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PubMedDate not supplied

[Celioscopic treatment of choledocholithiasis: strategic problems. A clinical case].

The authors report a case of suspected calculosis of the common bile duct (CBD) associated with cholecystolithiasis, both of which were treated using a coelioscopic approach. Using a flexible Olympus 5 mm urethroscope and Schuller-type urethral dilator sound, it was possible to explore the choledochus visually using a transcystic route prior to dilating the latter gradually and attempting to extract calculi using Dormia's probe. In selected cases of calculosis of the common bile duct, with a dilated cystic duct, it is possible to explore the choledochus using a transcystic route but it is not yet possible to extract stones at the same time. If, on the other hand, the choledochus is further dilated, it is preferable and more satisfactory to perform a choledochotomy using a coelioscopic route. In the light of coelioscopic progress and its diagnostic and therapeutic possibilities, the authors report their criteria for suspected lithiasis of the common bile duct and attribute a precise and important role to echo-endoscopy since its results lead to a different therapeutic strategy.

Endoscopy, Digestive System↗
PubMedDate not supplied

[Neonatal choledocholithiasis: a case report].

Cholelithiasis as cause of jaundice in newborn is rare. Usually is associated with known predisposing factors as hemolysis, congenital anomalies of biliary tree, total parenteral nutrition, prolonged fasting. However there are recent signals in literature about idiopathic neonatal cholelithiasis, that seems to be more common than previously suspected. We describe a case of idiopathic neonatal choledochal lithiasis with spontaneous resolution in few days from jaundice beginning. The importance of ultrasonographic investigation for diagnosis and follow-up is confirmed. However, because it is often a self limiting phenomenon, an aggressive approach is not warranted in the asymptomatic infant.

Age Factors↗
PubMed1995

Endoscopic sphincterotomy for suspected choledocholithiasis in patients with and without stones.

OBJECTIVE: To characterize a subgroup of patients treated with endoscopic sphincterotomy (ES) for a suspected common bile duct lithiasis (CBDL) that was not confirmed and to compare it with the subgroup with confirmed CBDL. METHODS AND RESULTS: Over 18 months, ES was successful in 245 consecutive patients (age 23-97, mean 75 yr, SE 17 yr) with suspected CBDL; 159 patients had CBDL (group 1), and 86 did not (group 2), as confirmed by CBD exploration. Fifty-nine percent of the patients in group 1 and 76.7% of the patients in group 2 had gallbladder in situ. Both groups were different for age (p < 0.001), prevalence of chronic alcoholism (p < 0.001), gallbladder in situ (p < 0.01), and gallbladder stones (p < 0.05). Patients from group 1 had two or more presenting symptoms suggestive of CBDL more often than patients from group 2 (p < 0.05), and pancreatitis was a more frequent presenting manifestation in group 2 (p < 0.0001). Overall morbidity and mortality were not different between groups, but acute cholecystitis developed in six patients from group 2 and in one patient from group 1 (p < 0.01). In a univariate analysis, only elevated alkaline phosphatase and a dilated common bile duct were positively discriminant for the diagnosis of CBDL; chronic alcoholism was negatively discriminant for the diagnosis of CBDL. In a multivariate analysis, only chronic alcoholism and a dilated bile duct were found to be independently discriminant. CONCLUSION: The risk of ES-related complications in the group without CBDL suggests that the selection of patients should be improved by a better use of preoperative criteria.

Adult↗
PubMed1995

[Preoperative instrumental diagnosis of postoperative choledocholithiasis].

Experience in examination of 221 patients with postoperative cholangiolithiasis is discussed. Analysis of the results of instrumental examination ERPCG to surpass all the existing methods of diagnosis of stones in the bile ducts in informativeness and safety. A diagnostic algorithm of examination is suggested by means of which the necessary tactical problems connected with the forthcoming operation were solved in 98.2% of cases.

Adult↗
PubMed1995

Transduodenal sphincterotomy for stenosing papillitis and massive choledocholithiasis after Billroth II gastrectomy.

Management of stenosing papillitis with massive cholecystodocholithiasis in patients previously operated upon with a Billroth II (B-II) type gastrectomy, is a challenging clinical problem. Endoscopic papillotomy in these patients has been described, but the success rate is low especially in the presence of a long afferent loop of the gastrojejunostomy and/or extensive adhesions. Long-standing common bile duct (CBD) stones lead to varying degrees of papillary stenosis. The latter could predispose to new stone formation because of the damaged CBD mucosa and varying degrees of stasis. In this paper we describe a simple method for intraoperative assessment of the papillary calibre and distensibility by correlation to the diameter of an inflated balloon catheter. This method has been used successfully in the management of five patients with no stone recurrence in the dilated CBD at follow-up.

Aged↗
PubMed1994

[Asymptomatic choledocholithiasis associated with diabetic neuropathy. Report of a case].

A case of severe autonomic diabetic neuropathy with abolished visceral pain sensitivity is reported. A patient was admitted who presented jaundice without abdominal pain. Diabetes was diagnosed. The pathogenesis of jaundice was traced to the inflammation of a postoperative stenosis of the choledochus. An episode of gallstone disease had occurred 7 years before. Interestingly, although there were stones located both in the gallbladder and in the distal extremity of the choledochus, no pain was present. Possible relationships between gallstone disease and diabetic autonomic neuropathy are discussed.

Diabetic Neuropathies↗
PubMed1994

Laparoscopic cholecystectomy: laboratory predictors of choledocholithiasis.

Liver function tests (LFTs) are most often employed to select patients for preoperative endoscopic retrograde cholangiography (ERC) and therapeutic sphincterotomy. Although ERC accurately detects CBD stones, the associated financial costs and potential morbidity argue against its indiscriminate use. We analyzed the value of LFTs to predict CBD stones in patients treated by laparoscopic cholecystectomy (LC). CBD stones were identified in 41 of 660 patients (6.2%) treated by LC during the study period (January 1991 to May 1993). CBD stones were identified by preoperative ERC in 19 of 33 patients (57.6%); by operative cholangiography in 18 of 289 patients (6.2%), and by postoperative ERC in 4 patients. In patients with CBD stones, there was a significant difference in alkaline phosphatase, total bilirubin, SGPT, and SGOT (P < 0.001). The positive predictive value (PPV) of a value > normal at admission was 5%-19%; and immediately before operation was 9%-36%. The PPV of a value > 2X normal was 30%-47%. Alkaline phosphatase and total bilirubin were independent predictors of CBD stones. If both were greater than twice normal, there was a 55 per cent incidence of CBD stones. Our analysis suggests that patients with greater than twice normal liver function tests have a sufficient incidence of CBD stones to warrant ERC. Patients without both these criteria should be managed by laparoscopic CBDE, with postoperative endoscopic stone retrieval for the failures of laparoscopic CBDE.

Adult↗
PubMed1994

[Combined use of laparoscopic cholecystectomy and endoscopic retrograde cholangiography (ERC) and papillotomy (ERCP) in management of cholecysto-choledocholithiasis].

In a review of 328 cases the combination of laparoscopic cholecystectomy with specific use of endoscopic retrograde cholangiography (pre- and postoperatively) proved to be a riskless, secure and time-saving procedure. In our opinion this is a minimal invasive method of treatment for patients with cholecysto-/choledocholithiasis.

Adult↗
PubMed1994

[Endoscopic techniques in therapy of choledocholithiasis].

Endoscopically, approximately 85% of all bile duct stones can be removed immediately after successful papillotomy. For the remaining cases, complete clearance of the bile duct is achieved by lithotripsy techniques. Due to the lower risks, endoscopic treatment is preferable.

Cholecystectomy, Laparoscopic↗
PubMed1994

[Laparoscopic techniques in therapy of choledocholithiasis].

Several methods for therapy of common bile duct stones (CBDS) during laparoscopic cholecystectomy are available. After intraoperative cholangiography laparoscopic removal of CBDS can be achieved via the cystic duct or a choledochotomy using a thin cholangioscope, balloon catheters and Dormia baskets. Lithotripsy (electrohydraulic or laser) is necessary in presence of larger stones. Also combined procedures with intraoperative antegrade or retrograde papillotomy have been described. Published studies show that laparoscopic common bile duct exploration can be performed successfully by experienced surgeons. However, these procedures are demanding and time-consuming. Further evaluation is essential.

Cholangiography↗
PubMed1994

[Choledocholithiasis--therapeutic splitting].

Despite new developments like chemolitholysis and extracorporeal shock wave lithotripsy, conventional cholecystectomy was the "gold standard" in the treatment of gallstones. The range of indications and the operative strategy were well standardized, although the management of common bile duct stones in gallstone disease was still under debate. For high-risk and elder patients endoscopic retrograde cholangio-pancreatography (ERCP), papillotomy and stone extraction was established, in younger patients the best management was questionable. According to better and more accurate preoperative tests like ultrasound and the ample evidence of the function of the papilla after endoscopic papillotomy the trend seemed to be the preoperative endoscopic bile duct clearance in all patients, just when the "bushfire" of laparoscopic cholecystectomy arised and until then praised standards were thrown overboard because of technical difficulties. Routine intraoperative cholangiography (IOC) was replaced by indicated selective IOC due to the lack of talent of many surgeons. Only the therapeutic concept of the removal of the stone-bearing gallbladder survived all new concepts and the debate of whether to perform routine IOC and whether to clear the bile ducts--pre-, intra- or postoperatively or primarily or secondarily convert to open cholecystectomy and bile duct revision. In the eye of a new "gold standard" and according to the literature and our own results we should standardize our management especially in the era of laparoscopic cholecystectomy as "therapeutical splitting" with indicated and selective preoperative ERCP and bile duct clearance offers the best results and facilitates minimally invasive surgery.

Adult↗
PubMed1994

[Percutaneous radiologic techniques in therapy of choledocholithiasis].

Interventional radiology offers a variety of techniques for percutaneous manipulation of intrahepatic and extrahepatic bile duct stones via the T-tube be tract and the transhepatic route, including extraction, fragmentation, transpapillary expulsion of stones into the duodenum, and chemolysis. These techniques can be combined with extracorporeal lithotripsy, balloon dilatation and electroincision of stenoses and implantation of metallic stents. Removal of stones via the T-tube tract is just as successful as endoscopic stone manipulation and leaves the papilla of Vater intact. Percutaneous transhepatic stone manipulation is more difficult and potentially more dangerous, and is restricted to patients where the endoscopic approach is not possible or operative techniques have been exhausted.

Combined Modality Therapy↗