The width of the common bile duct.
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Common Bile Duct↗
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Complications of T-tube drainage of the common bile duct.
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Common Bile Duct↗
Common bile duct obstruction in cystic fibrosis: utility of hepatobiliary scintigraphy.
Abdominal pain occurs commonly in patients with cystic fibrosis, and is the result of a variety of causes, including hepatobiliary disorders. With the increasing duration of survival in these patients, diagnostic investigations for abdominal pain, including hepatobiliary scanning, may be utilized more frequently than in the past. Difficulties in the interpretation of scintigraphic studies may arise because of associated gallbladder anomalies that occur in more than 50% of patients with cystic fibrosis. Hypoplasia of the gallbladder (microgallbladder) occurs commonly. A case is presented in which Tc-99m disofenin hepatobiliary scanning proved diagnostic in a patient with cystic fibrosis and cholelithiasis leading to common bile duct obstruction. The hepatobiliary abnormalities and causes of common bile duct obstruction encountered in cystic fibrosis are reviewed.
Abdominal Pain↗
[Carcinoma of the common bile duct].
The clinical courses of 18 patients with extrahepatic bile duct carcinoma operated on between 1960 and 1979 are reviewed retrospectively. The preoperative and intraoperative diagnostic difficulties due to marked peritumor sclerosis are pointed out. The location of the lesion appeared to bear the most important relationship to prognosis: the lesions located in the upper and middle thirds of the extrahepatic biliary system are often invasive of adjacent vascular structures and, hence, unresectable, necessitating a proximal biliary-enteric anastomosis or intubation to alleviate jaundice and pruritus. A more aggressive operative approach, however, will result in a higher survival rate, as shown in personal experience for lower third lesions resected by Whipple's procedure.
Adult↗
Laparoscopic common bile duct exploration.
BACKGROUND: Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). METHODS: From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). RESULTS: The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients ( n = 2530)--that is, those not undergoing LCBDE or any other additional procedure--was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. CONCLUSIONS: Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.
Catheterization↗
[Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography].
OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.
Adult↗
[The pathomorphogenetic characteristics of the wall of the common bile duct in cholestasis].
Data are presented on the reversibility of pathological changes of the common bile duct, causes and criteria of reversibility. Consideration of four stages of pathomorphogenesis of the common bile duct wall may be of help in the choice of surgical tactics in surgical intervention on the common bile duct.
Biopsy↗
Operative cholangiography: criteria which make exploration of the common bile duct desirable.
The purpose of this study was to evaluate the individual criteria and combination of criteria examined by operative cholangiography which make exploration of the common bile duct desirable. The overall accuracy of exploration of the common bile duct (89 per cent) was similar to that of previous series. In the normal group the accuracy of the criteria established by Le Quesne (1960) is confirmed. The most reliable criteria in the abnormal cholangiograms were the presence of single or multiple filling defects in the common bile duct, the absence of free flow of contrast medium into the duodenum and an abnormality of the terminal narrow segment. Measurements to aid assessment of free flow into the duodenum are suggested. In 34 of 40 positive explorations the common bile duct diameter was 14 mm or less; 10 common bile ducts which contained stones were less than 10 mm in diameter. Excess filling of the intrahepatic ducts was often impossible to judge in the abnormal group and was the least valuable criterion. Attention is drawn to the advantage of an immediate radiological report.
Cholangiography↗
Combined percutaneous balloon dilation and extracorporeal shock wave lithotripsy for treatment of biliary stricture and common bile duct stones.
We report a case of cholangitis, liver abscess, and common bile duct stones in a patient with a benign stricture at a choledochojejunal anastomosis, 3 yr after a complicated duodenohemipancreatectomy. Because surgical reintervention seemed inappropriate, a percutaneous transhepatic balloon dilation was performed after temporary internal-external biliary drainage. Extracorporeal shockwave lithotripsy (ESWL) was successfully applied to fragment all common bile duct stones, with subsequent spontaneous evacuation of all stone fragments through the dilated bilioenteric anastomosis. Only one similar case report has been published before (1), though with a different sequence of therapeutic modalities. Moreover, according to our literature review, this is the first report of ESWL of common bile duct stones by means of the Dornier Compact Lithotriptor (Dornier, Germany) with electromagnetic shockwave source.
Anastomosis, Roux-en-Y↗
Double common bile duct: a case report and a review of the Japanese literature.
BACKGROUND: A double common bile duct (DCBD) is a rare congenital anomaly. We report the case of a 60-year-old Japanese female, whose common bile duct divided into 2 channels and both channels opened individually into the second portion of the duodenum. This is the fourth reported case of DCBD with a choledochal cyst and pancreaticobiliary maljunction (PBM). METHODS: A review of the literature revealed that DCBD is more frequently diagnosed in Oriental people. We reviewed 47 cases of DCBD reported in the Japanese literature. RESULTS: Among these, cholelithiasis was found in 27.7%, a choledochal cyst in 10.6%, PBM in 29.8%, and cancers in 25.5%. Cancer and PBM were the 2 most serious concomitant conditions. The incidence and type of complicating cancer and PBM varied according to the site of the opening of the accessory common bile duct (ACBD). Concomitant gastric cancer was frequently noted when the ACBD opened into the stomach, whereas cancer of the biliary system was common when the ACBD opened into the second portion of the duodenum or the pancreatic duct. PBM was observed only in those patients in whom the ACBD opened into the second portion of the duodenum or the pancreatic duct. Therefore the treatment and prognosis of DCBD is influenced by the site of opening of the ACBD. CONCLUSIONS: In DCBD, the opening site of the ACBD was considered to have close implications for the type of concomitant cancer and concomitant PBM that would appear.
Anastomosis, Roux-en-Y↗
The concealed cystic duct--a significant cause of common bile duct injury in laparoscopic cholecystectomy.
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Adult↗
[Preoperative intravenous cholangiography and residual common bile duct calculi. 600 cases reviewed 2 to 15 years after operation].
The authors have carried out as a routine since 1960 before operation a good intravenous cholangiography, i.e. showing up satisfactorily the bile ducts from the bifurcation of the common bile duct to the duodenum and have abandoned routine per-operative radiography. Satisfactory cholangiography was obtained in 96% of cases of simple cholecystitis and in 80% of complicated cases. 600 cases were questionned 2 to 15 years after operation (average 7 years). The 567 controllable cases were all questionned or seen again. The reliability of pre-operative cholangiography is excellent: no common bile duct declared normal on X-ray was found to contain a gall stone either during or after operation and the negative choledocotomies were only 0.17%. The operative simplification permitted us to reduce the operative mortality of simple cholecystectomy to 0.4%. The number of controlled residual calculi was 5.8%. With routine per-operative radiomanometry, the average level without control at the Lille Colloquium in 1968 was 7%. But with late control according to the estimation of the authors it should be about 10%.
Adult↗
Agenesis of the common bile duct.
In a case of congenital absence of the common bile duct, the common hepatic duct emptied directly into the gallbladder; the latter drained by a long cystic duct into the second part of the duodenum. To my knowledge, only eight prior cases with this or very similar anomalies have been reported in the literature. This rare arrangement is common in certain lower animals and is explainable by embryologic studies. Cholecystectomy in these cases inevitably produces a complete defect in the biliary tract, which should be recognized and repaired primarily. Reconstruction using a modified Rodney Smith sutureless technique was successful, and apparently this is the first case where it has been used for this purpose.
Adult↗
The effect of nalbuphine on the common bile duct pressure.
The effect of Nalbuphine on the common bile duct pressure of ten women who had cholecystectomy and common duct exploration for cholelithiasis and choledocholithiasis was studied. In this pilot study, intravenously inject Nalbuphine (20 mg) significantly raised the common duct pressure (P less than 0.01). However, none of the patients experienced pain as a result of the elevation in the biliary pressure; there was no deleterious cardiopulmonary effect.
Adult↗
[Common bile duct stone formation on migrating ligature threads. A report on three cases (author's transl)].
Common bile duct stones developed around non-absorbable suture threads that had migrated into the common bile duct in three patients. Two cases were typical in that they involved migration of the gallbladder stump ligature thread, associated in one cases with that of the arterial ligature. the third, rather more unusual case, involved the formation of stone on a nylon thread fifteen years after removal of the head and body of the pancreas following an injury, without any intervention on the biliary tract. The only explanation possible for the presence of a thread in the biliary tract is that it migrated through the Wirsung's duct. The published literature on the particular subject of common bile duct stone formation on non-absorbable suture material is reviewed.
Adult↗
Changes in morphology of the distal common bile duct associated with aging.
A gross and microscopic study has been made of the changes associated with aging in the distal common bile duct of normal humans. Grossly a progressive narrowing develops with aging at the level of the preampullary portion of the common bile duct. On the contrary, the pancreatic portion of the common bile duct has a tendency to dilatation with aging. Histologically the thickening and sclerosis of the wall in the preampullary portion represent the changes increasing in degree with aging, consisting of: 1) submucosal glandular proliferation and fibrosis, and 2) intermuscular glandular proliferation and fibrosis. On the other hand, the diffuse sclerosis in the pancreatic portion gradually occurs with aging, consisting of: 1) proliferation and fragmentation of elastic fibers, and 2) increase in collagen fibers. Factors influencing the development of these changes associated with age are discussed. The author presumes that decrease in response to an upward tendency of the intraductal pressure resulting from diffuse sclerosis in the wall of the common bile duct, in addition to a progressive narrowing of the preampullary portion, may be responsible for dilatation of the common bile duct, moreover, bile stasis and infection on the biliary tract. It is suggested therefore that these alterations with aging process in the terminal bile duct may be a responsible agent in the formation of common duct stones.
Aged↗
Primary common bile duct closure following exploration: an effective alternative to routine biliary drainage.
Primary closure of the common bile duct following exploration has been safely and effectively performed, as advocated by Halsted, provided no evidence of pancreatitis, cholangitis, or ampullary obstruction exists. Using this precedent, the operative management and clinical course of 29 patients undergoing common bile duct exploration (CBDE) for choledocholithiasis from 1986 to 1992 were reviewed. Ten patients had primary closure of the common bile duct (CBD) following choledochotomy and exploration, and 17 patients had t-tube placement. Two patients had CBDE through an enlarged cystic duct that was then ligated. Patients were selected for t-tube placement if they had pancreatitis, ascending cholangitis, evidence of retained stones, or ampullary obstruction. Two patients in this series died. No patient with primary closure of the CBD suffered a biliary complication including retained stones, biliary fistula, pancreatitis, or bile peritonitis. Serious systemic complications were comparable in both groups. The results of this series support the safety of primary common bile duct closure in selected cases.
Cholecystectomy↗
Common bile duct healing. Do different absorbable sutures affect stricture formation and tensile strength?
Few basic investigations have addressed the problem of common bile duct strictures. We systematically investigated the healing canine end-to-end choledochal anastomosis and tested the hypothesis that common bile duct anastomoses sutured with monofilament polyglyconate absorbable suture would heal with less stricture formation and greater tensile strength than those sutured with braided polyglactin 910 and chromic catgut sutures. Seventy-six canines, randomized to control vs sutured groups, underwent either mobilization (controls) or transection of the mid-common bile duct and were allowed to heal 5, 10, 15, or 50 days postoperatively before sacrifice. The type of absorbable suture used to construct a common bile duct anastomosis was found to have no major effect on anastomotic strictures nor on anastomotic breaking strength. Polyglyconate suture caused significantly less perianastomotic inflammation than did chromic suture, with polyglactin 910 sutures evoking an intermediate inflammatory response. Surgeons may safely choose sutures for biliary procedures based on the clinical circumstances and personal preference.
Anastomosis, Surgical↗