EUS-guided choledochoduodenostomy for palliative biliary drainage in case of papillary obstruction: report of 2 cases.
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Aged, 80 and over↗
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Efficacy and safety of endoscopic ultrasound-guided choledochoduodenostomy compared with endoscopic ultrasound-guided gallbladder drainage for palliation of malignant distal biliary obstruction: a systematic review and meta-analysis.
BACKGROUND AND AIMS: When ERCP is not feasible or fails in the palliation of malignant distal biliary obstruction (MDBO), EUS-guided choledochoduodenostomy (EUS-CDS) and EUS-guided gallbladder drainage (EUS-GBD) are viable alternatives. We conducted a systematic review and meta-analysis comparing the safety and efficacy of the 2 techniques for the palliation of MDBO. METHODS: Multiple databases were searched through November 2025 for studies that reported outcomes of EUS-CDS and EUS-GDB in patients with MDBO. A meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% CIs. We compared the rates of technical and clinical success, overall adverse events (AEs), and lumen-apposing metal stent dysfunction. A random-effects model was used for our meta-analysis, and heterogeneity was assessed using the I2 (%) statistics. RESULTS: Five studies (352 patients; EUS-CDS: 193 and EUS-GBD: 159) were included. Technical success was 93.3% (95% CI, 70.6-98.8) for EUS-CDS and 95.9% (95% CI, 90.0-98.4) for EUS-GBD (RR, 1.02; 95% CI, 0.94-1.10; P = .6). Clinical success was 90.1% (95% CI, 84.7-93.7) versus 86.6% (95% CI, 80.3-91.0) (RR, 0.97; 95% CI, 0.90-1.05; P = .4). There were no significant differences in overall AEs (19.7% vs 17.6%; RR, 0.93; 95% CI, 0.58-1.48; P = .8), severe AEs (11.0% vs 8.3%; RR, 0.69; 95% CI, 0.33-1.44; P = .3), or stent dysfunction (15.0% vs 14.5%; RR, 0.95; 95% CI, 0.35-2.58; P = .9). CONCLUSIONS: EUS-GBD appears comparable to EUS-CDS in terms of technical and clinical success, AEs, and stent dysfunction. Further prospective studies are warranted to corroborate our findings.
Humans↗
Computed tomographic cholangiography in the diagnosis of bile duct injury in children.
A case of avulsion of the extrahepatic bile duct from the duodenum is described in association with severe liver trauma in a child. The value of computed tomographic (CT) cholangiography and laparoscopy in the diagnosis of this rare condition is outlined, and a paradigm for management is described.
Accidents, Traffic↗
Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy.
PURPOSE: The aim of this study was to describe the technical experience and outcome in laparoscopic-assisted total cyst excision of choledochal cyst with Roux-en-Y hepatoenterostomy. METHODS: Thirty-five patients with choledochal cyst were studied. Their age ranged from 3 months to 9 years (average age, 3.6 years). The choledochal cysts were cyst type in 33 cases and fusiform type in the other 2 cases. Four trocars were utilized with 3- to 5-mm instrumentation. Under laparoscopic guidance, the gallbladder and the dilated bile duct were excised completely. The Roux-en-Y jejunojejunostomy was performed extracorporeally by exteriorizing the jejunum through the extending umbilical incision (1.5 to 2 cm), and an end-to-side hepaticojejunostomy was carried out intracorporeally by the hand suture methods. RESULTS: Average duration of operation was 4.3 hours (range, 3.5 to 7.6 hours), intraoperative blood loss was 5 to 10 mL, and 8 of the 35 patients had associated hepatic ductal stenosis and underwent laparoscopic excision of the cyst and ductoplasty. In 1 of the 8 cases, bile leak was noticed from day 1 through 26 postoperatively. The postoperative course was uneventful in the other 34 patients with a hospital postoperative stay ranging from 3 to 6 days. There were no postoperative complications in the 3-month to 1(1/2)-year follow-up. CONCLUSIONS: Laparoscopic-assisted total cyst excision with Roux-en-Y hepatoenterostomy is feasible for the treatment of choledochal cyst in children.
Anastomosis, Roux-en-Y↗
Laparoscopic resection of congenital choledochal cyst, hepaticojejunostomy, and externally made Roux-en-Y anastomosis.
The authors present a 3-month-old patient with a congenital choledochal cyst, which was asymptomatic until treatment. On laparoscopy, a type I choledochal cyst was confirmed and excised laparoscopically. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. A laparoscopic end-to-side hepaticojejunostomy was carried out. The operation lasted 4(1/2) hours, without intraoperative problems. Oral food intake was started on day 2 and well tolerated with bile stained stools. Symptoms of bowel obstruction occurred on day 8. On minilaparotomy, the Roux-en-Y anastomosis was found to be adherent to the mesenterium of the colon, leading to obstruction. After mobilizing the loop, the postoperative course was uneventful. We conclude that laparoscopic resection of congenital choledochal cyst and choledochojejunostomy was feasible in the youngest patient operated on so far. However, adhesive small bowel obstruction can also occur, as after conventional operation, when the bowel is exteriorized for Roux-en-Y hepaticojejunostomy.
Anastomosis, Roux-en-Y↗
Management of children with pancreatic head mass.
The management of children with a mass in the head of the pancreas is not well defined. The medical records of 3 children with obstructive jaundice because of a mass in the head of the pancreas over a 4-year period were reviewed retrospectively. Abdominal ultrasonography and computed tomography showed intrahepatic and extrahepatic ductal dilatation and a pancreatic mass. Intraoperative frozen section revealed no evidence of malignancy. These patients were separately managed by pylorus-preserving pancreaticoduodenectomy, cholecystectomy and Roux-en-Y choledochojejunostomy, common duct exploration, and T-tube drainage. The final pathology of the pancreatic head mass in all cases demonstrated chronic pancreatitis. Follow-up at an average of 7 months postoperatively showed no recurrence of obstructive jaundice. Unlike adults with a mass in the head of the pancreas, it is recommended that children with similar presentation should undergo biopsy and biliary diversion rather than resection as the primary therapy. Adults presenting with similar radiologic and clinical features would be treated by a pancreaticoduodenectomy in the absence of histologic evidence of malignancy. This series would suggest histologic conformation should be obtained before radical surgery in children.
Adolescent↗
Regulation of bile acid synthesis under reconstructed enterohepatic circulation in rats.
Cholesterol 7alpha-hydroxylase (CYP7A1) is regulated by bile acids through the farnesoid X receptor (FXR) mechanism in a negative feedback fashion. However, the fact that CYP7A1 is down-regulated by intraduodenal administration of bile acid, but not by intravenous administration may not be explained only by this mechanism. The aim of this study was to establish a new rat model with reconstructed or simulated enterohepatic circulation to examine if intravenous or portal administration of bile acid can regulate CYP7A1. Under biliary drainage, taurocholate (0 or 6 micromol/h/100g body weight) was administered continuously for 48h into the duodenum (ID-0/ID-6), femoral vein (IV-0/IV-6), or portal vein (IP-0/IP-6) to create a condition in which biliary bile acids were continuously lost, and a similar dose of taurocholate was supplied to the liver simultaneously. CYP7A1 activity and mRNA expression of the ID-0 group were significantly increased compared with the no treatment (NT) group. CYP7A1 activity and mRNA expression of the ID-6 group were suppressed significantly to 41 and 46% of those of the ID-0 group, respectively. In the IV-6 and IP-6 groups, however, enzyme activity and mRNA expression were decreased slightly, but the suppression was not statistically significant. The results suggested that portal as well as intravenous administration of bile acids cannot suppress bile acid synthesis as effectively as intraduodenal administration. It was concluded that an unidentified regulatory factor other than the nuclear receptors may be involved in bile acid synthesis in vivo.
Alanine Transaminase↗
Do biliary endoprostheses decrease biliary complications after liver transplantation?
AIM: Most technical complications after orthotopic liver transplantation (OLT) are related to the biliary tree. This report reviews the role of routine intraoperative placement of stents to reduce biliary complications. METHODS: We retrospectively analyzed 396 consecutive OLTs. We reviewed rates of biliary complications after hepaticojejunostomy (HJA) as well as following choledochocholedochostomy (CCA) groups: "experimental" group (routine intraoperative biliary stenting, last 10 months), "recent" control group (nonstented, previous 10 months), "historical" control group (prior to that period of time). RESULTS: All groups were matched for donor/recipient characteristics and for graft cold/warm ischemia time. The overall prevalence of biliary complications was 30.7% after CCA versus 35% after HJA. In the experimental group 21 patients had a 4.8% biliary complication rate compared to the recent control and historical groups, where biliary complication rates were 30% and 32.6%, respectively (P <.05). CONCLUSIONS: The intraoperative use of biliary stents is feasible and appears to decrease the rate of biliary complications. These results support the need for a prospective randomized trial.
Choledochostomy↗
Biliary reconstruction without T-tube in liver transplantation.
Biliary complications have been reported in 9% to 34% of liver transplant patients. Although most centers seem to prefer a duct-to-duct anastomosis without a T-tube when feasible, the best method of biliary reconstruction remains controversial. The aim of this study was to review our experience on reconstruction of the biliary tract without drainage. Forty-one patients underwent 45 liver transplants over two periods. Forty patients underwent 15 liver transplants from October 1992 to March 1995; and 27 underwent 30 liver transplants from January 2002 to February 2003. Our standard biliary reconstruction was an end-to-end anastomosis without drain. The overall actuarial survival was 72.7% at 1 year, 64.7% at 3 years, and 56.6% at 5 years. The mean follow-up was 23 months. Eight patients (22.2%) developed biliary tract complications: five patients papillary dysfunction (13.9%); two, biliary stricture (5.5%); and one, biliary sludge without evidence of stricture (2.8%). Papillary dysfunction represented 62.5% of all complications. Biliary reconstruction without drainage may be routinely performed since the complications are only those not related to the T-tube.
Anastomosis, Surgical↗
Role of choledochojejunostomy in liver transplantation.
AIM: This study analyzes the efficacy and rate of complications related to Roux-en-Y choledochojejunostomy need either as the primary biliary reconstruction during orthotopic liver transplantation (OLT) or to treat biliary complications. METHODS: One hundred seventy-seven transplantation procedures were performed from September 1991 to December 2003 in recipients of mean age 51.9 years. Patients were reviewed for the type of biliary reconstruction, the prevalence of biliary complications, and the choice of treatment for these complications. Duct-to-duct anastomosis (group CDC) was performed in 153 patients (85.6%), and choledochojejunostomy (group CDJ) in 24 patients (14.4%). Biliary complications, including stenosis, bile leakage, calculosis, and extensive biliary necrosis, required hospitalization, surgical interventions or endoscopic approaches. Biliary complications in the CDC group first were addressed by endoscopic treatments. When endoscopic therapy failed, they were approached by surgical reintervention. All biliary complications in group CDJ were surgically treated, namely, revision of the Roux-en-Y choledochojejunostomy. The chi square test was used to compare frequencies, with Yates correction when necessary; P values were considered significant at <.05. The Mann-Whitney U test was used to evaluate survival. RESULTS: Fifty-eight (32.8%) biliary complications in 47 patients required endoscopic or surgical approaches. In group CDJ, 1 patient had bile leakage requiring surgical treatment. The prevalence of biliary complications was lower in the CDJ group than the CDC group (P < .05). Endoscopic treatment applied in 23 patients, failed in 11. Surgical approaches were performed in 11 patients after endoscopic failure, and in 13 patients as the first option to treat biliary complications. No failure was observed with surgical treatment. Cholangitis occurred in 3 patients who received surgical treatment and 4 patients who received endoscopic treatment. There was no statistically significant difference when comparing the mortality rates of the 3 types of treatment for biliary complications: endoscopy, surgery, and endoscopy followed by surgery. Survival rates were similar for the 3 types of treatment of biliary complications. CONCLUSION: Roux-en-Y choledochojejunostomy is a useful tool to treat biliary complications after OLT, especially when endoscopic treatment fails. In our experience, the rate of complications directly related to this technique is significantly lower than common duct anestomosis, whether used for biliary reconstruction during OLT or for posttransplantation biliary complications.
Anastomosis, Surgical↗
Preliminary study of choledochocholedochostomy without T tube in liver transplantation: a comparative study.
INTRODUCTION: Biliary anastomosis during liver transplantation can be safely performed using an end-to-end choledochocholedochostomy, with or without a T tube. The objective of this study was to determine whether the insertion of a T tube was related to more postoperative complications. METHODS: Between April 1986 and September 2004, we performed a retrospective, longitudinal, and comparative study of 1012 liver transplantations, including 50 adult recipients with a T tube and a control group with a choledochocholedochostomy without a T tube. RESULTS: T tube insertion was associated with more postoperative complications and worse actuarial survival of both the recipient and graft, though these differences did not reach statistical significance. CONCLUSION: The duct-to-duct biliary anastomosis stented with a T tube tends to be associated with more postoperative complications. Based on this analysis, we recommend the performance of a nonstented anastomosis.
Biliary Tract Diseases↗
Improved effects of viral gene delivery of human uPA plus biliodigestive anastomosis induce recovery from experimental biliary cirrhosis.
Gene therapy may represent a new avenue for the development of multimodal treatment for diverse forms of cirrhosis. This study explores the potential benefits of combining adenovirus-mediated human urokinase-plasminogen activator (AdHuPA) gene delivery and biliodigestive anastomosis to enhance the therapeutic efficacy of each treatment alone for cholestatic disorders resulting in secondary biliary cirrhosis. In an experimental model of secondary biliary cirrhosis, application of 6 x 10(11) vp/kg AdHuPA adenovirus vector resulted in 25.8% liver fibrosis reduction and some improvement in liver histology. The relief of bile cholestasis by a surgical procedure (biliodigestive anastomosis) combined with AdHuPA hepatic gene delivery rendered a synergistic effect, with a substantial 56.9 to 42.9% fibrosis decrease. AdHuPA transduction resulted in clear-cut expression of human uPA protein detected by immunohistochemistry and induction of up-regulation in the expression of metalloproteinases MMP-3, MMP-9, and MMP-2. Importantly, functional hepatic tests, specifically direct bilirubin, were improved. Also, hepatic cell regeneration, rearrangement of hepatic architecture, ascites, and gastric varices improved in cirrhotic rats treated with AdHuPA but not in counterpart AdGFP cirrhotic animals. We believe this might represent a novel therapeutic strategy for human cholestatic diseases.
Adenoviridae↗
[Percutaneous treatment of common bile duct lithiasis].
STUDY AIM: Biliary lithiasis in the main bile duct (particularly retained stones) may be treated percutaneously obviating reoperation or endoscopic sphincterotomy. The aim of this study was to determine risks and pitfalls of this approach. PATIENTS AND METHODS: Forty-two cases of biliary stones treated percutaneously between 1980 and 1998 were reported. Among them, 28 patients had already a biliary drainage and in 14, a drain was placed into the bile duct by transhepatic way or by punction of the intestinal loop of a bilio-jejunal anastomosis. The means to clear the bile ducts included percutaneous endoscopy and contact lithotripsy. Thirty patients had residual lithiasis (after a surgical intervention), 11 a new lithiasis above a bile duct stenosis and in 1 a bile duct lithiasis with a gallbladder lithiasis. RESULTS: Morbidity included four complications (9.5%--one severe) and no mortality. After 2.3 +/- 1 courses, desobstruction was complete in 33 cases (78.5%) and partial in one case (2.5%) allowing to optimize the patient for endoscopic sphincterotomy. Desobstruction failed in eight cases (19%), six patients were successfully treated by surgery and 2 by endoscopic sphincterotomy. CONCLUSIONS: Percutaneous desobstruction of the bile ducts may be proposed as a priority in patients with a biliary drain in place and when endoscopic sphincterotomy is impossible or contraindicated. These manoeuvres have a definitive place in hepato-biliary surgery.
Adult↗
[Monolobar Caroli's disease. Apropos of 12 cases].
BACKGROUND: Caroli's disease is the dilatation of the segmental intrahepatic bile ducts. It usually affects the entire liver but can occasionally involve only one lobe, commonly the left. This study included 12 cases of unilobular disease, nine localised in the left lobe and three in the right lobe, which were all treated by liver resection. PATIENTS AND METHODS: These 12 patients underwent surgery between 1974 and 1997. There were six men and six women (mean age: 51 years). The initial presentation and diagnosis were reported. The mean interval between the first symptoms and diagnosis was 12.5 years. Eight of the 12 patients had undergone 22 surgical or endoscopic procedures prior to liver resection. In the present series a preoperative ultrasonogram or CT scan established the diagnosis in all cases. Six patients did not have stones in the gallbladder. RESULTS: Surgical treatment consisted in seven left lobectomies, two left hepatectomies and three right hepatectomies (Couinaud's classification). A intrahilar cholangiojejunostomy was performed in five cases. Pathological examination showed cystic dilatation of the intrahepatic segmental and subsegmental bile ducts, measuring from a few millimetres to 4 cm, which contained calculi. Two cases were associated with congenital hepatic fibrosis. An intrahepatic focus of ectopic pancreatic tissue was seen in one case. There were no cases with cholangiocarcinoma. One patient developed a biliary fistula which required reoperation. All patients had an uneventful long term postoperative course except for one patient who died of colon carcinoma 3 years postoperatively. CONCLUSION: When associated with other malformations, most notably congenital hepatic fibrosis, this commonly diffuse disease is called Caroli's syndrome. The unilobar form, most usually involving the left lobe of the liver, is called Caroli's disease. Both monolobar and diffuse types are often characterised by recurrent bouts of cholangitis and, in over half of the cases, by common bile duct stones without gallbladder stones.
Adult↗
Laparoscopic common duct exploration in the management of choledocholithiasis.
BACKGROUND: Optimal treatment strategies for addressing common duct stones at laparoscopic cholecystectomy remain controversial. The study presents the authors' experience with laparoscopic common bile duct exploration (LCBDE). METHODS: A retrospective review was performed of 71 LCBDEs performed over 5 years using either transcystic duct flushing and mechanical techniques, transcystic duct basket retreival techniques, or laparoscopic choledochotomy. RESULTS: Laparoscopic CBDE resulted in ductal clearance in 61 of 71 (85%) cases with only 1 case of unsuspected retained common duct stones and only 1 major complication. Review of the cases that did not result in common duct clearance suggests that the success rate of laparoscopic CBDE could be increased. CONCLUSIONS: Laparoscopic CBDE is an effective treatment for concurrent gallstones and common duct stones and avoids the potential morbidity of an endoscopic sphincterotomy. General surgeons with adequate training and experience can perform laparoscopic CBDE safely and effectively.
Cholangiography↗
Primary bile reflux gastritis: diagnosis and surgical treatment.
Bile reflux gastritis has been recognized since the first successful gastric operations and has persisted for more than a century. Diagnosis has been difficult and non-operative therapy largely ineffective. Early attempts at surgical correction resulted in stomal ulceration and it was not until the advent of flexible endoscopy and other techniques that diagnosis became more secure. Operative attempts at correction have included the Roux-en-Y procedure, the Braun enteroenterostomy, and Henley jejunal interposition. None of the procedures has been uniformly successful, and the Roux-en-Y has resulted in a disabling stasis syndrome in most patients. The diagnosis of bile reflux without previous gastric surgery has been even more elusive and seems to be associated with previous cholecystectomy. Thirty-one patients diagnosed with primary bile reflux, having typical symptoms of epigastric pain, nausea, and bilious vomiting have been treated by diverting bile flow through a Roux-en-Y choledochojejunostomy without accompanying gastric resection or vagotomy. There were no operative deaths and no long-term problems, such as anastomotic stricture. Two patients had self-limited bile leaks. Twenty-seven of the 31 patients (87%) have achieved complete relief of symptoms and have no gastrointestinal complaints. Serial gastric emptying has demonstrated no alteration in 9 of 12 patients who were normal before operation, and improvement in 12 of the 19 (63%) patients with abnormal preoperative studies.
Anastomosis, Roux-en-Y↗
A review of 391 selected open cholecystectomies for comparison with laparoscopic cholecystectomy.
Laparoscopic cholecystectomy has become a popular operation, not only in the medical literature but also in the lay press. The most recent reports emphasize the advantages of the new method, comparing it with open cholecystectomy, using historical series of unselected patients. A review of 391 selected patients who underwent open cholecystectomy by the author in his private practice shows that open cholecystectomy has no mortality, a 4% incidence of complications, no biliary tract injury, and no need for readmission, reoperation, or blood transfusion. The criteria for selection were more restrictive than the ones used for laparoscopic cholecystectomy.
Adolescent↗
Palliative operations for pancreatic carcinoma.
Controversies in palliation of pancreatic carcinoma include the best biliary bypass, the best gastric by-pass, and how routinely gastric bypass should be used. We reviewed the records of 142 patients who underwent palliative operations for pancreatic carcinoma at the Cleveland Clinic over a 5-year period. Direct choledochal-enteric anastomosis proved superior to cholecystojejunostomy because of the high incidence of postoperative biliary sepsis and obstruction with the latter. The lowest incidence of these complications was achieved with choledochoduodenostomy. Loop gastrojejunostomy and Roux-Y gastrojejunostomy resulted in similar complication rates and postoperative stays, but, because loop reconstruction was simpler, it was deemed superior. Blood loss, operative time, and hospital stay were similar in patients with loop gastrojejunostomy and patients with no gastric bypass. This finding, coupled with a 10% incidence of subsequent gastric outlet obstruction in those without gastric bypass, indicates that gastric bypass should be liberally applied in the palliation of pancreatic carcinoma.
Adenocarcinoma↗