Percutaneous choledochoscopic biliary tract stone removal: experience in 645 consecutive patients.

Our experience in non-operative retrieval of biliary tract stones through PTCS (percutaneous transhepatic cholangioscopy, n = 103) and POC (post-operative choledochoscopy, n = 542) plus the use of Dormia basket and EHL (electrohydraulic lithotripsy) is presented. The results of transhepatic and T-tube routes are compared, with emphasis on the technical difficulties encountered. The success rates were 96% and 97% in POC and PTCS, respectively. No mortality was related to these procedures. Intrahepatic duct angulation and stricture were the factors most often responsible for failure. Postoperative choledochoscopic stone removal is safe and the method of choice for retained biliary tract calculi, while PTCS is highly indicated for those high-risk patients with or without previous biliary surgery. POC and PTCS have, therefore, their own indications and differ in their clinical applications.

Treatment of bleeding peptic ulcer by bilateral truncal vagotomy via a transpleural thoracoscopic approach and laparoscopic pyloromyotomy.

Six cases of recurrent bleeding duodenal ulcer were treated by bilateral truncal vagotomy via a right transpleural thoracoscopic approach and laparoscopic pyloromyotomy at Tainan Municipal Hospital. The vagus nerves were completely transected, which was proved by pathology. Basal acid output and insulin-stimulated maximum acid output were reduced by 68%-77% and 87%-92%, respectively, after vagotomy. On the other hand, there was no delay in gastric emptying on the basis of either patients' complaints or an upper gastrointestinal series of x-rays. Transpleural thoracoscopic bilateral truncal vagotomy and laparoscopic pyloromyotomy are safe, effective and offer more complete transection of the vagus nerves in treatment of complicated peptic ulcer. In addition, this new technique provides shorter hospitalization and an earlier convalescence.

Xanthogranulomatous cholecystitis: a complication of metallic biliary stent placement.

We present a case of 70-year-old female patient who was admitted due to progressive jaundice. Our clinical impression of cholangiocarcinoma (Klatskin tumor), was confirmed by ultrasound, abdominal CT scan, and percutaneous transhepatic cholangiography. Two self-expanding metallic stents were placed in both intrahepatic ducts through a single transhepatic tract. After successful biliary stenting, the jaundice subsided and she was discharged as improved. However, progressive right upper quadrant pain was noted a few days after discharge and persisted for about 5 months, thus the was readmitted. During admission, she was febrile, exhibiting leukocytosis, with clinical signs of impending septic shock. Gallbladder empyema with hilar cholangiocarcinoma were diagnosed. Percutaneous transhepatic cholecystotomy and drainage (PTCCD) was done to alleviate the symptoms and cholecystectomy was performed thereafter. Pathologic report was compatible with xanthogranulomatous cholecystitis. Post-operative recovery was fair at follow-up examination.

Spontaneous perforation of the left hepatic duct--a case report.

We report on a patient with spontaneous perforation of the left hepatic duct who presented with abdominal pain, jaundice and fever. The correct diagnosis was not established until extravasation of contrast medium from the left hepatic duct, as demonstrated by the cholangiogram, was observed. The patient developed two bile-stained intraperitoneal encapsulated fluid collections, which were diagnosed by ultrasonography, and high bilirubin levels in the fluid aspirated from the encapsulations, which were also found at operation. Closure of the perforation with sutures, decortication of the encapsulations and choledocholithotomy for stone extraction with T-tube insertion were performed. Recovery was complete at follow-up examinations.

Laparoscopic finding and imaging of the iatrogenic duodenal intramural hematoma.

Intramural duodenal hematoma is rarely seen in adults and may occur as an iatrogenic complication of endoscopic injection for peptic ulcer treatment. In the appropriate clinical setting, the diagnosis is easy with its ultrasonography and computed tomography characteristic findings. In one of our patients, UGI study revealed duodenal obstruction, bowel related lesion in sonography and hyperdense mass lesion in computed tomography. Clinical presentation of severe vomiting and epigastralgia were noted. Laparoscopy confirmed the location of the hematoma and subsequent evacuation was performed. The symptoms were relieved after the operation and a follow-up sonography demonstrated the regression of the duodenal hematoma.

Endoscopic sphincterotomy prior to laparoscopic cholecystectomy for the treatment of cholelithiasis.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is the standard treatment for symptomatic cholecystolithiasis; however, there is debate on the management of patients with concomitant common bile duct stones. Several options have been suggested; endoscopic sphincterotomy and laparoscopic common bile duct exploration seemed to be the preferred methods at this moment. MATERIALS AND METHODS: We performed endoscopic sphincterotomy prior to laparoscopic cholecystectomy in 51 cases of acute symptomatic cholelithiasis. RESULTS: Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy procedure-related complication rate was 5.4%, including 1 pancreatitis, 1 cholangitis, and 2 major bleeds. After follow up period of 15-42 months, recurrent stones were found in 2 patients. CONCLUSION: Endoscopic sphincterotomy combined with laparoscopic cholecystectomy is a safe and effective therapy for symptomatic cholecystolithiasis with concomitant choledocholithiasis. Recurrent stones did occur, but further studies are needed to compare the incidence of recurrent stones after endoscopic sphincterotomy and after laparoscopic common bile duct exploration.

Diagnostic and therapeutic interventions in post-laparoscopic cholecystectomy biliary complications.

Radiological imaging and therapeutic interventions were performed in eight patients with biliary complications following laparoscopic cholecystectomy. The diagnostic approach and the outcome of the therapeutic procedures were evaluated. Complications observed were bile leakage from the cystic duct stump (n = 2); erroneous identification of the cystic duct leading to common hepatic duct transection (n = 1) and hepatic duct ligation (n = 2); liver abscess (n = 1); and retained common duct stones (n = 2). Diagnostic ultrasonography is capable of detecting the presence of abnormal fluid collection and the diameter of the common duct with or without the presence of a stone, although bile leaks and retained common duct stones can only be demonstrated by either endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Once a bile leak had been confirmed, therapeutic endoscopic biliary stenting was successfully applied in one patient while the other received percutaneous transhepatic biliary drainage. Definitive diagnosis of retained common duct stone was established by endoscopic retrograde cholangiopancreatography, and immediate endoscopic sphincterotomy with stone extraction was performed. Follow-up radiological imaging was done to determine the effectiveness of the therapeutic procedures applied in each patient. All our patients improved clinically, and further surgical intervention was not needed.

Ultrasound-guided percutaneous transhepatic gallbladder drainage followed by laparoscopic cholecystectomy: a new trial in the treatment of severe acute suppurative cholecystitis.

Seven cases of acute suppurative cholecystitis underwent percutaneous transhepatic gallbladder drainage followed by laparoscopic cholecystectomy at the Tainan Municipal Hospital. All the patients had frank septic phenomena clinically, including fever, jaundice, leukocytosis and unstable blood pressure. Organisms were cultured from both blood and bile specimens. Ultrasound-guided transhepatic puncture of the gallbladder was performed for bile drainage, and laparoscopic cholecystectomy was subsequently performed two to five days later after the patients had stabilized. No procedure-related complications from either percutaneous transhepatic gallbladder drainage or laparoscopic cholecystectomy were observed. All patients had early recovery, shortened hospital stay and good cosmetic results. These preliminary results show that laparoscopic cholecystectomy is a safe method and can be employed in those patients with symptomatic gallstone associated with suppurative cholecystitis after preoperative biliary drainage.

Preoperative assessment of choledocholithiasis in laparoscopic cholecystectomy.

In order to determine the predictive value of noninvasive investigations for choledocholithiasis, we conducted a prospective preoperative study on 82 patients with symptomatic gallstones who received laparoscopic cholecystectomy. Ultrasonography (US), liver function tests and endoscopic retrograde cholangiography (ERC) were routinely performed in all cases prior to operation. The results showed a strong correlation between noninvasive procedures (liver function tests and US) and the presence of choledocholithiasis as shown by ERC. Using ERC as a reference, the sensitivity and selectivity of ductal dilatation at US and the elevation of alkaline phosphatase (ALP), gamma-glutamyltransferase and total bilirubin in the serum were studied for the detection of common bile duct (CBD) stones. The values of the combination of these tests were also calculated. From receiver operator characteristics curves, the best cut-off point for US in conjunction with ALP was chosen. ERC should be restricted to patients with possible CBD stones, suspected after a combination of the noninvasive US and ALP tests. This study emphasized the necessity and timing of performing ERC as a preoperative modality in the detection of choledocholithiasis in patients who are to undergo laparoscopic cholecystectomy.

Bilateral laparoscopic gonadectomy for testicular feminization syndrome.

Defects of androgen receptor gene lead to testicular feminization syndrome, which is one of the most common etiology of male pseudohermaphroditism. A 22-year-old phenotypic female with primary amenorrhea and insomnia is presented. Gross appearance revealed sparse axillary and pubic hair, poor breast development, clitoromegaly and absence of vagina. Ultrasound demonstrated no evidence of the uterus or adnexal structures, but the prostate gland was found. The laboratory data showed elevated follicle-stimulating hormone and a male 46, XY karyotype. Computed tomography localized the position of bilateral undescending testes, which were removed by operative laparoscopy procedures later. The patient was discharged without complication postoperatively.

Bilateral thoracoscopic lower sympathetic-splanchnicectomy for upper abdominal cancer pain.

Upper abdominal pain secondary to cancer may cause great disability to patients. Surgical sympathetic-splanchnicectomy, or coeliac plexus block, has been used to relieve intractable upper abdominal cancer pain from stomach, liver, gallbladder or pancreas for a long time. There are, however, intrinsic disadvantages when performing these procedures. Due to our long experience of therapeutic thoracoscopy, we recently performed bilateral thoracoscopic sympathetic-splanchnicectomy on 14 patients (eight male and six female) for relief of pain from primary or metastatic upper abdominal cancers. Most of them were satisfied with the immediate pain relief after the operation. In this new era of therapeutic endoscopy, endoscopic surgery will gradually take the place of open methods in treatment of many diseases. It can be anticipated that thoracoscopic lower sympathetic-splanchnicectomy is undoubtedly a good alternative method for management of intractable upper abdominal pain.

The role of ERCP and therapeutic biliary endoscopy in laparoscopic cholecystectomy.

The widespread use of laparoscopic cholecystectomy for the treatment of symptomatic gallstones has been associated with an increased use of diagnostic and therapeutic biliary endoscopy to treat common bile duct stones and postoperative complications. In 250 patients with successful laparoscopic cholecystectomy, 35 were selected for preoperative ERCP evaluation after fitting the criterion of clinical evidence with common bile duct stones (ultrasound and biochemical data). Stones were found in 16 of 35 patients (45.7%). Endoscopic sphincterotomy with stone removal was successfully carried out during the procedure. Laparoscopic cholecystectomy was performed 1 or 2 days after endoscopic sphincterotomy with good result. Only one patient without clinical evidence of common bile duct stones developed postoperative retained stone; he was successfully treated by endoscopic sphincterotomy. Three patients with postoperative bile leakage were successfully treated with endoscopic nasobiliary drainage. Diagnostic and therapeutic ERCP procedures should incorporate the newly developed method of laparoscopic cholecystectomy in order to provide a more safe and minimal invasive therapy.