Histological assessment of cholecystectomy specimens performed for symptomatic cholelithiasis: routine or selective?

Traditionally, all cholecystectomy specimens resected for symptomatic cholelithiasis were sent for histological evaluation. The objectives of such evaluation are to confirm the clinicoradiological diagnosis, identification of unsuspected findings including incidental gallbladder malignancy, audit and research purposes, and quality control issues. Currently, there is a developing trend to consider selective histological evaluation of surgical specimens removed for clinically benign disease. This article discusses the need for routine or selective histopathological evaluation of gallbladder specimens following cholecystectomy. Although several retrospective studies have suggested selective histological evaluation of cholecystectomy specimens performed for symptomatic cholelithiasis, the evidence is not adequate at present to recommend selective histological evaluation globally. However, it may be appropriate to consider selective histological evaluation on a regional basis in areas of extremely low incidence of gallbladder cancer only after unanimous agreement between the governing bodies of surgical and histopathological expertise.

Therapeutic value and outcome of gastric access loops created during hepaticojejunostomy for iatrogenic bile duct injuries.

BACKGROUND AND PURPOSE: Hepaticojejunostomy is the reconstructive procedure performed for iatrogenic bile duct injuries. Anastomotic site stricture is the most significant complication of this operation. Revision surgery is associated with a significant morbidity and mortality. Creation of access to the anastomotic site facilitates the management of such strictures by minimal access techniques and reduces the need for revision surgery. This retrospective study aims to investigate the technical accessibility, usefulness, morbidity related to and the outcome of hepaticojejunostomy with gastric access loops performed as the treatment for iatrogenic bile duct injuries. METHODOLOGY: Twenty-seven consecutive patients who have undergone hepaticojejunostomy (including three revision surgeries and a re-revision surgery) with gastric access loops from July 2005 to October 2009 were followed up for clinical, biochemical, radiological and endoscopic evidence of anastomotic site occlusion and the need for intervention. Morbidity related to gastric access loops was assessed by dyspepsia disability score. RESULTS: Mean follow up was 35.4 (range 6-61) months. Three patients developed anastomotic strictures at 4, 22 and 5 months after hepaticojejunostomy and had successful endotherapy via the gastric access loop. They remain well at 33rd, 31st and 3rd months, respectively, following intervention. Based on the dyspepsia disability score none of the patients had symptomatic dyspepsia affecting daily activities. CONCLUSIONS: Gastric access loop is accessible and useful for stricture dilation and other endotherapeutic procedures. In the absence of significant symptoms related to bile reflux, gastric access loop could be considered as a useful and safe adjunct in the management of hepaticojejunostomy by surgeons especially in settings with limited facilities and expertise for radiological manipulations.

Management and outcome of residual bile duct stones following cholecystectomy at a tertiary referral centre in Sri Lanka.

BACKGROUND: In spite of the advent of pre- and per-operative imaging techniques, the problem of residual bile duct stones following laparoscopic or open cholecystectomy still exists with a reported frequency of 2-10%. Endoscopic stone extraction is a minimally invasive technique which is fast becoming popular in the management of residual ductal stones. OBJECTIVE: To review the experience in our unit with regard to clinical presentation and the outcome following endoscopic management of residual bile duct stones. DESIGN: Retrospective descriptive study. SETTING: Patients referred to a tertiary referral centre with suspected residual bile duct stones following open or laparoscopic cholecystectomy from 5 March 2002 to 31 December 2006. PATIENTS AND METHOD: 56 patients with suspected residual bile duct stones were reviewed with regard to clinical presentation, stone profile, success rate and outcome. RESULTS: Mean age of the sample was 43.2 years. Female to male ratio was 34/22. 4 (73.3%). Main presenting symptom was epigastric or right hypochondrial pain (39.2%). Presence of residual stones or gravel noted in 91% (51) during ERCP. Complete stone extraction was achieved in 83.9% (47). All these patients became completely asymptomatic. Four patients had ERCP related morbidity. There were no deaths. Longest follow up was 38 months and the shortest 1.5 months. CONCLUSIONS: Endoscopic approach is a safe and effective method in the diagnosis and treatment of residual bile duct stones.