Resectoscopic ablation of the gallbladder mucosa after cholecystostomy.

PURPOSE: To investigate the feasibility of endoscopic ablation of the gallbladder mucosa after cholecystostomy. MATERIALS AND METHODS: The mucosa of the gallbladder was endoscopically electrocoagulated through the cholecystostomy tract. After ablation, repeated luminal irrigation with chymotrypsin solution was given before removal of the tube. The patients were followed up by ultrasonography after the procedure. RESULTS: Twenty patients accepted this operation. The mean operating time was 38 minutes (range, 25 to 55 min). There were no procedure-related mortality and complications including perforation, bleeding, and cholangitis. Eighteen gallbladders have completely obliterated in 3 months. The other 2 gallbladders developed asymptomatic retention cysts. During 48 months of follow-up period, no stone occurred and no signs of malignancy were found at the site of the gallbladder. Seven patients died from the other medical illness. CONCLUSION: Resectoscopic ablation of the gallbladder mucosa is a safe and promising approach to sclerosis of the gallbladder after cholecystostomy.

Laparoscopic treatment of choledocholithiasis with novel self-releasing biliary stent.

OBJECTIVES: The aim of this study was to evaluate the effect of a self-releasing biliary stent antegradely placed during laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. MATERIALS AND METHODS: The soft biliary stent, made of polyurethane, was designed as a J-umbrella form with a pigtailed duodenal part and an umbrella-like biliary anchoring part shaped with the rapidly absorbable suture. After the clearance of stones during LCBDE, a guide wire was inserted into the duodenum through the choledochoscope. The stent was advanced over the guide wire until the pigtail of the stent entered the duodenum. The choledochotomy was primarily closed. RESULTS: This technique has been performed on 33 patients with choledocholithiasis. The median length of postoperative hospital stay was 4.3 (3-8) days. All the stents were eliminated from the bile ducts and discharged out of the body. The median time of the stent stay in the body was 13.6 (+/- 2.55) days. Transient hyperamylasemia occurred in 4 of the 33 (12.1%) patients, and stent occlusion occurred in 1 patient who recovered soon after treatment. No bile leak, biliary infection, or stent dislocation was observed. During the follow-up of 12 months, no biliary infection, residual calculi, or stricture occurred. CONCLUSION: This novel self-releasing stent is safe and effective in the laparoscopic treatment of choledocholithiasis, and the subsequent removal of the stent can be avoided.

Treatment of hepatic artery thrombosis after orthotopic liver transplantation.

OBJECTIVES: This study evaluated conservative treatment for delayed hepatic artery thrombosis after orthotopic liver transplantation (OLT). METHODS: Whole-graft OLTs (n=108) and live donor liver transplants (LDLTs; n=140) were performed in 237 patients between October 1991 and July 2002. Seven episodes of hepatic artery thrombosis were identified in six patients. Among the six patients, three had received whole-graft OLT and three had received right-lobe LDLT. Treatment included retransplantation, thrombectomy plus thrombolysis, and conservative treatment of hepatic and biliary complications. RESULTS: Five patients survived after treatment. Among the three LDLT recipients who received conservative treatment, two had subsequent collateral formation and one had spontaneous recanalization of arterial inflow. Of the three recipients of whole-graft OLT, the first died because of hepatic failure and technically difficult retransplantation, the second had thrombectomy plus thrombolysis but had recurrence of thrombosis that spontaneously recannulated during conservative treatment, and the third patient had successful retransplantation for graft failure. CONCLUSION: In the absence of hepatic failure, conservative treatment appears to be effective for patients with hepatic artery thrombosis. Collateralization is more likely to develop after LDLT than after whole-graft OLT.

Outcome of gallbladder preservation in surgical management of primary bile duct stones.

AIM: To evaluate the methods and outcome of gallbladder preservation in surgical treatment of primary bile duct stones. METHODS: Thirty-five patients with primary bile duct stones and intact gallbladders received stone extraction by two operative approaches, 23 done through the intrahepatic duct stump (RBD-IDS, the RBD-IDS group) after partial hepatectomy and 12 through the hepatic parenchyma by retrograde puncture (RBD-RP, the RBD-RP group). The gallbladders were preserved and the common bile duct (CBD) incisions were primarily closed. The patients were examined postoperatively by direct cholangiography and followed up by ultrasonography once every six months. RESULTS: In the RBD-IDS group, residual bile duct stones were found in three patients, which were cleared by a combination of fibrocholedochoscopic extraction and lithotripsy through the drainage tracts. The tubes were removed on postoperative day 22 (range: 16-42 days). In the RBD-RP group, one patient developed hemobilia and was cured by conservative therapy. The tubes were removed on postoperative day 8 (range: 7-11 days). Postoperative cholangiography showed that all the gallbladders were well opacified, contractile and smooth. During 54 (range: 6-120 months) months of follow-up, six patients had mildly thickened cholecystic walls without related symptoms and further changes, two underwent laparotomies because of adhesive intestinal obstruction and gastric cancer respectively, three died of cardiopulmonary diseases. No stones were found in all the preserved gallbladders. CONCLUSION: The intact gallbladders preserved after surgical extraction of primary bile duct stones will not develop gallstones. Retrograde biliary drainage is an optimal approach for gallbladder preservation.