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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.  Endoscopic extraction of bile duct stones: management related to stone size. 
Gut  1993;34(12):1718-1721.
Endoscopic sphincterotomy has become the first line treatment for patients with common bile duct (CBD) stones. This technique may fail, however, due to difficult anatomy, previous surgery, periampullary diverticula or the presence of a large stone. The importance of stone size to the success of endoscopic sphincterotomy has not been fully assessed. A prospective study was carried out over the period January 1987 to December 1989 on 100 patients (45 male, 55 female, median age 69 years, range 19-97) with CBD stones in which a policy of early duct clearance was followed. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and the stone size and number recorded from the cholangiograms and corrected for magnification. Sphincterotomy was performed using a diathermy unit with a cutting current and stones were extracted using a balloon catheter or a Dormia basket. Of the 100 patients with CBD stones receiving ERCP, successful clearance of the biliary tree was possible in seven without endoscopic sphincterotomy and five were felt to be unsuitable for endoscopic sphincterotomy. Of the remaining 88 patients endoscopic sphincterotomy was successful in 75 (85%). Of the 75 patients having endoscopic sphincterotomy stone clearance was successful in 44 (59%). There were no deaths and only four complications, which rapidly resolved on conservative treatment (two acute pancreatitis, two bleeding). The number of CBD stones present was similar in those patients with successful endoscopic sphincterotomy and duct clearance (median 1, range 1-10, n = 44) as in those in whom it failed (median 2, range 1-6, n = 31). In contrast there was a highly significant difference when stone size was analysed (successful clearance median stone size 10 mm, range 3-27 mm; unsuccessful: median 18 mm, range 10-42, p<0.001). Stones less than 10 mm in diameter (n=21) were all removed successfully whereas in patients with stones over 15 mm (n=25) only three were removed endoscopically (12%). All patients with evidence of residual stones had additional treatment. Of these 31 patients, 10 had surgery, 11 had insertion of an endoprosthesis, and 10 had dissolution treatment with methyl-tert-butyl ether through a nasobiliary catheter. This study shows the importance of stone size to the success rate of endoscopic removal of bile duct stones.
PMCID: PMC1374470  PMID: 8282260
3.  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
4.  Laparoscopic left hepatectomy in patients with intrahepatic duct stones and recurrent pyogenic cholangitis 
Recently many studies have been reported the early results of a hepatectomy for various intrahepatic lesions. Also various types of laparoscopic hepatectomies are being performed in many centers. Some reports about the safety of laparoscopic parenchymal dissection of the liver have been published. In this study, we reported our experiences of laparoscopic left hepatectomies in patients with an intrahepatic duct (IHD) stone with recurrent pyogenic cholangitis (RPC), and investigated whether the total laparoscopic parenchymal dissection is as safe as open surgery.
From April 2008 to December 2010, 25 patients had been admitted for left IHD stones with RPC. Preoperatively, the type of surgery was decided with the intention of treating each patient. Initially 10 patients underwent a laparoscopy-assisted left hepatectomy and the next 15 patients underwent total laparoscopic left hepatectomy as our experience grew. Demographics, peri- and postoperative results were collected and analyzed comparatively.
The mean age, gender ratio, preoperative American Society of Anesthesiologists (ASA) score, accompanied acute cholangitis and biliary pancreatitis, and the number of preoperative percutaneous transhepatic biliary drainage (PTBD) inserted cases were not different between the two groups who had undergone laparoscopy-assisted and totally laparoscopic left hepatectomy. The operation time, intraoperative transfusions and postoperative complications also showed no difference between them. The postoperative hospital stay did not show a significant difference statistically.
In this study, we concluded that a laparoscopic left hepatectomy can be adapted to the patients with a left IHD stone with RPC. Also laparoscopic parenchymal dissection is safe and equivalent to an open procedure.
PMCID: PMC4575009  PMID: 26388917
Intrahepatic duct stone; Recurrent pyogenic cholangitis; Laparoscopic left hepatectomy
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.  Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones 
Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively.
Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded.
Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation.
A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.
PMCID: PMC3080093  PMID: 20223077
Bile duct stones; Intra-operative imaging; Pre-operative indicators; Cholangiography
7.  Is Cholecystectomy Necessary After ERCP for Bile Duct Stones in Patients with Gallbladder in situ? 
The requirement for subsequent cholecystectomy in patients with gallbladder in situ after endoscopic removal of stones from the common bile duct (CBD) is controversial. The aims of this study were to assess the requirement for subsequent cholecystectomy for gallbladder-related symptoms, and to identify the patients who develop symptoms after the endoscopic removal of CBD stones.
Of 241 patients with gallbladder in situ following endoscopic removal of stones from the CBD, 146 patients (78 men and 68 women; mean age 69±13 years, range 20–93) with a follow-up time of more than three months without elective cholecystectomy were enrolled in the study. Fifty-nine patients had gallbladder stones (single stones in 27 and multiple stones in 32) and 87 patients had gallbladder in situ without stones. The time from entry to the occurrences of death or cholecystectomy was evaluated retrospectively. Cox regression analysis was used to evaluate the risk factors associated with these events.
The mean duration of follow-up was 24.1±18.0 months (range 3–70 months). During follow-up, seven patients (4.8%) underwent cholecystectomy, on average 18.4 months after CBD stone removal, as the result of acute cholecystitis in four cases, biliary pain in two cases and acute pancreatitis in one case. Laparoscopic cholecystectomy was performed in four patients and open cholecystectomy in three patients. Post-operative morbidity occurred in two patients, with improvement after conservative management. Nine patients (6.2%) died as the result of unrelated biliary disease. Age, sex, presence of gallbladder stones, multiplicity of gallbladder stones and underlying disease did not correlate with subsequent cholecystectomy by Cox regression analysis.
Elective cholecystectomy is not warranted in patients with bile duct stones when the common duct can be cleared of stones by endoscopic sphincterotomy. We could not find any clinical predictors of further symptoms or complications arising from the retained gallbladder.
PMCID: PMC4578061  PMID: 11855156
Gallbladder in situ; cholecystectomy; common bile duct calculi; Sphincterotomy; endoscopic
8.  Treatment of gallbladder stone with common bile duct stones in the laparoscopic era 
BMC Surgery  2015;15:7.
Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients.
From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed.
Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs.
In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.
PMCID: PMC4417333  PMID: 25623774
Cholecystectomy; Laparoscopic; Common bile duct stones (CBDS); Transcystic; Choledochotomy; Primary closure
9.  Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones. 
BACKGROUND: The need for cholangiography to identify possible bile duct stones in all patients undergoing cholecystectomy is controversial. AIMS: To assess the results of a policy for selective pre-operative endoscopic retrograde cholangiography (ERC) in patients undergoing laparoscopic cholecystectomy and to determine the incidence of postoperative symptomatic bile duct stones. PATIENTS AND METHODS: Between 1993 and 1998, 600 patients underwent laparoscopic cholecystectomy under one consultant surgeon. Patients were selected for pre-operative or postoperative ERC based on symptoms, liver function tests and/or abnormalities on ultrasonography. A general practitioner questionnaire was used to assess follow-up of patients with postoperative stones. RESULTS: Of 600 patients, 107 (18%) with a median age of 57 years and male:female ratio of 1:2.1 were selected to undergo pre-operative ERC; of these, 41 patients (38%) had bile duct stones. Postoperative ERC was performed in 30 patients (5%) and stones were identified in seven (23.3%). Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years). The overall incidence of bile duct stones was 48 cases (8%). The stone rate was 11% in males and 7.3% in females. Stones were successfully extracted at ERC in 43 patients (89.6%). CONCLUSIONS: A policy of selective pre-operative ERC is the most effective technique for identifying and removing bile duct stones and the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low. With an overall stone rate of 8%, routine peroperative cholangiography is unnecessary and, in a surgical unit providing an ERC service, laparoscopic exploration of the bile duct is not a technique required for the management of bile duct stones.
PMCID: PMC1964365  PMID: 12831488
10.  Residual gallbladder stones after cholecystectomy: A literature review 
Journal of Minimal Access Surgery  2015;11(4):223-230.
Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy.
Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up.
Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct.
Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.
PMCID: PMC4640007  PMID: 26622110
Cystic duct remnant; gallbladder remnant; post-cholecystectomy syndrome; residual gallstones; retained gallbladder stones; subtotal cholecystectomy
11.  Endoscopic extraction of large common bile duct stones: A review article 
Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis, a plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Nowadays, endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients. Large common bile duct stones are treated conventionally with mechanical lithotripsy, while the most serious complication of the procedure is “basket and stone impaction” that is predominately resolved surgically. In cases of difficult, impacted, multiple or intrahepatic stones, more sophisticated procedures have been used. Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems, ultra-thin cholangioscopes, thin endoscopes and ultimately using the novel single use, single operator SpyGlass Direct Visualization System, in order to deliver intracorporeal shock wave energy to fragment the targeted stone, with very good outcomes. Recently, large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials. When compared with mechanical lithotripsy or with balloon dilation alone, it proved to be superior. Moreover, dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic. Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of “impaction” because it seems that is an effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. When complete extraction of large stones is unsuccessful, the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy. Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective. The great majority of patients with large stones can be treated endoscopically. In cases of unsuccessful stone extraction using balloons, baskets, mechanical lithotripsy, electrohydraulic or laser lithotripsy and large balloon dilation, the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.
PMCID: PMC3355239  PMID: 22624068
Large bile duct stones; Endoscopic sphincterotomy; Papillary balloon dilation; Large papillary balloon dilation; Mechanical lithotripsy; Electrohydraulic lithotripsy; Laser lithotripsy
12.  The Efficacy of Preoperative Endoscopic Retrograde Cholangiopancreatography in the Detection and Clearance of Choledocholithiasis 
Background and Objectives:
Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution.
A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998.
Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth.
Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.
PMCID: PMC3015383  PMID: 10917116
Choledocholithiasis; Preoperative endoscopic retrograde cholangiopancreatography; Laparoscopic common bile duct clearance
13.  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
14.  Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy during the same session: Feasibility and safety 
AIM: To explore the feasibility and safety of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy (LC) performed during the same session.
METHODS: Between July 2010 and May 2013, 156 patients with gallstones and common bile duct (CBD) stones were enrolled in this retrospective study. According to the sequence of endoscopic procedures and LC, patients were classified into two groups: in group 1, patients underwent endoscopic stone extraction and LC during the same session, and in group 2, patients underwent LC at least 3 d after endoscopic stone extraction. Outcomes of the endoscopic procedures and LC were compared between the two groups, respectively.
RESULTS: There were 91 patients in group 1 and 65 patients in group 2. The characteristics of the two groups were similar. The mean duration of the endoscopic procedures was 34.9 min in group 1 and 35.3 min in group 2. There were no significant differences in the success rate of the endoscopic procedures (97.8% for group 1 vs 98.5% for group 2), the total rate of endoscopic complications (4.40% for group 1 vs 4.62% for group 2) and CBD stone clearance rate (96.7% for group 1 vs 96.9% for group 2). Duration of LC was 53.6 min in group 1 and 52.8 min in group 2. There were no significant differences in the overall LC-related morbidity and postoperative hospital stay.
CONCLUSION: Endoscopic stone extraction and LC performed during the same session was feasible and safe in patients with gallstones and concomitant CBD stones.
PMCID: PMC3785632  PMID: 24106411
Cholecystectomy; Laparoscopic; Endoscopic; Therapy
15.  Role of ERCP in the era of laparoscopic cholecystectomy for the evaluation of choledocholithiasis in sickle cell anemia 
AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis in patients with sickle cell anemia (SCA) in the era of laparoscopic cholecystectomy (LC).
METHODS: Two hundred and twenty four patients (144 male, 80 female; mean age, 22.4 years; range, 5-70 years) with SCA underwent ERCP as part of their evaluation for cholestatic jaundice (CJ). The indications for ERCP were: CJ only in 97, CJ and dilated bile ducts on ultrasound in 103, and CJ and common bile duct (CBD) stones on ultrasound in 42.
RESULTS: In total, CBD stones were found in 88 (39.3%) patients and there was evidence of recent stone passage in 16. Fifteen were post-LC patients. These had endoscopic sphincterotomy and stone extraction. The remaining 73 had endoscopic sphincterotomy and stone extraction followed by LC without an intraoperative cholangiogram.
CONCLUSION: In patients with SCA and cholelithiasis, ERCP is valuable whether preoperative or postoperative, and in none was there a need to perform intraoperative cholangiography. Sequential endoscopic sphincterotomy and stone extraction followed by LC is beneficial in these patients. Endoscopic sphincterotomy may also prove to be useful in these patients as it may prevent the future development of biliary sludge and bile duct stones.
PMCID: PMC3080719  PMID: 21528058
Sickle cell anemia; Cholelithiasis; Choledocholithiasis; Laparoscopic cholecystectomy; Cholangiography; Endoscopic retrogradecholangiopancreatography
16.  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
17.  Selection of surgical treatment types for intrahepatic duct stones 
Complete elimination of intrahepatic duct (IHD) stones is difficult and IHD stone disease is frequently associated with various complications, recurrence and sometimes cholangiocarcinoma. Therefore, we analyzed the long-term surgical results and evaluated the management currently considered appropriate.
Overall 110 patients who had been diagnosed with benign IHD stone disease and who underwent surgical treatment were enrolled in this study. The patients were categorized into three groups according to the type of surgery performed; liver resection (LR) group, intrahepatic duct exploration (IHDE) group and hepaticoenterostomy (HE) group. We compared and analyzed the results of these three groups.
The number of cases in the LR group, IHDE group and HE group were 77, 25 and 8 respectively. The LR group required a longer operation time (p=0.000), more frequent transfusion (p=0.028) and had higher morbidity (p=0.049). However, the LR group had a higher clearance rate (90.9%) (p=0.000) than the other groups. In addition, there were a total of 22 cases of IHD stone recurrence during the follow-up, but there was no statistically significant difference among the three groups. The location of IHD stones was related to a risk factor for incomplete stone removal, but not for recurrence.
The fundamental principle for the treatment of IHD stone disease should be liver resection. However, it can lead to a longer operative time and higher rate of complications than the other procedures. There is also no difference in the IHD stone recurrence rate among the procedures. Therefore, these alternative and minor procedures could also be taken into account for patients with poor preoperative condition.
PMCID: PMC4582541  PMID: 26421030
Intrahepatic duct stones; Liver resection; Intrahepatic duct exploration; Hepaticoenterostomy
18.  Composition of common bile duct stones in Chinese patients during and after endoscopic sphincterotomy 
AIM: Endoscopic sphincterotomy (ES) is a well-established therapeutic modality for the removal of common bile duct (CBD) stones. After ES there are still around 10% of patients that experience recurrent CBD stones. The aim of this study is to investigate the composition of CBD stones before and after ES and its clinical significance in Chinese patients.
METHODS: From January 1996 to December 2003, 735 patients with CBD stones received ES at Kaohsiung Veterans General Hospital and stone specimens from 266 patients were sent for analysis. Seventy-five patients had recurrent CBD stones and stone specimens from 44 patients were sent for analysis. The composition of the stones was analyzed by infrared (IR) spectrometry and they were classified as cholesterol or bilirubinate stones according to the predominant composition. Clinical data were analyzed.
RESULTS: In the initial 266 stone samples, 217 (82%) were bilirubinate stones, 42 (16%) were cholesterol stones, 3 were calcium carbonate stones, 4 were mixed cholesterol and bilirubinate stones. Patients with bilirubinate stones were significantly older than patients with cholesterol stones (66 ± 13 years vs 56 ± 17 years, P = 0.001). In the 44 recurrent stone samples, 38 (86%) were bilirubinate stones, 3 (7%) were cholesterol stones, and 3 were mixed cholesterol and bilirubinate stones. In 27 patients, both initial and recurrent stone specimens can be obtained, 23 patients had bilirubinate stones initially and 2 became cholesterol stones in the recurrent attack. In the four patients with initial cholesterol stones, three patients had bilirubinate stones and one patient had a cholesterol stone in the recurrent attack.
CONCLUSION: Bilirubinate stone is the predominant composition of initial or recurrent CBD stone in Chinese patients. The composition of CBD stones may be different from initial stones after ES.
PMCID: PMC4615452  PMID: 16015699
Endoscopic sphincterotomy; Common bile duct stone; Bilirubinate stone; Cholesterol stone
19.  Transcystic Approach to Laparoscopic Common Bile Duct Exploration 
Background and Objectives:
One-stage laparoscopic management for common bile duct stones in patients with gallbladder stones has gained wide acceptance. We developed a novel technique using a transcystic approach for common bile duct exploration as an alternative to the existing procedures.
From April 2010 to June 2012, 9 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. The main inclusion criteria included no upper abdominal surgical history and the presence of a stone measuring <5 mm. After the gallbladder was dissected free from the liver connections in a retrograde fashion, the fundus of the gallbladder was extracted via the port incision in the right epigastrium. The choledochoscope was inserted into the gallbladder through the small opening in the fundus of the gallbladder extracorporeally and was advanced toward the common bile duct via the cystic duct under the guidance of both laparoscopic imaging and endoscopic imaging. After stones were retrieved under direct choledochoscopic vision, a drainage tube was placed in the subhepatic space.
Of 9 patients, 7 had successful transcystic common bile duct stone clearance. A narrow cystic duct and the unfavorable anatomy of the junction of the cystic duct and common bile duct resulted in losing access to the common bile duct. No bile leakage, hemobilia, or pancreatitis occurred. Wound infection occurred in 2 patients. Transient epigastric colic pain occurred in 2 patients and was relieved by use of anisodamine. A transient increase in the amylase level was observed in 3 patients. Short-term follow-up did not show any recurrence of common bile duct stones.
Our novel transcystic approach to laparoscopic common bile duct exploration is feasible and efficient.
PMCID: PMC4266225  PMID: 25516702
CBD stones; One-stage laparoscopic management; Transcystic approach
20.  A modified Rendezvous ERCP technique in duodenal diverticulum 
AIM: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs.
METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast.
RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%.
CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.
PMCID: PMC3831199  PMID: 24255749
Endoscopic retrograde cholangiopancreatography; Retained stones; Antegrade cannulation; Intradiverticular papilla; T-tube
21.  Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones 
AIM: The usual bile duct stone may be removed by means of Dormia basket or balloon catheter, and results are quite good. However, the degree of difficulty is increased when stones are larger. Studies on the subject reported many cases where mechanical lithotripsy is combined with a second technique, e.g., electrohydraulic lithotripsy (EHL), where stones are crushed using baby-mother scope electric shock. The extracorporeal shock-wave lithotripsy (ESWL) or laser lithotripsy also yields an excellent success rate of greater than 90%. However, the equipment for these techniques are very expensive; hence we opted for the simple mechanical lithotripsy and evaluated its performance.
METHODS: During the period from August 1996 to December 2002, Mackay Memorial Hospital treated 304 patients suffering from difficult bile duct stones (stone >1.5 cm or stones that could not be removed by the ordinary Dormia basket or balloon catheter). These patients underwent endoscopic papillotomy (EPT) procedure, and stones were removed by means of the Olympus BML-4Q lithotripsy. A follow-up was conducted on the post-treatment conditions and complications of the patients.
RESULTS: Out of the 304 patients, bile duct stones were successfully removed from 272 patients, a success rate of about 90%. The procedure failed in 32 patients, for whom surgery was needed. Out of the 272 successfully treated patients, 8 developed cholangitis, 21 developed pancreatitis, and 10 patients had delayed bleeding, and no patient died. Among these 272 successful removal cases, successful bile duct stone removal was achieved after the first lithotripsy in 211 patients, whereas 61 patients underwent multiple sessions of lithotripsy. As for the 61 patients that underwent multiple sessions of mechanical lithotripsy, 6 (9.8%) had post-procedure cholangitis, 12 (19.6%) had pancreatitis, and 9 patients (14.7%) had delayed bleeding. Compared with the 211 patients undergoing a single session of mechanical lithotripsy, 3 (1.4%) had cholangitis, 1 (0.4%) had delayed bleeding, and 7 patients (3.3%) had pancreatitis. Statistical deviation was present in post-procedure cholangitis, delayed bleeding, and pancreatitis of both groups.
CONCLUSION: Mechanical bile stone lithotripsy on difficult bile duct stones could produce around 90% successful rate. Moreover, complications are minimal. This finding further confirms the significance of mechanical lithotripsy in the treatment of patients with difficult bile duct stones.
PMCID: PMC4250818  PMID: 15641153
Common bile duct stones; Mechanical lithotripsy
22.  Giant choledocholithiasis treated by mechanical lithotripsy using a gastric bezoar basket 
Mechanical lithotripsy (ML) is usually considered as a standard treatment option for large bile duct stones. However, it is impossible to retrieve oversized stones because the conventional lithotripsy basket may not be able to grasp the stone. However, there is no established endoscopic extraction method for such giant stone removal. We describe a case of successful extraction of a 4-cm large stone using a gastric bezoar basket. A 78-year-old woman had suffered from upper abdominal pain for 20 d. Contrast-enhanced computed tomogram revealed a 4-cm single stone in the distal common bile duct (CBD). Endoscopic stone retraction was decided upon and endoscopic papillary balloon dilation was performed using a large balloon. An attempt to capture the stone using a standard lithotripsy basket failed due to the large stone size. Subsequently, we used a gastric bezoar basket to successfully capture the stone. The stone was fragmented into small pieces and extracted. The stone was completely removed after two sessions of endoscopic retrograde cholangiopancreatography; each of which took 30 min. No complications occurred during or after the procedure. The patient was fully recovered and discharged on day 11 of hospitalization. ML using a gastric bezoar basket is a safe and effective retrieval method in select cases, and is considered as an alternative nonoperative option for the management of difficult CBD stones.
PMCID: PMC3391773  PMID: 22783060
Giant choledocholithiasis; Mechanical lithotripsy; Bezoar basket; Common bile duct stone; Endoscopic papillary balloon dilatation
23.  Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones 
AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones.
METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed.
RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P = 0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P = 0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P = 0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P = 0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P = 0.00).
CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.
PMCID: PMC3631997  PMID: 23613639
Endoscopic papillary balloon dilatation; Endoscopic retrograde cholangiopancreatography; Endoscopic sphincterotomy; Common bile duct stones; Success rate
24.  Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration 
Choledocholithiasis is the most common cause of obstructive jaundice. Common bile duct stones are observed in 10–14% of patients diagnosed with gall bladder stones. In the case of gall bladder and common bile duct stones the procedure involves not only performing cholecystectomy but also removing the stones from bile ducts.
To compare the results of the treatment of patients with gallstone disease and ductal calculi by one-stage laparoscopic cholecystectomy and common bile duct exploration with two other methods: one-stage open cholecystectomy and common bile duct exploration, and a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy.
Material and methods
Between 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with common bile duct exploration. The data were analysed prospectively. The methods were compared according to complete execution, bile duct clearance and complication rate. Complications were analysed according to Clavien’s Classification of Surgical Complications. The results were compared using the ANOVA statistical test and Student’s t-test in Statistica. Value of p was calculated statistically. A p-value less than 0.05 (p < 0.05) signified that groups differed statistically, whereas a p-value more than 0.05 (p > 0.05) suggested no statistically significant differences between the groups.
The procedure could not be performed in 11.9% of patients in the first group and in 14.3% of patients in the third group. Residual stones were found in 13.5% of the patients in the first group, in 4.3% of the patients in the second group and in 6.7% of the patients in the third group. According to Clavien’s classification of complications grade II and III, we can assign the range in the first group at 21.6% for grade II and 0% for grade III, in the second group at 21.4% and 3.6% and in the third group at 6.7% and 3.3% respectively.
The use of all three methods of treatment gives similar results. One-stage laparoscopic cholecystectomy with common bile duct exploration is after all the least invasive, safer and more effective procedure.
PMCID: PMC4105674  PMID: 25097684
common bile duct stones; laparoscopic exploration of the common bile duct; choledochotomy
25.  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

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