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PubMed1995

Imaging of the common bile duct during laparoscopic cholecystectomy: sonography versus videofluoroscopic cholangiography.

OBJECTIVE: The purpose of this prospective study was to compare the accuracies of laparoscopic sonography and laparoscopic videofluoroscopic cholangiography in detecting common bile duct stones and in identifying ductal anomalies during laparoscopic cholecystectomy. SUBJECTS AND METHODS: Ninety-five patients who underwent laparoscopic videofluoroscopic cholecystectomy were prospectively studied with laparoscopic sonography and laparoscopic videofluoroscopic cholangiography. The number of successful studies, the time required to complete the study, and complications resulting from the study were recorded. The biliary system was evaluated for complete visualization of the common bile duct, visualization of the cystic duct, ductal anomalies, maximum diameter of the common bile duct, and common bile duct stones and/or debris. Also determined was whether laparoscopic sonographic findings altered operative management. RESULTS: Laparoscopic sonography was successfully performed in 93 of 95 patients, and laparoscopic videofluoroscopic cholangiography was successfully performed in 90 of 95 patients. The time required to complete laparoscopic sonography ranged from 3 to 18 min (mean +/- SD, 8 +/- 3 min), and that required to complete laparoscopic cholangiography ranged from 5 to 28 min (mean +/- SD, 14 +/- 6 min). Laparoscopic sonography visualized the complete common bile duct in 84 of 93 patients, and laparoscopic cholangiography did so in 86 of 90 patients. Laparoscopic sonography showed the cystic duct in 87 of 93 patients, and laparoscopic cholangiography did so in 80 of 90 patients. Laparoscopic sonography showed no ductal anomalies in any of the 93 patients. Laparoscopic cholangiography showed ductal variants in 13 of 90 patients; however, 11 of the variants were proximal to the sonographic scan plane. Laparoscopic sonography showed common bile duct stones in 12 of 93 patients, and laparoscopic cholangiography did so in five of 90 patients. Laparoscopic sonography altered operative management in two of 93 patients. CONCLUSION: Our results show that laparoscopic sonography is as accurate as laparoscopic videofluoroscopic cholangiography in visualizing the common bile duct and cystic duct and in detecting common bile duct stones. However, the data are too limited to determine whether laparoscopic sonography is as accurate as laparoscopic cholangiography in detecting ductal anomalies.

Adult↗
PubMed2002

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct.

BACKGROUND: Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence. METHODS: A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used. RESULTS: Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients. CONCLUSION: Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :

Aged↗
PubMed1980

Surgical significance of dilatation of the common bile duct--with special reference to choledocholithiasis.

Diameter of the common bile duct was measured in 3,119 patients who underwent primary operation for gallstones, during the period from 1975 to 1978. Although dilatation of the common bile duct was most marked in patients with bilirubin stones in the bile duct alone, dilatation was also observed in patients with cholesterol stones in the gallbladder alone. Drip infusion cholangiograms of 84 healthy patients showed that the common bile duct dilated in parallel with aging. A review of patients with congenital choledochal cysts reported in the literature in Japan revealed that few had gallstones. Thus, it was difficult to determine whether common bile duct dilatation was the cause or result of gallstones, and it was suggested that the so-called drainage operation such as choledochoenterostomy should be done only under strict indications.

Adult↗
PubMed1994

An autopsy case of pseudosarcoma of the common bile duct.

An autopsy case of pseudosarcoma in the common bile duct is reported. An 82-year-old Japanese male complaining of jaundice was admitted to our hospital; he was examined by abdominal ultrasonography (US), revealing biliary calculus, dilatation of the common bile duct, and choledocholithiasis, considered to be the possible cause of the obstructive jaundice. Endoscopic retrograde biliary drainage (ERBD) and cholangioscopy were performed concurrently, revealing a vaguely whitish tumor near the papilla of Vater. Two months later, the patient died from complications of the liver, infection, and disseminated intravascular coagulation (DIC). An autopsy study revealed tumor cells with extreme pleomorphic changes, growing diffusely, very like sarcoma. Further examination revealed epithelioid arrangements in the metastatic lymph node. Twelve kinds of immunohistochemical examination showed a positive reaction, reflecting the presence of an epithelioid cytoskeleton. Of 28 cases of true and pseudosarcoma of the biliary system reported in the Japanese literature, only 1 case was reported, in 1990, to involve the common bile duct. We therefore report the present case of pseudosarcoma of the common bile duct.

Aged↗
PubMed2004

Percutaneous cystic duct stent placement for the treatment of acute cholecystitis resulting from common bile duct stent placement for malignant obstruction.

Common bile duct (CBD) stent placement to relieve malignant biliary obstruction can occasionally cause cystic duct obstruction and acute cholecystitis. Cholecystostomy tube placement is often performed in patients with limited life expectancy but can have a significant impact on quality of life. To allow cholecystostomy tube removal, percutaneous metallic stent placement was performed across the cystic duct via the tube tract in such a patient. The procedure included traversal across the previously placed CBD stent. At 5-month follow-up, the patient remained symptom-free. In select patients who develop acute cholecystitis after CBD stent placement for malignant obstruction, percutaneous stent placement across the cystic duct may be considered a treatment option.

Acute Disease↗
PubMed1993

Posterior superior pancreaticoduodenal vein: mimic of distal common bile duct at sonography.

OBJECTIVE: Previous investigators have noted that the common bile duct may appear to merge with the portal vein on sagittal sonograms, mimicking a venous structure. The posterior superior pancreaticoduodenal vein courses adjacent to the distal part of the common bile duct within the pancreatic head. A prospective study was performed to assess the sonographic appearance of the posterior superior pancreaticoduodenal vein. SUBJECTS AND METHODS: The study included 50 consecutive subjects in whom the pancreatic head was well seen. Anatomic characteristics of the posterior superior pancreaticoduodenal vein were noted with gray-scale, duplex Doppler, and color Doppler sonography. The site of insertion of the posterior superior pancreaticoduodenal vein into the portal vein was noted. RESULTS: The posterior superior pancreaticoduodenal vein was visualized in all 50 cases. Although it usually (82% of cases) inserted into the posterior aspect of the portal vein, the posterior superior pancreaticoduodenal vein inserted into the anterior aspect of the portal vein in nine cases (18%), resulting in an appearance mimicking the common bile duct on sagittal sonograms. Doppler examination showed flow toward the portal vein in all obliquely oriented posterior superior pancreaticoduodenal veins, and in 40% overall. The common bile duct could always be followed into the porta hepatis and was anterior to the posterior superior pancreaticoduodenal vein in 49 cases (98%). CONCLUSION: The posterior superior pancreaticoduodenal vein can be seen routinely on sonograms when the pancreatic head is unobscured, and it can mimic the common bile duct in a significant number of cases. These structures can be distinguished by noting continuation of the common bile duct into the porta hepatis, the generally anterior position of the common bile duct, and flow in the posterior superior pancreaticoduodenal vein on Doppler examination. Awareness of the existence and anatomy of the posterior superior pancreaticoduodenal vein minimizes its confusion with the common bile duct at sonographic examination.

Adolescent↗
PubMed2004

Feasibility of laparoscopic common bile duct exploration in a rural centre.

BACKGROUND: Laparoscopic common bile duct exploration has emerged as a preferred option for the management of choledocholithiasis. The present study sought to review the feasibility of this technique in a rural centre. METHODS: A comprehensive retrospective review was undertaken of all patients who underwent surgical treatment of biliary calculi in Lismore, NSW (Australia), between January 1996 and December 2002. RESULTS: During the study period, 1567 consecutive patients underwent laparoscopic cholecystectomy, of whom 82 (5.2%) had choledocholithiasis identified at intraoperative cholangiography. A total of 86 laparoscopic common bile duct explorations were undertaken in these patients, 37 (43%) via a transcystic approach, and 49 (57%) via a laparoscopic choledochotomy. All common bile duct calculi were successfully removed in 78 cases, representing an overall duct clearance rate of 90.7%. Complications were noted in seven patients, a morbidity rate of 8.5%. Median operative time for the procedure over the study period was 173 min. Median hospital stay was 6 days for all patients. CONCLUSIONS: Laparoscopic common bile duct exploration can be successfully undertaken in a rural setting by general surgeons who have appropriate laparoscopic experience, and should be the procedure of choice for the management of choledocholithiasis in these patients. It should not be restricted to specialized surgical departments in major referral centres.

Cholecystectomy, Laparoscopic↗
PubMed2002

[Primary common bile duct closure after choledochotomy].

OBJECTIVE: To investigate the rationality and feasibility of primary closure of the common bile duct after choledochotomy for common bile duct calculi. METHODS: From January 1990 to June 2001, 386 patients with the evidence of stones in the common bile duct underwent choledochotomy. Among them, 215 received primary closure of the common bile duct (group A) and 171 T-tube drainage (group B). The patients with emergency operations were excluded. Intraoperative choledochoscopy or cholangiography was routinely performed to rule out the possibility of retained stones. The duct was meticulously stitched using 0/3 to 0/5 absorbent sutures for primary closure. A T-tube was placed in the subhepatic space in the patients of both groups. RESULTS: Postoperative bile leakage was seen in 9 patients of group A and in 5 of group B, respectively (P > 0.05), and no reoperations were necessary. After surgery, the average time and volume of transfusion was 4.9 days and 9.1 liters in group A, versus 7.3 days and 12.8 liters in group B (P < 0.01). The patients in group B had a longer postoperative hospital stay than the those in group A (average 17.6:10.0 days, P < 0.01). T-tube removal resulted in bile peritonitis in 5 patients at day 16, 17, 19, 21 and 22 after surgery in group B, and 3 patients required repeated surgery. CONCLUSIONS: Primary closure of the common bile duct after choledochotomy is safe, effective, and inexpensive in selected patients with common bile duct calculi, and should be regarded as an alternative procedure.

Adult↗
PubMed1979

[Idiopathic congenital dilatation of the common bile duct and pregnancy. Report of one case, reflexions and comments (author's transl)].

Congenital idiopathic dilatation of the common bile duct, called commonly and incorrectly congenital cyst of the common bile duct, is sometimes diagnosed during pregnancy. The latter may be the source of severe complications. The disease should thus be treated rapidly, even if the pregnancy is at a late stage. In a case of this type we carried out surgical treatment in two stages: firstly simple external drainage of the common bile duct and of the gall bladder and only after labour has been brought to term by Caesarian section, for breech presentation, was a cystojejunostomy carried out on a Y shaped jejunal loop.

Adult↗
PubMed1991

Transduodenal exploration of the common bile duct in patients with nondilated ducts.

Exploration of the small common bile duct can be technically difficult and is associated with a significant risk of ductal injury or late stricture, or both. Transduodenal common duct exploration after sphincteroplasty (TCDE/S) is an alternative method of duct exploration that avoids choledochotomy. Cholecystectomy followed by TCDE/S was performed upon 28 patients with nondilated ducts and suspected choledocholithiasis. Common duct stones were retrieved in 17 patients. Failure to retrieve stones in the remaining 11 patients was attributed to either false-positive results of cholangiography, forceful passage of stones into the duodenum during the initial insertion of a Fogarty catheter through the cystic duct or a false-negative finding at duct exploration. There was no perioperative mortality. Two patients had asymptomatic postoperative hyperamylasemia. One patient had postoperative pancreatitis, hyperbilirubinemia and cholangitis that resolved with antibiotic therapy by the eighth postoperative day. Other complications included wound infection, delayed gastric emptying, pneumonia and otitis media. The over-all morbidity rate was 28.6 per cent. Long term follow-up was obtained in all 28 patients. All patients in the follow-up group are free of recurrent biliary tract disease. TCDE/S appears to be a safe and effective method of exploring the nondilated common bile duct.

Adult↗
PubMedDate not supplied

Laparoscopic treatment of common bile duct stones.

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct is technically possible. The aim of this prospective study was to evaluate the feasibility of the different techniques of laparoscopic treatment of common bile duct stones and their complications. MATERIALS AND METHODS: From October 1990 to December 1995, 161 patients, age from 18 to 92, underwent a laparoscopic treatment for choledocholithiasis. A transcystic approach was attempted in 82 patients and was successful in 55 (67%). The failures were treated by 22 laparoscopic choledochotomies and in five patients by postoperative endoscopic sphincterotomy. A choledochotomy was performed in 101 cases and was successful in 97 (96%). The failures were treated by three laparotomies with a failure of intra-hepatic stone extraction and one postoperative endoscopic sphincterotomy. There were four residual lithiasis treated with endoscopic sphincterotomy. There were two failures treated one by laparotomy and one by laparoscopy. The total success rate was 92% (148/161). RESULTS: There was no postoperative mortality. There were five local complications, two abscesses, one liver injury, one small hemorrhage at the trocar site, and one pain lasting for more than 48 hours. There were seven general complications: two cardiac failures (medical treatment), one severe pancreatitis, one digestive hemorrhage, one psychiatric disorder, and two postoperative ileus. The total morbidity rate was 7.4% (12/161). Mean hospital stay was 7.6 days (2-36). CONCLUSIONS: Laparoscopic exploration of the common bile duct appears to be safe and effective. It could be included in the protocol of management of choledocholithiasis.

Adolescent↗
PubMed1997

What predicts gastroenterologists' and surgeons' diagnosis and management of common bile duct stones?

BACKGROUND: Because the literature suggests numerous indicators of common bile duct stones, we undertook a systematic assessment of physicians' judgments of the clinical utility of eight indicators: patient age, history of jaundice, history of pancreatitis, levels of serum alanine aminotransferase, alkaline phosphatase, amylase, and total bilirubin, and common bile duct diameter on ultrasonography. METHODS: Random samples of 1500 gastroenterologists and 1500 surgeons were sent a survey asking them to indicate the importance of each potential indicator of common bile duct stones, the likelihood of common bile duct stones for each of nine clinical vignettes, and whether they would order a preoperative ERCP. An abbreviated survey was sent to nonrespondents. RESULTS: Although there was substantial variation in the importances assigned to each indicator, the most important indicators were serum total bilirubin and diameter of common bile duct on ultrasound. The best predictors of the decision to order an ERCP were perceived likelihood of stones and specialty. The average threshold for ordering an ERCP was 37%. Respondents did not differ from nonrespondents in the perceived importance of the eight indicators. CONCLUSIONS: The substantial variation among gastroenterologists and surgeons regarding the optimal approach to common bile duct stones has clinical implications. Patients will receive varying recommendations for care, depending on whom they see.

Adult↗
PubMed1999

Laparoscopic common bile duct exploration: long-term outcome.

HYPOTHESIS: Transcystic laparoscopic common bile duct exploration (LCBDE) with biliary endoscopy results in excellent long-term clinical outcome and patient satisfaction. DESIGN: Prospective cohort study of unselected patients found to have common bile duct stones during laparoscopic cholecystectomy between October 1989 and April 1998. A mailed survey assessed symptoms, outcome, and satisfaction. SETTING: A large community teaching hospital. PATIENTS: Two hundred seventeen patients with common bile duct stones. INTERVENTION: Transcystic LCBDE with choledochoscopy. MAIN OUTCOME MEASURES: Success of LCBDE, morbidity, postoperative symptoms, and satisfaction. RESULTS: One hundred sixteen surveys (54%) were returned. Mean follow-up was 60 months. The LCBDE procedure failed in 6 patients and endoscopic retrograde cholangiopancreatography was performed in 4 patients (3%). One patient had unsuspected retained stones. No patient had late recognition of retained stones or a bile duct stricture. Abdominal pain was present in 90 patients (89%) preoperatively and in 29 patients (26%) postoperatively (P = .001). The LCBDE procedure reduced 3 specific pain profiles: epigastric, from 47% (n = 54) to 7% (n = 8); back, from 31% (n = 36) to 6% (n = 7); and shoulder, from 18% (n = 21) to 2% (n = 2). When pain persisted, it was different in character in 15%. All nonpain symptoms (such as nausea, bloating, indigestion, and gas) were reduced from 78% (n = 91) to 34% (n = 39) (P = .001) except diarrhea. Diarrhea was present in 24 patients (22%) preoperatively and postoperatively, though it was a new postoperative symptom in 11 patients (11%). One hundred two patients (95%) were satisfied or mostly satisfied with LCBDE. CONCLUSIONS: Pain and nonpain symptoms, while reduced significantly after LCBDE, may persist. The LCBDE procedure does not result in common bile duct strictures or a significant rate of retained stones. This relatively new treatment for common bile duct stones is safe and effective.

Cholecystectomy, Laparoscopic↗
PubMed1991

[A comparative electron microscope study on the fine structure of the muscular coat in the common bile duct].

Little is known about the architecture of common bile duct, especially smooth muscle, except for Oddi's sphincter. The purpose of this study is to reveal the ultrastructural architecture of the upper part of the common bile duct from the viewpoint of comparative anatomy. Animals used in this study were the hamster, rat, dog, monkey and rabbit, and the results obtained were as follows. There were considerable differences in the structural appearance and distribution of smooth muscle cells in the upper part of the common bile duct among the animals examined. In the rat, a small number of smooth muscle cells were sparsely distributed in the subepithelial connective tissue of the duct. In the dog, smooth muscle cells showed a star-shaped appearance with many cytoplasmic processes, by which networks were formed. In the monkey, smooth muscle cells with fibroblast-like appearance were circularly distributed. In the monkey and rabbit, muscular coats consisting of typical smooth muscle cells were observed in the outermost layer of the duct. The muscular coat in the monkey was arranged longitudinally, and in the rabbit circularly. The muscular coat in the rabbit was thicker than that in the monkey. In the hamster, however, the duct wall was devoid of smooth muscle cells. The present study suggests that the occurrence of smooth muscular coat is not essential for transport of the bile.

Animals↗