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PubMed1995

Biliary motility following endoscopic sphincterotomy for recurrent common bile duct stones.

BACKGROUND: Recurrent common bile duct (CBD) stones after cholecystectomy are a common biliary tract disease. The role of biliary emptying in the formation of these stones is not yet well defined. METHODS: Cholescintigraphy was used to evaluate the biliary motility in 50 cholecystectomized patients with recurrent CBD stones after endoscopic sphincterotomy (EST) with stone extraction. Complete clearance of the CBD stones was confirmed in all patients by endoscopic retrograde cholangiopancreatography. Absence of sphincter of Oddi (SO) pressure after EST was determined by means of biliary manometry, and 99mTc-diisopropyl iminodiacetic acid (DISIDA) cholescintigraphy was performed four to six weeks after recovery from sphincterotomy. RESULTS: Complete clearance of the radioisotopes from the bile duct within 1, and more than 1 hour, was observed in 3 (6%) and 47 (94%) of the patients, respectively. When a cutoff value of 2 hours indicating abnormal biliary motility was employed, 31 out of the 50 patients (62%) had delayed biliary emptying. In comparing the clinical parameters between the two groups, patients with delayed biliary emptying time demonstrated an increase in CBD size greater than those of the normals (11.7 +/- 0.5 vs 9.2 +/- 0.4 mm, p < 0.05), while the presence of juxtapapillary diverticula and length of time for recurrence of CBD stones after cholecystectomy were not significant. Follow-up study showed that repeated recurrence rate of CBD stones appeared to be higher in the patients associated with delayed (12.9%) rather than normal (5.3%) biliary emptying. CONCLUSIONS: These results suggested that, in the absence of a functioning SO, abnormal biliary motility in cholecystectomized patients is one of the clinical factors involved in the pathogenesis of recurrent CBD stones.

Adult↗
PubMed2001

The role of laparoscopy in the management of common bile duct obstruction in children.

BACKGROUND: Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. METHODS: Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. RESULTS: The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.

Adolescent↗
PubMed2002

Laparoscopic common bile duct exploration.

In recent years, laparoscopic common bile duct exploration has become the procedure of choice in the management of choledocholithiasis in several laparoscopic centers. The increasing interest for this laparoscopic approach is due to the development of instrumentation and technique, allowing the procedure to be performed safely, and it is also the result of the revised role of endoscopic retrograde cholangiopancreatography, which has been questioned because of its cost, risk of complications and effectiveness. Many surgeons, however, are still not familiar with this technique. In this article we discuss the technique and results of laparoscopic common bile duct exploration. Both the laparoscopic transcystic approach and choledochotomy are discussed, together with the results given in the literature. When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with preoperative or postoperative endoscopic sphincterotomy. However, the technique requires advanced laparoscopic skills, including suturing, knot tying, the use of a choledochoscope, guidewire, dilators and balloon stone extractor. Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones, it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.

Biliary Tract Surgical Procedures↗
PubMed1995

Alterations in bile ducts and peribiliary microcirculation in rats after common bile duct ligation.

The chronological changes in ductular epithelium and peribiliary capillary plexuses (PBPs) after bile duct ligation are not well understood. Therefore, we examined alterations in both intrahepatic bile ductules and peribiliary microcirculation in rats after ligation of the common bile duct using immunohistochemistry, transmission electron microscopes (TEM), and scanning electron microscopes (SEM). Ductular proliferations appeared first in the peripheral areas of the portal spaces and then gradually advanced along with increasing jaundice. Distorted configuration of the hepatic parenchyma with interconnecting stroma rich in irregular ductules developed 4 weeks after the ligation. Numerous biliary cell types and cells of types intermediate between hepatocytes and biliary cells together with poorly fenestrated capillary-type vessels appeared in the periportal parenchyma, in association with an increased number of canalicular-ductular junctions on TEM. These biliary cells were often found within the lobules and apart from the stroma. SEM examination of hepatic microvascular casts using methacrylated resin showed formation of irregular portal and periportal capillary networks, partly derived from coarsened sinusoids. Direct connections between the newly formed capillary networks and the pre-existing PBPs or sinusoids were numerous, although there were few direct connections between the capillary networks and the hepatic arterial branches. Thus, these proliferated ductules and newly formed complicated capillary networks might play an important role in the effective transport of biliary materials between hepatocytes and native bile ducts or proliferated ductules through the altered microcirculation after bile duct ligation.

Animals↗
PubMed1998

Laparoscopic endobiliary stenting as an adjunct to common bile duct exploration.

BACKGROUND: The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. METHODS: Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. RESULTS: CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. CONCLUSIONS: Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.

Cholangiography↗
PubMedDate not supplied

Treatment of chronic pancreatitis complicated by obstruction of the common bile duct or duodenum.

In patients with chronic pancreatitis, common bile duct obstruction is reported in 3.2-45.6% of patients; however, only 5-10% of all patients with chronic pancreatitis require operative decompression of the bile duct. The cause of the intrapancreatic stricture of the common bile duct may be either a fibrotic inflammatory restriction, or compression by a pseudocyst. Obstruction of the duodenum is much less common than common bile duct obstruction in chronic pancreatitis occurring in less than 1-2% of patients with chronic pancreatitis. Colonic obstruction secondary to pancreatitis is very infrequent. The intrapancreatic strictures of chronic pancreatitis are characteristically smooth and tapering on endoscopic retrograde cholangiopancreatography (ERCP), but in some patients, they may have a sharp cut-off and closely resemble the appearance of carcinoma of the pancreas invading the bile duct. The natural history of these intrapancreatic strictures is variable. They may progress and be associated with cholangitis, biliary cirrhosis, common duct stones, or may remain stable for years or regress. Prior pancreaticojejunostomy is not protective against the development of intrapancreatic biliary strictures which may follow in 5-30% of patients, with most authors reporting an incidence of less than 10%. Evaluation of alkaline phosphatase, bilirubin, the presence of jaundice, or the appearance of an intrapancreatic stricture on ERCP is not predictive of whether cholangitis or biliary cirrhosis may or may not develop. The incidence of cholangitis and biliary cirrhosis in patients with intrapancreatic stricture is 9.4% and 7.3%, respectively. Laennec's cirrhosis occurs in a similar number of patients. Operation is indicated in patients with intrapancreatic strictures of the common bile duct in association with chronic pancreatitis in patients developing cholangitis, biliary cirrhosis, common duct stones, progression of the stricture, persistent high elevations of alkaline phosphatase and/or bilirubin for over a month or inability to rule out cancer of the pancreas or periampullary region. The operation of choice is choledochoduodenostomy or Roux-en-Y choledochojejunostomy to bypass the obstructed intrapancreatic portion of the common bile duct. Persistent duodenal obstruction for over 3 or 4 weeks is an indication for gastrojejunostomy. Pain is not a feature of common bile duct obstruction in the absence of cholangitis. In the presence of pain associated with chronic pancreatitis, longitudinal pancreaticojejunostomy is the operation of choice combined with Roux-en-Y choledochojejunostomy. Some of the newer operations, e.g., the Beger and Frey procedures, may make the necessity of a separate operation for biliary decompression superfluous.

Chronic Disease↗
PubMed2004

[Laparoscopic exploration of the common bile duct].

Since the first laparoscopic common bile duct exploration in Hungary published in 1999 the authors use the technique themselves. We review and analyse our activity between 1 June 1999 and 31 August 2003. The minimally invasive approach was selected in twelve patients with obstructive jaundice for suspected bile duct stones. Eight of these patients underwent preoperative endoscopy, but either the number and/or size of stones or various complications prevented successful endoscopic stone extraction; five sphincterotomies--two followed by stenting--were performed. The four other patients did not consent to endoscopy. During surgery the biliary tract was visualised by choledochoscope (a bile duct endoscope with video connection) in four cases via the distended cystic duct and in eight cases via longitudinal choledochotomy. In one case there was no occlusion at all, in another one dilatation was performed because of a structure. In nine patients stones were removed either through the choledochotomy/cystic duct or by passing them into the duodenum. In one patient we converted to open procedure due to a stone impacted in the papilla of Vater. After choledochotomy intracorporal suturing and knot tying techniques were used to close the incision. On six occasions a cystic drain, three occasions a T-tube and on three occasions primary closure was used. Two bile leaks were treated by endoscopic stenting and in one patient a laparotomy was needed. There was no mortality. We believe that laparoscopic common bile duct exploration can be successful even in complicated situations.

Adult↗
PubMed1991

Variations of common bile duct diameter after endoscopic sphincterotomy.

Diameters of the common bile duct (CBD) and common hepatic duct (CHD) were measured before and after endoscopic sphincterotomy (EPT) in 100 patients. There was a significant reduction of the lumen diameter in both the CBD and CHD (p less than 0.01) after EPT. A comparison between 32 patients without symptoms (such as pain, residual stones, and elevated levels of liver enzymes) and 19 patients with remaining symptoms after EPT, showed a statistically significant reduction in both CBD and CHD diameters (p less than 0.001) in the former group, and no statistically proven changes in the diameters in the latter group, since a change of less than 1.5 mm was not considered significant. Therefore, the absence of a reduction or a dilatation of the diameter of the CBD after EPT may suggest that these patients may have persisting complaints after EPT. Measurements on models (phantoms) show that body position of the patient during endoscopic retrograde cholangiopancreatography (ERCP) has little and negligible influence on the measured diameters of the CBD and CHD.

Aged↗
PubMedDate not supplied

Acute cholangitis secondary to a common bile duct adenoma.

We report a case of distal common bile duct adenoma presenting with acute cholangitis. A 47-year-old woman suffered from right upper abdominal pain with persistent fever for 4 days. Abdominal ultrasonography showed mild dilatation of common bile duct and bilateral intrahepatic ducts. Endoscopic retrograde cholangiopancreatography disclosed a fixed filling defect in the distal common bile duct. Transpapillary biopsy and brush cytology was performed after sphincterotomy. The biopsy specimen showed adenomatous change with dysplasia and negative stain for p53. No significant regional lymph node enlargement was found on computed tomography. The patient subsequently received exploratory laparotomy and sphincteroplasty with excision of the distal common bile duct tumor. Finally, the tumor was diagnosed as common bile duct tubular adenoma with moderate nuclear dysplasia. Postoperatively, the patient had an uneventful course and has been well at follow-up for 8 months. We encountered a rare case of common bile duct adenoma in which malignant change was hard to rule out. We propose that sphincterotomy with biopsy is crucial before operation and p53 immunohistochemical staining is valuable for determining whether or not malignant change occurs in this borderline tumor.

Acute Disease↗
PubMed1995

[The age-related characteristics of the muscular layer of the common bile duct in man].

Walls of 22 common bile ducts of corpses of both sexes people aged from 21 to 73 were studied. Longitudinal and cross sections of the common bile ducts walls obtained by the improved histotopographical method were stained with hematoxylin-eosin after Jenner-Giemsa, picrofuchsine after Van-Gieson and orsein impregnated after Gordon-Svit and Kuprianov in modification corresponding with biliary tracts tissues. Specific volumes of myocyte bands and connective tissue forming the demonstrated smooth myocytes bands were determined and their correlation was defined in 4 age groups with research material divided in correspondence with the age classification adopted. Changes of capillary-tissue coefficient in ontogenesis were also determined. It was demonstrated that in proximal middle regions the common bile duct muscular coat was represented with longitudinal smooth myocyte bands, isolated from the surrounding loose connective tissue by reticulo-elastic framework. Regular order of these bands forms the crimpet construction of the common bile ducts in longitudinal direction of the tube. By the end of the 2nd maturity period and in elderly age separate location of the myocytes and zigzag course of the bands, their fragmentation with connective tissue layers were observed. Substitution of smooth myocytes with connective tissue fibres occurs. Analysis of the numeral values of the specific volumes obtained mathematically confirms all the morphological transformations listed above. Capillary-tissue coefficient increases in elderly and senile and age indicates disturbance in the tissue metabolism resulting from significant worsening of blood supply.

Adult↗
PubMed1980

[Immediate results of deep suture of the common bile duct].

The continuous suture of the common bile duct was used in 304 patients. It was used with the curative, curative-diagnostic and diagnostic purposes in mind. The indications for this suture were a complete removal of all stones from the bile ducts and a good passability of the distal portion of ductus choledochus. The authors analyze complications of the continuous suture of the common bile duct, such as "forgotten" stones in the ducts, incompetence of its sutures, peritonitis etc. Their causes are disclosed and the means of prevention are recommended. It is concluded that the continuous suture of the common bile duct is the most physiological method for the completion of choledochotomy with the corresponding indications. Peritonitis, pancreatitis and suppurative cholangitis are believed to be contraindications for using the continuous suture.

Adult↗
PubMed1991

[Extracorporeal shockwave therapy in giant stones in the common bile duct--a case report].

A huge common bile duct stone of 6 to 3 cm in diameter in a 64 year old lady was approached by ESWL, after endoscopic therapy such as mechanical lithotripsy and removal with the Dormia basket had failed because of the extraordinary size of this stone. A surgical therapy was not possible because of pronounced vascular and cardiopulmonary risk, so ESWL was applied to this patient. The stone was fragmented in two sessions of ESWL under sonographic targeting and the fragments were removed endoscopically. After one month one fragment still remained in the common bile duct, which then was removed also endoscopically. Two months later the ERC showed a stone-free common bile duct. This case demonstrates, that even common bile duct stones of extraordinary size can be removed by combining ESWL with endoscopic techniques. Following the trend to minimally invasive therapy, sonography should be preferred over XRay in diagnosis before ESWL as well as during ESWL.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2001

Laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct (CBD) exploration is gaining favor in the treatment of patients with gallstones and CBD stones. Our aim is to report our results with this procedure, focusing on the technical aspects. PATIENTS AND METHODS: All patients with proven CBD stones undergo laparoscopic transcystic CBD exploration, preferably, or a choledochotomy if the former is not feasible. According to CBD stone load and diameter, a biliary drainage tube is positioned for postoperative biliary decompression. RESULTS: Among 284 patients who underwent laparoscopic CBD exploration, 4 (1.4%) were converted to open surgery. Transcystic CBD exploration was feasible in 163 cases (58.2%), but a choledochotomy was required in 117 (41.8%). Biliary drains were positioned in 204 patients (72.8%). Minor complications included hyperamylasemia (11; 3.9%) and minor subhepatic bile collection (7; 2.5%). Major complications were bile leakage (5; 1.8%), hemoperitoneum from cystic artery bleeding (2; 0.7%), subhepatic abscess (2; 0.7%), acute pancreatitis (1; 0.3%), and jejunal perforation (1; 0.3%). Retained CBD stones in 15 patients (5.3%) were removed through the biliary drainage sinus tract (8) or after endoscopy and sphincterotomy (6). In one patient, a small stone passed spontaneously (overall success rate 94.6%). Death from a cardiovascular complication was observed in one elderly high-risk patient (0.3%). Recurrent ductal stones in 5 patients (1.8%) were treated with ERCP and endoscopic sphincterotomy. One patient with re-recurrent ductal stones underwent hepaticojejunostomy. CONCLUSIONS: Laparoscopic CBD exploration during LC in unselected patients solves two problems during the same anesthesia with high success rates (94.6%), low minor (6.4%) and major (3.8%) morbidity rates, and a low mortality rate (0.3%). Standardization of the technique is mandatory to achieve high success rates.

Adolescent↗
PubMed1982

[Radiological investigation of the bile ducts following cholecystectomy. Paper III: Determination of the diameter of the common bile duct by isotope methods (author's transl)].

The diameter of the common bile duct can be determined by means of quantitative hepato-biliary functional scintigraphy to an accuracy of +/- 2 mm. It is necessary to keep the conditions of the test constant, such as constant regions of interest and size of region. A common bile duct diameter greater than 10 mm. is suggestive of biliary obstruction, diameters above 15 mm. are definite proof. For the demonstration of post-hepatic obstruction, the hilar flow curve is confirmatory. Peristalsis of the common bile duct, which is an unlikely phenomenon in view of the anatomic studies of the muscle in the bile duct, cannot be demonstrated in this way.

Cholecystectomy↗