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PubMed2006

Pylephlebitis associated with acute infected choledocholithiasis.

Pylephlebitis, also called septic thrombophlebitis of the portal vein, is a life-threatening complication of intra-abdominal infection. Although rare, it remains a less recognized entity with a high rate of mortality. We present a 66-year-old man with acute infected choledocholithiasis complicated with Bacteroides fragilis bacteremia. The contrast-enhanced computed tomography scan of the abdomen showed nearly total thrombotic occlusion of the left portal vein. The comprehensive studies for hypercoagulation disorders all yielded negative results. After endoscopic extraction of bile duct stones and broad-spectrum antibiotic therapy, the patient recuperated with complete recanalization of the occluded portal vein. To our knowledge, pylephlebitis associated with acute infected choledocholithiasis has never been reported. This report details the clinical features, radiographic findings, pathogenesis, and treatment of this distinctly unusual manifestation. Early identification of pylephlebitis and underlying intra-abdominal infection can be achieved by exquisite imaging studies with raised awareness in the clinical setting. Eradication of infectious foci and judicious administration of antimicrobials are essential to reduce the catastrophic morbidity and mortality of pylephlebitis.

Abdominal Cavity↗
PubMed2006

Accuracy of MDCT in the diagnosis of choledocholithiasis.

OBJECTIVE: Our purpose was to evaluate the diagnostic performance of contrast-enhanced and unenhanced MDCT, performed for various indications, in detecting choledocholithiasis. CONCLUSION: Unenhanced and contrast-enhanced MDCT images, interpreted in PACS workstations with axial images, are moderately sensitive and specific for showing choledocholithiasis.

Adolescent↗
PubMed2006

Endoscopic papillary balloon dilation with large balloon after limited sphincterotomy for retrieval of choledocholithiasis.

Endoscopic papillary balloon dilation (EBD) for choledocholithiasis is known to be comparable to endoscopic sphincterotomy (EST) especially in cases of small stones. With larger stones, EBD with conventional balloon, which have a diameter of 6-8 mm, was reported as less effective for extraction of stones. We evaluated the efficacy and complications of EBD with large balloons (10-15 mm) after limited EST for retrieval of choledocholithiasis. From February 2005, we have performed EBD with limited EST for retrieval of common bile duct (CBD) stones. The patients who admitted with hyperamylasemia and gallstone pancreatitis were excluded. In cases without CBD dilation, EPBD with 12 mm for 40 seconds was performed. And in cases with CBD dilation, we dilated the sphincters with 15 mm sized balloon for 40 seconds. Total 22 patients (11 of male) were performed EBD with limited EST for retrieval of CBD stones. The median diameter of the stones was 10 mm (5-25 mm). Ten cases had multiple stones and 6 cases periampullary diverticuli. Successful stone removal in the initial session of ERCP with EBD was accomplished in 16 patients (72.7%). And complete retrieval of bile duct stones was achieved in all patients with repeated ERCP. In the aspect of complications, any episodes of perforation, bleeding was not developed. Only one case of mild grade of post-procedural pancreatitis was noted. However, post-procedural hyperamylasemia was developed in 16 cases (68.2%). EBD with larger balloon seems to be a feasible and safe alternative technique for conventional EST in CBD stone extraction.

Aged↗
PubMed2006

Choledocholithiasis: evolving standards for diagnosis and management.

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct (CBD) stones. CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancreatography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMedDate not supplied

[Endoscopic removal of a Dormia basket impacted in the biliary tract during treatment of a difficult residual choledocholithiasis. Report of a case].

OBJECTIVE: The authors report their experience about the treatment of a broken Dormia in CBD in elder with "difficult" residual choledocholithiasis, with T tube. DESIGN: Report of case. Evaluation of effectiveness of endoscopic treatment with 2-years follow-up. SETTING: Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico "Paolo Giaccone"--Palermo. INTERVENTION: Endoscopic removal of Dormia broken and impacted in CBD after 2 session of extracorporeal shock wave lithotripsy (ESWL). RESULTS: Resolution of the pathology with 2 session of ERCP and cholangiographic control. CONCLUSIONS: ERCP and ES are the gold standard in the treatment of choledocholithiasis. Rare complication of this method is the rupture of Dormia Basket in CBD: this occurrence can be solved by endoscopy, but only in well experienced endoscopic teams.

Aged↗
PubMed2003

[Transhepatic cholangioscopy in the treatment of choledocholithiasis].

Endoscopic methods gained the leading position in the treatment of choledocholithiasis. Transhepatic cholangioscopy and contact lithotripsy is used, if standards methods (ERC) are not successful. The transhepatic approach is predominantly used for the therapy of complicated choledocholithiasis. Cholangioscopy and lithotripsy can be performed after PTC, external drainage of bile ducts and dilatation of intrahepatic channel. The success rate for transhepatic methods is 90 to 100%, the major complication rate is 5 to 7.5%.

Bile Ducts↗
PubMed2004

[Surgical policy in patients with chronic calculous cholecystitis complicated by choledocholithiasis].

Results of surgical treatment in 116 patients with chronic calculous cholecystitis complicated by choledocholithiasis were studied. Introduction in clinical practice of endoscopic papillosphincterotomy (EPST) and laparoscopic cholecystectomy changed surgical policy for benign combined lesions of gall bladder and extrahepatic bile ducts. Complex endoscopic treatment is preferable if contraindications are absent. Complex endoscopic treatment was used in 26.7% cases, combined surgical and endoscopic (trans-papillar surgeries) - in 30.2%, conventional surgical - in 33.6%. Isolated EPST and endo-biliary procedures were performed in 9.5% patients. Complex endoscopic treatment is preferable for chronic calculous cholecystitis complicated with choledocholithiasis. Combined and conventional surgical policy is indicated when appliance of endoscopic technologies is not possible.

Adolescent↗
PubMed2004

Intraoperative monitoring of the biliary tracts as a means of preventing choledocholithiasis oversight.

The aim of the work is to assess the performance and effectiveness of intraoperative cholangiography or choledochoscopy in the prevention of choledocholithiasis oversight. The effectiveness of choledochoscopy was assessed in 50 patients during the years 2001-2002. Since 2000 intraoperative cholangiography has been performed on all patients after classic cholecystostomy in the absence of indications to choledochotomy. The effectiveness of intraoperative cholangiography was assessed in 50 patients in 2001. Both groups underwent ultrasonographic control and tests of biochemical parameters a year after surgery. The advisability of performing intraoperative cholangiography or choledochoscopy and their high degree of effectiveness in the prevention of choledocholithiasis oversight was confirmed.

Biliary Tract↗
PubMed2004

[The treatment of esophageal microbiocenosis in patients with choledocholithiasis by enteral feeding].

The results of studying of alimentary canal microbiocenosis in 40 patients with choledocholithiasis are presented. There was determined that the patients with mechanical jaundice had the degree (30%) of disbiosis twice higher then patients without jaundice. The oligomer enteral mixture "Peptamen" (Nestle) was used in the comolex postoperative therapy. The way of correction of disbiosis by enteral tube feeding in patients with choledocholithiasis had allowed to improve the results of surgical treatment by decrease of postoperative complications frequence by 22.7% and to reduce the hospital treatment duration by 3.6 days.

Adult↗
PubMed2005

[Two-stage policy of treatment of cholelithiasis complicated with choledocholithiasis].

Results of endo-surgical treatment in 81 patients with choledocholithiasis are analyzed. There were 60 women and 21 men aged from 24 to 77 years. It is demonstrated that inclusion of octreotid and dicetel in combined two-stage treatment of choledocholithiasis decreases the risk of pancreatitis and bleeding after endoscopic papillosphincterotomy, number of postoperative complications, hospital stay, cost of treatment and provides good cosmetic effect.

Adult↗
PubMed2005

[A case of spontaneous biloma complicated with choledocholithiasis and chronic cholecystitis].

A biloma is an encapsulated bile collection outside the biliary tree. Most cases of biloma are caused by iatrogenic injury or trauma. Intrahepatic rupture of the biliary tree due to nontraumatic cause is a rare event. A 68- year-old man was admitted because of abdominal pain and fever. He had no past history of abdominal surgery, instrumentation or trauma. Computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) demonstrated a large subcapsular fluid collection in the right liver associated with choledocholithiasis and cholecystitis. Biloma was confirmed by sono-guided percutaneous needle aspiration and was drained through a pigtail catheter. After the successful treatment by percutaneous drainage and endoscopic sphincterotomy, the patient recovered. Here, we report an uncommon case of spontaneous biloma formation in association with choledocholithiasis with a review of literatures.

Aged↗
PubMedDate not supplied

A "one-stage" laparoscopic procedure for treating choledocholithiasis.

OBJECTIVES: A minimally invasive approach is considered the treatment of choice for gallbladder stones. We report our experience with the treatment of choledocholithiasis. METHODS: From January 1993 to December 2002, 3118 patients underwent minimally invasive surgery for symptomatic gallstones, 2681 for gallbladder stones and 437 (14%) for cholecysto-choledocholithiasis. RESULTS: We performed endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy in 71 patients (18.7%) with high operative risks, transcystic clearance and transcystic drainage in 96 cases (26.2%) and transcholedochal clearance with a T-tube in 270 cases (73.8%). In 2 patients, residual stones were removed with endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Postoperative stay ranged from 4 days to 12 days. No morbidity or mortality occurred. CONCLUSION: In our experience, "one-stage" laparoscopic procedure for cholecystocholedocholithiasis is safe and effective in skilled hands.

Adult↗
PubMed2004

[Exploration of biliary tracts for laparoscopy for treatment of choledocholithiasis].

BACKGROUND: Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made in the preoperative work-up it is a common practice to refer patients to endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during the intraoperative cholangiogram the surgeon confronts a therapeutic dilemma between laparoscopic common bile exploration, conversion to open surgery or post-operative endoscopic sphincterotomy. OBJECTIVE: We have opted to resolve the choledocholithiasis in only one session during the laparoscopic cholecystectomy, with the transcystic common bile duct exploration technique using the choledochoscope, or with laparoscopic choledochotomy. We report our early experience in terms of success of stone removal, operative time, morbidity, mortality and hospital stay. METHODS: from 1992 to 2003 we performed 460 laparoscopic cholecystectomies and using selective cholangiography in 138 patients (30%) we found 52 patients with common bile duct stones, for an incidence of 11.3%. RESULTS: Of this group we performed laparoscopic common bile duct exploration in 46 patients, and our success rate for stone removal was 95.6% (44 of 46) with only two failures related to multiple stones and impactation at the ampulla for a conversion rate of 4%. The mean operative time was 120 +/- 40 min. A morbidity of 8.6% was found, with no mortality. Hospital stay was 48 hrs. Mean recovery time was 7 days, and time to return to work 15 +/- 3 days. CONCLUSIONS: We concluded that must of the patients with common bile duct stones found during laparoscopic cholecystectomy can be treated with success using the laparoscopic technique with choledochoscopy, without increased morbidity or mortality, and with a short hospital stay and recovery time similar to patients in whom only laparoscopic cholecystectomy is perform. According to our results we encourage that this method should become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography.

Adolescent↗
PubMed1979

Choledocholithiasis associated with acute cholecystitis.

A retrospective review of the records of 1,507 patients with a diagnosis of cholecystitis was conducted for the five-year period, 1972 to 1977. Of this group of patients, a histopathologic diagnosis of acute cholecystitis was established in 154 patients (10.2%). Common duct calculi were detected in 17 of these 154 patients, an incidence of 11%. Preoperative evaluation by means of serum bilirubin and alkaline phosphatase levels and intravenous cholangiography was unsatisfactory for consistent demonstration of choledocholithiasis in the presence of acute cholecystitis. Intraoperative cholangiography was found to be the most reliable method for detection of common duct calculi and was successfully employed in 14 of 17 patients with choledocholithiasis. The remaining three patients had palpable stones.

Acute Disease↗
PubMed1991

Choledocholithiasis in acute gallstone pancreatitis. Incidence and clinical significance.

A prospective study of choledocholithiasis was performed using 110 patients with presumptive diagnoses of acute gallstone pancreatitis. The incidence of migrating and persistent bile duct stones was determined using stool screening and intraoperative cholangiography, and the clinical significance of continued stone obstruction of the papilla was investigated using ultrasound assessment of migration time and a second evaluation of prognostic signs. Pancreatic inflammation was confirmed at surgery in 51 patients, of whom only 27 had stones in the stools (n = 22) or the bile duct (n = 5), suggesting that choledocholithiasis may not be the sole triggering factor of acute gallstone pancreatitis. Neither delayed migration nor persistent stone obstruction of the papilla promoted pancreatic inflammation.

Acute Disease↗
PubMed1995

Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis.

The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative ES. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative ES, has been developed. A prospective assessment of the use of peroperative ES in 13 patients in whom choledocholithiasis was demonstrated with operative cholangiography is presented. Eleven patients had successful ES and clearance of stones. The CBD could not be cannulated in one patient, and an adequate ES for stone extraction could not be performed in the remaining patient. Both procedures were converted to open CBD exploration. Complications were mild postoperative pancreatitis (two patients) and pulmonary atelectasis (one). The median total operating time was 165 min and the median postoperative hospital stay was 3 days. Peroperative ES at the time of laparoscopic cholecystectomy provides a safe technique for clearance of the CBD.

Adult↗
PubMed1996

Laparoscopic treatment of known choledocholithiasis.

BACKGROUND: Occasionally patients present to the surgeon with known common duct stones. These will frequently have been detected by imaging modalities: ultrasound, computed tomography (CT) scans, transhepatic cholangiogram (THC) or IV cholangiography. Occasionally there are stones that had failed attempts at endoscopic retrieval (ERCP). METHODS: A retrospective analysis of a prospectively gathered database of 77 laparoscopic common bile duct explorations was done to assess the incidence, treatments and outcomes of patients who had known common duct stones (CDS) before surgery. RESULTS: Eighteen patients (23%) were identified as having a preoperative diagnosis of CDS. All underwent a laparoscopic common bile duct exploration. This exploration was successful in all cases. Outcomes were good with a 4% complication rate and one case of retained common duct stones (4%). CONCLUSIONS: Before laparoscopic cholecystectomy, known choledocholithiasis was considered a surgical disease except in cases of acute cholangitis or the very morbidly ill. The ability to perform cholecystectomy laparoscopically made many practitioners avoid open common duct exploration and, instead, rely on ERCP as primary treatment for known or suspected common duct stones. As techniques of laparoscopic common duct exploration improve, the ability to deal with common duct pathology surgically has increased, offering new options for treatment of this patient population. We present our experience with 18 patients who presented with known choledocholithiasis and were treated laparoscopically with good results.

Gallstones↗
PubMed1988

Bile duct measurements after ceruletide as an aid to the ultrasound diagnosis of choledocholithiasis.

Despite good results in gallbladder imaging, ultrasound (US) diagnosis of choledocholithiasis remains a challenge. The value of US before and after a provocative injection of the decapeptide ceruletide was examined in 25 patients with suspected common duct stones immediately prior to diagnostic retrograde cholangiography. An abnormal response (increase in US duct diameter) was seen in 4 of 6 patients with an obstructed duct, giving a sensitivity of 67% and predictive value of 80% for the procedure. There was a normal response (decrease in US diameter of a dilated duct or decrease/no change in a normal duct) in 14 of 19 with an unobstructed duct (specificity 79%, predictive value 93%) and an equivocal response (no change in diameter of a dilated duct) in 5 patients. In 1 patient a calculus not seen on the initial US became visible as the duct distended by ceruletide administration. Symptoms after ceruletide were few and not discriminatory. Although it added to the time and difficulty of performing biliary US, ceruletide administration proved a useful adjunct to the diagnosis of choledocholithiasis.

Bile Ducts↗