This document discusses the diagnosis and management of choledocholithiasis (CBD stones). Key points include:
- CBD stones occur in 3-10% of patients undergoing cholecystectomy and may be discovered preoperatively, intraoperatively, or postoperatively.
- Preoperative evaluation involves laboratory tests, ultrasound, CT, and MRCP to detect CBD stones. Elevated liver enzymes and bilirubin or a dilated CBD on imaging increase the likelihood of stones.
- The most common intervention for CBD stones is ERCP. Other options include intraoperative exploration or percutaneous transhepatic removal of stones. The optimal timing and approach depends on the individual clinical situation.
More than 350,000 new cases of bladder cancer are diagnosed worldwide each year; the vast majority (> 90%) of these are transitional cell carcinomas (TCC). The most important risk factors for the development of bladder cancer are smoking and occupational exposure to toxic chemicals. Painless visible haematuria is the most common presenting symptom of bladder cancer; significant haematuria requires referral to a specialist urology service. Cystoscopy and urine cytology are currently the recommended tools for diagnosis of bladder cancer. Excluding muscle invasion is an important diagnostic step, as outcomes for patients with muscle invasive TCC are less favourable. For non-muscle invasive bladder cancer, transurethral resection followed by intravesical chemotherapy (
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
Background: Nonalcoholic Fatty Liver Disease (NAFLD) is the most common liver disease in the developed countries. Patients with Nonalcoholic Steatohepatitis (NASH), a subset of NAFLD, are at risk for progressive liver disease and in need of effective treatment options. There is a lack of data assessing sleeve gastrectomy and their effect on NAFLD.
Objective: To assess the effects of Sleeve Gastrectomy (SG) on NAFLD.
Methods: An online search of PubMed, Medline, and Google Scholar was independently carried out by two researchers using key words like Non-Alcoholic Fatty Liver Disease, Non-Alcoholic Steato-Hepatitis, Bariatric Surgery, Obesity Surgery, Sleeve Gastrectomy and Liver Biopsy, percutaneous liver biopsy, to identify all articles. Articles were also identified from references of relevant articles. All sleeve gastrectomies that had ntraoperative and postoperative liver biopsies were included.
Gallbladder polyp more than 1cm. is cholecystectomy necessarySujan Shrestha
Gallbladder polyps are elevated lesions projecting into the gallbladder lumen. The document outlines the definition, types, epidemiology, studies, and conclusion regarding gallbladder polyps and the need for cholecystectomy. The prevalence of gallbladder polyps is reported between 2-12% in the general population. Size is an important factor, as polyps greater than 1cm carry a risk of malignancy and are an indication for cholecystectomy.
- Gallbladder polyps are common findings that require evaluation to determine if they are true polyps with malignant potential or pseudopolyps which are benign.
- Transabdominal ultrasound is usually the initial imaging study, while EUS may help in certain cases, though evidence is limited.
- Polyps greater than 10mm or those exhibiting certain high risk features like being sessile or in patients over 50 years old typically warrant cholecystectomy.
- For smaller polyps, follow up imaging is reasonable if they lack concerning characteristics, though risk of malignancy increases with size.
Colonoscopy to find colon cancer in asymptomatic adultGil Lederman
Colonoscopy is a procedure that allows direct visualization of the colon to screen for colon cancer. A recent large study found that colonoscopy identified pre-cancerous polyps and early-stage colon cancers in 37.5% of asymptomatic men who underwent the procedure. While generally safe, serious complications occurred in 0.3% of patients. The study concluded that colonoscopy screening can detect advanced lesions that may be treatable, and that over half of advanced cancers in the upper colon would be missed by less invasive sigmoidoscopy screening. Colonoscopy appears to be a generally safe and effective screening tool for colon cancer in asymptomatic adults.
More than 350,000 new cases of bladder cancer are diagnosed worldwide each year; the vast majority (> 90%) of these are transitional cell carcinomas (TCC). The most important risk factors for the development of bladder cancer are smoking and occupational exposure to toxic chemicals. Painless visible haematuria is the most common presenting symptom of bladder cancer; significant haematuria requires referral to a specialist urology service. Cystoscopy and urine cytology are currently the recommended tools for diagnosis of bladder cancer. Excluding muscle invasion is an important diagnostic step, as outcomes for patients with muscle invasive TCC are less favourable. For non-muscle invasive bladder cancer, transurethral resection followed by intravesical chemotherapy (
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
Background: Nonalcoholic Fatty Liver Disease (NAFLD) is the most common liver disease in the developed countries. Patients with Nonalcoholic Steatohepatitis (NASH), a subset of NAFLD, are at risk for progressive liver disease and in need of effective treatment options. There is a lack of data assessing sleeve gastrectomy and their effect on NAFLD.
Objective: To assess the effects of Sleeve Gastrectomy (SG) on NAFLD.
Methods: An online search of PubMed, Medline, and Google Scholar was independently carried out by two researchers using key words like Non-Alcoholic Fatty Liver Disease, Non-Alcoholic Steato-Hepatitis, Bariatric Surgery, Obesity Surgery, Sleeve Gastrectomy and Liver Biopsy, percutaneous liver biopsy, to identify all articles. Articles were also identified from references of relevant articles. All sleeve gastrectomies that had ntraoperative and postoperative liver biopsies were included.
Gallbladder polyp more than 1cm. is cholecystectomy necessarySujan Shrestha
Gallbladder polyps are elevated lesions projecting into the gallbladder lumen. The document outlines the definition, types, epidemiology, studies, and conclusion regarding gallbladder polyps and the need for cholecystectomy. The prevalence of gallbladder polyps is reported between 2-12% in the general population. Size is an important factor, as polyps greater than 1cm carry a risk of malignancy and are an indication for cholecystectomy.
- Gallbladder polyps are common findings that require evaluation to determine if they are true polyps with malignant potential or pseudopolyps which are benign.
- Transabdominal ultrasound is usually the initial imaging study, while EUS may help in certain cases, though evidence is limited.
- Polyps greater than 10mm or those exhibiting certain high risk features like being sessile or in patients over 50 years old typically warrant cholecystectomy.
- For smaller polyps, follow up imaging is reasonable if they lack concerning characteristics, though risk of malignancy increases with size.
Colonoscopy to find colon cancer in asymptomatic adultGil Lederman
Colonoscopy is a procedure that allows direct visualization of the colon to screen for colon cancer. A recent large study found that colonoscopy identified pre-cancerous polyps and early-stage colon cancers in 37.5% of asymptomatic men who underwent the procedure. While generally safe, serious complications occurred in 0.3% of patients. The study concluded that colonoscopy screening can detect advanced lesions that may be treatable, and that over half of advanced cancers in the upper colon would be missed by less invasive sigmoidoscopy screening. Colonoscopy appears to be a generally safe and effective screening tool for colon cancer in asymptomatic adults.
HCC Clinical update and hints from AASLD 2017 guidelines mainly about surveillance, diagnosis and treatment of Hepatocellular carcinoma in different stages.
This research article studied preoperative predictive factors of occult and frank intrabiliary rupture of liver hydatid cysts. The study reviewed 56 patients with 82 liver hydatid cysts who underwent surgery. Cysts were divided into three groups: no rupture, occult rupture with bile in cyst but no passage into bile duct, and frank rupture with passage into bile duct. Multivariate analysis identified jaundice, cyst size >6.5cm, and symptoms >45 days as predictors of frank rupture. Predictors of occult rupture included cyst size >6.5cm, ≥3 recurrences, type II/III cyst, leukocytosis >9,000/mm3, and eosinophilia >5.5
This document summarizes risk stratification and treatment options for prostate cancer. It discusses using risk prediction models to stratify patients into low, intermediate, and high risk groups to help determine appropriate initial treatment. Options include active surveillance, radical prostatectomy, radiotherapy, and hormone therapy depending on risk level. Treatment selection involves weighing factors like life expectancy, disease control, and side effects.
Symptomatic Correlation with site of Colorectal Canceriosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The document presents expert consensus guidelines for the management and follow-up of gallbladder polyps based on a systematic review. It recommends cholecystectomy for polyps greater than 10mm. For polyps less than 10mm, management depends on patient symptoms, risk factors for gallbladder cancer, and polyp characteristics with ultrasound follow-up at intervals from 6 months to 5 years. The guidelines aim to determine which polyps require surgery versus surveillance to address the challenge of predicting malignant potential.
This document provides an overview of the research process. It defines research and describes the main types as qualitative and quantitative. The key steps in designing and conducting research are outlined, including formulating the research question, selecting an appropriate design, defining variables, sampling, data collection and analysis, and reporting findings. Guidelines for selecting a research topic and writing objectives are also presented. Different study designs - descriptive, analytical, experimental and observational - are explained.
Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition characterized by pelvic pain perceived to be related to the bladder along with urinary symptoms. The cause is multifactorial and likely includes alterations in bladder permeability and neurogenic inflammation. Diagnosis involves ruling out other causes through history, exam, cystoscopy, and urine testing. Treatment is individualized and may include conservative measures, oral medications like amitriptyline, intravesical therapies, minimally invasive procedures, and rarely surgery. Management aims to control symptoms and improve quality of life through a stepwise approach utilizing various options.
This randomized controlled trial studied 198 patients having major cancer surgery who were assigned to either a restrictive or liberal red blood cell transfusion strategy. The restrictive strategy transfused patients when their hemoglobin was <7 g/dl, while the liberal strategy transfused at <9 g/dl. The primary outcome of death or major complications within 30 days occurred in 19.6% of the liberal group but 35.6% of the restrictive group, a statistically significant difference. A liberal transfusion strategy was associated with fewer complications. This study provides evidence that a more liberal transfusion approach may be preferable for patients having major cancer surgery.
Radical Salvage Prostatectomy with Pelvic Lymphadenectomy Extended Post Primary Treatment with Prostate Radiotherapy - Case Report and Literature Review by Daniel Savoldi Juraski, MD; Rodrigo Galves Mesquita Martins, MD; Diogo Eugenio Abreu da Silva, MsC; Tomás Accioly de Souza, MD and José Anacleto Dutra de Resende* in Experimental Techniques in Urology & Nephrology
Radiotherapy in hepatocellular carcinomasPratap Tiwari
External Radiotherapy in hepatocellular carcinomas (HCC). A brief summary of the guidelines statements on radiotherapy role in hepatocellular carcinoma (hcc).
This study investigated long-term survival outcomes of 320 patients who underwent radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) or colorectal liver metastases (CLM) between 1999-2010. Minimum 5-year follow-up data was available for 89% of patients, with median follow-up of 115.3 months. For HCC patients, 5-year and 10-year overall survival rates were 38.5% and 23.4%. For CLM patients, 5-year and 10-year overall survival rates were 27.6% and 15%. The study concludes RFA can provide 10-year overall survival rates of over 23% for HCC and 15% for CLM
The document discusses acute cholangitis, including its pathogenesis, clinical manifestations, diagnostic criteria, severity assessment, imaging, and management. Regarding diagnostic criteria, it summarizes that Charcot's triad has low sensitivity for diagnosing acute cholangitis compared to the Tokyo Guidelines 2007 and 2013 criteria. It also notes that the Tokyo Guidelines 2007 criteria for severity assessment were insufficient and have been revised in subsequent guidelines to better distinguish mild from moderate cases in the initial diagnosis.
Role of Radiotherapy in HCC. What do the guidelines say ? A comprehensive review of guidelines and other studies on role of radiotherapy in hepatocellular carcinoma.
Comparison of endoscopic ultrasonography and magnetic resonance cholangiopanc...Ginna Saavedra
This study compared the diagnostic value of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing diseases of the pancreatobiliary system. 135 patients were prospectively evaluated with both EUS and MRCP and assigned to one of two groups - those with an unexplained dilated biliary tree and those with a nondilated biliary tree suspected of having gallstones. EUS and MRCP accurately diagnosed or ruled out malignancy and gallstones in most patients. The study found that both techniques are extremely useful for diagnosing or excluding diseases of the pancreatobiliary system in patients with dilated or nondilated biliary trees.
Colorectal Cancer Screening - What does the evidence really say?Jarrod Lee
Colorectal cancer is one of the most common cancers around the world. Screening has been proven to detect cancers in early curable stages, and to even prevent them. Yet, few topics are as controversial as colorectal cancer screening in medicine today. We take an evidence based approach to examine what the science truly says about the different modalities of cancer screening.
The document discusses the management of Barrett's esophagus with dysplasia. It describes Barrett's esophagus and why it is important as a premalignant condition. There are several treatment options for dysplasia including surveillance, endoscopic mucosal resection, and endoscopic ablation techniques like radiofrequency ablation. Endoscopic ablation techniques aim to eliminate dysplasia and intestinal metaplasia without the risks of surgery. Radiofrequency ablation in particular has been shown to be safe and effective in multiple clinical trials, achieving high rates of eradication of intestinal metaplasia.
Author: Dr Christa Maria Joel
Module: Effects of lifestyle on health
Supervisor: Ms Jane Tobias and Dr Daniel Boakye
University of the West of Scotland
1) The document is a translation of schematic diagrams into pictorial diagrams. It provides examples of common symbols used in schematic diagrams and guides the reader through a series of exercises to translate schematics into pictorial layouts with labeled components.
2) It includes 6 practice exercises where the reader is given a schematic diagram and must arrange the labeled components in a pictorial layout. Feedback is provided to check their work.
3) The diagrams get increasingly more complex, starting with a single component and progressing to diagrams with multiple components including transistors, integrated circuits, and capacitors.
HCC Clinical update and hints from AASLD 2017 guidelines mainly about surveillance, diagnosis and treatment of Hepatocellular carcinoma in different stages.
This research article studied preoperative predictive factors of occult and frank intrabiliary rupture of liver hydatid cysts. The study reviewed 56 patients with 82 liver hydatid cysts who underwent surgery. Cysts were divided into three groups: no rupture, occult rupture with bile in cyst but no passage into bile duct, and frank rupture with passage into bile duct. Multivariate analysis identified jaundice, cyst size >6.5cm, and symptoms >45 days as predictors of frank rupture. Predictors of occult rupture included cyst size >6.5cm, ≥3 recurrences, type II/III cyst, leukocytosis >9,000/mm3, and eosinophilia >5.5
This document summarizes risk stratification and treatment options for prostate cancer. It discusses using risk prediction models to stratify patients into low, intermediate, and high risk groups to help determine appropriate initial treatment. Options include active surveillance, radical prostatectomy, radiotherapy, and hormone therapy depending on risk level. Treatment selection involves weighing factors like life expectancy, disease control, and side effects.
Symptomatic Correlation with site of Colorectal Canceriosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The document presents expert consensus guidelines for the management and follow-up of gallbladder polyps based on a systematic review. It recommends cholecystectomy for polyps greater than 10mm. For polyps less than 10mm, management depends on patient symptoms, risk factors for gallbladder cancer, and polyp characteristics with ultrasound follow-up at intervals from 6 months to 5 years. The guidelines aim to determine which polyps require surgery versus surveillance to address the challenge of predicting malignant potential.
This document provides an overview of the research process. It defines research and describes the main types as qualitative and quantitative. The key steps in designing and conducting research are outlined, including formulating the research question, selecting an appropriate design, defining variables, sampling, data collection and analysis, and reporting findings. Guidelines for selecting a research topic and writing objectives are also presented. Different study designs - descriptive, analytical, experimental and observational - are explained.
Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition characterized by pelvic pain perceived to be related to the bladder along with urinary symptoms. The cause is multifactorial and likely includes alterations in bladder permeability and neurogenic inflammation. Diagnosis involves ruling out other causes through history, exam, cystoscopy, and urine testing. Treatment is individualized and may include conservative measures, oral medications like amitriptyline, intravesical therapies, minimally invasive procedures, and rarely surgery. Management aims to control symptoms and improve quality of life through a stepwise approach utilizing various options.
This randomized controlled trial studied 198 patients having major cancer surgery who were assigned to either a restrictive or liberal red blood cell transfusion strategy. The restrictive strategy transfused patients when their hemoglobin was <7 g/dl, while the liberal strategy transfused at <9 g/dl. The primary outcome of death or major complications within 30 days occurred in 19.6% of the liberal group but 35.6% of the restrictive group, a statistically significant difference. A liberal transfusion strategy was associated with fewer complications. This study provides evidence that a more liberal transfusion approach may be preferable for patients having major cancer surgery.
Radical Salvage Prostatectomy with Pelvic Lymphadenectomy Extended Post Primary Treatment with Prostate Radiotherapy - Case Report and Literature Review by Daniel Savoldi Juraski, MD; Rodrigo Galves Mesquita Martins, MD; Diogo Eugenio Abreu da Silva, MsC; Tomás Accioly de Souza, MD and José Anacleto Dutra de Resende* in Experimental Techniques in Urology & Nephrology
Radiotherapy in hepatocellular carcinomasPratap Tiwari
External Radiotherapy in hepatocellular carcinomas (HCC). A brief summary of the guidelines statements on radiotherapy role in hepatocellular carcinoma (hcc).
This study investigated long-term survival outcomes of 320 patients who underwent radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) or colorectal liver metastases (CLM) between 1999-2010. Minimum 5-year follow-up data was available for 89% of patients, with median follow-up of 115.3 months. For HCC patients, 5-year and 10-year overall survival rates were 38.5% and 23.4%. For CLM patients, 5-year and 10-year overall survival rates were 27.6% and 15%. The study concludes RFA can provide 10-year overall survival rates of over 23% for HCC and 15% for CLM
The document discusses acute cholangitis, including its pathogenesis, clinical manifestations, diagnostic criteria, severity assessment, imaging, and management. Regarding diagnostic criteria, it summarizes that Charcot's triad has low sensitivity for diagnosing acute cholangitis compared to the Tokyo Guidelines 2007 and 2013 criteria. It also notes that the Tokyo Guidelines 2007 criteria for severity assessment were insufficient and have been revised in subsequent guidelines to better distinguish mild from moderate cases in the initial diagnosis.
Role of Radiotherapy in HCC. What do the guidelines say ? A comprehensive review of guidelines and other studies on role of radiotherapy in hepatocellular carcinoma.
Comparison of endoscopic ultrasonography and magnetic resonance cholangiopanc...Ginna Saavedra
This study compared the diagnostic value of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing diseases of the pancreatobiliary system. 135 patients were prospectively evaluated with both EUS and MRCP and assigned to one of two groups - those with an unexplained dilated biliary tree and those with a nondilated biliary tree suspected of having gallstones. EUS and MRCP accurately diagnosed or ruled out malignancy and gallstones in most patients. The study found that both techniques are extremely useful for diagnosing or excluding diseases of the pancreatobiliary system in patients with dilated or nondilated biliary trees.
Colorectal Cancer Screening - What does the evidence really say?Jarrod Lee
Colorectal cancer is one of the most common cancers around the world. Screening has been proven to detect cancers in early curable stages, and to even prevent them. Yet, few topics are as controversial as colorectal cancer screening in medicine today. We take an evidence based approach to examine what the science truly says about the different modalities of cancer screening.
The document discusses the management of Barrett's esophagus with dysplasia. It describes Barrett's esophagus and why it is important as a premalignant condition. There are several treatment options for dysplasia including surveillance, endoscopic mucosal resection, and endoscopic ablation techniques like radiofrequency ablation. Endoscopic ablation techniques aim to eliminate dysplasia and intestinal metaplasia without the risks of surgery. Radiofrequency ablation in particular has been shown to be safe and effective in multiple clinical trials, achieving high rates of eradication of intestinal metaplasia.
Author: Dr Christa Maria Joel
Module: Effects of lifestyle on health
Supervisor: Ms Jane Tobias and Dr Daniel Boakye
University of the West of Scotland
1) The document is a translation of schematic diagrams into pictorial diagrams. It provides examples of common symbols used in schematic diagrams and guides the reader through a series of exercises to translate schematics into pictorial layouts with labeled components.
2) It includes 6 practice exercises where the reader is given a schematic diagram and must arrange the labeled components in a pictorial layout. Feedback is provided to check their work.
3) The diagrams get increasingly more complex, starting with a single component and progressing to diagrams with multiple components including transistors, integrated circuits, and capacitors.
Nota ini memberikan panduan untuk projek kemasan tingkatan dua yang meliputi faktor reka bentuk, jenis bahan, alat tangan dan mesin, proses kerja, membentuk dan mencantum serta kemasan projek. Ia menjelaskan aspek penting seperti fungsi, rupa bentuk, kesesuaian bahan, kos dan keselamatan produk. Jenis bahan seperti aluminium, keluli lembut dan PVC dibincangkan dengan terperinci.
Staging and investigation of hepatobillary caAtulGupta369
This document provides an overview of cancers affecting the liver, gallbladder, and pancreas. It discusses the epidemiology, risk factors, clinical presentation, diagnosis, and staging of liver cancer, gallbladder cancer, and pancreatic cancer. Diagnostic tests include blood tests, imaging like ultrasound, CT, MRI, and PET scans. Biopsy may be done for unresectable tumors. The document also provides details on noninvasive diagnosis criteria and treatment guidelines for liver cancer put forth by professional associations.
Gallbladder cancer is an uncommon but highly fatal cancer. It is most often diagnosed in patients undergoing surgery for gallbladder stones. Over 90% of gallbladder cancer patients have gallstones or chronic gallbladder inflammation. Major risk factors include female sex, older age, obesity, smoking, and gallbladder diseases. Symptoms are often vague, and many cases are diagnosed late when the cancer has spread. Surgery offers the best chance of treatment when the cancer is localized, but palliative options are usually necessary for advanced cases. Prognosis remains very poor due to late diagnosis and limited effective therapies.
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.
Understanding Bile Ducts Cancer (Cholangiocarcinoma).pdfMeghaSingh194
Cholangiocarcinoma, often known as bile ducts cancer, is a life-threatening condition. Despite its rarity, understanding its risks and symptoms is crucial for early detection and effective treatment. Let's explore more: https://www.southlakegeneralsurgery.com/understanding-bile-ducts-cancer-cholangiocarcinoma/
This document discusses the management of gallbladder cancer. It covers diagnosis, staging, and surgical treatment approaches based on tumor stage. For early stage T1a tumors found incidentally after cholecystectomy, simple cholecystectomy may be adequate. For T1b and T2 tumors, radical resection including lymph node dissection is recommended due to higher risk of residual disease and lymph node involvement. For locally advanced T3/T4 or node positive cancers, radical surgery with hepatic resection or multi-organ resection is supported, though morbidity and mortality are high; N2 node involvement carries a poor prognosis. Staging laparoscopy is important to identify unresectable disease not apparent on imaging.
Hepatic carcinoma, also known as hepatocellular carcinoma (HCC), is one of the most common and deadly cancers worldwide, killing over 1 million people per year. Risk factors include hepatitis B and C infections, cirrhosis, alcohol use, and aflatoxin exposure. HCC typically presents in patients with cirrhosis as an asymptomatic liver mass and is diagnosed through blood tests showing elevated AFP levels and imaging exams like ultrasound, CT, or MRI. Treatment depends on the stage but may include surgical resection, liver transplantation, ablation procedures, embolization, or chemotherapy. Long-term surveillance after treatment is important for early detection of recurrence.
Information about Obstructed Recto Sigmoid Malignancy by Dr Dhaval Mangukiya.
Details of introduction of obstructed recto sigmoid malignancy, Epidemiology, Pathophysiology, Complications, Early Presentation, Stools, History, Late Presentation, Diagnosis, Imaging, Contrast enema, Screenig, Treatment, Management, Surgical management, Surgical options etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
This document provides guidelines for the role of endoscopy in evaluating suspected choledocholithiasis (gallstones in the common bile duct). It recommends a risk-stratified approach based on initial evaluation. For low risk patients, only cholecystectomy is needed. For intermediate risk, additional imaging like EUS, MRCP or preoperative ERCP is recommended to further evaluate need for ductal stone removal. For high risk, preoperative ERCP or operative cholangiography is recommended due to frequent need for therapy. Non-endoscopic options like CT, MRCP, IOC and laparoscopic ultrasound are also discussed. The guidelines are meant to help endoscopists provide care while considering individual clinical factors.
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 summarizes primary and secondary liver malignancies, their management, and principles of liver resection. It covers hepatocellular carcinoma (HCC), the most common primary liver cancer, risk factors, presentation, diagnosis, staging, and treatment options. Intrahepatic cholangiocarcinoma and metastatic tumors to the liver are also discussed. Surgical resection is the main curative treatment for early-stage HCC and intrahepatic cholangiocarcinoma when possible.
Colon cancer epidemiology, risk factors, and etiology, pathology, screening, diagnosis, workup, staging, treatment, chemotherapy and follow-up.
These slides are selections from the major references in surgery, oncology, and internal medicine. I have tried to gather the information from valid and recently-updated references such as NCCN guidelines and Cancer statistics. I hope it helps!
Review of Diagnostic Procedures and Progress in the Management of Acute Chole...semualkaira
Many authors have agreed to diagnostic methods that
include clinical findings, radiologic and laboratory outcomes. Early laparoscopic cholecystectomy is the best treatment for Grade
I and Grade II patients of the Tokyo Guideline 2018. For many
decades, the treatment protocol has been controversial for patients
presenting severe cholecystitis (Grade III AC) and those unfits for
surgery because of co morbidities. Recent authors advocated for
early laparoscopic cholecystectomy for Grade III patients. Delayed laparoscopic cholecystectomy is recommended for patients
who missed the golden 72 hours and presenting high risk of intra
operative complications. Cholecystostomy is described by many
scholars as alternative treatment for patients presenting comorbidities. Nowadays, Endoscopic trans papillary or transmural and
ultrasound-assisted cholecystostomy are the new techniques of
cholecystostomy
All you need to know about peri-ampullary cancer
Periampullary cancer is a common diagnosis with patient with progressive jaundice in northern part of India
Timely diagnosis and proper treatment in a way towards cure
Small bowel obstruction and Intestinal FistulasJose Cortes
Small bowel obstruction is a common surgical condition where the small intestine becomes blocked. The most frequent cause is adhesions from prior abdominal surgery, accounting for up to 75% of cases. Symptoms include abdominal pain, nausea, vomiting and constipation. Diagnosis involves imaging like abdominal x-rays showing dilated bowel loops or CT scans identifying transition points. Treatment depends on the severity and cause but generally involves surgery to remove blockages or adhesions and repair hernias or tumors. Outcomes are good if caught early but mortality rises with delay in surgery or if the obstruction becomes strangulated.
1) The management of hepatocellular carcinoma (HCC) has improved in recent decades due to better patient stratification using tools like the Barcelona Clinic Liver Cancer staging system and new therapies such as sorafenib.
2) However, HCC remains a major cause of cancer deaths worldwide. Clinical practice guidelines strongly recommend five treatments for HCC - resection, transplantation, radiofrequency ablation, chemoembolization, and sorafenib - based on evidence from clinical trials.
3) Additional research is still needed to clarify the roles of other treatments like radioembolization and adjuvant therapies after resection, as well as second-line therapies for advanced HCC. Many ongoing clinical trials aim to address these
Controversies in diverticular disease and diverticulitis conference presentationDr Edward Fitzgerald
This document discusses several controversies and areas of ongoing debate in the treatment of diverticular disease. It summarizes recent evidence questioning traditional practices like routine antibiotics for uncomplicated diverticulitis, prophylactic resection after a single attack, and the natural history assumptions of disease progression. The role of laparoscopic versus open surgery and conservative management of complicated diverticulitis are also addressed. Overall, the treatment paradigm is shifting to a more conservative approach with many prior standards now being re-examined based on emerging evidence.
This case report describes a 61-year-old male patient who presented with chronic abdominal pain and was found to have xanthogranulomatous cholecystitis (XGC), a rare inflammatory disease of the gallbladder, along with gallstones. Imaging studies revealed thickening of the gallbladder wall and a mass, concerning for possible gallbladder carcinoma. The patient underwent cholecystectomy and was found to have XGC pathology, characterized by lipid-laden macrophages and chronic inflammatory cells infiltrating the gallbladder wall. XGC is a benign condition that can be confused for gallbladder cancer. The patient's surgery and recovery were uncomplicated.
Oesophageal cancer a clinical review bmj 2012Abdulsalam Taha
The incidence of oesophageal cancer is increasing. While the incidence of squamous cell carcinoma of the oesophagus has recently been stable or declined in Western societies, the incidence of oesophageal adenocarcinoma has risen more rapidly than that of any other cancer in many countries since the 1970s, particularly among white men.
The United Kingdom has the highest reported incidence worldwide, for reasons yet unknown.
Overall, the prognosis for patients diagnosed with oesophageal cancer is poor, but those whose tumours are detected at an early stage have a good
Similar to Standard for dx & tx for choledocholithiasis (20)
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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2. and endoscopic retrograde cholangiopancreatography
(ERCP), as a complement to routine laboratory and imag-
ing studies. The most common intervention for common
bile duct (CBD) stones is ERCP. Other procedures for
CBD stone extraction include percutaneous, transhepatic
stone removal and intraoperative CBD exploration, wheth-
er laparoscopic or open. The availability of equipment and
skilled practitioners who are facile with these techniques
varies among institutions. The timing of the intervention
is often dictated by the clinical situation.
PREOPERATIVE EVALUATION AND THERAPY
Diagnosis of choledocholithiasis is not always straight-
forward and clinical evaluation and biochemical tests are
often not sufficiently accurate to establish a firm diagnosis.
Imaging tests, particularly abdominal ultrasound, are used
routinely to confirm the diagnosis. Liver function tests
(LFT) can be used to predict CBD stones[4,5]
. Elevated
serum bilirubin and alkaline phosphatase typically reflect
biliary obstruction but these are neither highly sensitive
nor specific for CBD stones. Excepting obvious jaundice,
a raised GGT level has been suggested to be the most
sensitive and specific indicator of CBD stones. A value of
greater than 90 U/L has been proposed to indicate a high
risk of choledocholithiasis[4]
. However, laboratory data
may be normal in as many as a third of patients with cho-
ledocholithiasis, warranting further evaluation of the CBD
by imaging studies to clarify the diagnosis.
In order to help select from the various diagnostic and
therapeutic options, patients may be classified preopera-
tively into high, moderate or low risk groups. The high risk
(> 50% risk) group includes those patients with obvious
clinical jaundice or cholangitis, choledocholithiasis or a
dilated CBD on ultrasonography. Patients with a history
of pancreatitis or jaundice, elevated preoperative bilirubin
and alkaline phosphatase levels or multiple small gallstones
carry a moderate (10%-50%) risk of choledocholithiasis.
Patients with large gallstones, without a history of jaundice
or pancreatitis and with normal liver function tests are
considered unlikely to have CBD stones and therefore at
low risk (< 5%)[6-8]
.
The transabdominal ultrasound examination (US) is the
most commonly used screening modality. In patients who
present with symptoms attributable to gallstone disease,
US may be the only radiologic study ordered. It has the
advantages of being widely available, non-invasive, and
inexpensive. Ultrasonography, however, is highly operator
dependent, but it can provide useful information in ex-
perienced hands. For a diagnosis of cholecystitis, in most
circumstances, gallbladder stones need to be visualized.
The sonographic presence of wall thickening, perichole-
cystic fluid, and a Murphy’s sign, may be helpful but are
not required for a diagnosis of acute cholecystitis. The
ultrasonographer should routinely report indirect informa-
tion suggestive of the presence or absence of CBD stones,
specifically the CBD diameter or any signs of intrahepatic
bile duct dilation. The sensitivity of US for detecting bili-
ary dilatation, as reported in various studies, varies from 55
to 91 percent[9]
. A CBD diameter of greater than 6 mm on
US is associated with a higher prevalence of choledocholi-
Freitas ML et al. Diagnosis and management of choledocholithiasis 3163
www.wjgnet.com
thiasis[10]
.
Computed tomography (CT) may have some role in
diagnosis of gallstone disease and choledocholithiasis.
Many patients presenting with acute abdominal pain will
undergo a diagnostic CT scan as part of the acute workup.
A diagnosis of acute cholecystitis may be evident based on
signs of gallbladder inflammation. Cholelithiasis may be
detected on CT[11]
and often the diameter of the CBD can
be measured. In the clinical setting, US may not be neces-
sary for preoperative evaluation if the CT scan provides
this information. The role of helical CT cholangiography
is still in evolution, particularly in the United States. Intra-
venously administered contrast agents, combined with high
resolution helical scans and three dimensional reconstruc-
tions that can be very useful in diagnosing choledocholi-
thiasis[12,13]
. The sensitivity of this technique can be as high
as 95.5%[12]
. This technique is not widely utilized in the U.S.
as the available contrast agents often cause significant nau-
sea on administration. The availability of MRCP also limits
the need for this modality.
MRCP has emerged as an accurate, non-invasive diag-
nostic modality for investigating the biliary and pancreatic
ducts[14]
and has been recommended in some circles as
the preoperative procedure of choice for the detection of
CBD stones[4,15,16]
. MRCP provides excellent anatomic de-
tail of the biliary tract and has a sensitivity of 81%-100%
and a specificity of 92%-100% in detecting choledocho-
lithiasis[14]
. The accuracy of MRCP in diagnosing CBD
stones is comparable with that of ERCP and IOC[14,17]
. It
thus avoids the need for a potentially high risk, invasive
procedure in more than 50% of patients, allowing selec-
tive use of ERCP or surgical CBD exploration in those
patients who require a therapeutic intervention. These
results have led some practitioners to consider MRCP the
new gold standard for biliary imaging[14,18]
. MRCP may,
however, miss stones less than 5 mm in diameter. MRCP
is an expensive option that requires significant expertise
for interpretation; this modality may not always be readily
available.
Endoscopic techniques such as endoscopic ultrasound
(EUS) and ERCP can also be useful tools in preoperative
diagnosis and, in the case of ERCP, management of cho-
ledocholithiasis. Both procedures are more invasive than
strictly radiologic techniques, and carry the low, but inher-
ent risks of upper gastrointestinal tract endoscopy. ERCP
also carries the risks associated with biliary instrumenta-
tion, such as pancreatitis. Endoscopic ultrasound (EUS)
can been used to evaluate the CBD and identify calculi.
Studies comparing the accuracy of EUS to US, CT and
ERCP for detecting choledocholithiasis show a sensitiv-
ity of EUS ranging from 88%-97%, with a specificity of
96%-100%[19]
. This is comparable to ERCP and avoids the
risks of pancreatitis, cholangitis and radiation exposure[19]
.
The role of EUS, however, is not well established espe-
cially when cost and availability of less invasive modalities
such as MRCP are considered. EUS may be combined
with ERCP at the same endoscopy session if biliary calculi
are identified, allowing it to be a bridge to therapeutic in-
tervention.
ERCP has been the gold standard for preoperative diag-
nosis of CBD calculi. When compared to other tests such
3. as ultrasonography and MRCP, ERCP has the advantage
of providing a therapeutic option when a CBD stone is
identified. Stone retrieval and sphincterotomy has sup-
planted surgical treatment of choledocholithiasis in many
institutions[14,20]
. Successful cholangiography by an experi-
enced endoscopist is achieved in greater than 90% of pa-
tients. Complications associated with ERCP can be as high
as 15% and include pancreatitis, cholangitis, perforation of
the duodenum or bile duct, and bleeding. These individual
complications can occur in 5%-8% of patients. The mor-
tality rate from ERCP is 0.2%-0.5%[21,22]
INTRAOPERATIVE EVALUATION AND
THERAPY
Since laparoscopic cholecystectomy became a routine pro-
cedure in the early 1990’s, debate has continued about the
role of intraoperative bile duct assessment. The interest in
intraoperative cholangiography (IOC) came from both the
desire to detect CBD stones and to potentially identify any
bile duct abnormalities, including iatrogenic injuries at the
time of surgery. Routine cholangiography is not generally
considered to be the standard of care but still has its pro-
ponents[3]
. Most surgeons selectively evaluate the bile duct
intraoperatively. A smaller subset relies only on preopera-
tive assessment tools including magnetic resonance chol-
angiopancreatography (MRCP) and endoscopic retrograde
cholangiopancreatography (ERCP) as a complement to
routine laboratory and imaging studies.
Intraoperative cholangiography can be a useful tool to
identify choledochal calculi but its application remains con-
troversial. Proponents often believe that IOC enables clear
definition of the biliary tree anatomy[3,23,24]
, thus reducing
the risk of bile duct injury during cholecystectomy. Most
studies on the subject show no significant difference in the
rates of ductal injury between routine and selective IOC.
Routine IOC has been found to yield little benefit over the
selective approach in the detection of symptomatic CBD
stones[3]
Cholangiography is a relatively straight forward
procedure to perform. It does add to the operative time,
approximately an additional 15 min[25,26]
, but surgeon and
operative team experience can minimize this. Dynamic
fluoroscopic imaging is the technique of choice and can
provide a specificity and sensitivity of 94% and 98%, re-
spectively, in experienced hands[27]
. This technique may be
somewhat less sensitive for patients presenting with biliary
pancreatitis[27]
. A complete IOC should demonstrate the
cannulation of the cystic duct, filling of the left and right
hepatic ducts, CBD and common hepatic duct diameter,
the presence or absence of filling defects in the biliary tree,
and free flow of contrast into the duodenum (Figure 1).
Obstruction or other biliary abnormality should be sus-
pected if these findings are not clear.
The overall safety profile of IOC is very good. The inci-
dence of pancreatitis, in contrast to ERCP, is negligible[28]
.
The reliability, ease to perform, and low complication rate
of IOC suggest that, at least in cases where choledocho-
lithiasis is not proven, IOC during a cholecystectomy is a
better choice than preoperative ERCP assessment of the
bile ducts. More recently intraoperative ultrasonography
3164 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol May 28, 2006 Volume 12 Number 20
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of the CBD during laparoscopic cholecystectomy has
been shown to satisfactorily demonstrate stones and the
biliary tree. Use of intraoperative ultrasound requires a
significant learning curve, but in experienced hands takes
less operative time than traditional IOC[25,26]
. Laparoscopic
ultrasound compares well with intraoperative cholangiog-
raphy. With a sensitivity of 96% and a specificity of 100%,
and the advantages of saved time and lack of radiation,
intraoperative ultrasound may be a superior diagnostic mo-
dality when compared to IOC[23]
. The use of intraoperative
laparoscopic ultrasound is limited by the availability of
equipment and surgeon training and experience. Efforts
to incorporate ultrasonography training in to surgical resi-
dency curricula should aid its acceptance and use.
When CBD stones are detected intraoperatively, a sur-
geon must make a clinical decision on how to proceed.
This decision is often dictated by the availability of equip-
ment, surgeon preference and skill, and the availability of
ERCP at a facility. Available options include laparoscopic
CBD exploration, intraoperative ERCP, open CBD explo-
ration, or postoperative therapy. Many surgeons are reluc-
tant to proceed with an open procedure when other, less
invasive, options are generally available. However, a deci-
sion to delay therapy to the postoperative period risks en-
countering procedural difficulties that preclude endoscopic
therapy. Options for intraoperative CBD clearance include
variations of laparoscopic exploration. Laparoscopic CBD
exploration is most commonly performed with acholedo-
choscope. The scope, attached to a second video camera
and light source, is inserted into the CBD via either the
cystic duct (Figure 2) or via a choledochotomy. Placement
of the choledochoscope directly into the CBD via a cho-
ledochotomy is generally reserved for patients with ducts
dilated to greater than 6 mm in diameter on cholangio-
gram[20]
. A continuous saline infusion through the choledo-
choscope dilates the duct and clears debris. CBD stones
can be directly visualized (Figure 3) and instrumented.
Between 66 and 82.5% of laparoscopic CBD explorations
can be performed via the cystic duct[20,29]
. In experienced
hands, the CBD clearance rate is as high as 97%[2,29]
. In one
large series of laparoscopic CBD exploration, the overall
morbidity rate of this procedure is approximately 9.5%,
with a 2.7% retained stone rate[2]
. These data are equivalent
to the experience with ERCP.
An alternate technique of laparoscopic CBD clearance
involves stone extraction under fluoroscopic guidance.
Figure 1 Intraoperative
cholangiogram via the
cystic duct demonstrating
proximal biliary dilation and
two filling defects in the
CBD (Arrows).
←
←
4. This technique, as described by Traverso et al, does not use
a choledochoscope, but can be highly effective in CBD
clearance for single stones (87%), with an overall 59% suc-
cess rate[30]
. In this technique, instruments, including stone
extraction baskets, are passed into the CBD (usually via
the cystic duct) under fluoroscopy. The fluoroscopic im-
ages facilitate stone capture and removal. This technique
simplifies the operating room set up for CBD exploration
because additional video equipment is not required. In this
series, patients whose ducts were not cleared laparoscopi-
cally, underwent ERCP. The authors noted a significantly
lower complication rate in patient who did not undergo
ERCP[30]
. Likewise, the overall associated costs were lower
in these patients[31]
.
Laparoscopic techniques can be very effective at clearing
CBD stones, but significant expertise and experience is re-
quired to achieve high success rates. Stones impacted at the
sphincter of Oddi are often the most difficult to extract by
this technique. Long term follow up does not demonstrate
a significant risk of CBD stricture or other complications
for these procedures[2,29,30]
. This technique is also advocated
in the pediatric population by some practitioners as a way
of avoiding an ERCP[32]
. Intraoperative ERCP, although
often limited by the immediate availability of a qualified
endoscopist, is a technique that can be very useful. This
takes advantage of the preexisting anesthetic and does
not prolong hospital stay by delaying the procedure[33,34]
.
In some instances, cooperation between the surgeon and
the endoscopist can expedite the procedure[35]
. Guidewire
placement, throught the sphincter of Oddi, into the duo-
denum via the IOC catheter can facilitate cannulation, es-
pecially for patients with difficult duodenal anatomy[34]
. In
the case of an unsuccessful extraction, open CBD explora-
tion or drainage of the duct should be considered.
POSTOPERATIVE EVALUATION AND
THERAPY
Postoperative ERCP is commonly used modality for CBD
clearance when a stone is detected intraoperatively. This
technique is highly effective[20]
, but can be complicated
when anatomic variables such as duodenal diverticulae or
unusual biliary anatomy, are encountered[36]
. On the occa-
www.wjgnet.com
sion that ERCP fails, a primary option includes returning
to the operating room for a laparoscopic or open explora-
tion. However, other less invasive options may be available.
In selected patients, percutaneous transhepatic (PTH)
therapies should be considered for CBD clearance. Ac-
cess to the biliary system can be obtained percutaneously,
under ultrasound guidance. Via this access point, stones
can be extracted, a sphincterotomy can be performed, or
lithotripsy can be used over a single, or multiple sessions
to ensure duct clearance[37,38]
. A percutaneous drain can be
used to decompress the system between procedures or for
temporary stenting after the duct is clear.
Novel approaches have been performed in other ana-
tomic settings which preclude ERCP, such as prior gas-
tric surgery. The most common gastric surgery currently
performed is the Roux-Y gastric bypass. In this surgery, a
small gastric pouch is created and anastomosed to a limb
of jejunum. The majority of the stomach, duodenum, and
proximal jejunum are bypassed, making endoscopic access
technically difficult. Combined laparoscopic surgical and
endoscopic procedures have been described. Endoscopic
access can be achieved via a gastrostomy[39]
or jejunos-
tomy[40]
. The endoscope can be passed under surgical
guidance, and an ERCP can be performed in the standard
fashion. These procedures are only described in short case
reports, but will undoubtedly become more common place
with the prevalence of gastric bypass.
In conclusion, given the various diagnostic and thera-
peutic options available for managing choledocholithiasis,
clinical judgment is paramount. The surgeon and the pa-
tient are best served by accurate laboratory and radiologic
assessment prior to cholecystectomy. In the setting of high
preoperative suspicion for choledocholithiasis, preopera-
tive imaging with MRCP may help guide subsequent treat-
ment. If CBD stones are present on MRCP or in the set-
ting of clinical jaundice or cholangitis, preoperative ERCP
is the first line option. However, preexisting anatomic
abnormalities may influence this decision. Laparoscopic
IOC with a CBD exploration is a reliable approach in ex-
perienced hands and if an ERCP is unsuccessful.
Cholangiography during cholecystectomy is recom-
mended for patients with a history of gallstone pancreati-
tis, LFT abnormalities, or an enlarged CBD on preopera-
tive imaging who have not undergone MRCP or ERCP.
IOC is also recommended when intraoperative findings
suggest anatomic abnormalities or unsuspected CBD calculi.
Intraoperative laparoscopic CBD exploration is the first
Figure 3 CBD stone
as seen through the
choledochoscope.
Figure 2 Laparoscopic view of a choledochoscope (CS) entering the CBD via the
cystic duct. The gallbladder (GB) is retracted to the left of the image.
←
Cystic duct CBD
GB
CS
Liver
Freitas ML et al. Diagnosis and management of choledocholithiasis 3165
5. option for choledocholithiasis detected in the operating
room. Intraoperative or postoperative ERCP are options
for incompletely cleared ducts. Percutaneous treatment or
combined laparoendoscopic options are available in some
centers for patients who cannot undergo ERCP or laparo-
scopic choledochotomy. Open CBD exploration is a safe
option, but usually limited to the setting of concomitant
open surgery or as a last resort when other therapeutic
modalities fail.
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