Comprehensive and innovative techniques for laparoscopic choledocholithotomy: A surgical guide to successfully accomplish this advanced manipulation.

Surgeries for benign diseases of the extrahepatic bile duct (EHBD) are classified as lithotomy (i.e., choledocholithotomy) or diversion (i.e., choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures, and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy. Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes; however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons.

Endoscopic ultrasonography guided drainage: summary of consortium meeting, May 21, 2012, San Diego, California.

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary and pancreatic drainage. While ERCP is successful in about 95% of cases, a small subset of cases are unsuccessful due to altered anatomy, peri-ampullary pathology, or malignant obstruction. Endoscopic ultrasound-guided drainage is a promising technique for biliary, pancreatic and recently gallbladder decompression, which provides multiple advantages over percutaneous or surgical biliary drainage. Multiple retrospective and some prospective studies have shown endoscopic ultrasound-guided drainage to be safe and effective. Based on the currently reported literature, regardless of the approach, the cumulative success rate is 84%-93% with an overall complication rate of 16%-35%. endoscopic ultrasound-guided drainage seems a viable therapeutic modality for failed conventional drainage when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and therapeutic endoscopy.

Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results.

BACKGROUND: The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. METHODS: We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. RESULTS: The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangitis," "fewer episodes of peritonitis," and showed a favorable trend for "overall biliary complications." Although the "with T-tube" group showed superior result for "anastomotic and nonanastomotic strictures," the incidence of interventions was not diminished. CONCLUSIONS: Our systematic review and meta analysis favor the abandonment of T-tubes in orthotopic liver transplantation.

[Value of the bilio-intestinal bypass in biliary disease in the Far East: retrospective study of 5 year experience at the Calmette Hospital of Phnom Penh (Cambodia)]. / Intérêt de la dérivation bilio-digestive dans la pathologie biliaire Extrême-Orientale: étude rétrospective sur 5 ans à l'Hôpital Calmette de Phnom Penh (Royaume du Cambodge).

Gallstone disease in the Far East exhibits a number of special features regarding epidemiology and etiology as well as indications for and response to surgical treatment. Surgical bypass techniques seldom used for treatment of gallstone disease in the West can be highly effective in lowering complication and recurrence rates in oriental patients. The purpose of this retrospective report is to describe a 5-year experience with gallstone disease at the Calmette Hospital in Phnom Penh (Kingdom of Cambodia). After reviewing the main pathological features encountered, we describe the indications for the two bypass techniques used. Choledocoduodenostomy was used for frail, elderly patients while choledochojejunostomy was the treatment of choice and achieved excellent short, middle, and long-term results in younger patients.

Clinical pathway implementation improves outcomes for complex biliary surgery.

BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

Iatrogenic bile duct injuries. The real incidence and contributing factors--implications for laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has achieved wide acceptance as the preferred treatment for symptomatic gallbladder disease. Yet there are alarming reports of iatrogenic bile duct injuries. To establish a comparison standard, the incidence of iatrogenic bile duct injury during conventional cholecystectomy has to be known. A single institutional retrospective review of 1,617 consecutive open cholecystectomies between 1980 and 1989 was performed. Eight patients (0.49%) sustained iatrogenic bile duct injury in this study. Inflammation, anatomic variation, or both were contributing factors in all injuries. Operative cholangiography identified the injury at the initial operation in three patients. Treatment consisted of either primary ductal repair, ductal repair over a stent, or ductal-enteric anastomosis. There were no late complications after surgery (follow-up 26 to 97 months; mean 50.9 months). The implications for laparoscopic cholecystectomy are apparent. Iatrogenic bile duct injuries are associated with acute inflammation and/or variant ductal anatomy; routine operative cholangiography assumes increased importance; and immediate repair of the injury minimizes long-term complications.

A simple modification of choledochoenterostomy using continuous pull through suture.

A simple modification of choledochoenterostomy is described. Using continuous suture and pull through technique, the posterior line of the anastomosis is completed without immediate approximation of the two structures. By improving the access, good control of the posterior suture line is ensured, the risk of anastomotic leakage is minimized and the use of stent or T tube is unnecessary.

Surgical treatment for cholelithiasis.

In a retrospective study, the results of 1,631 consecutive operations for cholelithiasis were analyzed. With an overall mortality rate of 0.18 percent and a reoperation rate of 1.3 percent, conventional cholecystectomy proved to be a safe method. Mortality proved to be age dependent, with a zero mortality rate for patients less than 60 years of age. Choledochotomy had a 13-fold greater mortality rate than simple cholecystectomy (0.92 versus 0.07 percent). For acute cholecystitis, we observed an unusual zero mortality rate, whereas the mortality rate in chronic cholecystitis was 0.2 percent. All three patients who died had an accompanying cirrhosis of the liver. Morbidity, defined as reoperation during the same period of hospitalization, was mainly the result of retained stones after choledochotomy; endoscopic papillotomy was the treatment of choice. Cholecystectomy remains the "gold standard" in the treatment of cholelithiasis.

Iatrogenic injuries to the extrahepatic biliary tract.

Iatrogenic injuries to the extrahepatic biliary tract continue to occur and result in significant morbidity. Over the last 10 years, 26 patients have been referred to Westmead Hospital for management of iatrogenic biliary tract injuries. Of these injuries, 22 occurred during cholecystectomy, three during hepatectomy and one during a pancreaticoduodenectomy. The principles of avoidance and repair are discussed. It is concluded that these injuries, although uncommon, continue to occur and that the best treatment results are achieved in specialized hepatobiliary units.

Obstructive jaundice after laparoscopic cholecystectomy with electrocautery.

The authors describe a special complication, bile duct stenosis, which occurred after a laparoscopic cholecystectomy using electrocautery. The preventive precautions that were taken and the remedial surgical procedures performed are stated.