Laparoscopic exploration can salvage failed endoscopic bile duct stone extraction

<p><b>INTRODUCTION</b>Conventionally, patients who failed endoscopic removal of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreaticography (ERCP) would be treated with open cholecystectomy and common bile duct exploration. Laparoscopic common bile duct exploration (LCBDE) is an established option for treating CBDS. The aim of this paper was to look at the feasibility of LCBDE as a salvage procedure after failed endoscopic stone extraction (ESE). The secondary endpoint was to examine the short-term outcomes of our LCBDE series.</p><p><b>METHODS</b>We retrospectively reviewed a prospective database to study the feasibility of LCBDE as a salvage procedure for failed ERCP.</p><p><b>RESULTS</b>Since its inception in 2006, 43 patients had undergone LCBDE at our centre. This was achieved via a transcystic approach in 25 patients and laparoscopic choledochotomy in 15 patients. There were three conversions. Of these 43 patients, 21 had a pre-operative attempt at ESE, but only six patients had their ducts cleared endoscopically. The 15 patients who failed ESE underwent LCBDE, of which 14 achieved successful stone clearance and one required open conversion. One patient developed a bile leak, which resolved spontaneously. The median length of stay (LOS) for these 15 patients was three days, while the median LOS for the whole cohort was two days.</p><p><b>CONCLUSION</b>LCBDE has been shown to be a safe and effective method for treating CBDS, with the added bonus of a short hospital stay. Where the expertise is available, LCBDE is a safe option as a salvage procedure for failed ESE.</p>

Laparoscopic common bile duct exploration: our first 50 cases

<p><b>INTRODUCTION</b>Laparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted.</p><p><b>RESULTS</b>Fifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, T-tube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required.</p><p><b>CONCLUSION</b>Laparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefits of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis.</p>

New hope for an old cure: a pilot animal study on selective venesection in attenuating the systemic effects of ischaemic-reperfusion injury

<p><b>INTRODUCTION</b>Reperfusion of acutely ischaemic tissue may, paradoxically, lead to systemic complications. This phenomenon is believed to be initiated by humoral factors that have accumulated in the ischaemic tissue. The ancient art of venesection may reduce the load of these mediators at the point of reperfusion. The aim of this study is to test if selective venesection, by removing the initial venous return from the ischaemic tissue, can attenuate the systemic effects of the ischaemic-reperfusion injury using a porcine model of acute limb ischaemia.</p><p><b>MATERIALS AND METHODS</b>The right femoral arteries of anaesthetised female pigs were clamped. Twelve pigs were divided into 2 groups (n = 6 per group). In the treatment group, 5% of blood volume was venesected from the ipsilateral femoral vein upon reperfusion; the other arm served as control. The animals were sacrifi ced after 4 days for histological examination. A pathologist, blinded to the experimental groups, graded the degree of microscopic injury.</p><p><b>RESULTS</b>For the control group, the kidneys showed glomeruli and tubular damage. The livers demonstrated architectural distortion with cellular oedema. There was pulmonary oedema as well as extensive capillary congestion and neutrophil infiltration. Such findings were absent or reduced in the venesected animals. Consequently, the injury scores for the kidney, lung, liver and heart were significantly less for the venesected animals.</p><p><b>CONCLUSION</b>Selective venesection reduces the remote organ injuries of the ischaemic-reperfusion phenomenon.</p>