscopic cholecystectomy (LC) as a one-stage procedure was evaluated.
Retrospectively, the files of 63 patients treated with LTPBD in a one-stage procedure undergoing laparoscopic cholecystectomy between December 1996 and December 2006 were studied.
Fifty-three patients were treated successfully in a one-stage procedure, seven patients were treated in two steps with an endoscopic retrograde cholangiopancreatography (ERCP) postoperatively, and in three cases a conversion to open surgery was required. The median operation time was 128 min, and the median hospital stay was 4 days. No patients developed postoperative pancreatitis. In one case contrast leakage from the common bile duct was detected. It was the only complication directly related to the LTPBD. There were no postoperative deaths.
We consider the wash out of common bile duct stones after LTPBD in a one-stage procedure to be an easy to do and safe operation with great results. Cooperation with an intervention radiologist and application of an angioplastic dilatation dotter balloon catheter are the keys to success in this procedure. In our hospital, it is the treatment of choice for choledocholithiasis associated with cholelithiasis.
PMCID: PMC2939343  PMID: 20177926
Common bile duct stones; One-stage procedure; Laparoscopic cholecystectomy; Choledocholithiasis; Cholelithiasis; Papillary balloon dilatation
4.  Laparoscopic laser cholecystectomy: our first 200 patients. 
A series of 200 consecutive patients were considered for laparoscopic laser cholecystectomy. Laparoscopic laser cholecystectomy was attempted in 195 cases and was performed in 192 cases. Laparoscopy was performed in five patients, but laparoscopic cholecystectomy was not attempted owing to dense adhesions (3), cholangiocarcinoma (1) and an absent gallbladder (1). The indications for operation were symptomatic gallstones which included biliary colic (142), acute cholecystitis (49) and gallstone pancreatitis (9). The median duration of operation was 75 min. Operative cholangiography was attempted in 151 (77%) of cases, and was successful in 85% of attempts. Laparoscopic common bile duct visualisation was performed three times with successful stone extraction twice. The other common bile duct was normal. The median duration of postoperative hospital stay was 2 days, for return to normal activity 6 days, and for return to work 10 days. Mean analgesic and antiemetic requirements were approximately one-third of those for open cholecystectomy. Of the patients, 94% reported good or excellent overall satisfaction and 96% reported excellent cosmetic results. Seven complications occurred (4%). Three patients had immediate conversion to laparotomy owing to haemorrhage (2) and gallbladder rupture (1). Four patients required laparotomy for postoperative complications (common bile duct damage, slipped clips from cystic duct, perforated duodenum and leaking accessory hepatic duct). No complications occurred in the last 140 cases. These data suggest that laparoscopic laser cholecystectomy reduces the discomfort of laparotomy and allows a shorter postoperative recovery. The operation has a learning curve, but will ultimately be applicable to the majority of patients with symptomatic gallstones.
PMCID: PMC2497622  PMID: 1416673
5.  Laparoscopic managment of common bile duct stones: our initial experience. 
The Ulster Medical Journal  2002;71(1):22-25.
The management of choledocholithiasis has changed radically since the introduction of laparoscopic cholecystectomy. However, perceived technical difficulties have deterred many surgeons from treating common bile duct stones laparoscopically at the time of cholecystectomy. This has lead to reliance on endoscopic retrograde cholangiopancreatography followed by endoscopic sphincterotomy to deal with common bile duct stones. We retrospectively reviewed the charts of patients who had laparoscopic common bile duct exploration at Downe Hospital between December 1999 and August 2001. Among 149 laparoscopic cholecystectomies done by our group in this period, 10 patients (6.7%) underwent laparoscopic CBD exploration, three by the transcystic technique and seven by choledochotomy. Three patients (2%) had unsuspected stones found on routine per- operative cholangiogram. The mean operative time was 2.34hrs (range 1.50-3.30hrs). The mean hospital post- operative stay was 3 days (range 1-6 days). Post-operative morbidity was zero. Stone clearance was achieved in all cases. We conclude, laparoscopic exploration of the common bile duct is relatively safe and straightforward method. The key skill required is the ability to perform laparoscopic suturing with confidence.
PMCID: PMC2475345  PMID: 12137159
6.  Reoperation of biliary tract by laparoscopy: Experiences with 39 cases 
AIM: To evaluate the safety and feasibility of biliary tract reoperation by laparoscopy for the patients with retained or recurrent stones who failed in endoscopic sphincterotomy.
METHODS: A retrospective analysis of data obtained from attempted laparoscopic reoperation for 39 patients in a single institution was performed, examining open conversion rates, operative times, complications, and hospital stay.
RESULTS: Out of the 39 cases, 38 (97%) completed laparoscopy, 1 required conversion to open operation because of difficulty in exposing the common bile duct. The mean operative time was 135 min. The mean post-operative hospital stay was 4 d. Procedures included laparoscopic residual gallbladder resection in 3 cases, laparoscopic common bile duct exploration and primary duct closure at choledochotomy in 13 cases, and laparoscopic common bile duct exploration and choledochotomy with T tube drainage in 22 cases. Duodenal perforation occurred in 1 case during dissection and was repaired laparoscopically. Retained stones were found in 2 cases. Postoperative asymptomatic hyperamylasemia occurred in 3 cases. There were no complications due to port placement, postoperative bleeding, bile or bowel leakage and mortality. No recurrence or formation of duct stricture was observed during a mean follow-up period of 18 mo.
CONCLUSION: Laparoscopic biliary tract reoperation is safe and feasible if it is performed by experienced laparoscopic surgeons, and is an alternative choice for patients with choledocholithiasis who fail in endoscopic sphincterectomy.
PMCID: PMC2712179  PMID: 18494063
Minimally invasive surgery; Reoperation; Choledocholithiasis; Laparoscopic common bile duct exploration
7.  Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy. 
Gut  1994;35(7):991-995.
Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.
PMCID: PMC1374850  PMID: 8063230
8.  Non-operative removal of bile duct stones by duodenoscopic sphincterotomy in the elderly. 
Between January 1975 and December 1979, 71 patients over the age of 70 underwent attempted duodenoscopic sphincterotomy for stones in the common bile duct. Fifteen patients still had gall bladders in situ. Sphincterotomy was possible in 69 of the patients and in 65 of these duct clearance was achieved, giving an overall success rate of 92%. Failure to achieve sphincterotomy in two cases was due to substantial peripapillary diverticula. Duct clearance failed in four patients, mostly due to the size of the retained stones. The largest stone extracted was 24 mm diameter. There were no deaths but complications occurred in nine patients (13%); these were haemorrhage in four (requiring surgery in one), cholangitis in four (two of whom required surgical extraction of stones), and pancreatitis in one. The average duration of hospital stay in successful cases was 11 days (range three to 30). Clinical follow-up of 55 patients one to five years after sphincterotomy showed no evidence of stones or of stenosis of the sphincter. Duodenoscopic sphincterotomy is a major advance in the management of elderly patients with stones in the common bile duct.
PMCID: PMC1507951  PMID: 6790050
9.  Cost-Effective Treatment of Patients with Symptomatic Cholelithiasis and Possible Common Bile Duct Stones 
Journal of the American College of Surgeons  2011;212(6):1049-1060.e1-7.
Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones.
Study Design
Our decision model included five treatment strategies: (1) laparoscopic cholecystectomy (LC) alone followed by expectant management, (2) preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC, (3) LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE), (4) LC followed by postoperative ERCP, and (5) LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National CMS data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability.
Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to one health input: specificity of IOC, and three costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC.
The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.
PMCID: PMC3163150  PMID: 21444220
10.  Surgical options in the management of cystic duct avulsion during laparoscopic cholecystectomy 
Avulsion of cystic duct during laparoscopic cholecystectomy (LC) is not a common intraoperative complication, but may be encountered by any laparoscopic surgeon. Surgeons are rarely familiar with management of this condition.
Patients with gall stone related problems who were scheduled for LC at the minimal invasive surgery unit of a tertiary referral hospital during a 5 years period (April 2002–April 2007) were prospectively enrolled.
12 cases were identified (incidence: 1.15%). All 12 patients had gallbladder inflammation. Five patients had acute and seven patients had chronic cholecystitis. The avulsed cystic duct (ACD) was managed by clipping in 4, intracorporeal suturing in 3, converting to open surgery with suture ligation in 2, and lonely external drainage in 3 patients. Bile leakage had ceased within 3 days in 2, 14 days in one, and 20 days in the other patient. Bile volume increased gradually in one of the patients, which stopped only after endoscopic sphincterotomy (ES) at 25th postoperative day. No major late complication or mortality occurred.
ACD during LC is a rare complication. Almost all standard methods of treatment yield to successful outcomes with low morbidity. According to the situation, ACD may be successfully managed laparoscopically. Available cystic stump remnant was clipped. Intracorporeal suture ligation was performed when short length of stump precluded clipping. Deeply retracted cystic duct with active bile leak led to conversion to open surgery. With minimal or no bile leak at ACD stump, closed tube drainage of sub-hepatic area was attempted. Persistent bile leak was assumed to be controlled by ES, successfully accomplished in one patient.
PMCID: PMC2442050  PMID: 18565237
11.  Laparoscopic Common Bile Duct Exploration in Patients With Gallstones and Choledocholithiasis 
Failed ERCP appears to decrease the success rate of a laparoscopic approach for common bile duct exploration.
To compare the effectiveness of laparoscopic common bile duct exploration in patients with failed endoscopic retrograde cholangiopancreatography (ERCP).
This is a descriptive, comparative study. Patients with an indication of common bile duct exploration between February 2005 and October 2008 were included. We studied 2 groups: Group A: patients with failed ERCP who underwent LCBDE plus LC. Group B: patients with common bile duct stones managed with the 1-step approach (LCBDE + LC) with no prior ERCP.
Twenty-five patients were included. Group A: 9 patients, group B: 16 patients. Success rate, operative time, and hospital stay were as follows: group A 66% vs group B 87.5%; group A 187 minutes vs 106 minutes; group A 4.5 days vs 2.3 days; respectively.
Patients with failed ERCP should be considered as high-complex cases in which the laparoscopic procedure success rate decreases, and the conversion rate increases considerably.
PMCID: PMC3043576  PMID: 20932377
Choledocholithiasis; Laparoscopy; Endoscopic retrograde; Cholangiopancreatography
12.  Retroperitoneal laparoscopic pyelolithotomy versus extra corporeal shock-wave lithotripsy for management of renal stones 
The purpose of this study was to evaluate the role of retroperitoneal laparoscopic pyelolithotomy (RPPL) and its comparison with extra corporeal shock wave lithotripsy in the management of renal calculi.
The study was carried out in the Department of surgery, Maulana Azad Medical College, New Delhi, India. The study included 86 cases of solitary renal calculi in the retroperitoneoscopic (RPPL) group and 82 cases in the shock wave lithotripsy (SWL) group. The parameters compared were stone clearance, hospital stay, number of postoperative visits, mean time to resume normal activities, number of man days lost, and analgesic requirement.
The RPPL group showed better stone clearance, fewer hospital visits, low analgesic requirement, fewer number of man days lost, and early resumption of normal activities, as compared to the SWL group.
Shock wave lithotripsy, being a noninvasive modality, is an established procedure all over the world. However RPPL achieves comparable or better results in high volume centers.
PMCID: PMC2992658  PMID: 21120067
Laparoscopic pyelolithotomy; minimal invasive; renal stones; shock waves; shock wave lithotripsy
13.  A Case of Clonorchiasis with Focal Intrahepatic Duct Dilatation Mimicking an Intrahepatic Cholangiocarcinoma 
Clinical Endoscopy  2011;44(1):55-58.
Biliary strictures can be caused by various diseases. Intrahepatic duct (IHD) strictures are usually related to IHD stones and cholangitis. However, focal IHD strictures without IHD stones often create diagnostic problems. Parasitic diseases such as clonorchiasis can be a rare cause of an IHD stricture. Human clonorchiasis (Clonorchis sinensis infection) is an endemic parasitic disease in Eastern Asia, including Korea, and patients acquire the infestation by eating raw fish. On radiological examinations, clonorchiasis shows typically diffuse, minimal, or mild dilatation of the small IHD, particularly in the periphery, without dilatation of the extrahepatic duct. However, diagnosis of clonorchiasis can sometimes be difficult when radiological changes are atypical. We report a case of focal left IHD dilatation caused by clonorchiasis that was confused with a malignancy.
PMCID: PMC3363046  PMID: 22741114
Clonorchiasis; Intrahepatic bile duct; Dilatation; Stricture
14.  Two-stage vs single-stage management for concomitant gallstones and common bile duct stones 
AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.
METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.
RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.
CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.
PMCID: PMC3386330  PMID: 22791952
Laparoscopic cholecystectomy; Laparoscopic common bile duct exploration; Endoscopic retrograde cholangiopancreatography; Endoscopic sphincterotomy; Gallstones; Common bile duct stones; Meta-analysis
15.  Extracorporeal shock wave lithotripsy of bile duct stones: a single institution experience. 
Gut  1992;33(10):1416-1420.
Extracorporeal shock wave lithotripsy treatment with Dornier HM3 or MPL 9000 machines was applied in 37 patients with problematic bile duct stones. General anaesthesia was not required. After one extracorporeal shock wave lithotripsy session 14/37 patients (38%) were spontaneously stone free, and additional endoscopic extraction (eight of 37) and retreatments with extracorporeal shock wave lithotripsy (seven cases) increased the stone free rate to 29/37 (78%). In three patients with intrahepatic stones, the bile ducts could not be evaluated decisively at cholangiography and ultrasonography, but they were all symptom free at 15 to 38 months follow up. If these three patients are added to the radiologically stone free patients, the overall clinical success rate was 32/37 (86%). There were no serious complications, hospital admissions, or 30 day mortality as a result of extracorporeal shock wave lithotripsy or endoscopic procedures. It is concluded that extracorporeal shock wave lithotripsy is a valuable adjunct to the non-surgical treatment of bile duct stones.
PMCID: PMC1379616  PMID: 1446872
16.  Laparoscopic Management of Remnant Cystic Duct Calculi: A Retrospective Study 
Even though cholecystectomy relieves symptoms in the majority of cases, a significant percentage suffer from ‘postcholecystectomy syndrome’. Cystic duct/gall bladder remnant calculi is a causative factor. We present our experience with the laparoscopic management of cystic duct remnant calculi.
We managed 15 patients with cystic duct remnant calculi from 1996 to 2007 in our institute. All these patients had earlier undergone laparoscopic subtotal cholecystectomy at our centre. They were successfully managed by laparoscopic excision of the remnant.
The mean duration between first and second surgery was 8.35 months (range, 6–10.7 months). The mean operating time was 103.5 min (range, 75–132 min). Duration of hospital stay was 4–12 days. There was a higher incidence of remnant duct calculi following laparoscopic subtotal cholecystectomy than conventional laparoscopic cholecystectomy 13/310 (4.19%) versus 2/9590 (0.02%). The morbidity was 13.33%, while there were no conversions and no mortality.
Leaving behind a cystic duct stump for too long predisposes stone formation, while dissecting too close to the common bile duct and right hepatic artery in acute inflammatory conditions is dangerous. We believe that the former is a wiser policy to follow, as cystic duct remnant calculi are easier to manage than common bile duct or vessel injury. Laparoscopic excision of the remnant is effective, especially when performed by experienced laparoscopists. ‘T’-tube is used to canulate the common bile duct in case the tissue is friable. Magnetic resonance cholangiopancreaticography is the imaging modality of choice, and is mandatory.
PMCID: PMC2752238  PMID: 18990269
Laparoscopic subtotal cholecystectomy; Post-cholecystectomy syndrome; Cystic duct remnant calculus; Excision
17.  Endoscopic sphincteroplasty: a novel and safe alternative to papillotomy in the management of bile duct stones. 
Gut  1994;35(1):127-129.
Removal of bile duct stones during endoscopic retrograde cholangiopancreatography (ERCP) usually includes papillotomy. Papillotomy is associated with occasional complications and in addition, the longterm sequelae of papillotomy in young patients having laparoscopic cholecystectomy remain unclear. As an alternative to papillotomy, this study prospectively evaluated the efficacy and safety of endoscopic balloon sphincteroplasty to facilitate bile duct clearance. Of 32 patients with bile duct stones (diameter 3-30 mm) at ERCP, sphincteroplasty was considered inappropriate in four patients because of stone size (> 20 mm) necessitating papillotomy for bile duct clearance. Sphincteroplasty was performed in the remaining 28 patients to permit duct clearance by dormier basket, balloon or mechanical lithotripsy. The bile duct was cleared in 22 patients (79%) while additional measures including papillotomy or stent insertion were required in the remaining six patients (21%) because of stone size or technical difficulties. There was no associated papillary haemorrhage. Pancreatitis was seen in one patient (4%) but resolved within 24 hours. Our preliminary experience suggests that sphincteroplasty is a safe and effective sphincter preservation technique that significantly reduces the necessity for papillotomy in the management of bile duct stones.
PMCID: PMC1374647  PMID: 8307433
18.  Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. 
BACKGROUND: Little is known about the spontaneous passage of bile duct stones. The aim of this study was to determine the rate of spontaneous stone passage and relate it to the clinical presentation of the bile duct stone. PATIENTS AND METHODS: Prospectively collected data were studied on a total of 1000 consecutive patients undergoing laparoscopic cholecystectomy with or without laparoscopic common duct exploration. Comparisons were made between 142 patients with common bile duct stones (CBDS), 468 patients who had no previous or current evidence of duct stones, and 390 patients who had good evidence of previous duct stones but none at the time of cholecystectomy. The evidence used for previous duct stones included a good history of jaundice or pancreatitis. In patients with biliary colic or cholecystitis, abnormal pre-operative liver function tests and/or a dilated common bile duct were taken as evidence of bile duct stones. RESULTS: Of the 1000 patients studied, 532 had evidence of stones in the common bile duct at some time prior to cholecystectomy. At the time of operation, only 142 patients had bile duct stones. By implication, 80%, 84%, 93% and 55% of patients presenting with pancreatitis, colic, cholecystitis and jaundice (73% overall) had passed their bile duct stones spontaneously. All 4 patients with cholangitis had duct stones at the time of operation. CONCLUSIONS: It is likely that most bile duct stones (3 in 4) pass spontaneously, especially after pancreatitis, biliary colic and cholecystitis but less commonly after jaundice. Cholangitis appears to be always associated with the presence of duct stones at the time of operation.
PMCID: PMC1964371  PMID: 12831489
19.  Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy. 
Gut  1995;37(4):576-579.
A policy of preoperative endoscopic retrograde cholangiography (ERC) for suspected bile duct stones was used in 1507 patients considered for laparoscopic cholecystectomy in three district general hospitals. Altogether 306 patients underwent ERC, and bile duct cannulation was achieved in 276 (90%). Bile ducts were cleared by endoscopic sphincterotomy in 128 of 161 patients (79%) with proven duct stones. Laparoscopic cholecystectomy was completed in 1396 patients. Ten laparotomies were necessary for complications of laparoscopic cholecystectomy. The complication rate for endoscopic sphincterotomy/laparoscopic cholecystectomy was 2.7%, with no mortality. Overall, a combined endoscopic/laparoscopic approach succeeded in 1386 patients (92%). Fourteen patients (1%) had retained stones during a median of 14 months (range 1-42) follow up, all of which were removed by ERC/endoscopic sphincterotomy. If a policy of selective ERC before laparoscopic cholecystectomy is used for all patients with symptomatic gall stones, most will avoid an open operation and laparoscopic exploration of the bile duct is not necessary.
PMCID: PMC1382914  PMID: 7489949
20.  Acute pancreatitis and obstructive jaundice as initial complaints of hepatocellular carcinoma: case report 
Patients with cirrhosis-associated hepatocellular carcinoma (HCC) rarely present with acute pancreatitis (AP) and obstructive jaundice as the main clinical features. AP with obstructive jaundice caused by common bile duct embolism (CBDE) is very rare.
Case presentation
A 54-year-old man with CBDE was misdiagnosed with common bile duct stones three times over a 7-month period. Investigations during this time did not identify CBDE. Surgical exploration was performed because of AP, obstructive jaundice, and a tumor in the left lobe of the liver. CBDE from the hepatic tumor was diagnosed by intraoperative biopsy and frozen section examination. The patient underwent left hemihepatectomy, cholecystectomy, and bile duct exploration.
Preoperative diagnosis of CBDE is difficult because of the rarity of the condition, lack of physician awareness, and easy misdiagnosis on imaging examinations. Early and accurate diagnosis of this condition is important.
PMCID: PMC3896744  PMID: 24422982
Pancreatitis; Obstructive jaundice; Hepatocellular carcinoma; Common bile duct embolism
21.  Endoscopic papillary large balloon dilation alone without sphincterotomy for the treatment of large common bile duct stones 
BMC Gastroenterology  2011;11:69.
Lethal pancreatitis has been reported after treatment for common bile duct stones using small endoscopic papillary balloon dilation.
We retrospectively evaluated the safety and efficacy of using large balloon dilation alone without the use of sphincterotomy for the treatment of large common bile duct stones in Kaohsiung Veterans General Hospital. Success rate of stone clearance, procedure-related adverse events and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded.
A total of 247 patients were reviewed in the current study. The mean age of the patients was 71.2 years. Most of them had comorbidities. Mean stone size was 16.4 mm. Among the patients, 132 (53.4%) had an intact gallbladder and 121 (49%) had a juxtapapillary diverticulum. The mean size of dilating balloon used was 13.2 mm. The mean duration of the dilating procedure was 4.7 min. There were 39 (15.8%) patients required the help of mechanical lithotripsy while retrieving the stones. The final success rate of complete retrieval of stones was 92.7%. The rate of pancreatic duct enhancement was 26.7% (66/247). There were 3 (1.2%) adverse events and 6 (2.4%) intra-procedure bleeding incidents. All patients recovered completely after conservative and endoscopic treatment respectively, and no procedure-related mortality was noted. 172 patients had a follow-up duration of more than 6 months and among these, 25 patients had recurrent common bile duct stones. It was significantly correlated to the common bile duct size (p = 0.036)
Endoscopic papillary large balloon dilation alone is simple, safe, and effective in dealing with large common bile duct stones in relatively aged and debilitated patients.
PMCID: PMC3142528  PMID: 21668994
22.  Biliary peritonitis caused by a leaking T-tube fistula disconnected at the point of contact with the anterior abdominal wall: a case report 
Operations on the common bile duct may lead to potentially serious complications such as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurring postoperatively. Biliary leakage at the point of insertion into the common bile duct, or along the fistula, can sometimes occur after T-tube removal and this has been reported extensively in the literature. We report a case where the site at which the T-tube fistula leaked proved to be the point of contact between the fistula and the anterior abdominal wall, a previously unreported complication.
Case presentation
A 36-year-old sub-Saharan African woman presented with gallstone-induced pancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed, common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tube removal led to biliary peritonitis due to the disconnection of the T-tube fistula which was recannulated laparoscopically using a Latex drain.
This case highlights a previously unreported mechanism for bile leak following T-tube removal caused by detachment of a fistula tract at its contact point with the anterior abdominal wall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use of laparoscopy to recannulate the fistula.
PMCID: PMC2557018  PMID: 18796154
23.  Liver Resection for Intrahepatic Stones 
HPB Surgery  1990;2(2):145-147.
Intrahepatic stones are difficult to manage, especially when they are associated with bile duct stricture, cholangitis and destruction of liver parenchyma. Suggested modes of treatment include surgical bile duct exploration, endoscopic procedures, transhepatic cholangiolithotomy and liver resection. This paper reports 2 patients in whom liver resection was performed because of intrahepatic ductal stones, bile duct strictures and repeated episodes of cholangitis. Liver resection was uncomplicated and long-term results were satisfactory. Our results support the view that liver resection is indicated in rare instances of intrahepatic bile duct stones associated with bile duct strictures.
PMCID: PMC2423565  PMID: 2278909
24.  Laparoscopic Cholecystectomy and Management of Biliary Tract Stones in a Freestanding Ambulatory Surgery Center 
We conducted a retrospective 4-year study of patients undergoing laparoscopic cholecystectomy at a freestanding ambulatory surgery center. Data on rates of hospital admission, conversion to open surgery, bile duct injury, postoperative bile leakage, and incidence of choledocholithiasis were analyzed. The success rate for dynamic fluoroscopic intraoperative cholangiography was computed, and outpatient laparoscopic common bile duct exploration and anesthetic management were reviewed.
Patient charts from the ambulatory surgery center, office, and hospital were reviewed over a 4-year period commencing in October 1999. All cases were performed by 1 of 3 surgeons who are experienced with outpatient laparoscopic cholecystectomy and practice routine dynamic fluoroscopic intraoperative cholangiography.
A total of 338 laparoscopic cholecystectomies were performed. Dynamic fluoroscopic intraoperative cholangiography was successfully performed in 89% (n=302). No instances of bile duct injury or conversions to open surgery were reported. A 0.89% (n =3) incidence of postoperative bile leak occurred. Six patients were admitted for inpatient care for a rate of 1.78%. Choledocholithiasis occurred in 2.0% and was managed successfully in the ambulatory setting.
Laparoscopic cholecystectomy can be adapted to the freestanding ambulatory surgery environment with very high standards of care and very low complication rates.
PMCID: PMC3015679  PMID: 16709357
Ambulatory surgery; Cholangiogram; Choledocholithiasis; Laparoscopic cholecystectomy; Laparoscopic common bile duct exploration
25.  Acute Cholecystitis and Severe Ischemic Cardiac Disease: Is Laparoscopy Indicated? 
Background and Objectives:
Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication.
We report the case of a patient who presented with acute cholecystitis and choledocholithiasis concurrent with unstable angina. Our experience in laparoscopic management of patients with calculous biliary disease and severe coronary artery disease is examined.
The patient was managed by coronary angioplasty and stenting immediately followed by laparoscopic cholecystectomy and common bile duct exploration under close invasive hemodynamic monitoring and low-pressure pneumoperitoneum. Between 1996 and 2001, 39 patients with coronary artery disease and an ASA class of III or IV underwent laparoscopic cholecystectomy. Eight of these patients (20.5%) had common bile duct stones necessitating laparoscopic common bile duct exploration. No conversions were necessary, and no major morbidity or mortalities occurred.
Laparoscopic cholecystectomy and common bile duct exploration can be safely performed in patients with severe ischemic cardiac disease under close hemodynamic monitoring and a low-pressure pneumoperitoneum (10 to 12 mm Hg).
PMCID: PMC3015516  PMID: 14974666
Laparoscopy; Acute cholecystitis; Ischemic cardiac disease

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