Outcomes of laparoscopic choledochotomy using cholangioscopy via percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis: A preliminary Vietnamese study.

Backgrounds/Aims: Hepatolithiasis and choledocholithiasis are frequent pathologies and unfortunately, with the current treatment strategies, the recurrence incidence is still high. This study aimed to assess the outcomes of laparoscopic choledochotomy using cholangioscopy via the percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis in Vietnamese patients. Methods: A cross-sectional study of patients with hepatolithiasis and/or choledocholithiasis who underwent laparoscopic choledochotomy using intraoperative cholangioscopy via percutaneous-choledochal tube at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, from June 2017 to March 2020. Results: A total of 84 patients were analyzed. Most patients were females (56.0%) with a median age of 55.56 years. Among them, 41.8% of patients had previous abdominal operations, with 33.4% having choledochotomy. All patients underwent successful laparoscopic common bile duct exploration followed by T-tube drainage without needing to convert to open surgery. Most patients (64.3%) had both intrahepatic and extrahepatic stones. The rate of stones ≥ 10 mm in diameter was 64.3%. Biliary strictures were observed in 19.1% of patients during cholangioscopy. Complete removal of stones was achieved in 54.8% of patients. Intraoperative complications were encountered in two patients, but there was no need to change the strategy. The mean operating time was 121.85 ± 30.47 minutes. The early postoperative complication rate was 9.6%, and all patients were managed conservatively. The residual stones were removed through the T-tube tract by subsequent choledochoscopy in 34/38 patients, so the total success rate was 95.2%. Conclusions: Laparoscopic choledochotomy combined with cholangioscopy through the percutaneous-choledochal tube is a safe and effective strategy for hepatolithiasis and/or choledocholithiasis, even in patients with a previous choledochotomy.

Risk factors for postoperative cholangitis after pancreaticoduodenectomy and evaluation of internal stenting on hepaticojejunostomy: A single-center propensity score-based analysis.

BACKGROUND/PURPOSE: This retrospective study aimed to investigate the risk factors for postoperative cholangitis (POC) after pancreaticoduodenectomy (PD) and the efficacy of stenting on hepaticojejunostomy (HJ). METHODS: We investigated 162 patients. Postoperative cholangitis occurring before and after discharge was defined as early-onset POC (E-POC) and late-onset POC (L-POC), respectively. Risk factors for E-POC and L-POC were identified using univariate and multivariate logistic regression analyses. Propensity score matching (PSM) between the stenting group (group S) and the non-stenting group (group NS), and subgroup analysis in patients with risk factors were performed to evaluate the efficacy of stenting on HJ in preventing POC. RESULTS: Body mass index (BMI) ≥ 25 kg/m2 and preoperative non-biliary drainage (BD) were risk factors for E-POC and L-POC, respectively. PSM analysis revealed that E-POC occurrence was significantly higher in group S than in group NS (P = .045). In the preoperative non-BD group (n = 69), E-POC occurrence was significantly higher in group S than in group NS (P = .025). CONCLUSIONS: BMI ≥ 25 kg/m2 and preoperative non-BD status were risk factors for E-POC and L-POC, respectively. Stenting on HJ implants did not prevent POC after PD.

Feasibility of Cholangioscopy Using Multibending Ultra-Slim Endoscope Through a Lumen-Apposing Metal Stent for Choledochoduodenostomy.

BACKGROUND AND AIMS: Endoscopic ultrasound (EUS) guided choledochoduodenostomy using a lumen-apposing metal stent (LAMS) allows access to the biliary system with a sufficiently large diameter stent. However, an appropriate endoscope for this purpose is required. We evaluated the feasibility of per-oral cholangioscopy (POC) using a multibending ultra-slim endoscope through a LAMS for EUS-guided choledochoduodenostomy. METHODS: Twelve patients who underwent EUS-guided choledochoduodenostomy, followed by POC via a LAMS, were enrolled. POC was performed with an multibending ultra-slim endoscope. The primary outcome was technical success, defined as examination of both hepatic ducts and either the distal common bile duct or stricture site within 10 min. The types of intervention and adverse events were also assessed. RESULTS: Technical success was achieved in all cases with the multibending ultra-slim endoscope. Narrow-band imaging endoscopy was performed in five cases (41.7%) and POC-guided targeted biopsy was performed in three cases (25.0%). Stone extraction during POC was performed in two patients (16.7%) and foreign body removal from the intrahepatic duct was performed in one patient. One patient underwent additional metal stent insertion under direct visualization. After POC, no stent migration or severe adverse events were seen in any case. CONCLUSIONS: POC using a multibending ultra-slim endoscope for diagnostic or therapeutic purposes can be performed effectively and safely through a LAMS after EUS-guided choledochoduodenostomy.

Intraoperative ultrasound-guided percutaneous hepatocholangiostomy applied in the cholangioscopic lithotripsy for hepatolithiasis and choledocholithiasis.

BACKGROUND: Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is a minimally invasive treatment for hepatolithiasis. But it may make a long cycle of treatment so that it was further improved to complete the percutaneous hepatic choledochotomy and choledochoscopic lithotripsy in phase I surgery. The aim of this study was to evaluate the efficacy of the modified technique comparing with laparoscopic choledochotomy. METHODS: Retrospective analysis of the clinical data of patients with hepatolithiasis or choledocholithiasis consulted at our hospital from February 2018 to December 2021. The cases were divided into two groups according to surgical modality, intraoperative ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (IUG-PTCSL) and laparoscopic choledochotomy lithotripsy (LC-L). Contrast analysis determined the advantages of the two approaches. RESULTS: IUG-PTCSL was performed in 44 patients, aged 58.14 ± 14.01 years, including 9 male and 35 female. There were 15 patients underwent LC-L, aged 62.13 ± 15.03 years, including 1 male and 14 female. There was not statistically significant difference in the composition of patients' age and sex between the two groups (p = 0.356, 0.219). The success rate of intraoperative ultrasound-guided percutaneous hepatic bile duct puncture was 100% followed with the success rate of hepatocholangiostomy was 100%. Although 1 (1/44) patient showed significant bleeding during choledochoscopic lithotripsy and was converted to open choledochotomy for stone extraction, 43 patients completed IUG-PTCSL with the rate of phase I surgical stones removal was 81.40% (35/43), whereas the stones removal rate of LC-L was 66.67% (10/15). There was not statistically significant difference between them (p = 0.067). Both the groups showed no significant complications with the postoperative hospital stay of 8 (6, 10) days and 10 (8, 11) days, respectively, and the difference was statistically significant (p = 0.028). CONCLUSION: Intraoperative ultrasound-guided percutaneous transhepatic cholangioscopy might be a safe and reliable ideal method for bile duct stones with the advantages of rapid recovery for patients. Intraoperative ultrasound-guided percutaneous hepatocholangiostomy may be the key technique for the successful completion of the surgery.

Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow-up of endoscopic ultrasound-guided choledochoduodenostomy: Multicenter evaluation from the Leuven-Amsterdam-Milan Study Group.

OBJECTIVES: Long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) performed with lumen apposing metal stents (LAMS) have been poorly evaluated in small or retrospective series, leading to an underestimation of LAMS dysfunction. METHODS: All consecutive EUS-CDS performed in three academic referral centers were included in prospectively maintained databases. Technical/clinical success, adverse events (AEs), and dysfunction during follow-up were retrospectively analyzed. Kaplan-Meier analysis was used to estimate dysfunction-free survival (DFS), with Cox proportional hazard regression to evaluate independent predictors of dysfunction. RESULTS: Ninety-three patients were included (male 56%; mean age, 70 years [95% confidence interval (CI) 68-72]; pancreatic cancer 81%, metastatic disease 47%). In 67% of procedures, 6 mm LAMS were used. Technical and clinical success were achieved in 97.8% and 93.4% of patients, respectively, with AEs occurring in 9.7% (78% mild/moderate). Dysfunction occurred in 31.8% of patients after a mean of 166 days (95% CI 91-241), with an estimated 6 month and 12 month DFS of 75% and 52%, respectively; mean DFS of 394 (95% CI 307-482) days. Almost all dysfunctions (96%) were successfully managed by endoscopic reintervention. Duodenal invasion (hazard ratio 2.7 [95% CI 1.1-6.8]) was the only independent predictor of dysfunction. CONCLUSIONS: Endoscopic ultrasound-guided choledochoduodenostomy shows excellent initial efficacy and safety, although stent dysfunctions occurs frequently during long-term follow-up. Almost all stent dysfunctions can be managed successfully by endoscopic reinterventions. We propose a comprehensive classification of the different types of dysfunction that may be encountered and rescue procedures that may be employed under these circumstances. Duodenal invasion seems to increase the risk of developing EUS-CDS dysfunction, potentially representing a relative contraindication for this technique.

Endoscopic ultrasound-guided biliary drainage: a literature review / Drenagem biliar endoscópica ecoguiada: revisão da literatura

ABSTRACT Neoplasms of the biliopancreatic confluence may present with obstruction of the bile tract, leading to jaundice, pruritus and cholangitis. In these cases drainage of the bile tract is imperative. Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a choledochal prosthesis is an effective treatment in about 90% of cases, even in experienced hands. In cases of ERCP failure, therapeutic options traditionally include surgical bypass by hepaticojejunostomy (HJ) or percutaneous transparietohepatic drainage (DPTH). In recent years, endoscopic ultrasound-guided biliary drainage techniques have gained space because they are less invasive, effective and have an acceptable incidence of complications. Endoscopic echo-guided drainage of the bile duct can be performed through the stomach (hepatogastrostomy), duodenum (choledochoduodenostomy) or by the anterograde drainage technique. Some services consider ultrasound-guided drainage of the bile duct the procedure of choice in the event of ERCP failure. The objective of this review is to present the main types of endoscopic ultrasound-guided biliary drainage and compare them with other techniques.

RESUMO Neoplasias da confluência biliopancreática podem cursar com obstrução da via biliar, levando a icterícia, prurido e colangite. Nesses casos a drenagem da via biliar é imperativa. A colangiopancreatografia endoscópica retrógrada (CPER) com colocação de prótese coledociana constitui tratamento eficaz em cerca de 90% dos casos mesmo em mãos experientes. Nos casos de insucesso da CPER, tradicionalmente as opções terapêuticas incluem a derivação cirúrgica por hepaticojejunostomia (HJ) ou drenagem percutânea transparietohepática (DPTH). Nos últimos anos as técnicas endoscópicas ecoguiadas de drenagem biliar ganharam espaço por serem menos invasivas, eficazes e apresentarem incidência aceitável de complicações. A drenagem endoscópica ecoguiada da via biliar pode ser realizada pelo estômago (hepatogastrostomia), duodeno (coledocoduodenostomia) ou pela técnica de drenagem anterógrada. Alguns serviços consideram a drenagem ecoguiada da via biliar o procedimento de escolha no caso de insucesso da CPER. O objetivo desta revisão é apresentar os principais tipos de drenagem biliar endoscópica ecoguiada e confrontá-los com outras técnicas.

Treatment of ectopic variceal bleeding at choledochojejunostomy by endoscopic glue injection therapy with cyanoacrylate: Report of three cases including long-term outcomes.

Ectopic varices around the choledochojejunostomy site after pancreatoduodenectomy are rare. Diagnosing ectopic varices is difficult but, if untreated or misdiagnosed, the resulting mortality is high. This report describes three cases of ectopic variceal bleeding at the choledochojejunostomy site that were improved by endoscopic glue injection therapy (EGIT) with cyanoacrylate (CA). Case 1 was a 68-year-old man admitted to the hospital with hematemesis and melena. Six years prior, the patient underwent a total pancreatectomy for intraductal papillary mucinous adenocarcinoma. We diagnosed ectopic variceal rupture at the choledochojejunostomy site and controlled bleeding by EGIT with alpha-CA (αCA). Two recurrences of bleeding were improved by EGIT. Case 2 was a 71-year-old man admitted to the hospital with melena. Two and a half years prior, the patient underwent pancreatoduodenectomy for pancreatic head adenocarcinoma. We found the red plug on the ectopic varices at the choledochojejunostomy site through endoscopic observation and performed EGIT with αCA. He had no recurrence. Case 3 was a 77-year-old woman admitted to the hospital with melena. Eleven years prior, the patient underwent pancreatoduodenectomy for chronic pancreatitis at the pancreatic head. We controlled ectopic variceal bleeding at the choledochojejunostomy site by EGIT with αCA. Seven years after EGIT, ectopic varices could not be identified with an endoscope and there was no recurrence of ectopic bleeding.

Transient Biliary Fistula After Pancreatoduodenectomy Increases Risk of Biliary Anastomotic Stricture.

BACKGROUND: Biliary fistula after pancreatoduodenectomy (PD) is associated with significant morbidity and mortality. The aim of this study was to determine the risk of early postoperative biliary fistula for developing biliary anastomotic stricture after PD. METHODS: Retrospective review of all PD performed for various indications at a single institution between 2013 and 2018. Postoperative biliary fistulae were graded according to the International Study Group of Liver Surgery (ISGLS) as grade A-C. Multivariable analysis was performed for all comparative patient subgroups. RESULTS: A total of 843 patients underwent PD for malignant (68%) and benign (32%) indications. Postoperative biliary fistula developed in 66 (8%) patients; ISGLS grade A in 29 (3%), grade B in 32 (4%), and grade C in 5 (0.6%). Ninety-day mortality was 3% (25 patients). The remaining 818 patients were evaluated with a median follow-up of 16 months (IQR, 5-32 months). Biliary anastomotic stricture developed in 41 (5%) patients at a median of 10 months (IQR, 6-18 months) postoperatively. Strictures were managed with percutaneous (27 patients, 66%) or endoscopic (14 patients, 34%) stenting. No biliary stricture required operative anastomotic revision. Postoperative biliary fistula (HR, 4.4; 95% CI, 2.0-9.9; P = 0.0002) was associated with biliary anastomotic stricture; an increased risk for biliary anastomotic stricture was seen in patients with grade A (HR, 6.4; 95% CI, 2.4-16.9; P = 0.0002) and grade B (HR, 3.6; 95% CI, 1.2-10.9; P = 0.02) postoperative biliary fistula. CONCLUSION: Postoperative biliary fistula after pancreatoduodenectomy, including clinically insignificant, transient biliary fistula, is associated with an increased risk of a late biliary anastomotic stricture requiring stenting.

What is the better surgical treatment option for recurrent common bile duct stones?

PURPOSE: Repeating endoscopic retrograde cholangiopancreatography (ERCP) in patients with recurrent common bile duct (CBD) stones is problematic in many ways. Choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) are 2 surgical treatment options for recurrent CBD stones, and each has different advantages and disadvantages. The aim of this study was to compare the 2 surgical options in terms of the recurrence rate of CBD stones after surgical treatment. METHODS: This retrospective multicenter study included all patients who underwent surgical treatment due to recurrent CBD stones that were not effectively controlled by medical treatment and repeated ERCP between January 2006 and March 2015. We collected data from chart reviews and medical records. A recurrent CBD stone was defined as a stone found 6 months after the complete removal of a CBD stone by ERCP. Patients who underwent surgery for other reasons were excluded. RESULTS: A total of 27 patients were enrolled in this study. Six patients underwent CDS, and 21 patients underwent CJS for the rescue treatment of recurrent CBD stones. The median follow-up duration was 290 (180-1,975) days in the CDS group and 1,474 (180-6,560) days in the CJS group (P = 0.065). The postoperative complications were similar and tolerable in both groups (intestinal obstruction; 2 of 27, 7.4%; 1 in each group). CBD stones recurred in 4 patients after CDS (4 of 6, 66.7%), and 3 patients after CJS (3 of 21, 14.3%) (P = 0.010). CONCLUSION: CJS may be a better surgical option than CDS for preventing further stone recurrence in patients with recurrent CBD stones.

Biliary Anastomotic Stricture after Surgical Management of Mirizzi Syndrome: Treated with Long-term Percutaneous Transhepatic Biliary Drainage / 대한췌담도학회지

Mirizzi syndrome (MS) is a rare complication of cholecystolithiasis that is characterized by obstruction of the common hepatic duct due to mechanical compression by impacted stones in the neck of the gallbladder or the cystic duct. Treatment of MS is surgical, and operative procedure would vary depending on its classification type. Biliary stricture after surgical treatment of MS is an unusual complication and endoscopic approach is not possible for patients who have undergone bilioenteric anastomosis. We report a case of a 60-year-old patient with biliary anastomotic stricture after surgical management of MS who was successfully treated with long-term percutaneous transhepatic biliary drainage.

Research advances in sump syndrome / 临床肝胆病杂志

Sump syndrome is a rare complication of side-to-side choledochoduodenostomy (CDD) and occasionally occurs after spontaneous gallbladder-bile duct-digestive tract fistula or end-to-side choledochojejunostomy.Before the development of minimally invasive surgery,conventional surgical operation used to be the most important treatment method.This article reviews the research advances in sump syndrome in recent years and points out that endoscopic retrograde cholangiopancreatography is the major diagnostic method for this disease,and endoscopic sphincterotomy combined with bile duct debridement is the most simple and effective measure for the treatment of sump syndrome.Meanwhile,this article briefly reviews sump syndrome with reference to related literature and clinical practice,in order to raise the awareness for sump syndrome.

Laparoscopic Common Bile Duct Exploration: 9 Years Experience from a Single Center.

INTRODUCTION: The aim of the study was to evaluate the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) through cholangiotomy with T-tube placement in one séance for common bile duct stones (CBDS). METHODS: Between January 2005 and December 2010, a total of 99 patients with CBDS stones undergoing LCBDE with T-tube insertion at Enköping Hospital, Sweden, were registered prospectively. All patients were followed up by review of the patient records according to a standardized protocol. RESULTS: No severe intraoperative complications were registered. Four procedures required conversion to open cholecystectomy due to impacted stones or technical difficulty. The mean operative time was 194 min [(SD) 57 min]. The mean postoperative hospital stay was 4.8 days, SD 2.4 days. At secondary cholangiography, 2 (2%) retained stones were found. Two (2%) patients had minor bile leakage, which resolved spontaneously. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis, or cholangitis. No death within 30 days after surgery was seen. No patient was readmitted with clinical signs of stricture. CONCLUSION: If performed by a surgeon familiar with the technique, LCBDE is a safe and feasible alternative for managing CBDS. The advantages are most pronounced in the case of multiple and large CBDS. The risk for retained stones and stricture is low.

The rat choledochojejunostomy model for microsurgical training.

PURPOSE: The feasibility of a rat choledochojejunostomy (CJ) training model was investigated, as an introductory model to microsurgery for general surgeons. METHODS: Roux-en-Y CJ was performed on 20 rats. Interrupted 10-0 prolene sutures were used to perform CJ. The animals were observed for 7 days and sacrificed and examined. RESULTS: The rats were divided into 2 groups of 10 based on surgical order. The CJ time showed a significant decrease from 36.2 ± 5.6 minutes in group 1 to 29.4 ± 5.7 minutes in group 2 (P = 0.015). The bile leakage rate was 40% in group 1 and 10% in group 2. The survival time was 5.4 ± 2.2 days in group 1 and 7 days in group 2 (P = 0.049). CONCLUSION: The rat CJ training model is a feasible introductory model for general surgeons with no previous experience in microsurgery.

The rat choledochojejunostomy model for microsurgical training

PURPOSE: The feasibility of a rat choledochojejunostomy (CJ) training model was investigated, as an introductory model to microsurgery for general surgeons. METHODS: Roux-en-Y CJ was performed on 20 rats. Interrupted 10-0 prolene sutures were used to perform CJ. The animals were observed for 7 days and sacrificed and examined. RESULTS: The rats were divided into 2 groups of 10 based on surgical order. The CJ time showed a significant decrease from 36.2 ± 5.6 minutes in group 1 to 29.4 ± 5.7 minutes in group 2 (P = 0.015). The bile leakage rate was 40% in group 1 and 10% in group 2. The survival time was 5.4 ± 2.2 days in group 1 and 7 days in group 2 (P = 0.049). CONCLUSION: The rat CJ training model is a feasible introductory model for general surgeons with no previous experience in microsurgery.

Endoscopic ultrasound guided interventional procedures.

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.

A coparative study of laparoscopic Roux-en-Y choledochojejunostomy vs open Roux-en-Y choledochojejunostomy / 中华普通外科杂志

Objective To compare the feasibility and safety of laparoscopic Roux-en-Y choledochojejunostomy versus open Roux-en-Y choledochojejunostomy.Methods From October 2011 to June 2013,37 patients underwent laparoscopic Roux-en-Y choledochojejunostomy (observation group) and 42 underwent open Roux-en-Y choledochojejunostomy (control group).We retrospectively compare the two groups in terms of operation time,intraoperative blood loss,length of incision,postoperative hospital stay,postoperative gastrointestinal function recovery time,incision infection rate and the incidence of biliary fistula after surgery.Results In observation group operation time was (275.43 t 12.28) min,higher than that of control group (189.12 ± 19.35) min (P =0.031),intraoperative blood loss was (83.13 ±6.34) ml,incision length (5.76 ±0.7) cm,postoperative recovery time of gastrointestinal tract of (43.33 ±3.15) h,postoperative hospital stay (12.65 ± 2.19) d,were in favor of the observation group which were respectively (180.37 ±9.67) ml,(18.51 ±1.9) cm,(70.45 ±4.97) h and (22.16 ±4.61) d (t =33.17,36.73,33.17,P ＜ 0.05).Postoperative incision infection rate in observation group was 5.4％,lower than the control group (19.07％) (chi-square =22.12,P ＜ 0.05).Between the two groups there was no significant difference in the incidence of biliary fistula.Conclusions Laparoscopic Roux-en-Y hepatojejunostomy is safe,effective,and less traumatic procedure.

Value of laparoscopic cholecystectomy through the superior margin of public symphysis approach / 中华消化外科杂志

Objective To investigate the value of laparoscopic cholecystectomy through superior margin of public symphysis approach.Methods The clinical data of 72 patients with benign gallbladder diseases who were admitted to the Lihuili Hospital from December 2012 to August 2013 were retrospectively analyzed.There were 54 patients with cholecystolithiasis and 18 with gallbladder polyps.Thirty patients received laparoscopic cholecystectomy through the superior margin of public symphysis approach (new method group).Forty-two patients who received transumbilical single-port laparoscopic cholecystectomy were in the control group.The operation time,intraoperative blood loss,duration of postoperative hospital stay,degree of postoperative pain and cosmetic effect of the 2 groups were compared.Patients were followed up via out-patient examination and phone call till December 2013.Data were analyzed using the t test or chi-square test.Results Two patients in the new method group and 1 patient in the control group were converted to receive traditional laparoscopic cholecystectomy.The operation time,intraoperative blood loss,duration of postoperative hospital stay,scores of satisfaction with the incision and degree of postoperative pain were (28 ± 3) minutes,(23 ± 10) mL,(2.0 ± 0.5) days,4.3 ± 0.5 and 5.8 ± 0.8 in the new method group,and (39±4)minutes,(24±l0)mL,(2.0±0.6)days,3.9±0.5 and 5.9±0.9 in the control group.There were significant differences in the operation time and score of satisfaction with the incision between the 2 groups were detected (t =10.032,2.423,P ＜ 0.05),while no significant differences in the volume of intraoperative blood loss,duration of postoperative hospital stay and degree of pain between the 2 groups (t =1.021,0.000,1.760,P ＞ 0.05).All the patients were recovered,and were administered with semi-fluid food at postoperative day 2.No bleeding,bile leakage,incisional infection occurred,and no patient died perioperatively.Analgesics were not needed in the 2 groups.All the patients were followed up for 1-6 months.Patients were satisfied with the cosmetic appearance of the incision,and no inflammation,pain and infection of the incision occurred.Conclusions Laparoscopic cholecystectomy through the superior margin of public symphysis approach is safe and feasible,with the advantages of short operation time,cosmetic appearance of incision and easy manipulation.

Percutaneous transhepatic biliary drainage using a ligated catheter for recurrent catheter obstruction: antireflux technique.

Percutaneous transhepatic biliary drainage (PTBD) is an established procedure for biliary obstruction. However, duodenobiliary or jejunobiliary reflux of the intestinal contents through a PTBD catheter sometimes causes recurrent catheter obstruction or cholangitis. A 64-year-old female patient with a history of choledochojejunostomy was referred to our department with acute cholangitis due to choledochojejunal anastomotic obstruction. Emergent PTBD was performed, but frequent obstructions of the catheter due to the reflux of intestinal contents complicated the post-PTBD course. We therefore introduced a catheter with an antireflux mechanism to prevent jejunobiliary reflux. A commercially available catheter was modified; side holes were made at 1 cm and 5 to 10 cm (1 cm apart) from the tip of the catheter, and the catheter was ligated with a nylon thread just proximal to the first side hole. Using this novel "antireflux PTBD technique," jejunobiliary reflux was prevented successfully, resulting in a longer patency of the catheter.

Percutaneous Transhepatic Biliary Drainage Using a Ligated Catheter for Recurrent Catheter Obstruction: Antireflux Technique

Percutaneous transhepatic biliary drainage (PTBD) is an established procedure for biliary obstruction. However, duodenobiliary or jejunobiliary reflux of the intestinal contents through a PTBD catheter sometimes causes recurrent catheter obstruction or cholangitis. A 64-year-old female patient with a history of choledochojejunostomy was referred to our department with acute cholangitis due to choledochojejunal anastomotic obstruction. Emergent PTBD was performed, but frequent obstructions of the catheter due to the reflux of intestinal contents complicated the post-PTBD course. We therefore introduced a catheter with an antireflux mechanism to prevent jejunobiliary reflux. A commercially available catheter was modified; side holes were made at 1 cm and 5 to 10 cm (1 cm apart) from the tip of the catheter, and the catheter was ligated with a nylon thread just proximal to the first side hole. Using this novel "antireflux PTBD technique," jejunobiliary reflux was prevented successfully, resulting in a longer patency of the catheter.