One hundred laparoscopic choledochotomies with primary closure of the common bile duct.

BACKGROUND: Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage. METHODS: Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients). RESULTS: The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1-26). No patient required additional CBD procedures during follow-up. CONCLUSIONS: In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available.

Laparoscopic treatment of common bile duct stones.

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct is technically possible. The aim of this prospective study was to evaluate the feasibility of the different techniques of laparoscopic treatment of common bile duct stones and their complications. MATERIALS AND METHODS: From October 1990 to December 1995, 161 patients, age from 18 to 92, underwent a laparoscopic treatment for choledocholithiasis. A transcystic approach was attempted in 82 patients and was successful in 55 (67%). The failures were treated by 22 laparoscopic choledochotomies and in five patients by postoperative endoscopic sphincterotomy. A choledochotomy was performed in 101 cases and was successful in 97 (96%). The failures were treated by three laparotomies with a failure of intra-hepatic stone extraction and one postoperative endoscopic sphincterotomy. There were four residual lithiasis treated with endoscopic sphincterotomy. There were two failures treated one by laparotomy and one by laparoscopy. The total success rate was 92% (148/161). RESULTS: There was no postoperative mortality. There were five local complications, two abscesses, one liver injury, one small hemorrhage at the trocar site, and one pain lasting for more than 48 hours. There were seven general complications: two cardiac failures (medical treatment), one severe pancreatitis, one digestive hemorrhage, one psychiatric disorder, and two postoperative ileus. The total morbidity rate was 7.4% (12/161). Mean hospital stay was 7.6 days (2-36). CONCLUSIONS: Laparoscopic exploration of the common bile duct appears to be safe and effective. It could be included in the protocol of management of choledocholithiasis.

Ulnar artery aneurysm of the hand.

A case of traumatic ulnar artery aneurysm is presented in this study, and the relationship between the various forms of ulnar artery aneurysm and the different methods of treatment, as well as the arterial implications are discussed. The individual palmar arch anatomy may indicate and influence the choice of management technique, in each case.

[Treatment of common bile duct stones with laparoscopy. Retrospective multicenter study with 612 patients]. / Traitement de la lithiase de la voie biliaire principale sous laparoscopie. Etude rétrospective multicentrique chez 612 malades.

OBJECTIVE: To analyse retrospectively the results of one-stage laparoscopic treatment for common bile duct stones in 19 surgical centers in France. PATIENTS: From January 1991 to July 1996, 612 patients with choledocholithiasis underwent laparoscopic treatment. RESULTS: Overall duct clearance was obtained in 489 of the 612 patients (80%): through the cystic duct in 222 of 380 patients (58.4%), by secondary choledochotomy (after unsuccessful transcystic duct extraction) in 77 of 96 (80%), and in 190 of 232 (82 %) by primary choledochotomy. The overall duct clearance rate increased from 65% in 1991 to 84% in 1996. The use of the choledochotomy approach increased from 43% in 1991 to 69% in 1996 (P<0.01), due to a substantial increase in primary choledochotomy. In contrast, the use of the transcystic approach decreased from 57% to 31% (P<0.01). The mean time for surgery was shorter for cystic duct exploration than for primary choledochotomy (101+/-51 vs. 155+/-62 min, P<0.0001). The mean hospital stay decreased from 7.7+/-3.6 days in 1991 to 4.1+/-2 days in 1996 (P<0.001). The main biliary complications were related to biliary drainage (2,8%) and retained stones (3.1%). CONCLUSION: This study confirms that laparoscopy is a good alternative with a low complication rate, a short hospital stay, and is an effective and safe option for the management of common bile duct stones.

[Cystic mesothelioma of the peritoneum in a male]. / Mésothéliome kystique du péritoine chez un homme.

We report a case of cystic mesothelioma of the peritoneum in a young male with local recurrences and whose diagnosis was confirmed by standard histological studies and immunohistochemistry. This rare tumor appears generally in young females through abdominal pain and mass. Local recurrences without distant metastases are a feature of this pathology. The adequate treatment requires complete resection.

[Laparoscopic treatment of common bile duct calculi]. / Traitement laparoscopique de la lithiase de la voie biliaire principale.

Laparoscopic exploration of the common bile duct is now technically possible. This prospective study evaluates the feasibility of the different techniques and their complications. From January 1990 to March 1995, 140 patients, aged from 22 to 92, underwent laparoscopic treatment for choledocholithiasis. A transcystic approach was attempted in 70 patients and was successful in 46 (65.7%). The failures were treated by 19 laparoscopic choledochotomies and 5 postoperative endoscopic sphincterotomies. A choledochotomy was performed in 89 cases and was successful in 85 (94.4%). The failures were treated by 3 laparotomies and 2 postoperative endoscopic sphincterotomy. The total success rate was 92.8% (130/140). The 5 local complications were pain (1), liver injury (1), and wound abscess (2), bleeding from a trocar site. Heart failure (medical treatment) (2), gastrointestinal haemorrhage from intestinal angiomas, severe pancreatitis after transcystic failure and psychiatric disorders were the 5 general complications. The total morbidity rate was 7.1%. There were 2 residual common bile duct stones. The mortality rate was 0. Mean hospital stay was 7.8 days. Laparoscopic exploration of the common bile duct appears to be safe and effective and should be included in the management protocol of choledocholithiasis.

[A rare case of double biliary fistula (author's transl)]. / Un cas rare de double fistule bilaire.

The authors report a rare case of a double cholecysto-duodenal and cholecysto-colic fistula.

Evaluation of laparoscopic management of common bile duct stones in 220 patients.

BACKGROUND: The aim of this study was to evaluate the feasibility and results of laparoscopic management of common bile duct stones (CBDS). METHODS: From October 1990 to November 1996, 220 patients with CBDS have been managed laparoscopically. CBDS were suspected or diagnosed preoperatively in 130 patients (59.1%) and at intraoperative cholangiography (IOC) in 90 patients (40.9%). A transcystic duct extraction (TCDE) was attempted in 112 patients and a primary choledochotomy in 108 patients. RESULTS: TCDE was successful in 77 cases (68.8%). The 35 failures were treated by 29 laparoscopic choledochotomies, 1 intraoperative and 5 postoperative endoscopic sphincterotomies (ES). A choledochotomy was thus performed in 137 cases and was successful in 133 cases (97.1%). The four failures were managed by three laparotomies and one postoperative ES. The overall success rate was 95.5% (210/220). There was 4 deaths (0.9%) within the 1st postoperative month in ASA 3 patients and the morbidity rate was 9.1% (20/220). There were 7 residual stones (3.2%). CONCLUSIONS: Laparoscopic desobstruction of CBDS appears to be safe and effective and has the advantage to be a single-stage procedure. It could become in the future with refinement of instrumentation and skill of surgeons the best treatment for the majority of patients harboring CBDS.

Splenosis: ultrasound and CT findings in a case complicated by an intraperitoneal implant traumatic hematoma.

A case of intraperitoneal splenosis, found incidentally at ultrasound examination in a 35-year-old man, is reported. The diagnosis, suspected on the basis of computed tomographic (CT) and radionuclide studies, was established by surgery. Three years later, after direct trauma, ultrasound and CT studies revealed a surgically proven splenosis implant hematoma. The contribution of radiologic examinations in the diagnosis of splenosis is emphasized.

[Rheumatoid polyarthritis with Gougerot-Sjögren's syndrome, pulmonary pseudolymphoma and digestive lymphoma. Apropos of a case]. / Polyarthrite rhumatoïde avec syndrome de Gougerot-Sjögren, pseudo-lymphome pulmonaire et lymphome digestif. A propos d'une observation.

The authors report a case of the Gougerot-Sjögren syndrome with rheumatoid arthritis, of particular interest because of lymphocytic proliferation. This was initially confined to the broncho-pulmonary tissues with histological appearances of pseudo-lymphoma, a diagnosis supported by clinical regression with immunosuppressive drugs, over a 5 years period. This difficult diagnosis needs histological, biochemical and clinical confirmation and, the very existence of this entity is debatable. The occurrence of a malignant lymphoma of the small intestine in the same patient a few years later is an argument in favour of the hypothesis that the pseudo-lymphoma was an intermediary pre-malignant stage of B-lymphocytic proliferation.