Risk factors analyses associated with postoperative infection in choledochoscopy for intrahepatic bile duct stones (IHDs): a single-center retrospective study in real-world setting.

BACKGROUND: Choledochoscopy is a highly effective approach for managing intrahepatic bile duct stones (IHDs). However, postoperative infection is a common complication that significantly impacts treatment outcomes. Despite its clinical relevance, the risk factors associated with this procedure remain largely unexplored. METHODS: This study focused on a consecutive cohort of patients who underwent choledochoscopy for IHDs at our institution between January 2016 and December 2022. The primary objective was to analyze the relationship between various clinical factors and postoperative infection, and to compare the postoperative infection of different choledochoscopic procedures. RESULTS: The study cohort consisted of 126 patients, with 60 individuals (47.6%) experiencing postoperative infection. Notably, preoperative biliary obstruction (odds ratio [OR] 1.861; 95% confidence interval [CI] 1.314-8.699; p = 0.010) and operation time (OR 4.414; 95% CI 1.635-12.376; p = 0.004) were identified as risk factors for postoperative infection. Additionally, biliary tract infections (60.00%) were primarily responsible for postoperative infection, with Escherichia coli (47.22%) being the predominant bacterial strain identified in bile cultures. Furthermore, biliary tract obstruction (OR 4.563; 95% CI 1.554-13.401; p = 0.006) and body mass index (BMI) (OR 1.186; 95% CI 1.015-1.386; p = 0.031) were determined to be independent risk factors for postoperative biliary tract infection. CONCLUSIONS: The occurrence of postoperative infection in patients undergoing choledochoscopy was primarily associated with the duration of the operation and the presence of preoperative biliary obstruction.

The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis.

BACKGROUND: Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions. METHODS: Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests. RESULTS: A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%). CONCLUSION: Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis.

Choledochoscope-guided treatment of pulmonary embolism caused by ventricular myxoma.

A 33-year male patient presented with a 6-month history of cough and shortness of breath upon physical activity. Echocardiography demonstrated right ventricular space-occupying lesions. Contrast-enhanced computed tomography of the chest showed multiple emboli in the pulmonary artery and its branches. Right ventricle tumor (myxoma) resection, tricuspid valve replacement, and clearance of the pulmonary artery thrombus were performed under cardiopulmonary bypass. Minimally invasive forceps and balloon urinary catheters were used to clear the thrombus. Clearance was confirmed by direct visualization using a choledochoscope. The patient recovered well and was discharged. The patient was prescribed oral warfarin 3 mg/day, and the international normalized ratio for prothrombin time was maintained between 2.0 and 3.0. Pre-discharge echocardiogram showed no lesion in the right ventricle or pulmonary arteries. The 6-month follow-up echocardiography indicated that the tricuspid valve was functioning well and showed no thrombus in the pulmonary artery.

Relationship between postoperative biliary stricture and clinical characteristics of patients with benign and malignant biliary diseases.

Introduction: Postoperative biliary stricture (POBS) is one of the common complications of biliary surgery. Previous literature on risk factors of POBS was scarce, and the classification of POBS in benign and malignant biliary diseases was incomplete. Aim: To analyze clinicopathological factors of POBS in usual biliary diseases, and to facilitate preoperative diagnosis of biliary stricture. Material and methods: A retrospective analysis was made on the clinical data of 2228 patients who underwent biliary surgery in our hospital from July 2010 to June 2022. With the inclusion and exclusion criteria, the clinicopathological factors for POBS were classified, and data analysis was conducted. Results: Benign diseases with age ≥ 60 years (p = 0.034), diabetes (p = 0.001), common bile duct diameter < 0.8 cm (p = 0.034), Mirizzi syndrome (p = 0.001), seniority of surgeons < 25 years (p = 0.001), and operation time for the first 6 years (p = 0.015) are more likely to evolve into POBS; malignant diseases with conjugated bilirubin ≥ 6.8 µmol/l (p = 0.042), alkaline phosphatase ≥ 125 U/l (p = 0.042), γ-glutamyl transferase ≥ 50 U/l (p = 0.047), diabetes (p = 0.038), and seniority of surgeons < 25 years (p = 0.008) are prone to POBS. Different surgical approaches affect the incidence of POBS (χ2 = 9.717, p = 0.034). The choice of surgical site is important for the incidence of POBS in malignant diseases (χ2 = 7.935, p = 0.041). Conclusions: Surgeons need to identify risk factors, conduct patient visits and assessments preoperatively, standardize the operation in order to avoid structural damage, and reduce the occurrence of POBS.

Double common bile duct with cholelithiasis.

Double common bile duct is a rare congenital anomaly among biliary anomalies. The anomaly has an important clinical implication because of its association with biliary tract obstruction. In addition, if one of the two common bile ducts is mistaken for the cystic duct during surgery, residual stones and bile duct injury are likely to occur. Here, we report a case of double choledochal variation (Type Vb) with choledochal calculi. An 82-year-old woman was admitted to the hospital due to mild pain in the upper abdomen accompanied by vomiting for 3 days. Magnetic resonance imaging suggested common bile duct lithiasis, variation of the common bile duct and moderate biliary tract dilation. Laparoscopy combined with choledochoscopic lithotomy was performed for choledocholithotomy. During the operation, left and right choledocholithotomy was performed, and all the gallstones were removed via choledochoscope. The patient's post-operative recovery was good, and no recurrence of cholelith had been observed at the time of writing.

Clinical advantages of absorbable barbed wires in laparoscopy combined with choledochoscopy treatment of gallbladder polyps / 中国基层医药

Objective:To investigate the clinical advantages of absorbable barbed wires in laparoscopy combined with choledochoscopy treatment of gallbladder polyps.Methods:The clinical data of 103 patients with gallbladder polyps who received laparoscopy combined with choledochoscopy treatment in The First People's Hospital of Lianyungang from February 2016 to March 2018 were retrospectively analyzed. Sixty-five patients in the observation group underwent gallbladder wall sutures with absorbable barbed wires, and thirty-eight patients in the control group underwent gallbladder wall sutures with common absorbable wires. The operative time, gallbladder wall suture time, intraoperative blood loss, average hospitalization time, and postoperative bile leakage were compared between the two groups.Results:There were no significant differences in intraoperative blood loss and average hospitalization time between the two groups ( P = 0.312, P = 0.114). In the observation group, gallbladder wall suture time and operative time were (5.58 ± 1.14) minutes and (60.71 ± 11.03) minutes, respectively, which were shorter than (6.32 ± 1.04) minutes and (68.24 ± 9.61) minutes in the control group ( t = 3.23, 3.50, P = 0.002, 0.001). No bile leakage occurred in the observation group and bile leakage occurred in four (10.5%) patients in the control group. There was a significant difference in bile leakage between the observation and control groups ( χ2 = 4.57, P = 0.032). Conclusion:Absorbable barbed wires for gallbladder wall sutures during operation in laparoscopy combined with choledochoscopy treatment of gallbladder polyps is safe and feasible. It can markedly shorten gallbladder wall suture time and operative time, decrease the incidence of bile leakage, and has a clinical advantage over common absorbable wires.

Total robotic lateral pancreaticojejunostomy and modified Frey's procedure for chronic calcific pancreatitis.

BACKGROUND: Surgical intervention has been shown to have good post-operative outcomes in patients with chronic pancreatitis with pain refractory to oral analgesics. We present our initial experience with robotic lateral pancreaticojejunostomy (LPJ) and modified Frey's procedure (MFP). METHODOLOGY: Patients with chronic calcific pancreatitis were evaluated with routine biochemical and radiological investigations. The indication of surgery was intractable pain which was recorded by an Intensity Frequency, Consequence (IFC) pain score. The patient was placed in a reverse Trendelenburg position with four 8-mm robotic ports and one 12-mm assistant port. Robotic ultrasound was utilized to identify the pancreatic duct. After retrieving all the calculi, which was confirmed by pancreatoscopy with the help of a video choledochoscope and performing the head coring in particular cases, the Roux-en-Y LPJ was performed. RESULTS: Among five patients (4 males, one female), robotic LPJ was performed in 2 and MFP in 3 patients. The cohort's median age was 32 (interquartile range (IQR), 28, 40) years, and the median (IQR) pancreatic duct size was 9 (9, 13) mm. The median (IQR) duration of the procedure was 385 (380, 405) minutes, with a median (IQR) blood loss of 100 (50-100) ml, and the patients were discharged on median post-operative day 5. The patients continue to do well at a median follow-up of 3-30 months without the requirement of oral analgesics. CONCLUSION: Robotic LPJ and MFP are feasible in experienced hands with good post-operative outcomes and enhanced quality of life. Intra-operative pancreatoscopy with the help of a choledochoscope can be utilized to ascertain the complete clearance of pancreatic duct stones and the consequent pain relief.

Design and Development of a Disposable Superfine Catheter for Visual Examination of Bile Ducts and Related Animal Experiments.

Objective: To design and develop a disposable superfine catheter system for visual examination of bile and pancreatic ducts and predict its clinical application value. Methods: The superfine triple-lumen catheter and miniature photography technology were used to design and produce a disposable superfine catheter for visual examination of bile and pancreatic ducts, and animal experiments were conducted to compare said catheter and SpyGlass™. Results: The designed and developed disposable superfine catheter for visual examination of bile ducts with a diameter of 2.4 mm could enter the third-order and fourth-order bile ducts in the animal liver and also the gallbladder via the cystic duct for observation. The said catheter has a water injection rate of 0.8 mL/s, 0.16 megapixels, a resolution of 400 × 400, a depth of field of 0.3 to 20 mm, and a tilting up angle >90°. Conclusion: The new disposable catheter for visual examination of bile ducts has a superfine diameter, easier operation, and clearer imaging, and is expected to have a higher clinical practical value.

Analysis of Laparoscopic Ultrathin Choledochoscope Curative Effect on Common Bile Duct Exploration and Choledocholithotomy in 47 Cases.

Objective: The aim of the present study is to summarize the experience of using a 2. 7 mm choledochoscope for laparoscopic cholecystectomy combined with an ultrathin choledochoscope for common bile duct exploration and choledocholithotomy in the treatment of cholecystolithiasis associated with choledocholithiasis after the implementation of strict inclusion and exclusion criteria. Methods: A retrospective analysis of 47 patients with cholecystolithiasis complicated with choledocholithiasis who were treated in the hepatopancreatobiliary surgery department of the Chinese People's Liberated Army General Hospital between January 2015 and December 2019 was performed in the present study. Clinical data of laparoscopic cholecystectomy combined with ultrathin choledochoscope transcystic duct exploration for common bile duct and choledocholithotomy. Results: All 47 patients completed the operation successfully. The gallbladder duct was closed using a surgical clamp. Only 2 patients were administered with an abdominal drainage tube. The operation time was 50-160 min, the intraoperative blood loss was 5-50 ml, and the postoperative hospital stay was 2-8 days. No patients had serious complications, such as bile leakage, postoperative bleeding, cholangitis, biliary pancreatitis, and wound infection. Minor complications, such as abdominal pain (Abdominal pain was defined as a patient felt tolerable or unbearable abdominal pain but improved or disappeared with medication) and diarrhea, were present in a few patients; these improved after conservative treatment. There was no recurrence of calculi during the 1-5 years of follow-up, and the patient quality of life was good. Conclusion: Laparoscopic cholecystectomy combined with ultrathin choledochoscope common bile duct exploration and choledocholithotomy is a safe and effective method after adopting strict inclusion and exclusion criteria. This technology was started in the First Medical Center, Chinese People's Liberation Army General Hospital in September 2009, and it has become extremely mature in the past 5 years.

A propensity score matching study between conventional and soft fiber-optic choledochoscope guided percutaneous transhepatic cholangioscopic lithotripsy for treatment of cholelithiasis.

BACKGROUND: Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) provides an alternative method for cholelithiasis treatment. Since conventional rigid choledochoscope applied in PTCSL lacks high flexibility and high-resolution vision, we developed a new, soft fiber-optic choledochoscope (SFCS) to solve these problems. OBJECTIVE: We aim to verify the safety and efficacy of PTCSL guided by the newly developed choledochoscope, SCFS. METHODS: In this study, a total of 58 patients undergoing PTCSL from November, 2020 to December, 2020 in Zhuhai People's Hospital were enrolled, including 32 patients undergoing conventional PTCSL and 26 patients undergoing SFCS-guided PTCSL. A method of propensity score matching was used in order to balance the pre-operative indexes of the two groups. As a result, a total of 21 pairs (1:1) were created. SFCS-guided PTCSL was performed on patients in the SFCS group for the treatment of cholelithiasis. The operation time, intraoperative blood loss, immediate clearance rate, final clearance rate, postoperative hospitalization time, postoperative complication rate, and recurrence rate were compared between the two groups. A 6-month follow-up was performed for the two groups. RESULTS: SFCS-guided PTCSL represents safe and effective treatment outcomes. The immediate clearance rate and final clearance rate in the SFCS group were significantly higher than that of the conventional group. Operation time, intraoperative blood loss, postoperative hospitalization days, and recurrence rate in the SFCS group were significantly lower than that of the conventional group. CONCLUSIONS: SFCS applied in PTCSL appears to be a safe and effective method for the treatment of cholelithiasis. This study has been registered in Chinese Clinical Trial Registry as required by legislation (Registration number: ChiCTR1800016864, Registration time: 2018/02/08).

A retrospective comparative study on the therapeutic effect of one-stage means two-stage percutaneous transhepatic biliary fistulation lithotripsy in treatment of complex hepatolithiasis / 中华肝胆外科杂志

Objective:To compare the therapeutic effect of one-stage versus two-stage percutaneous transhepatic biliary fistulation lithotripsy in treatment of complex hepatolithiasis.Methods:A retrospective study was conducted on 145 patients with complex hepatolithiasis who were treated at the First Affiliated Hospital of Guangzhou Medical University between September 2013 and June 2018. There were 60 males and 85 females, aged 21 to 91 (56.5±14.1) years. According to the method of fistula establishment, patients were divided into the percutaneous transhepatic one-step biliary fistulation (PTOBF) group ( n=94) or the two-stage percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) group ( n=51). The success rates of one-time puncture and fistula dilation, operation time of lithotripsy, operative conversion rate (PTCSL was converted to laparotomy and laparoscopic surgery), postoperative complications (including catheter dislodgement), residual stone rates and stone recurrence rates were compared between groups. Results:In the PTOBF group, operation time (105.8±43.6) min, success rate of one puncture 73.4% (69/94), and success rate of one fistula dilation 93.6% (88/94), the rate of operative conversion 0. All these results were significantly better than the corresponding results of the two-stage PTCSL group of (130.0±70.0) min, 54.9% (28/51), 68.6% (35/51), and 13.7%(7/51) respectively (all P<0.05). There were no significant differences in stone residual rate [17.0%(16/94) vs. 15.7% (8/51)] and stone recurrence rate [14.9%(14/94) vs. 17.6% (9/51)] between groups (both P>0.05). The postoperative complications rate was 7.4%(7/94) in PTOBF group, which was 39.2% (20/51) in two-stage PTCSL group (χ 2=22.02, P<0.001). The catheter dislodgement rate of PTOBF group was 2.1% (2/94), lower than that of two-stage PTCSL group 27.4% (14/51), the difference was statistically significant (χ 2=21.59, P<0.001). Conclusion:One-stage PTOBF and two-stage PTCSL were both safe and effective in treatment of complex hepatolithiasis. However, PTOBF had shorter operative times, lower catheter dislodgement and operative conversion rates than PTCSL.

Risk Factors for Early Recurrence of Gallstones in Patients Undergoing Laparoscopy Combined With Choledochoscopic Lithotomy: A Single-Center Prospective Study.

Objective: For patients with gallstones, laparoscopy combined with choledochoscopic lithotomy is a therapeutic surgical option for preservation rather than the removal of the gallbladder. However, postoperative recurrence of gallstones is a key concern for both patients and surgeons. This prospective study was performed to investigate the risk factors for early postoperative recurrence of gallstones. Methods: The clinical data of 466 patients were collected. Each patient was followed up for up to 2 years. The first follow-up visit occurred 4 months after the operation, and a follow-up visit was carried out every 6 months thereafter. The main goal of each visit was to confirm the presence or absence of gallbladder stones. The factors associated with gallstone recurrence were analyzed by univariate analysis and Cox regression. Results: In total, 466 eligible patients were included in the study, and 438 patients (180 men and 258 women) completed the 2-year postoperative follow-up. The follow-up rate was 94.0%. Recurrence of gallstones was detected in 5.71% (25/438) of the patients. Univariate analysis revealed five risk factors for the recurrence of gallstones. Multivariate Cox regression analysis showed that multiple gallstones, a gallbladder wall thickness of ≥4 mm, and a family history of gallbladder stones were the three predictive factors for postoperative recurrence of gallstones (P < 0.05). Conclusion: The overall 2-year recurrence rate of gallstones after the operation was 5.71%. Multiple gallstones, a gallbladder wall thickness of ≥4 mm, and a family history of gallstones were the three risk factors associated with early postoperative recurrence of gallstones.

Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis.

OBJECTIVES: Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency. METHODS: This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected. RESULTS: Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications. CONCLUSIONS: CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

Value of multidisciplinary team (MDT) in minimally invasive treatment of complex intrahepatic bile duct stones.

This study aimed to investigate the value of multidisciplinary team (MDT) management in minimally invasive treatment of complex intrahepatic bile duct stones (IHDs) by laparoscopy, choledochoscopy and percutaneous choledochoscopy. The characteristics, perioperative index, complication rate and minimally invasive rate of patients in MDT group (n = 75) and non-MDT group (n = 70) were compared. The members of MDT include doctors in ultrasound, imaging, hepatobiliary and pancreatic surgery, anaesthesia and intensive care medicine. The results showed that minimally invasive surgery reduced the incidence of postoperative residual stones, OR (95% CI) = 0.365 (0.141-0.940) (p = 0.037). MDT reduced the operation time, OR (95% CI) = 0.406 (0.207-0.796) (p = 0.009). Minimally invasive surgery significantly reduced intraoperative bleeding, OR (95% CI) = 0.267 (0.133-0.534) (p < 0.001). Minimally invasive surgery also reduced hospitalization time, OR (95% CI) = 0.295 (0.142-0.611) (p = 0.001). The stone clearance rates of MDT group and non-MDT group were 81.33% and 81.43% respectively. In the MDT group, the operative time was less than that in the non-MDT group (p = 0.010); the intraoperative bleeding volume was significantly less than that in the non-MDT group (p < 0.001); the hospitalization time was less than that in the non-MDT group (p = 0.001). Minimally invasive operation rate:48 cases (64.00%) in MDT group were significantly higher than 17 cases (24.29%) in non-MDT group (p < 0.001). In conclusion, minimally invasive procedures can be selected more through MDT. MDT can shorten the operation time, and minimally invasive surgery can reduce the incidence of residual stones, reduce intraoperative bleeding, and may shorten hospital stay. Therefore, MDT management model can provide personalized and minimally invasive surgical protocol for patients with complex IHD, which has high application value.

Minimally invasive strategy for type I choledochal cyst in adult: combination of laparoscopy and choledochoscopy.

BACKGROUND: Choledochal cyst (CC)is a rare disease entity, more commonly occurring in Asian populations. In case of no contraindication, CC is resected to avoid future malignancies and future complications. OBJECTIVE: To determine the optimal technique for treatment of patients with type I choledochal cyst by comparisons of indicators, including the duration of surgery, loss of blood, rates of complication, duration of hospitalization, and outcomes of long-term follow-up. METHODS: From January 2009 to September 2017, a combination of laparoscopy and choledochoscopy surgery was implemented for type I choledochal cyst in adult. Patients' demographics data and treatment outcomes were collected prospectively during the follow-up. RESULTS: Fifty-eight patients with type I choledochal cyst were managed using this strategy. The combination of laparoscopic and intraoperative choledochoscopy was successfully performed in all patients without conversion or morbidity. When compared with a historical cohort of 71 patients who underwent a surgery for CC, this group of patients had significantly shorter duration of hospitalization (9.0 ± 6.5 days vs. 13.0 ± 8.0 days, P < 0.05). We also observed a lower blood loss (128.8 ± 60.2 mL vs. 178.1 ± 58.2 mL, P < 0.05), although the duration of the surgery (320.0 ± 50.0 min vs. 190.0 ± 24.5 min, P < 0.05) was longer. However, no significant difference was found in the rate of postoperative bleeding complication (3.45% vs. 4.23%, P = 0.82) and bile leakage complication (6.90% vs. 4.23%, P = 0.51). The two groups had similar rates of anastomotic stenosis (0.96% vs. 0.61%%, P = 0.47), jaundice (0.58% vs. 0.61%, P = 0.95), cholangitis (0.38% vs. 0.30%, P = 0.81), and reoperation (0.38% vs. 0.15%, P = 0.43). CONCLUSION: The type I choledochal cyst in adult can be effectively managed by laparoscopic surgery combined with inoperative choledochoscopy, which is feasible and minimally invasive. With the development of laparoscopic techniques and instruments, laparoscopic surgery may become the first-choice treatment for type I choledochal cyst treatment.

Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons.

BACKGROUND: Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE. METHODS: A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results. RESULTS: Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments. CONCLUSIONS: ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.

Choledochoscope-assisted antegrade-retrograde endoscopic dilation of complete esophageal stenosis in a patient with dystrophic epidermolysis bullosa.

Dystrophic epidermolysis bullosa is a mucocutaneous disorder, characterized by recurrent formation of blisters and scarring. The gastrointestinal tract is commonly affected by the disease and the proximal esophagus is the most common area of involvement of the gastrointestinal tract. The esophageal strictures are common in patients with dystrophic epidermolysis bullosa that can lead to complete esophageal stenosis in some cases. The antegrade/retrograde endoscopic dilation is a commonly used method in these patients. Different kinds of endoscopes may be used for the retrograde procedure, such as conventional upper gastrointestinal (UGI) endoscopes, slim-paediatric UGI endoscopes and ultrathin UGI nasal endoscopes. Herein, we reported the first antegrade/retrograde esophageal dilation case performed under choledochoscopic guidance.

Laparoscopic retrieval of impacted and broken dormia basket using a novel approach.

We encountered a 73-year-old patient who presented with right upper abdominal pain and jaundice. On evaluation, he was found to have cholelithiasis with choledocholithiasis. Endoscopic retrograde cholangiography was attempted, but during the procedure, the wire snapped and the dormia basket got retained in the common bile duct (CBD). Laparoscopic CBD exploration was performed and the basket with calculus was found impacted in the lower CBD. The basket was disengaged by holding its tip through another dormia introduced through choledochoscope and basket with all calculi retrieved. Clearance of CBD was ascertained with choledochoscopy and CBD was closed primarily. He did well in the post-operative period and was discharged on the 5th post-operative day. At 1-year follow-up, the patient was doing well. Laparoscopic CBD exploration is a feasible and safe option for the retained dormia basket. We utilised the 'dormia with dormia technique' to retrieve the impacted basket which has not been reported before.

Prevention of bile leakage after laparoscopic primary suturing of common bile duct by transabdominal placement of nasal bile duct / 中华肝胆外科杂志

Objective To study the advantages of laparoscopic primary suturing of common bile duct plus transabdominal nasobiliary drainage in reducing the rate of bile leakage.Methods The clinical data of laparoscopic primary suturing of common bile duct with or without nasal bile duct drainage in Second People's Hospital of Chengdu were analyzed retrospectively.Results During laparoscopic common bile duct exploration,286 patients were treated by primary suturing without nasobiliary drainage (group without drainage),including 32 (11.2％) patients with bile leakage;350 patients were treated by primary suturing with transabdominal nasobihary drainage (group with drainage),including 11 (3.1％) patients with bile leakage.The incidences of bile leakage of the two groups were significantly different (P ＜ 0.05).When the diameter of the common bile duct was less than 11.0 mm,the incidence of bile leakage in the non-drainage group and the drainage group were 18.5％ (20/108) and 2.1％ (3/143),respectively.The incidence in the drainage group was significantly lower than that in the non-drainage group,and the difference was statistically significant (P ＜ 0.05).When the diameter of common bile duct was larger than 11.0 mm,there was no significant difference in the incidences of bile leakage between the two groups (P ＞ 0.05).Conclusions The choice after laparoscopic primary suturing of common bile duct between with or without nasobiliary drainage should be determined according to the diameter of common bile duct.When a common bile duct diameter of less than 11.0 mm,nasobiliary drainage is recommended to reduce the rate of bile leakage.

Confocal laser endomicroscopy distinguishing benign and malignant gallbladder polyps during choledochoscopic gallbladder-preserving polypectomy: A case report.

BACKGROUND: In the last decade, confocal laser endomicroscopy (CLE) has emerged as a new endoscopic imaging modality for real-time in vivo histological examination at the microscopic level. CLE has been shown to be useful for distinguishing benign and malignant lesions and has been widely used in many digestive diseases. In our study, we used CLE for the first time to examine the morphology of cholesterol polyps as well as the different parts of normal gallbladder mucosa. CASE SUMMARY: A 57-year-old woman was diagnosed by ultrasound with a polyp of 21 mm in the gallbladder wall. She consented to polyp removal by laparoscopic choledo-choscopy. During laparoscopic cholecystectomy combined with choledochoscopic polyp resection, CLE was used to observe the morphology of the polyp surface cells. The appearance of the mucosa and microvessels in various parts of the gallbladder were also observed under CLE. Through comparison between postoperative pathology and intraoperative CLE diagnosis, the reliability of intraoperative CLE diagnosis was confirmed. CLE is a reliable method to examine living cell pathology during cholecystectomy. Based on our practice, CLE should be prioritized in the diagnosis of gallbladder polyps. CONCLUSION: Compared with traditional histological examination, CLE has several advantages. We believe that CLE has great potential in this field.