Comparison of the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy.

OBJECTIVE: To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC). METHODS: From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation. RESULTS: The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05). CONCLUSION: The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.

A feasibility study of percutaneous transhepatic gallbladder filling (PTGBF) in a swine model.

Background: Treatments for acute cholecystitis include cholecystectomy and percutaneous drainage. However, some patients are at high risk for surgery, and prolonged drainage can decrease their quality of life. Purpose: To determine the feasibility of percutaneous transhepatic gallbladder filling (PTGBF) with n-butyl-cyanoacrylate (NBCA) in a swine model. Material and methods: After the induction of general anesthesia, percutaneous transhepatic gallbladder puncture to a pig weighing 49 kg using a 20-G-percutaneous transhepatic cholangio drain (PTCD) needle was performed under ultrasound guidance. A 2.1 F-microcatheter was inserted through the outer PTCD needle, then the cystic duct was coil-embolized. The microcatheter was removed, the gallbladder was filled with 25% NBCA-Lipiodol, then the PTCD needle was withdrawn without complications. Blood was sampled and CT images were acquired from the pig immediately after the procedure and on postoperative day 7. The pig was euthanized on postoperative day 7 and the gallbladder was evaluated by microscopy. Results: Vital signs were stable, and the CT images showed that the gallbladder contained NBCA-Lipiodol without complications such as leakage. Hepatobiliary enzymes were not elevated. Histological findings demonstrated loss of most mucosa with partial regeneration, and lymphocytic infiltration. The muscle layer was intact. Conclusion: This technique might offer a feasible alternative to surgery for high-risk patients with acute cholecystitis, but further studies are needed to determine the safety and long-term effects of this procedure.

Long-term outcome following cholecystocolostomy in 41 patients with progressive familial intrahepatic cholestasis.

PURPOSE: Progressive familial intrahepatic cholestasis (PFIC) is a cohort of autosomal recessive syndromes which presents with jaundice, severe pruritus and liver derangement. Without treatments, patients progress to liver failure in early childhood. Biliary diversion strategies have been deployed to interrupt enterohepatic circulation to alleviate symptoms and delay progression to cirrhosis. Cholecystocolostomy has been the diversion method of choice at our institution and we aim to evaluate its long-term outcome. METHODS: All patients with PFIC who underwent cholecystocolostomy between August 2003 to May 2019 were included. PFIC diagnosed by clinical course, serum liver biochemistry and genotyping excluding other causes of cholestasis. All patients received ursodeoxycholic acid prior to biliary diversion. Those without long-term follow-up were excluded. Long-term follow-up conducted with physical examination, abdominal ultrasonography, liver function tests, contrast enema studies and colonoscopies. Outcome analysis was performed with patients divided into three groups according to their postoperative responses. RESULTS: 58 children underwent cholecystocolostomy, 41 were included in the study. Overall survival rate was 73.2% without a liver transplant. Survival improved to 81.1% in those without cirrhosis. 83.3% of those without a transplant was to no longer need any medication after their cholecystocolostomy. Recurrent cholestasis was seen in those with constipation (n = 8), ascending cholangitis (n = 10), intrahepatic reflux from Y-loop (n = 3) and cystic duct stenosis (n = 4). CONCLUSION: Cholecystocolostomy is a safe and effective technique for treatment of cholestasis in PFIC patients without cirrhosis. Careful monitoring and proactive management of postoperative constipation and ascending cholangitis is required to prevent stenosis of the cystic duct leading to recurrent cholestasis.

Successful endoscopic management of a persistent bronchobiliary fistula with Histoacryl®/Lipiodol® mixture.

Introduction A bronchobiliary fistula (BBF) following liver directed therapy (resection/ablation) is a rare complication in which an abnormal communication between the biliary tract and bronchial tree is formed. This case report describes the successful management of a persistent BBF following multiple liver wedge resections and microwave ablation in a patient with a metastatic neuroendocrine tumour of the terminal ileum. Case history A 69-year-old man presented with unexplained weight loss and was subsequently diagnosed with a neuroendocrine tumour of the terminal ileum and liver metastasis. Following elective right hemicolectomy and multiple bilobar liver wedge resections combined with liver microwave ablation, he developed an early bile leak. A month later, a right subphrenic collection was identified and four months following surgery, biloptysis was noted. Numerous attempts with endoscopic retrograde biliary drainage (ERBD) failed to achieve sufficient drainage. The patient was treated successfully with endoscopic injection of a mixture of Histoacryl® glue (B Braun, Sheffield, UK) and Lipiodol® (Guerbet, Solihull, UK). There was no evidence of the BBF one year following intervention. Conclusions This novel approach for persistent BBF management using endoscopic Histoacryl® glue embolisation of the fistula tract should be considered either as an adjunct to ERBD or when biliary tract decompression by drainage and/or sphincterotomy fails, prior to proceeding with surgical interventions.

[PREVENTION OF INFLAMMATORY COMPLICATIONS AFTER CHOLECYSTECTOMY IF BROWN STONES IN THE GALL BLADDER AND ITS DESTRUCTIVE CHANGES].

The experience of treatment in the clinic of 47 patients with acute calculous cholecystitis was analysed. The removal of the gallbladder found brown pigment stones. The clinical course of the disease in such patients, ultrasound data and instrumental methods were described. The triple antibiotic therapy application helped to reduce the risk of infection of bile, the elimination of the inflammatory process.

Bloqueo fascial ecoguiado de las ramas cutáneas de los nervios intercostales: una buena alternativa analgésica para la cirugía abierta de vesícula biliar / Ultrasound-guided cutaneous intercostal branches nerves block: a good analgesic alternative for gallbladder open surgery

El abordaje laparoscópico es el tratamiento de elección para la cirugía de vesícula, sin embargo, algunos pacientes requieren una conversión de la técnica, lo que origina en ellos un dolor postoperatorio moderado-severo. Tradicionalmente los opioides han sido utilizados para tratar dicho dolor, pero sus efectos secundarios han llevado a la búsqueda de nuevas alternativas (administración de anestésicos locales en plexos, fascias, nervios o herida). Presentamos 4 casos clínicos a los que se realizó el bloqueo ecoguiado de las ramas cutáneas de los nervios intercostales en la línea axilar media de T6 a T12 con levobupivacaína como alternativa analgésica en cirugía abierta de vesícula, con unos buenos resultados (AU)

Laparoscopic cholecystectomy has become the standard treatment for gallbladder diseases. However, there are still some patients for whom conversion to open surgery is required. This surgery can produce significant post-operative pain. Opioids drugs have traditionally been used to treat this pain, but side effects have led to seeking alternatives (plexus, nerve or fascia blocks or wound). The cases are presented of 4 patients subjected to ultrasound-guided intercostal branches blocks in the mid-axillary line from T6 to T12 with levobupivacaine as an analgesic alternative in open surgery of gallbladder, with satisfactory results (AU)

Design and application of a new series of gallbladder endoscopes that facilitate gallstone removal without gallbladder excision.

In recent years, some Chinese doctors have proposed a new concept, gallstone removal without gallbladder excision, along with transition of the medical model. As there is no specialized endoscope for gallstone removal without gallbladder excision, we designed and produced a new series of gallbladder endoscopes and accessories that have already been given a Chinese invention patent (No. ZL200810199041.2). The design of these gallbladder endoscopes was based on the anatomy and physiology of the gallbladder, characteristics of gallbladder disease, ergonomics, and industrial design. This series of gallbladder endoscopes underwent clinical trials in two hospitals appointed by the State Administration of Traditional Chinese Medicine. The clinical trials showed that surgeries of gallstones, gallbladder polyps, and cystic duct calculus could be smoothly performed with these products. In summary, this series of gallbladder endoscopes is safe, reliable, and effective for gallstone removal without gallbladder excision. This note comprehensively introduces the research and design of this series of gallbladder endoscopes.

[Effects of laparoscopic cholecystectomy under different anesthetic methods on T-lymphocyte immune function and postoperative analgesia].

OBJECTIVE: To compare the differences in the effect of laparoscopic cholecystectomy (LC) with different anesthetic methods on T-lymphocyte immune function and postoperative analgesia as well as validate the specificity of meridian points. METHODS: Ninety cases of LC were randomized into three groups, named group A (compound general anesthesia group with meridian points involved), group B (compound general anesthesia group with placebo points involved) and group C (general anesthesia group). In group A, electroacupuncture was applied at first for 15 to 30 min to bilateral Hegu (LI 4), Neiguan (PC 6), Zusanli (ST 36), Yanglingquan (GB 34) and Quchi (LI 11). Afterwards, the general anesthesia was conducted and electric stimulation lasted till the end of operation. In group B, the points adopted were the midpoints between the meridians in which the acupoints were selected in group A and the adjacent meridians on the lateral side, at the level of selected meridian points correspondingly. The method and time of electroacupuncture were same as those in group A. In group C, the general anesthesia was adopted simply. The changes of T-lymphocyte subgroup were detected before anesthesia, in 2 h, 1 day and 3 days after operation separately; and the dose of narcotic in operation as well as the dose of analgesia pumper in 4 h, 6 h, 8 h, 24 h and 44 h after operation separately. RESULTS: (1) In comparison between the result 2 h after operation and that before operation, the levels of CD3+, CD4+ and CD8+ in all of three groups were lower than those before operation. Except that the change in CD4+ in group A did not present significant statistical difference as compared with that before operation (P > 0.05), all of the other differences in T-lymphocyte subgroup indicated statistical significance (all P < 0.05). The ratio of CD4+/CD8+ in three groups was higher than that before operation, but the difference in group A was significant statistically (P < 0.05). In 3 days after operation, the levels of CD3+, CD4+ and CD4+/CD8+ were all higher than those before operation, indicating significant statistical differences (all P < 0.05) except CD4+/CD8+ in group B (P > 0.05). (2) In group A, during operation, the dose of narcotic reduced apparently (P < 0.05). (3) Separately, in 4, 6 and 8 h after operation, the dose of analgesia pumper reduced significantly in group A (all P < 0.05). CONCLUSION: Compound general anesthesia with meridian points involved can increase pain threshold of human body, reduce the dose of narcotic during operation, alleviate the suppression in body immune regulation due to stress reaction of general anesthesia and operation, prolong the time-effect of postoperative analgesia and explain the specificity of meridian points.

A case of primary mesenteric embryonal carcinoma.

We describe a case of primary mesenteric embryonal carcinoma. The patient was a 73-year-old man who presented with a huge mass palpable at the right upper side of the abdomen. Laboratory evaluations showed very high alpha-fetoprotein and PIVKA-II levels, and an abdominal computed tomographic scan demonstrated a mass contiguous with the liver. These findings suggested hepatic cell carcinoma extending beyond the liver. However, angiography showed the mass to be supplied mainly by the middle colic artery and greater omentum artery, suggesting a mesenteric tumor. Gastroscopy demonstrated a IIc lesion in the anterior wall of the antrum. This lesion was histologically diagnosed to be moderately differentiated adenocarcinoma. The large tumor adjacent to the liver was diagnosed to be a primary mesenteric tumor or a metastatic mesenteric tumor from arising gastric cancer. At laparotomy, a huge tumor was found in the gastrocolic ligament. The tumor adhered to the distal part of stomach, the transverse colon, and the gallbladder. En-bloc resection of the tumor was performed, including the distal part of stomach, Part of the transverse colon, and the gall-bladder. The tumor mass measured 26.0 x 21.0 x 9.0 cm, weighted 2750 g, and showed central necrosis and hemorrhage. The histopathological diagnosis was a primary embryonal carcinoma originating in the mesentery. Primary mesenteric embryonal carcinoma is extremely rare. To our knowledge, no other cases have been reported. We describe this case and briefly discuss the related literature.

Treatment of progressive familial intrahepatic cholestasis: liver transplantation or partial external biliary diversion.

Progressive intrahepatic familial cholestasis (PFIC), previously called Byler's disease, is a syndrome in which children develop severe cholestasis progressing to biliary cirrhosis and chronic liver failure, usually during the first decade of life. Clinical features include jaundice, hepatomegaly, splenomegaly, growth retardation and severe pruritus. Laboratory tests demonstrate elevated bilirubin and bile acids, without an increase in serum gamma-glutamyl-transpeptidase or cholesterol. This study was performed to evaluate our experience with medical therapy as well as two types of surgical treatment used in children with PFIC, particularly partial external biliary diversion (PEBD) as an alternative method of therapy to liver transplantation (OLTx). Between 1979 and 1998 we have treated 46 children with PFIC (27 boys and 19 girls), aged 10 months to 19 yr (at the time of this study). Medical treatment with ursodeoxycholic (UDCA) was used in 39 patients for the period between 6 and 82 months. PEBD (cholecysto-jejuno-cutaneostomy) was performed in 16 patients, OLTx in eight children (including one after unsuccessful PEBD). Retrospective analysis of the clinical course and selected laboratory tests (bilirubin, ASPAT, ALAT, bile acids), and histopathological examinations were performed. Results of treatment were assessed by means of influence of the type of treatment on clinical symptoms, laboratory tests, progress of liver cirrhosis and hepatic failure, as well as physical development and survival. Medical therapy was effective in the long term in four (10%) of the patients resulting in clinical and biochemical normalization. Both surgical methods of therapy of PFIC, PEBD and OLTx, resulted in an 80% success rate and therefore should be used as complementary therapies. In patients before established liver cirrhosis, PEBD should be the first choice of treatment. Patients presenting with cirrhosis or after ineffective PEBD should qualify for OLTx. With this strategy most children with PIFC can be cured.

Cholecystojejunostomy varices demonstrated by enteroclysis.

Varices in unusual sites constitute a minor but significant cause of gastrointestinal bleeding in patients with liver disease. We report a case of varices across the anastomotic line between the jejunum and gallbladder after cholecystojejunostomy. Although such varices have been demonstrated by angiography, to our knowledge they have never been demonstrated by small bowel enema (enteroclysis). We report a case and describe the findings on enteroclysis.

Afecciones quirúrgicas de la vesícula biliar en niños / Gallblader diseases in childhooder

Se analizan las complicaciones luego del tratamiento quirúrgico con la operación de Soave, en 83 pacientes con Enfermedad de Hischsprung,sobre un total de 105, asistidos desde junio de 1988 hata abril de 1994.El seguimiento postoperatorio fue realizado por un equipo multidisciplinario según un protocolo que tuvo en cuenta el estado clínico, el desarrollo pondoestatural,la evaluación de la cantidad y características de las disposiciones, el tacto rectal para control del calibre del descanso, el coprocultivo en los pacientes con enterocolitis , la revisión histológica de las piezas quirúrgicas y el colon por enema en el postoperatorio alejado.La enterocolitis postoperatoria se presentó en 19 pacientes (23 por ciento ): en 5 atribuíble a estenosis de la anatomosis que mejoraron al desaparecer la causa y en 14 con calibre normal. Se investigaron exhaustivamente sin encontrar la etiología y se los medicó con antibióticos en forma prolongada,con remisión de los síntomas. El 18 por ciento tuvo episodios esporádicos de constipación sin lesión orgánica evidente.La necrosis del muñón rectal con o sin autoamputación se vió en 5 pacientes.Hubo 14 niños con estenosis del descenso, 4 de ellos se resolvieron quirúrgicamente, las restantes cedieron con dilataciones.en dos pacientes , uno por perforación rectal y otro con aganglionosis residual,se realizó una nueva de descenso, con técnica de Duhamel.Se registroó una fístula enterocolónica cuya resolución fué quirúrgica.cuatro pacientes tuvieron oclusión por bridas.Fallecieron 2 pacientes en el postoperatorio alejado:uno con aganglionosis total por sepsis a partir de la alimentación parenteral y otro por un cuadro oclusivo, en otro centro hospitalario

Afecciones quirúrgicas de la vesícula biliar en niños / Gallblader diseases in childhooder

Se analizan las complicaciones luego del tratamiento quirúrgico con la operación de Soave, en 83 pacientes con Enfermedad de Hischsprung,sobre un total de 105, asistidos desde junio de 1988 hata abril de 1994.El seguimiento postoperatorio fue realizado por un equipo multidisciplinario según un protocolo que tuvo en cuenta el estado clínico, el desarrollo pondoestatural,la evaluación de la cantidad y características de las disposiciones, el tacto rectal para control del calibre del descanso, el coprocultivo en los pacientes con enterocolitis , la revisión histológica de las piezas quirúrgicas y el colon por enema en el postoperatorio alejado.La enterocolitis postoperatoria se presentó en 19 pacientes (23 por ciento ): en 5 atribuíble a estenosis de la anatomosis que mejoraron al desaparecer la causa y en 14 con calibre normal. Se investigaron exhaustivamente sin encontrar la etiología y se los medicó con antibióticos en forma prolongada,con remisión de los síntomas. El 18 por ciento tuvo episodios esporádicos de constipación sin lesión orgánica evidente.La necrosis del muñón rectal con o sin autoamputación se vió en 5 pacientes.Hubo 14 niños con estenosis del descenso, 4 de ellos se resolvieron quirúrgicamente, las restantes cedieron con dilataciones.en dos pacientes , uno por perforación rectal y otro con aganglionosis residual,se realizó una nueva de descenso, con técnica de Duhamel.Se registroó una fístula enterocolónica cuya resolución fué quirúrgica.cuatro pacientes tuvieron oclusión por bridas.Fallecieron 2 pacientes en el postoperatorio alejado:uno con aganglionosis total por sepsis a partir de la alimentación parenteral y otro por un cuadro oclusivo, en otro centro hospitalario

Endoscopic magnetic cholecystodigestive anastomoses: personal technique for palliative treatment of distal bile duct obstruction.

A new type of endoscopic surgery (magnetic cholecystodigestive anastomoses) is presented as an alternative to conventional palliative treatment of mechanical obstruction with icterus located below the bile duct inlet. By means of endoscopic technique, two clinically usable methods of creating delayed magnetic cholecystogastric anastomoses and one modality of implanting cholecystoenteric and enteroenteric anastomosis have been worked out in the experiment conducted on 50 mongrels with mechanical icterus. Ring-shaped or rectangular magnets were implanted in the gallbladder through laparoscopic cholecystostomy. Implantation into the stomach was accompanied by simultaneous gastroscopy. In clinical conditions, four endoscopic cholecystogastric anastomoses and one cholecystoduodenal anastomosis have been performed on patients suffering from malignant obstruction of distal bile duct due to cancer of the head of the pancreas, making any radical surgery pointless. The preliminary results indicate that endoscopic magnetic cholecystodigestive anastomoses can serve as a form of palliative treatment of distal bile duct malignant obstructions.

Colelitíase na criança: apresentaçäo de 5 casos e revisäo bibliográfica / Cholelithiasis in children: presentation of 5 cases and bibliography review

Os autores apresentam cinco crianças portadoras de litíase biliar, diagnosticadas e operadas no Hospital das Clínicas da UFMG, no período de 1977-1990. Apesar de näo ser täo prevalente quanto na populaçäo adulta, a litíase biliar em crianças constitui uma afecçäo bem documentada na literatura médica. Na casuística dos autores, a idade variou de seis a onze anos, sendo quatrocrianças do sexo feminino e uma do sexo masculino. A dor abdominal em cólicas, no flanco direito e regiäo periumbilical constituiu o sintoma mais importante. A ultra-sonografia abdominal foi o método de diagnóstico mais eficaz e inócuo. Em uma criança, portadora de esferocitose hereditária, o diagnóstico de litíase biliar foi feito pela palpaçäo da vesícula durante a esplenectomia. O tratamento instituído foi a colecistectomia, e os pacientes tiveram evoluçäo pós-operatória sem anormalidades. O exame histológico da vesícula biliar mostrou espessamento e fibrose da parede vesicular, semelhante a colecistite crônica. Doenças näo hemolíticas associadas à litíase biliar na criança foram diagnosticadas: hepatite crônica ativa, cirrose, pancreatite, obesidade e toxoplasmose. Ressalta-se neste trabalho dados da literatura médica sobre novas condiçöes e afecçöes que se associam à litíase biliar na criança, tais como: nutriçäo parenteral total prolongada, uso de furosemida, ressecçäo ileal, malformaçöes das vias biliares extra-hepáticas, eritoblastose fetal, fototerapia, mucoviscidose, deficiência de IgA, cirrose hepática, pancreatite e obesidade.