Application of Electrohydraulic Lithotripsy for Bile Duct Stones Difficult to Remove

BACKGROUND: The use of choledochoscopy has been increasing lately in open and laparoscopic surgery for bile duct stones. Intraoperative choledochoscopy is useful for assessing the biliary trees and stones and for assisting in the removal of bile duct stones. However, large or impacted bile duct stones are difficult to remove using choledochoscopy alone. Application of electrohydraulic lithotripsy (EHL) seems to be suited for these difficult cases. METHODS: Twenty-six (26) patients with bile duct stones were treated with intraoperative cho ledochoscopic EHL to remove stones which could not be retrieved using stone forceps, a basket, saline flushing, or a Fogarty catheter. We divided the 26 cases into two groups: 12 cases of laparoscopic surgery and 14 cases of open surgery. These cases were further divided into two groups: common bile duct stones and intrahepatic duct stones RESULTS: The indications of EHL in laparoscopic surgery for common bile duct stones were large stones in 2 cases and impacted stones in 4 cases. Eighteen (18) patients with intrahepatic duct stones were treated with EHL for impacted stones. Stone clearence rate was 88.5%, and complications occurred in 3 cases (11.5%). One case of a biliary fistula was managed conservatively, and two cases of mucosal bleeding of the bile duct were spontaneously controlled. CONCLUSION: Intraoperative choledochoscopic electrohydraulic lithotripsy is a safe and effective method for removing large or impacted bile duct stones.

Preduodenal Portal Vein and Left Sided Gallbladder in Hepatolithiasis Patient: A case report

A preduodenal portal vein is a rare anomaly. A left-sided gallbladder is also a rare anatomical variant that may be occasionally combined with a preduodenal portal vein. We report here a patient with multiple biliary stones whose preduodenal portal vein was discovered at operation. The anomaly was a preduodenal portal vein associated with a left-sided gallbladder, which is very rare. This is the first case reported in Korea. An abnormal location of the round ligament to the right side can make the gallbladder appear to be a left-sided gallbladder. Our case belongs to this category. This patient had multiple biliary stones in the intrahepatic duct, the common bile duct, and the gallbladder. We treated him with a cholecystec tomy, choledochotomy, and choledochoscopic stone extraction using a basket, and electrohydraulic lithotripter. All procedures were done using a laparoscopic method. The patient was treated well with no complication.

Clinical Pathways for Acute Appendicitis: Approach for DRG

BACKGROUND: The current health care system demands provision of quality patient care in a cost-effective manner. A clinical path defines an optimal sequencing and timing of intervention by a health care team. This path facilitates the streamlining of this process. Implementation of clinical paths may decrease hospital cost without increasing complications in acute appendicitis patients. METHODS: A prospective evaluation of a clinical pathway for acute appendicitis (during March 1999) was conducted and the results were compared with those for control patients (during Feb 1999). Pregnant patients or patients with chronic disease were excluded. The patients with acute appendicitis were classified into three groups: A-type for acute focal and suppurative appendicitis, B-type for gangrenous appendicitis, and C-type for perforative appendicitis. RESULTS: The data for 40 patients with a clinical pathway were compared to those for 30 control patients. The mean age was 25.3 11.7 years in the pathway group versus 39.3 15.8 years in the control group. The mean hospital duration were 4.5 days for the pathway with A-type appendicitis versus 5 days for the control patients (p<0.05) and the mean hospital cost was 85.73% of that for the control group (p<0.05). In B- and C-type, the hospital duration and the cost were not different. The satisfaction rates were increased in all the types of pathway patients. The complication rates for in all the pathways were no different from those for the control patients. CONCLUSION: The clinical pathway with A-type appendicitis decreased the duration of hospitalization and the cost without adversely affecting the diagnosis or the therapy. The clinical paths were useful as means to minimize cost while increasing patient satisfaction.