Stone removal by percutaneous papillary balloon dilatation for cystic duct and bile duct stones after cholecystectomy and distal gastrectomy with Roux-en-Y gastrojejunostomy.

A 71-year-old woman was referred to our department for abdominal pain. She was diagnosed with acute obstructive cholangitis due to cystic duct and bile duct stones after cholecystectomy and Roux-en-Y gastrojejunostomy. Two years ago, the patient underwent endoscopic and laparoscopic treatment for cystic duct and bile duct stones, however, the stones remained. This time, she was treated with stone removal using percutaneous papillary balloon dilatation (PPBD). Large stones in the common hepatic and bile ducts were crushed by electrohydraulic lithotripsy and then pushed out into the duodenum through the dilated papilla of Vater using a balloon catheter covered with the sheath and cholangioscopy. Stone in the cystic duct was pulled to the common bile duct and pushed to the duodenum. Stone removal using PPBD is an excellent alternative for patients with cystic duct and bile duct stones unable to be treated with endoscopic or laparoscopic stone removal.

Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis.

PURPOSE: Retained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. METHODS: A total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. RESULTS: RS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. CONCLUSIONS: The presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

Assessment of postoperative common bile duct stones after endoscopic extraction and subsequent cholecystectomy.

BACKGROUND: Common bile duct stones (CBDSs) occasionally cause serious diseases, and endoscopic extraction is the standard procedure for CBDS. To prevent biliary complications, cholecystectomy is recommended for patients who present with gallbladder (GB) stones after endoscopic CBDS extraction. However, CBDS can occasionally recur. To date, the occurrence of CBDS after endoscopic CBDS extraction and subsequent cholecystectomy is not fully understood. Hence, the current study aimed to evaluate the incidence of postoperative CBDSs. METHODS: This retrospective observational study included consecutive patients who underwent postoperative endoscopic retrograde cholangiography after endoscopic CBDS extraction and subsequent cholecystectomy between April 2012 and June 2021 at our institution. After endoscopic CBDS extraction, a biliary plastic stent was inserted to prevent obstructive cholangitis. Endoscopic retrograde cholangiography was performed to evaluate postoperative CBDSs after cholecystectomy until hospital discharge. The outcomes were the incidence of postoperative CBDSs and CBDSs/sludge. Moreover, the predictive factors for postoperative CBDSs were evaluated via univariate and multivariate analyses. RESULTS: Of eligible 204 patients, 52 patients (25.5%) presented with postoperative CBDSs. The incidence rate of CBDS/sludge was 36.8% (n = 75). Based on the univariate analysis, the significant predictive factors for postoperative CBDSs were ≥ 6 CBDSs, presence of cystic duct stones, and ≥ 10 GB stones (P < 0.05). Moreover, male sex and < 60-mm minor axis in GB might be predictive factors (P < 0.10). Based on the multivariate analysis, ≥ 6 CBDSs (odds ratio = 6.65, P < 0.01), presence of cystic duct stones (odds ratio = 4.39, P < 0.01), and ≥ 10 GB stones (odds ratio = 2.55, P = 0.01) were independent predictive factors for postoperative CBDSs. CONCLUSIONS: The incidence of postoperative CBDS was relatively high. Hence, patients with predictive factors for postoperative CBDS must undergo imaging tests or additional endoscopic procedure after cholecystectomy.

"Semicut" skill on the cystic duct in laparoscopic cholecystectomy.

This study aimed to decrease the incidence of residual stones in the cystic duct and consequently decrease the incidences of intractable pain and the formation of a small gallbladder after laparoscopic cholecystectomy (LC). We changed the order of the clamps when performing LC, used the "semicut" skill of the cystic duct, and removed the stones residing in the cystic duct. A total of 45 patients underwent the operation, and all operations were completed successfully. This technique did not increase the operation time or difficulty. In conclusion, the "semicut" skill of the cystic duct is a safe and feasible surgical method that may change the occurrence of intractable pain after LC.

Factors affecting technical success of endoscopic transpapillary gallbladder drainage for acute cholecystitis.

BACKGROUND/PURPOSE: Endoscopic transpapillary gallbladder drainage (ETGBD), including endoscopic nasogallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS), has been reported to be an effective treatment for acute cholecystitis. However, ETGBD is considered to be more difficult than percutaneous transhepatic gallbladder drainage (PTGBD), and few studies have evaluated the factors that affect technical success of the procedure. We investigated the factors predicting its technical success from among patient characteristics and image findings before treatment. METHODS: Three hundred twenty three patients who underwent ETGBD for acute cholecystitis from November 2006 to December 2018 were analyzed retrospectively. RESULTS: The technical success rate was 72.8% (235/323). The technical success rate by cystic duct direction was as follows: proximal/distal, 65.9%/93.6%; right/left: 74.0%/65.2%; cranial/caudal, 83.5%/20.0%. The clinical response rate was 96.2% (226/235). Adverse events were encountered in 5.9% of cases (19/323), including cystic duct injury (11 patients), pancreatitis (five patients), and bleeding (three patients). In both univariate and multivariate analysis, presence of cystic duct stone, dilation of the common bile duct (CBD), and cystic duct direction (proximal and caudal branches) were identified as significant factors affecting technical failure of ETGBD. CONCLUSION: Although ETGBD was an effective and safe procedure for acute cholecystitis, it has a limited success rate. The presence of cystic duct stone, dilation of CBD, and cystic duct direction (proximal and caudal branches) can serve as important predictors of ETGBD difficulties. These findings should be considered before procedures and the necessary adaptation of ETGBD made.

Successful Treatment of Mirizzi's Syndrome Using SpyGlass Guided Laser Lithotripsy.

The majority of common bile duct stones can be effectively treated by endoscopic sphincterotomy and stone extraction using basket or balloon extractor. Stones more than 2 cm in diameter on the other hand require mechanical, electrohyraulic lithotripsy and sphincterotomy and balloon dilation. Mechanical lithotripsy may not be successful because of the size, consistency and site of the stones. In these cases, laser lithotripsy is the treatment of choice. This however requires direct visualization of the stone which may not be feasible for impacted cystic duct stones. This report describes the successful treatment of difficult cystic duct stones in two patients with Mirizzi's syndrome type I using per oral Spyglass and intraductal holmium: YAG Laser Lithotripter.

Laparoscopic Resection for the Treatment of Symptomatic Remnant Huge Cystic Duct with Stone after Laparoscopic Cholecystectomy

During laparoscopic cholecystectomy, the cystic duct is frequently divided closer to the gallbladder to avoid iatrogenic injury to the common bile duct. Postcholecystectomy syndrome can be considered if the patient complains of right upper abdominal discomfort after cholecystectomy. We report a case of a laparoscopic resection for the treatment of a symptomatic remnant huge cystic duct with stones after a previous laparoscopic cholecystectomy. A 46-year-old male was admitted to our hospital due to right upper quadrant abdominal pain. Five years earlier, the patient had undergone a laparoscopic cholecystectomy under the diagnosis of acute calculous cholecystitis but he subsequently suffered from intermittent right upper abdominal pain and fever. An abdominal computed tomography scan revealed a stone in a dilated remnant cystic duct. A laparoscopic remnant cystic duct resection was performed and apathologic diagnosis was made with chronic calculus cystic duct inflammation. The patient was discharged without complications and has been doing well without recurrent symptoms.

Management of stone impacted at cystic duct during laparoscopic cholecystectomy / 中国微创外科杂志

Objective To summarize our experience in the management of stones impacted at cystic duct during laparoscopic cholecystectomy(LC). Methods There were 58 patients with stones impacted at cystic duct during LC from July 1997 to June 2001.Cystic duct was incised to remove stones first,then intraoperative cholangiography was performed.If stones were found in common bile duct,they would be taken out by intraoperative endoscopic sphincterotomy or open operation. Results All the impacted stones in 58 patients were removed successfully.51 coses underwent LC.Intraoperative cholangiography showed there were common bile duct stones in 7 cases.For these 7 coses,5 cases were treated by LC combined with intraoperative endoscopic sphincterotomy and other 2 cases were converted into open operation.No Severe complication occurred. Conclusions Nearly all cases with stones impacted at cystic duct can receive LC by removing impacted stones through incising the cystic duct and intraoperative cholangiography.If there are any stones in common bile duct,they can be removed by endoscopic sphincterotomy.

Endoscopic Treatment with ESWL of Impacted Cystic Duct Stones / 대한소화기내시경학회지

BACKGROUND/AIMS: The established treatment for cystic duct stones is surgery, but nonoperative removal of gallstones through percutaneous cholecystostomy can also be a useful procedure in patients at high risk for surgery. Conventional methods using endoscopic or percutaneous stone extraction usually fail due to the inability to access or capture the cystic duct stones in the narrow, long, spiral portion of the cystic duct, especially in impacted cases. As a result stone fragmentation is required during endoscopic stone removal. It is impossible for an electrohydraulic lithotripsy (EHL) to gain access to the stones, due to the rigid distal metal tip of the lithotripter and the narrowness of the long, spiral cystic duct. Using extracorporeal shockwave lithotripsy (ESWL) to disintegrate gallstones is a more effective method for removal of cystic duct stones. Experiences of endoscopic treatment for cystic duct stones of patients with high risk for surgery were reviewed, and conclusions are included in this study. METHODS: Patient records of endoscopic management of cystic duct stones between January, 1994 and December, 1997, were reviewed for methods and results of treatment. Most of the patients had undergone lithotripsy followed by percutaneous transhepatic cholecystostomy.

Endoscopic Biliary Lithotripsy in a Patient with Gallstones of Gallbladder, Cystic Duct, and Common Bile Duct / 대한소화기내시경학회지

Endoseopic sphincterotomy(EST) has been an accepted procedure in patients with current or recurrent common bile duct stones. The success rate of sphineterotomy and of subaequent stone extraction were reported upto 90%. Percutaneous transhepatic cholecystoscopy-lithotripsy(PTCCS-L) could be one of the non-surgical treatment modalities for gallbladder stones, and has been considered as a safe, reliable and technically easy therapeutic procedure through improvement in PTCCS-L manipuiatian and through the development of new devices for this technique. PTCCS-L could be usually performed in the sgrgically high risk groups with gallbladder stones. In this report, we presented successful endoscopic biliary lithotripsy in a 60-year-old male with gallstones of gall bladder, cystic duct, and common bile duct, who was highly risk for surgery, because he has been suffered from advanced liver disease. Endoseopic sphincterotomy and stone removal with basket were done for the removal of common bile duct stones. PTCCS was performed and complete removal of gallbladder stones was achieved. Cystic duict stone was successfully removed after bougie dilation of cystic duct. There has been no recurrence of gallstones until 1 year of follow-up.