This document describes a study comparing a modified transcystic biliary decompression (mTCBD) technique using a ureteral catheter secured with a Lapro-Clip to a standard T-tube drainage technique after laparoscopic choledochotomy. Eighty-two patients undergoing laparoscopic choledochotomy for choledocholithiasis were included, with 30 receiving mTCBD and 52 receiving T-tube drainage. Outcomes such as bile output, drain removal time, complications, and retained stones were compared. The mTCBD group had less bile output, earlier drain removal, and no complications, while the T-tube group had higher morbidity including bile leakage after drain removal and longer hospital stay.
Management of concomitant gall bladder and common bile duct stones, single st...wael mansy
This document summarizes a study comparing two treatment approaches for patients with gallstones and common bile duct stones: 1) one-stage laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreaticography (ERCP-LC), and 2) one-stage laparoscopic cholecystectomy and laparoscopic exploration of the common bile duct (LC-LCBDE). The study found no significant differences between the two approaches in terms of surgical time, success rate, complications, retained stones, or length of hospital stay. However, patients undergoing ERCP-LC were more likely to develop low-grade cholangitis due to sphincterotomy during stone extraction. Overall, both approaches provided safe
Single stage laparoscopic management for concomitant gallstones and common bi...MohamedTag14
The aim of this study is to compare between the outcome of management of concomitant gallstones and common bile duct by two stage (ERCP+LC) versus one stage(LECBD+LC) as regard:
Intraoperative complications
Conversion to other procedure
Total operative time
Postoperative complications
Postoperative mortality
Retained CBD stones
Length of hospital stay
Patient satisfaction
This study aimed to establish the optimal timing between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) for patients with common bile duct stones. Sixty patients were randomized into three groups based on the interval between ERCP and LC: short (≤3 days), medium (4-60 days), or long (≥60 days). The study found fewer intraoperative adhesions and shorter operative time and hospital stay in the short interval group. While conversion rates and complications did not differ significantly between groups, the results suggest an interval of within 72 hours between ERCP and LC may be preferable to allow for less adhesions and quicker recovery. Further larger studies
This document provides information about a textbook on choledocholithiasis (gallstones in the common bile duct). The editors are B. Fernando Santos and Nathaniel Soper. The textbook aims to address the current lack of knowledge among general surgeons on comprehensively managing patients with choledocholithiasis, with an emphasis on how surgeons can provide single-stage management for most patients. It includes discussions of the history of surgical techniques, preoperative evaluation, decision-making, economics, and simulation training curricula. The goal is for surgeons to embrace managing common duct stones again as beneficial for patients.
This randomized controlled trial compared duct-to-mucosa pancreaticojejunostomy (PJ) to invagination PJ for patients undergoing pancreatoduodenectomy (PD). The study found that invagination PJ resulted in significantly fewer postoperative pancreatic fistulas (POPFs) compared to duct-to-mucosa PJ for patients with soft pancreas tissue. Additionally, invagination PJ was associated with shorter drain duration, shorter hospital stays, and lower costs compared to duct-to-mucosa PJ, especially for patients who developed clinically significant POPFs. Therefore, the authors concluded that invagination PJ may be superior to duct-to-mucosa
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
Management of concomitant gall bladder and common bile duct stones, single st...wael mansy
This document summarizes a study comparing two treatment approaches for patients with gallstones and common bile duct stones: 1) one-stage laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreaticography (ERCP-LC), and 2) one-stage laparoscopic cholecystectomy and laparoscopic exploration of the common bile duct (LC-LCBDE). The study found no significant differences between the two approaches in terms of surgical time, success rate, complications, retained stones, or length of hospital stay. However, patients undergoing ERCP-LC were more likely to develop low-grade cholangitis due to sphincterotomy during stone extraction. Overall, both approaches provided safe
Single stage laparoscopic management for concomitant gallstones and common bi...MohamedTag14
The aim of this study is to compare between the outcome of management of concomitant gallstones and common bile duct by two stage (ERCP+LC) versus one stage(LECBD+LC) as regard:
Intraoperative complications
Conversion to other procedure
Total operative time
Postoperative complications
Postoperative mortality
Retained CBD stones
Length of hospital stay
Patient satisfaction
This study aimed to establish the optimal timing between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) for patients with common bile duct stones. Sixty patients were randomized into three groups based on the interval between ERCP and LC: short (≤3 days), medium (4-60 days), or long (≥60 days). The study found fewer intraoperative adhesions and shorter operative time and hospital stay in the short interval group. While conversion rates and complications did not differ significantly between groups, the results suggest an interval of within 72 hours between ERCP and LC may be preferable to allow for less adhesions and quicker recovery. Further larger studies
This document provides information about a textbook on choledocholithiasis (gallstones in the common bile duct). The editors are B. Fernando Santos and Nathaniel Soper. The textbook aims to address the current lack of knowledge among general surgeons on comprehensively managing patients with choledocholithiasis, with an emphasis on how surgeons can provide single-stage management for most patients. It includes discussions of the history of surgical techniques, preoperative evaluation, decision-making, economics, and simulation training curricula. The goal is for surgeons to embrace managing common duct stones again as beneficial for patients.
This randomized controlled trial compared duct-to-mucosa pancreaticojejunostomy (PJ) to invagination PJ for patients undergoing pancreatoduodenectomy (PD). The study found that invagination PJ resulted in significantly fewer postoperative pancreatic fistulas (POPFs) compared to duct-to-mucosa PJ for patients with soft pancreas tissue. Additionally, invagination PJ was associated with shorter drain duration, shorter hospital stays, and lower costs compared to duct-to-mucosa PJ, especially for patients who developed clinically significant POPFs. Therefore, the authors concluded that invagination PJ may be superior to duct-to-mucosa
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
This document discusses bile duct injuries (BDI) that can occur during cholecystectomy. It notes that BDI are rare but potentially devastating, and are most commonly caused by laparoscopic cholecystectomy. The document covers anatomy of the bile ducts, classifications of BDI, risk factors, prevention techniques like obtaining the "critical view of safety", and management approaches depending on the type and timing of injury identification. For injuries identified during surgery, the goal is usually repair or reconstruction. For later injuries, management involves drainage, antibiotics, and definitive reconstruction once inflammation decreases. Surgical repair via Roux-en-Y hepaticojejunostomy is often needed but endoscopic or radiologic techniques can sometimes be
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
This document discusses a case of a 46-year-old male who presented with abdominal pain after a laparoscopic cholecystectomy and was found to have a bile leak. An ERCP revealed a leak from the cystic duct stump that was treated with stent placement. Bile duct injuries are a risk of cholecystectomy and can be classified in various ways. Diagnosis involves imaging studies and treatment aims to redirect bile flow away from leak sites.
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
The document discusses the management of choledocholithiasis or common bile duct stones. It covers the clinical features, investigations like ultrasound, CT, ERCP and MRCP. It discusses the diagnostic approach and various management options including endoscopic procedures like ERCP with sphincterotomy and plastic stent placement. It also discusses open CBD exploration techniques like choledochotomy and T-tube placement. Laparoscopic CBD exploration is mentioned as a minimally invasive method. Guidelines recommend ERCP as first-line treatment for CBD stones with timing based on severity of cholangitis. Sphincterotomy with balloon dilation and cholangioscopy-assisted lithotripsy are suggested for difficult stones.
CBDSs are one of the medical conditions leading to surgical intervention. They may occur in 3%–14.7% of all patients for whom cholecystectomies are preformed. When patients present with CBD, the one important question that should be answered: what is the best modality of treatment under the giving conditions? There are competing technologies and approaches for diagnosing CBDS with regard to diagnostic performance characteristics, technical success, safety, and cost effectiveness. Management of CBDS usually requires two separate teams: the gastroenterologist and the surgical team. One of the main factors in the management is initially the detection of CBDS, before, during, or after cholecystectomy. The main options for treatment are pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST), laparoscopic or open surgical bile duct clearance. There are other options for the treat- ment of CBDS such as electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy (ESWL), dissolving solutions, and laser lithotripsy. It is unlikely that one option
will be appropriate for all clinical circumstances in all centers. Variables such as disease status, patient demographics, availability of endoscopic, radiological and surgical expertise, and healthcare economics will all have significant influence on practice
1. CBD stones can have deadly consequences like cholangitis, septicemia, and gallstone pancreatitis.
2. Preoperative risk assessment determines if patients undergo ERCP or laparoscopic procedures. High risk patients undergo ERCP while low risk may have laparoscopic exploration.
3. Laparoscopic CBD exploration or open exploration are options if CBD stones are detected during cholecystectomy. ERCP remains the gold standard treatment.
This document describes the medical history and treatment of a 50-year-old female patient who presented with right upper quadrant pain and was diagnosed with cholelithiasis. She underwent an open cholecystectomy but was later readmitted with signs of bile duct injury, which was repaired during a second surgery. The patient was discharged after the drainage from her bile duct decreased sufficiently over a two week follow up period.
This document describes a case report of a patient who underwent laparoscopic cholecystectomy and was found to have an accessory cystic duct close to the gallbladder fundus. Accessory bile ducts are rare anatomical variations that occur in about 10% of patients due to complex embryonic development of the biliary system. Failure to identify these variations can result in bile leaks after surgery. The accessory duct in this case was carefully dissected and clipped to prevent complications.
This document describes the renogram procedure. It provides details on:
- The radiopharmaceuticals used, including 99mTc-DTPA, 99mTc-MAG3, and 99mTc-DMSA
- How the procedure is performed, including patient preparation, image acquisition, and time-activity curve analysis
- The roles of the radiopharmaceuticals in evaluating renal blood flow, glomerular filtration rate, and renal handling and excretion
- Factors that can affect the procedure such as hydration, medications, and kidney positioning
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injuries can occur due to anatomical variations, technical errors, or inflammation and can be classified using systems like Bismuth's or Strasberg's. Clinical presentation includes jaundice, abdominal pain, and fever. Investigations include liver function tests, imaging, and cholangiography. Surgical repair such as Roux-en-Y hepaticojejunostomy is often needed for significant injuries. Prevention through surgeon experience and identification of anatomical variations is key to avoiding biliary strictures.
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
This document discusses surgical and interventional approaches for gallbladder disease. It describes laparoscopic cholecystectomy as the standard treatment for cholelithiasis and mild-to-moderate acute cholecystitis. Variations like single-incision laparoscopic cholecystectomy aim to reduce scarring but have technical challenges. Natural orifice transluminal endoscopic surgery (NOTES) offers improved cosmesis through transgastric or transvaginal access but requires special equipment. Percutaneous cholecystostomy effectively treats acute cholecystitis in patients who cannot undergo surgery but has frequent complications and diminishes quality of life. The optimal approach considers the patient's condition and disease consequences.
This document discusses various applications of nanotechnology in urology, including imaging and treatment of genitourinary cancers, prostate cancer screening, tissue engineering, and more. It describes how nanoparticles can improve detection of cancer through imaging modalities like MRI. Nanoparticles are also explored as drug delivery vehicles to selectively target cancer cells and overcome issues like drug resistance. The document outlines several preclinical and early clinical studies investigating nanoparticle formulations to treat cancers of the prostate, bladder, and kidneys with reduced toxicity compared to conventional therapies.
This document discusses the history of biliary injuries and laparoscopic cholecystectomy. It begins with a brief overview of milestones in the history of cholecystectomy and bile duct surgery. It then describes biliary anatomy and variations that can increase risk of injury. The advantages of laparoscopic cholecystectomy are noted but also the increased risk of bile duct injuries compared to open surgery. Risk factors for injuries are discussed including surgeon experience, patient factors like inflammation, and anatomic variations. Techniques for prevention are outlined including obtaining the "critical view of safety" and using intraoperative cholangiography. Classification systems for injuries and approaches to treatment are also summarized. Throughout, the importance of prevention over treatment is emphasized
Damage Control Laparotomy - an evidence based approachYasser Abbas
Dr. Yasser Abbas outlines the concept of damage control surgery, which involves temporarily controlling bleeding and contamination through techniques like packing and temporary abdominal closure, to allow time for resuscitation before definitive repair. Damage control is indicated for patients who are hemodynamically unstable, coagulopathic, acidotic, or hypothermic and involves three phases - initial surgery to control bleeding, ICU resuscitation to correct physiological derangements, and a second surgery for definitive repair once stabilized. The goal of damage control is to prevent the "lethal triad" of acidosis, coagulopathy, and hypothermia in order to improve survival rates.
Acs0521 Cholecystectomy And Common Bile Duct Exploration 2009medbookonline
1) The document discusses preoperative evaluation, patient selection, positioning, and techniques for laparoscopic cholecystectomy.
2) Key aspects of preoperative evaluation include patient history, physical exam, imaging such as ultrasound and MRCP to assess for gallstones and bile duct anatomy, and lab tests. Patient risk for CBD stones is assessed as high, moderate, or low.
3) Outpatient cholecystectomy is appropriate for low-risk, healthy patients. Technically challenging patients include those who are obese, have had prior abdominal surgery or acute cholecystitis, or have anatomic distortions.
4) The goal of cholecystectomy is safe gallbladder removal while minimizing bile duct injury
Peritonectomy is a surgical technique used to treat advanced ovarian cancer that aims to remove all visible tumor from the peritoneal cavity. A study was conducted on peritonectomies performed at the Queensland Centre for Gynaecological Cancer to evaluate the safety and outcomes. The results showed that peritonectomy can debulk tumor down to less than 2cm in size, with smaller residuals associated with better survival rates. However, going from 2cm or less to no visible tumor takes significantly more time and expertise. Patient selection remains a challenge, but modified peritonectomy appears to be a viable option for some advanced ovarian and primary peritoneal cancer cases. Training future surgeons in these complex procedures is important to improving patient outcomes.
This document provides information about the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the professors and assistant professors in the department and provides definitions and principles of renal replacement therapy including dialysis and transplantation. It discusses indications for renal replacement therapy and covers various modalities like hemodialysis, peritoneal dialysis, vascular access and complications.
n (%)
Results
Patient demographics and indications
Table 1 Patient demographics and indications
Surgeon 2
75 min (35–120 min)
85 min (45–180 min)
Junior resident
30 (50)
Fellow
30 (50)
due to severe inflammation (n = 2), inability to retract the
gallbladder (n = 2), and bleeding from the cystic artery
(n = 1). No patient required conversion to open cholecystectomy.
Intraoperative cholangiography and bile duct
exploration
Age (years): mean (range)
47 (18–80)
Gender: n
1) The study evaluated the effectiveness of endoscopic biliary stenting combined with ursodeoxycholic acid (UDCA) and a terpene preparation for treating difficult common bile duct (CBD) stones in elderly patients.
2) 28 elderly patients with difficult CBD stones underwent biliary stenting and were given UDCA and terpene preparation daily for 6 months on average.
3) After treatment, CBD stone size and CBD diameter decreased significantly. Complete stone removal was achieved in 26 of 28 patients (92.8%) with an average of 1.7 additional ERCP sessions.
This document discusses bile duct injuries (BDI) that can occur during cholecystectomy. It notes that BDI are rare but potentially devastating, and are most commonly caused by laparoscopic cholecystectomy. The document covers anatomy of the bile ducts, classifications of BDI, risk factors, prevention techniques like obtaining the "critical view of safety", and management approaches depending on the type and timing of injury identification. For injuries identified during surgery, the goal is usually repair or reconstruction. For later injuries, management involves drainage, antibiotics, and definitive reconstruction once inflammation decreases. Surgical repair via Roux-en-Y hepaticojejunostomy is often needed but endoscopic or radiologic techniques can sometimes be
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
This document discusses a case of a 46-year-old male who presented with abdominal pain after a laparoscopic cholecystectomy and was found to have a bile leak. An ERCP revealed a leak from the cystic duct stump that was treated with stent placement. Bile duct injuries are a risk of cholecystectomy and can be classified in various ways. Diagnosis involves imaging studies and treatment aims to redirect bile flow away from leak sites.
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
The document discusses the management of choledocholithiasis or common bile duct stones. It covers the clinical features, investigations like ultrasound, CT, ERCP and MRCP. It discusses the diagnostic approach and various management options including endoscopic procedures like ERCP with sphincterotomy and plastic stent placement. It also discusses open CBD exploration techniques like choledochotomy and T-tube placement. Laparoscopic CBD exploration is mentioned as a minimally invasive method. Guidelines recommend ERCP as first-line treatment for CBD stones with timing based on severity of cholangitis. Sphincterotomy with balloon dilation and cholangioscopy-assisted lithotripsy are suggested for difficult stones.
CBDSs are one of the medical conditions leading to surgical intervention. They may occur in 3%–14.7% of all patients for whom cholecystectomies are preformed. When patients present with CBD, the one important question that should be answered: what is the best modality of treatment under the giving conditions? There are competing technologies and approaches for diagnosing CBDS with regard to diagnostic performance characteristics, technical success, safety, and cost effectiveness. Management of CBDS usually requires two separate teams: the gastroenterologist and the surgical team. One of the main factors in the management is initially the detection of CBDS, before, during, or after cholecystectomy. The main options for treatment are pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST), laparoscopic or open surgical bile duct clearance. There are other options for the treat- ment of CBDS such as electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy (ESWL), dissolving solutions, and laser lithotripsy. It is unlikely that one option
will be appropriate for all clinical circumstances in all centers. Variables such as disease status, patient demographics, availability of endoscopic, radiological and surgical expertise, and healthcare economics will all have significant influence on practice
1. CBD stones can have deadly consequences like cholangitis, septicemia, and gallstone pancreatitis.
2. Preoperative risk assessment determines if patients undergo ERCP or laparoscopic procedures. High risk patients undergo ERCP while low risk may have laparoscopic exploration.
3. Laparoscopic CBD exploration or open exploration are options if CBD stones are detected during cholecystectomy. ERCP remains the gold standard treatment.
This document describes the medical history and treatment of a 50-year-old female patient who presented with right upper quadrant pain and was diagnosed with cholelithiasis. She underwent an open cholecystectomy but was later readmitted with signs of bile duct injury, which was repaired during a second surgery. The patient was discharged after the drainage from her bile duct decreased sufficiently over a two week follow up period.
This document describes a case report of a patient who underwent laparoscopic cholecystectomy and was found to have an accessory cystic duct close to the gallbladder fundus. Accessory bile ducts are rare anatomical variations that occur in about 10% of patients due to complex embryonic development of the biliary system. Failure to identify these variations can result in bile leaks after surgery. The accessory duct in this case was carefully dissected and clipped to prevent complications.
This document describes the renogram procedure. It provides details on:
- The radiopharmaceuticals used, including 99mTc-DTPA, 99mTc-MAG3, and 99mTc-DMSA
- How the procedure is performed, including patient preparation, image acquisition, and time-activity curve analysis
- The roles of the radiopharmaceuticals in evaluating renal blood flow, glomerular filtration rate, and renal handling and excretion
- Factors that can affect the procedure such as hydration, medications, and kidney positioning
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injuries can occur due to anatomical variations, technical errors, or inflammation and can be classified using systems like Bismuth's or Strasberg's. Clinical presentation includes jaundice, abdominal pain, and fever. Investigations include liver function tests, imaging, and cholangiography. Surgical repair such as Roux-en-Y hepaticojejunostomy is often needed for significant injuries. Prevention through surgeon experience and identification of anatomical variations is key to avoiding biliary strictures.
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
This document discusses surgical and interventional approaches for gallbladder disease. It describes laparoscopic cholecystectomy as the standard treatment for cholelithiasis and mild-to-moderate acute cholecystitis. Variations like single-incision laparoscopic cholecystectomy aim to reduce scarring but have technical challenges. Natural orifice transluminal endoscopic surgery (NOTES) offers improved cosmesis through transgastric or transvaginal access but requires special equipment. Percutaneous cholecystostomy effectively treats acute cholecystitis in patients who cannot undergo surgery but has frequent complications and diminishes quality of life. The optimal approach considers the patient's condition and disease consequences.
This document discusses various applications of nanotechnology in urology, including imaging and treatment of genitourinary cancers, prostate cancer screening, tissue engineering, and more. It describes how nanoparticles can improve detection of cancer through imaging modalities like MRI. Nanoparticles are also explored as drug delivery vehicles to selectively target cancer cells and overcome issues like drug resistance. The document outlines several preclinical and early clinical studies investigating nanoparticle formulations to treat cancers of the prostate, bladder, and kidneys with reduced toxicity compared to conventional therapies.
This document discusses the history of biliary injuries and laparoscopic cholecystectomy. It begins with a brief overview of milestones in the history of cholecystectomy and bile duct surgery. It then describes biliary anatomy and variations that can increase risk of injury. The advantages of laparoscopic cholecystectomy are noted but also the increased risk of bile duct injuries compared to open surgery. Risk factors for injuries are discussed including surgeon experience, patient factors like inflammation, and anatomic variations. Techniques for prevention are outlined including obtaining the "critical view of safety" and using intraoperative cholangiography. Classification systems for injuries and approaches to treatment are also summarized. Throughout, the importance of prevention over treatment is emphasized
Damage Control Laparotomy - an evidence based approachYasser Abbas
Dr. Yasser Abbas outlines the concept of damage control surgery, which involves temporarily controlling bleeding and contamination through techniques like packing and temporary abdominal closure, to allow time for resuscitation before definitive repair. Damage control is indicated for patients who are hemodynamically unstable, coagulopathic, acidotic, or hypothermic and involves three phases - initial surgery to control bleeding, ICU resuscitation to correct physiological derangements, and a second surgery for definitive repair once stabilized. The goal of damage control is to prevent the "lethal triad" of acidosis, coagulopathy, and hypothermia in order to improve survival rates.
Acs0521 Cholecystectomy And Common Bile Duct Exploration 2009medbookonline
1) The document discusses preoperative evaluation, patient selection, positioning, and techniques for laparoscopic cholecystectomy.
2) Key aspects of preoperative evaluation include patient history, physical exam, imaging such as ultrasound and MRCP to assess for gallstones and bile duct anatomy, and lab tests. Patient risk for CBD stones is assessed as high, moderate, or low.
3) Outpatient cholecystectomy is appropriate for low-risk, healthy patients. Technically challenging patients include those who are obese, have had prior abdominal surgery or acute cholecystitis, or have anatomic distortions.
4) The goal of cholecystectomy is safe gallbladder removal while minimizing bile duct injury
Peritonectomy is a surgical technique used to treat advanced ovarian cancer that aims to remove all visible tumor from the peritoneal cavity. A study was conducted on peritonectomies performed at the Queensland Centre for Gynaecological Cancer to evaluate the safety and outcomes. The results showed that peritonectomy can debulk tumor down to less than 2cm in size, with smaller residuals associated with better survival rates. However, going from 2cm or less to no visible tumor takes significantly more time and expertise. Patient selection remains a challenge, but modified peritonectomy appears to be a viable option for some advanced ovarian and primary peritoneal cancer cases. Training future surgeons in these complex procedures is important to improving patient outcomes.
This document provides information about the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the professors and assistant professors in the department and provides definitions and principles of renal replacement therapy including dialysis and transplantation. It discusses indications for renal replacement therapy and covers various modalities like hemodialysis, peritoneal dialysis, vascular access and complications.
n (%)
Results
Patient demographics and indications
Table 1 Patient demographics and indications
Surgeon 2
75 min (35–120 min)
85 min (45–180 min)
Junior resident
30 (50)
Fellow
30 (50)
due to severe inflammation (n = 2), inability to retract the
gallbladder (n = 2), and bleeding from the cystic artery
(n = 1). No patient required conversion to open cholecystectomy.
Intraoperative cholangiography and bile duct
exploration
Age (years): mean (range)
47 (18–80)
Gender: n
1) The study evaluated the effectiveness of endoscopic biliary stenting combined with ursodeoxycholic acid (UDCA) and a terpene preparation for treating difficult common bile duct (CBD) stones in elderly patients.
2) 28 elderly patients with difficult CBD stones underwent biliary stenting and were given UDCA and terpene preparation daily for 6 months on average.
3) After treatment, CBD stone size and CBD diameter decreased significantly. Complete stone removal was achieved in 26 of 28 patients (92.8%) with an average of 1.7 additional ERCP sessions.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
This study reviewed 196 patients who underwent single-incision laparoscopic cholecystectomy (SILC) with routine intraoperative cholangiography (IOC) at a single institution. IOC was successful in 178 patients (90.8%) and detected abnormalities in 21 patients (10.7%), including common bile duct stones in 16 patients. IOC helped accurately identify biliary anatomy and avoided potential bile duct injury in one case. The authors conclude that routine IOC during SILC is feasible and useful for detecting bile duct stones and gaining an accurate picture of biliary anatomy.
This document summarizes information on gallbladder removal surgery (cholecystectomy). It discusses the history and types of cholecystectomy procedures, including open and laparoscopic techniques. Key points include that laparoscopic cholecystectomy has become the gold standard treatment for gallstone disease since the 1990s as it is associated with less pain, smaller incisions, shorter hospital stays and faster recovery compared to open cholecystectomy. However, laparoscopic approaches may be more technically challenging and carry a higher risk of bile duct injuries.
Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy.
Common Bile Duct Stones: Leave Them Get Them or Refer ThemGeorge S. Ferzli
The document discusses various approaches for managing common bile duct (CBD) stones, including:
- Preoperative identification using blood tests, ultrasound, ERCP, MRCP, which have varying sensitivity and specificity
- Intraoperative options like cholangiography, laparoscopic ultrasound, and indocyanine green injection
- Postoperative ERCP can be used for diagnostic and therapeutic purposes but has risks of pancreatitis and cholangitis
- The optimal management strategy depends on individual patient risk factors and circumstances.
BILE DUCT INJURY AFTER CHOLECYSTECTOMY.pptxSultanBhai4
This document summarizes research on bile duct injury after cholecystectomy and surgical approaches for treatment. Key points include:
- Bile duct injury is a risk of laparoscopic cholecystectomy and can lead to strictures or leaks requiring further intervention.
- Surgical repair by an experienced hepatobiliary surgeon offers the best outcomes for major bile duct injuries.
- Proper identification of ductal anatomy using techniques like the "critical view of safety" are important for prevention of injury during cholecystectomy.
- Management of bile duct injuries may require a multidisciplinary team including surgeons, gastroenterologists, and interventional radiologists.
Dr. Sreenath K discusses bile duct injuries that can occur during cholecystectomy. The document covers risk factors, classifications, presentations, prevention strategies, and management approaches for bile duct injuries. Prevention focuses on obtaining a clear view of structures in Calot's triangle before division. Management depends on the type and extent of injury, and may involve drainage, stenting, or surgical reconstruction like hepaticojejunostomy. Surgical repair aims to reestablish biliary enteric continuity in a tension-free manner.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
Trimodal Management of Locally Invasive Urinary Bladder CancerNainaAnon
To evaluate the response of the modern bladder-preservation treatment modality; Trimodal Therapy (TMT) in Muscle-Invasive Bladder Cancer (MIBC). Aiming at bladder preservation in MIBC, TMT was to offer a quality- of-life advantage and avoid potential morbidity and mortality of Radical Cystectomy (RC) without compromising oncologic outcomes.
Percutaneous Drainage of Abscess and Post Operative CollectionsDr.Suhas Basavaiah
Ultrasound guided percutaneous drainage is an image guided minimally invasive procedure to treat accessible fluid collections. It has advantages over CT like real-time visualization and lack of radiation. The document outlines the patient preparation, equipment, techniques, post-procedure care and complications of this procedure. Percutaneous drainage is effective for treating many types of collections when performed carefully under imaging guidance using the correct technique and equipment.
The document discusses residual common bile duct (CBD) stones following cholecystectomy. It notes that CBD stones occur in 5-10% of patients undergoing elective cholecystectomy and are usually seen within 6 weeks to 1 year later. ERCP is the definitive test for identifying CBD stones and options for removal include ERCP sphincterotomy, percutaneous lithotomy, extracorporeal lithotripsy, or surgical lithotomy if other options fail or are contraindicated. Surgical CBD exploration may involve opening the bile duct and milking out stones or flushing them out with saline via a catheter.
A 62-year-old male presented with pain in the right hypochondrium for 2 months and was found to have gallbladder stones and a dilated common bile duct (CBD) of 11.5mm. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the CBD, followed by laparoscopic cholecystectomy (LC) 1 month later. During the LC, the surgeon discovered that the CBD stent had migrated into the gallbladder. This case report discusses the migration of CBD stents into the gallbladder during LC after ERCP and emphasizes performing LC within 3 days of ERCP to avoid complications from stent migration.
The field of transcatheter mitral valve repair (TMVr) for
mitral regurgitation (MR) is rapidly evolving. Besides the
well-established transcatheter mitral edge-to-edge repair
approach, there is also growing evidence for therapeutic
strategies targeting the mitral annulus and mitral valve
chordae. A patient-tailored approach, careful patient
selection and an experienced interventional team is crucial
in order to optimise procedural and clinical outcomes. With
further data from ongoing clinical trials to be expected,
consensus in the Heart Team is needed to address these
complexities and determine the most appropriate TMVr
therapy, either single or combined, for patients with severe
MR
This research article evaluated the efficacy and safety of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation for treating rectal cancer. 211 patients underwent either laparoscopic (131 patients) or open (80 patients) surgery. Results showed that both surgeries were successfully completed with no differences in lymph nodes removed or post-op complications. The laparoscopic group had shorter time to pass gas, get out of bed, and hospital stay. No differences were found in recurrence, mortality, or urinary/sexual dysfunction between groups. The study concludes that laparoscopic D3 lymphadenectomy combined with nerve preservation is a feasible and safe treatment for rectal cancer.
2. 3176 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol November 1, 2004 Volume 10 Number 21
catheter inside CBD was correct, the catheter was fixed to the Table 2 Comparison of clinical outcome between two groups
cystic duct by a 12 mm absorbable Lapro-Clip (Figure 1). Saline
mTCBD T-tube t or χ2 (z) P
irrigation through the catheter was maintained during application
of the Lapro-Clip to prevent overtightening the catheter. A loose Operative time (min) 178 173 -0.469 0.640 2
loop of the catheter was left. A completion IOC was performed Output of bile (mL/24 h) 306 409 2.118 0.037 2
to confirm the correct position of the ureteral catheter, also to Postoperative stay(d) 5.4-61 4.4-6 1 (-2.060) 0.039 4
ensure the adequate closure of the CBD and free flow of contrast Drain removal (d) 5.4-5 1 29.22-32 1 (-7.560) 0.0004
into the duodenal lumen. A postoperative cholangiogram was
Complications (%) 0 11.5 5.736 0.017 3
performed on d 3 to 7 after surgery. Under fluoroscopy, the
Retained stones (%) 3.3 13.5 2.574 0.1093
catheter was removed.
T-tube drainage A latex rubber T-tube of appropriate size Convert to open (%) 6.5 3.8 0.315 0.575 3
(12-16 Fr) was inserted completely into the abdomen. The T 1
Median, 25-75% quartile rang; 2 t-test; 3Chi square test with
limbs were advanced with grasping forceps into the choledochotomy.
Likelihood Ratio; 4Mann-Whitney test.
After proper positioning, the choledochotomy was closed using
interrupted sutures (3-0 vicryl). T-tube clamping was carried
One patient (3.3%) had unexpected retained stones, requiring
out 7-10 d postoperatively. A postoperative cholangiogram was
endoscopic sphincterotomy (ES). Two patients had problems.
performed 3 to 4 wk after surgery. If the examination was normal,
The ureteral catheter was dislocated with the biliary tree not
the T-tube was removed. If retained stones were shown, the T- shown in the postoperative cholangiogram, but there was no
tube was left for another 3 to 4 wk. A No. 10 Jackson-Pratt drain
bile leakage.
was placed in the subhepatic space for all patients. The subhepatic
drain tube was removed on the 3rd d for most of patients.
Five surgeons performed the 82 laparoscopic choledochotomies.
Outcome of T-tube group
In the mTCBD group, one senior author performed 25 of 30 The average operative time was 173±45 min (Table 2). There
procedures, whereas the remaining 5 procedures by one junior were two conversions to open surgery (6.5%). Two patients
staff member. In the T-tube group, three senior staff performed had large impacted stones. The average output of bile via T-
47 of 52 procedures, whereas 7 procedures by two junior members. tube was 409±243 mL/24 h. The median drain removal time was
29 (range 22 to 32) d. The median postoperative hospital stay
The output of bile was measured only during the hospital
was 4 (range 4 to 6) d.
stay. The data recorded were insufficient in the case notes to
Seven (13.5%) had retained stones (Table 4). There were
compare the number and size of CBD stones, and postoperative
intentionally retained stones in 5 patients (9.6%), 2 with intrahepatic
liver function test.
duct stones, 1 with multiple common duct stones because of
A “drain complication” was defined as an event causing
difficulty in removing them laparoscopically, and another 2
morbidity, requiring medical intervention, or resulting in a
patients with temporary unavailability of the choledochoscope.
prolonged admission or requiring readmission. The complication
There were unexpected residual stones in 2 patients (3.8%). All
had to be clearly related to the presence or removal of the drain.
of the stones were successfully removed, 5 patients through
the T-tube tract, using a choledochoscope, and a stone basket.
Statistical analysis The T-tube was taken out in two patients prior to planed removal,
Statistical analyses were performed using Student’s t test, chi
thereby requiring ES.
square test for likelihood ratio, and Mann-Whitney test for
nonparametric data. Significance was set at the 5% level. Table 3 Complications and problems of biliary drainage
T-tube mTCBD
Complications
n 6 (11.5%) 0
Drain in situ
Leak around drain 1 0
Stricture 1 0
Drain pulled out 1 0
Drain removed 3 (5.8%)
Bile collection 2 0
Bile peritonitis 1 0
Figure 1 A 5 Fr ureteral catheter was placed for biliary decom- Problems
pression and secured with a 12 mm absorbable Lapro-Clip. n 3 (5.8%) 2 (6.7%)
Drain out 2 2
RESULTS Dislocation 1 0
Outcome of mTCBD group
The average operative time was 178±34 min (Table 2). There
were two conversions to open surgery (6.5%). One patient had Table 4 Retained stones in T-tube group
large impacted stones, and the other had multiple stones. The
n(%)
modified transcystic biliary decompression (mTCBD) was also
used in those patients. The average output of bile via the ureteral Known stones 5 (9.6)
catheter was 306±141 mL/24 h. The median postoperative time Instrument problems 2
of drain removal was 5 (range 4 to 5) d. Under fluoroscopy, the Intrahepatic stones 2
catheter could be pulled out easily from the cystic duct without Multiple stones 1
any bile leakage or slippage of the Lapro-Clip (Figure 2). No Unexpected stones 2 (3.8)
patients developed complications from ureteral catheter occlusion.
Total 7 (13.5)
The median postoperative hospital stay was 5 (range 4 to 6) d.
3. Wei Q et al. Biliary drainage 3177
outer body could was then slide over the track piece to secure
the cystic duct[17]. The ureteral catheter was pulled out easily
with no bile leakage and the cystic duct was closed automatically
with the Lapro-Clip even if drain displacement occurred.
In mTCBD group, no bile leakage was related to drain tube
removal, and median time for ureteral catheter removal was 5
(range 4 to 5) d. The ureteral catheter in two patients was dislocated,
this also caused no bile leakage.
Complications related to T-tubes were reported to occur
between 5-15.3%[7,18,19]. Biliary leakage following removal was
the most serious. Incidence of bile leak was 4.12-6.9%[19,20].
There was no difference when laparoscopic cases were compared
Figure 2 A ureteral catheter was pulled out without bile leakage. to open and converted cases for overall complications (13.8%
The cystic duct was closed with the Lapro-Clip.
vs 15.5%) or for bile leakage after planned tube removal (6.9%
Postoperative complications occurred in 6 patients (11.5%) vs 6.9%)[19].
(Table 3). Following T-tube removal, three patients had In our study, postoperative complications in the T-tube group
significant bile leakage (5.8%). Two patients developed severe occurred in 6 patients (11.5%) (Table 3). Following T-tube
abdominal pain, sweating and tachycardia and were diagnosed removal, 3 patients developed bile leakage (5.8%). The T-tube
as localized bile collection. They were treated with antibiotics, was left in the three patients for three weeks postoperatively.
parental fluids, analgesia, and the drain tube was reinserted Sinus tract formation of the T-tube might need a longer time
through T-tube sinus tract. Recovery was achieved with this because of the less reaction of laparoscopic approach[21-23]. Bile
management. The third patient developed biliary peritonitis leakage was inevitable with accidental T-tube dislocation[7,18-20].
and required open drainage. The median time for T-tube removed was 29 (range 22 to 32) d,
One patient had a CBD stricture and T-tube stenting was even if cases of retained stones were excluded. The data suggest
necessary for 3 mo. In the other patient the T-tube was pulled that placement of T-tube may require a longer time than 4 wk.
out on the second day after surgery and the subhepatic suction Biliary drainage with a TCBD tube and primary closure of
drain provided biliary drainage for two weeks postoperatively. the choledochotomy were indicated only for patients whose
Other related morbidity was found in one patient with a bile stones were completely extracted at the time of surgery. Routine
leak around the T-tube. In addition, the tip of the T-tube in one intraoperative cholangiogram and chledochoscopy were used
patient was dislocated from the bile duct, but caused no problem. in the laparoscopic approach, and the occurrence of retained
stones was decreased to accepted levels [7,24,25]. Endoscopic
Comparison of clinical outcome between two groups sphincterotomy could be a back up procedure for retained
The statistical analyses comparing the mTCBD group with the stones[25,26]. In the mTCBD group, one patient (3.3%) had
T-tube group are presented in Table 2. There were no significant unexpected retained stones retrieved by ES.
differences in operative time and retained stones. Patients in If there was any possibility of residual stones, T-tube
mTCBD group had a significantly decreased average output of placement was mandatory for postoperative choledochoscopy.
bile compared with those in T-tube group (P = 0.000). The biliary Five patients (9.6%) in the T-tube group had intentionally
drainage tube in the mTCBD group was removed significantly retained stones (Table 4). T-tube placement may be needed for
earlier than that in the T-tube group (P = 0.000). No morbidity another 3-4 wk[21-23], in order to form a mature tract. It was
was directly related to drain tube in the mTCBD group, and the worthwhile without any injury to the sphincter of Oddi, and
morbidity rate in the T-tube group was significantly higher (11.5%, complete removal could be expected.
P = 0.017). However, the postoperative hospital stay in the Although patients in the mTCBD group had a significantly
mTCBD group was significantly longer compared with that in decreased average output of bile compared with those in the T-
the T-tube group (P = 0.039). tube group (306±141 vs 409±243 mL/24 h, P = 0.000), it was
There was no postoperative mortality or recurrence of shown that enough output of bile led to a decrease in the biliary
choledocholithiasis in this study. The length of follow-up was pressure. Consequently, this finding suggested that the output
4 to 30 wk. of bile from mTCBD was sufficient to decompress the biliary
tract as T-tube. On the other hand, the T-tube drain mostly was
clamped on d 7 to 10, which means that many patients were
DISCUSSION discharged with an open drain.
Previous studies have documented a temporary obstruction at The postoperative hospital stay in mTCBD group was
the lower end of the CBD due to sludge, fibrin debris, or edema significantly longer compared with that in T-tube group (median,
following manipulations to extract duct calculi or retained stones 5 vs 4 d, P = 0.039). It may relate to the drain removal during
in the first few days after surgery[9,11-16], thus temporary decompression hospitalization because of our initial trial for the mTCBD.
is advisable in the prevention of postoperative bile leakage. A A modified TCBD is not suitable for patients with abnormal
transcystic biliary decompression (TCBD) tube, like a T-tube, anatomy of cystic duct, intrahepatic duct stones and stricture
could achieve biliary decompression and has the advantage of of duodenal papillary.
avoiding the well-known complications of T-tubes. A TCBD The chief concern of the Lapro-Clip is the occlusion of the
tube was secured to the cystic duct with two Roeder knots or a catheter. Maintaining saline irrigation through the ureteral
transfixing suture. The biliary drainage tube must be kept in catheter prevents occluding. We also feel that the diameter of
place for 2-4 wk[9,10]. This might not be easy to manipulate, and the ureteral catheter is an important factor for avoiding occlusion
could reduce the benefits of the minimal access approach. or dislocation, so a 5Fr ureteral catheter is most suitable. We
In October 2002, a modified TCBD (mTCBD) was placed used a 5Fr ureteral catheter in all mTCBD cases.
followed by primary closure of the CBD. The ureteral catheter A 12 mm Lapro-Clip holds the cystic duct tightly to a 5Fr
was inserted down into the CBD and once in the correct position, ureteral catheter while the spring of the Lapro-Clip closes the
the cystic duct was clipped by a 12 mm Lapro-Clip. The Lapro- cystic duct when the ureteral catheter is removed. In this study,
Clip has a two-part compression closure mechanism, the inner no slippage of the clip occurred. The short period of TCBD
flexible track piece could close around the cystic duct, and rigid could reduce the risk of ureteral catheter occlusion. No patients
4. 3178 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol November 1, 2004 Volume 10 Number 21
in the present study developed catheter occlusion. to drain the common bile duct after laparoscopic choledochotomy.
Our results were similar to the use of exclusive C-tube and Surg Endosc 1998; 12: 933-935
elastic thread described by some authors[27-30]. Our initial 13 Gersin KS, Fanelli RD. Laparoscopic endobiliary stenting as
experiences demonstrated that the modified transcystic biliary an adjunct to common bile duct exploration. Surg Endosc 1998;
12: 301-304
decompression (mTCBD) after laparoscopic choledochotomy 14 Isla AM, Griniatsos J, Wan A. A technique for safe placement
(LCD) was useful for decreasing postoperative complications, of a biliary endoprosthesis after laparoscopic choledochotomy.
especially bile leakage, and easy to perform. The patients were J Laparoendosc Adv Surg Tech A 2002; 12: 207-211
discharged without any drainage tube within a wk. If biliary 15 Chen XP, Peng SY, Peng CH, Liu YB, Shi LB, Jiang XC, Shen HW,
drainage was used carefully with selected indications, patients Xu YL, Fang SB, Rui J, Xia XH, Zhao GH. A ten-year study on
with laparoscopic choledochotomy for CBD stones could achieve non-surgical treatment of postoperative bile leakage. World J
a better postoperative quality of life. We propose mTCBD as an Gastroenterol 2002; 8: 937-942
option for patients with CBD stones. 16 Yamaner S, Bilsel Y, Bulut T, Bugra D, Buyukuncu Y, Akyuz A,
Sokucu N. Endoscopic diagnosis and management of compli-
cations following surgery for gallstones. Surg Endosc 2002; 16:
ACKNOWLEDGMENTS 1685-1690
17 Darzi A, Soin B, Coleman J, Lirici NM, Angelini L. Initial expe-
We thank Dr. C.Welch for editorial assistance and helpful rience with an absorbable laparoscopic ligation clip. Br J Surg
suggestions. 1997; 84: 974-976
18 Moreaux J. Traditional surgical management of common bile
duct stones: a prospective study during a 20-year experience.
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Edited by Zhang JZ and Wang XL Proofread by Xu FM