A Study of Clinical Outcome in 30 Patients of Common Bile Duct Stone

Introduction: Management of common bile duct stones(CBDS) presents a surgical challenge since it is the majorcause of hepatobiliary morbidity and complications. The aimof the study was to evaluate the clinical outcome for CBDstone and evaluate the treatment modality.Material and Methods: This retrospective study was done in30 cases of Common bile duct stone for period of 1 year. All 30patients included in the study were appropriately investigatedby laboratory investigations, USG, CT scan and MRCP.Results: Out of 30 patients included in the study, 26 hadundergone successful ERCP and had successful clearance ofCBD which were followed by Laparoscopic cholecystectomy.2 patients had failed ERCP clearance, out of which 1 patienthad undergone re-ERCP with successful clearance of the stone.The other 1 patient had to undergo Open CBD explorationfollowed by cholecystectomy. 2 patients with CBD stonegreater than 2 cm had to undergo direct CBD explorationwithout undergoing ERCPConclusion: Appropriate identification of CBD stone size,location, number and CBD diameter associated with featuresof cholangitis, jaundice and pancreatitis is essential. It isa complicated procedure requiring a step-wise strategicapproach. The gold standard for the removal of CBD stoneis ERCP followed by laparoscopic cholecystectomy.Commonbile duct exploration is considered in patients with failedclearance of CBD following ERCP OR CBD stone size > 2cm.

Harmonic Scalpel Assisted Laparoscopic Cholecystectomy Vs Monopolar Assisted Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy is the standardof care for Gall Stone diseases. Conventionally monopolarenergy source is used for dissection of cystic artery and ductand dissection of Gall Bladder from GB fossa. There arehigh risk of thermal injury and biliary complications, morevisceral and solid organ injury due to frequent exchange ofinstruments. All these factors lead to increased operating timeand complications. The use of harmonic assisted laparoscopiccholecystectomy has decreased the operating time andcomplications. The objective of this study was to compareHarmonic assisted Laparoscopic cholecystectomy withconventional monopolar energy.Material and Methods:- This prospective study was carriedout on 158 patients which were randomly assigned toeither group. Total 75 patients were present in conventionalmonopolar assisted LC and 83 patients in Harmonic assistedLC.Result: This study reveals that in harmonic assistedLaparoscopic cholecystectomy time taken for surgery is less,minimal thermal dispersion of energy, reduced requirements ofanalgesics, reduced incidence of bleeding and GB perforation.Conclusion: Harmonic Assisted LaparoscopicCholecystectomy advantage over Conventional MonopolarAssisted Laparoscopic Cholecystectomy with respectto operating time, postoperative pain, and perioperativecomplications. Thus its use should be advocated whereFacilities are available

Correlation of the Serum Nitrate/Nitrite Level with the Severity of Biliary Tract Inflammation

PURPOSE: The relationship between the biophysical and biochemical processes of gallbladder bile and nitric oxide is still not well known. In this study, the correlation between nitric oxide production and the degree of biliary tract inflammation was investigated and the levels of nitrate/nitrite (NOx) and stable metabolite of nitric oxide in the serum proposed for assessing the severity of biliary tract inflammation. METHODS: Eighty two patients with biliary tract inflammation who underwent operative treatment between March and July 2002 were included in this study. Of the 82 patients, there were 31 and 51 men and women, respectively. The mean age was 53, ranging from 21 to 82 years. The subjects were divided into three groups, GB stone (n=42), and acute cholecystitis (n=27), and cholangitis (n= 13). The severity of biliary tract inflammation was assessed using the WBC count, total bilirubin count, GB wall thickness on pathology, bile duct stone detected on ultrasonography, open conversion of cholecystectomy, pyrexia and tenderness/rebound tenderness on physical examination. The serum NOx concentrations were analyzed according to the groups, clinicopathological, laboratory and radiological findings. The serum NOx levels were measured using the Griess reaction after conversion of all nitrates to nitrites. RESULTS: The nitrate/nitrite levels in the GB, acute cholecystitis and cholangitis groups were 70.0+/-44.6, 126.8+/-54.5 and 142.0+/-44.6mumol/L, respectively, with statistical differences between the three groups (P< 0.05). The NOx level in patients with pyrexia, hyperbilirubinemia, leukocytosis, GB wall thickness on pathology and open conversion were markedly increased compared with the control group (P<0.05). These data demonstrate the relationship between the intensity of nitric oxide and the severity of biliary tract inflammation. CONCLUSION: Measurement of the NOx concentration in patients with biliary tract inflammation provides information about the severity and course of the disease. These results suggest there is a correlation between nitric oxide and the degree of biliary tract inflammation.

Effect of Camostat Mesylate on Chemical Compositions of Bile and Crystallization in Gallbladder Stone Patients

BACKGROUND: It has been well demonstrated that trypsin inhibitor can stimulate the secretion of cholecystokinin. Camostat mesylate (C20H22N4O5 CH3SO3H) is a synthetic trypsin inhibitor. We demonstrated the effect of camostat mesylate on the chemical composition of bile and the crystallization in gallbladder-stone patients. METHODS: Gallbladder bile sample from 22 patients with GB stones were analyzed. In 11 patients, camostat mesylate (Foy-pan ) was administered orally in a dosage of 600 mg per day for more than 5 days, and the results of the bile analysis were compared to those of 11 controls. RESULTS: The total protein concentration in the camostat group was lower than that in control group (0.21+/-0.10 vs 0.24+/-0.06 g/dl) but the difference was not significant (p=0.41). The total bile acid concentration in the camostat group was significantly lower than that in the control group (5.47+/-1.56 vs 6.85+/-1.32 g/dl, p=0.04). The concentrations of cholesterol and phospholipid were lower in the camostat group (0.35 +/- 0.19 vs 0.44 +/- 0.11 g/dl, 2.10 +/- 1.19 vs 2.92 +/- 0.93, respectively), but the differences were not statistically significant (p=0.20, p=0.09, respectively). The total lipid concentration which reflects the concentrated magnitude of the bile, was significantly lower in the camostat group (7.93 +/- 2.87 vs 10.20 +/- 2.01 g/dl, p=0.04). The cholesterol saturation index didn't demonstrate a significant difference between the two groups (1.06 +/- 0.27 vs 0.95 +/- 0.31, p=0.38). Crystallization in the bile from cholesterol stone patients, was observed every day for 7 days. Crystallizations was less frequent in the camostat group, but the difference was not statistically significant (1/6 vs 4/8, p=0.39). DISIDA (disofenin iminediacetate) scans were performed in 3 healthy volunteers to observe the changes in the radioactivities and the volumes of the gallbladders before and after the administrations of camostat. The peak radioactivities, the transittime to the peak radioactivity, and the gallbladder volume at the peak radioactivity in the scan after the administration of camostat were lower than in the corresponding values before the administration. CONCLUSIONS: Camostat mesylate lowers the concentration of all bile components. We assume that the effects of Camostat mesylate are mediated by CCK, which enhances gallbladder motility and limits the concentrating function of the gallbladder.

A Comparative Study of Bile Compositions From patients with Gallbladder Stones and Common Bile Duct stones

To clarify the mechanisms of stone formation in gallbladder and in common bile duct, the bile composition, such as cholesterol, total bile acid, major bile acids, phospholipid, protein and calcium, from patients with gallbladder stones, common bile duct stones and control groups were analyzed for comparison. The control group consisted of patients who had neither biliary stone nor biliary tract disease. The results obtained are as follows; 1. In the mean concentrations of bile cholesterol and protein from each disease group, no statistically significant difference of these compositions was observed according to sorts of stone(p > 0.05). 2. In the cholesterol stone group the mean concentration of total bile acid of bile from gallbladder stone group was higher than that of common bile duct stone group (p < 0.05). In the pigment stone group, T/D ratio of bile from gallbladder stone group tended to be higher than that of CBD stone group. But these differences were not statistically significant (p = 0.09). 3. In the pigment stone groups, the mean concentration of bile phospholipid from gallbladder stone group was significantly higher than that of CBD stone group (p < 0.05). 4. The mean concentration of bile protein from gallbladder stone group was higher than that of CBD stone group in the pigment stone group (p < 0.05). 5. The mean concentration of bile calcium was significantly higher in gallbladder stone group than that in CBD stone group (p < 0.05). In conclusion, supersaturation of cholesterol in bile may not be sufficient to explain cholesterol gallstone formation. The increase in total bile acid especially LCA, DCA, CDCA may be involved in cholesterol gallbladder stone formation, whereas pigment gallbladder stone formation is thought to be related to decreased T/D ratio of bile which means high dihydroxycholanic acid of bile. Additionally, the results suggest that phospholipid, protein and calcium contribute to pigment gallbladder stone formation by playing great roles in forming matrix as nucleus in pigment stone, but further investigation may be needed to detect calcium ion critical for calcium crystal formation.