Cystic Duct Stones Research Articles

WP3.3 - Surgical Management of multiple mega large stones of a congenitally low inserted Cystic Duct – A Case Report

Abstract Introduction Low cystic duct insertion is uncommon, and the presence of multiple large stones in the cystic duct with normal laboratory investigation is rare. The infrequency with which it is encountered and the management done makes this an interesting presentation. Case presentation A 61-year-old female with incidental gall stones and possible CBD/cystic duct stones on a CTAP during a workup for management of an incisional hernia of the abdomen. The patient initially presented with abdominal pain that was thought to be due to the incisional hernia. On examination, the patient had a soft abdomen with no jaundice and normal laboratory investigations. MRCP scan demonstrated multiple gall stones and cystic duct stones suggestive of Mirizzi syndrome. The patient underwent laparoscopic repair of the incisional hernia and cholecystectomy with an on-table cholangiogram. Cholangiogram showed a low inserting cystic duct joining the common hepatic duct at the sphincter of Oddi with an almost nonexistent common bile duct and a cystic duct containing multiple mega-large stones. The cystic duct was explored and stones were milked out except the most inferior stone which was impacted at the sphincter of Oddi. This was dislodged with a Fogarty catheter and all stones were retrieved. Completion cholangiogram demonstrated complete clearance of the biliary tree with dye entering the duodenum. The patient recovered well postoperatively with no complications at 1 month post-operative. Conclusion This case illustrates a rare presentation of large cystic duct stones in the presence of abnormal anatomy and provides an option for surgical management.

Mirizzi Syndrome Secondary to Impacted Stone in A Low Inserted Cystic Duct Variant: Case Report

Abstract Introduction. Cystic duct anatomical variations are encountered frequently during surgical procedures. In this report, a female patient underwent laparoscopic cholecystectomy for acute cholecystitis and developed symptoms of obstructive jaundice subsequently, which was diagnosed as low insertion of the cystic duct and an impacted stone that was causing common hepatic duct obstruction. Case report. A 42-year-old female presented to the emergency room complaining of persistent right upper quadrant pain that was radiating to the back. White blood count (WBC) was slightly elevated with normal liver function tests (LFTs). An abdominal ultrasound was performed and confirmed cholelithiasis with no signs of acute cholecystitis or biliary dilatation. The patient underwent laparoscopic cholecystectomy as an emergency procedure for persistent biliary colic. Eight days later, the patient returned to the emergency room with obstructive jaundice and continued right upper quadrant pain with elevated WBC and LFTs. Further tests were conducted, and the patient was found to have a long cystic duct with a low insertion variant to the common hepatic duct. An impacted stone was identified in the cystic duct, referred to as Mirizzi syndrome Type I. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) several times, but the common bile duct could not be cannulated. In the last ERCP session, SpyGlass and electrohydraulic lithotripsy were performed with a balloon sweep. Conclusion. This case demonstrates the importance of understanding Mirizzi syndrome and cystic duct variation to achieve optimal treatment, and careful assessment and investigation are essential for proper diagnosis. In experienced hands, Mirizzi syndrome secondary to an impacted cystic duct stone can be managed successfully with ERCP, electrohydraulic lithotripsy, and SpyGlass.

Digital cholangioscopy-assisted, direct visualization-guided, radiation-free, endoscopic retrograde intervention for cholelithiasis: technical feasibility, efficacy, and safety.

Nonradiation, digital cholangioscope (DCS)-assisted endoscopic intervention for cholelithiasis has not been widely performed. For this study, we aimed to report the feasibility, efficacy, and safety of an established DCS-guided lithotomy procedure. Data relating to biliary exploration, stone clearance, adverse events, and follow-up were obtained from 289 patients. The choledocholithiasis-related outcomes via the DCS-guided procedure were subsequently compared to those via conventional endoscopic retrograde cholangiopancreatography (ERCP). Biliary access was achieved in 285 patients. The technical success rate for the exploration of the common bile duct, the cystic stump, the hilar ducts, and secondary radicals was 100%. Moreover, the success rates were 98.4%, 61.7%, and 20.7%, for the exploration of the cystic duct, complete cystic duct, and gallbladder, respectively. Suspicious or confirmed suppurative cholecystitis, cholesterol polyps, and hyperplastic polyps were detected in 42, 23, and 5 patients, respectively. Stone clearance was achieved in one session in 285 (100%), 11 (100%), 13 (100%), 7 (100%), 6 (100%), and 3 (14.3%) patients with choledocholithiasis and hepatolithiasis, cystic duct stump stones, nondiffuse located intrahepatic lithiasis, a single cystic duct stone, a single gallbladder stone, and diffuse located intrahepatic lithiasis, respectively. Complete stone clearance for diffuse intrahepatic lithiasis was achieved in 19 (90.5%) patients, and fractioned re-lithotomy was performed in 16 (76.2%) patients. One patient developed mild acute cholangitis, and 12 developed mild pancreatitis. Stones recurred in one patient. Compared with conventional ERCP, DCS-guided lithotomy has the advantages of clearing difficult-to-treat choledocholithiasis and revealing concomitant biliary lesions, and this technique has fewer complications and a decreased risk of stone recurrence. The technical profile, efficacy, and safety of nonradiation-guided and DCS-guided lithotomy are shown in this study. We provide a feasible modality for the endoscopic removal of cholelithiasis.

Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC

BackgroundIn the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis.MethodsAccording to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups.ResultsAmong the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05).ConclusionsThe preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

Laparoscopic common bile duct exploration: what factors determine success?

Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified. Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Predictors of success of conventional ERCP for bile duct stones and need for single-operator cholangioscopy.

Background and study aims The characteristics of difficult stones requiring cholangioscopy-assisted lithotripsy are poorly defined. We sought to determine clinician perception of these characteristics and decision-making in biliary endoscopy. Methods One hundred twenty-four delegates attending an online course were invited to assess 20 clinical stone cases. Each image was graded on a 4-point Likert for: grading of stone difficulty, confidence of clearance with conventional endoscopic retrograde cholangiopancreatography (ERCP) methods, likelihood of needing cholangioscopy-assisted lithotripsy, and confidence of clearance with one session of lithotripsy. An independent reviewer rated each case on largest stone size, stone number, presence of stricture distal to stone, size of stone relative to distal duct size, and acute common bile duct (CBD) angulation < 135°. Multilevel (mixed) statistical methods with a two-level model were utilized with multilevel ordinal logistic regression. Results Stone size and location, stricture and stone diameter:duct ratio impacted perceived procedural difficulty P < 0.01). Stone:duct ratio (< 50% odds ratio [OR] 0.22, P < 0.001), stricture (OR 7.26, P < 0.001) and stone location impacted confidence of clearance with conventional ERCP. Intrahepatic and cystic duct stones were least likely to engender confidence ( P < 0.01). The same factors plus CBD angulation < 135° predicted cholangioscopy requirement ( P < 0.01). Stone number did not influence procedure difficulty or cholangioscopy requirement. Strictures (OR 0.29, P < 0.001) and location, especially intrahepatic (OR 0.42, P < 0.001) impaired confidence in clearance with one cholangioscopy session. Conclusions Ductal anatomy, the presence of a stricture distal to a stone, cystic and intrahepatic stones and stones larger than the distal duct are considered by endoscopists to be significant predictors of requiring cholangioscopy-assisted lithotripsy.

Continuous suture closure using a LapraTy® suture clips is an effective method for reconstruction of cystic duct stump after laparoscopic subtotal cholecystectomy

ObjectiveRecently, number of laparoscopic subtotal cholecystectomy (LSC) has been increasing. Summary background dataLSC is suitable as a treatment as it can avoid intraoperative bile duct injury and bleeding for difficult laparoscopic cholecystectomy. On the other hand, improper handling of remnant of GB can lead to postoperative bile leakage. MethodsHere, we report our positive experience utilizing new technique of continuous suture closure and omental covering using Lapra Ty® suture clips on the remnant of GB. ResultsFrom January 2016 to July 2021, we experienced 30 cases of LSC for LC patients who had difficulty securing critical view of safety (CVS). In six of the 30 cases, we repaired remnant of GB using continuous suture closure and omental covering with Lapra Ty® suture clips. The median operating time was 136 min (range 112–199 ml), and amount of bleeding was 1 ml (range 1–100). There were no cases of postoperative bile leakage (postope. BL), remnant cystic duct stone, and abscess formation in abdomen. Conclusionwe recommend this new suturing technique for closure of remnant of GB as it was very effective in preventing postope. BL after LSC.

The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones.

The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.

Hemobilia in the setting of cystic artery pseudoaneurysm secondary to type I Mirizzi syndrome

Hemobilia is an uncommon diagnosis and is often not suspected in the absence of recent hepatobiliary intervention or trauma. Hemobilia in the setting of cystic artery pseudoaneurysm secondary to type I Mirizzi syndrome is a rare occurrence. We report the case of a 61-year-old male who presented with epigastric pain and vomiting. Blood tests demonstrated hyperbilirubinemia with elevated inflammatory markers. Magnetic resonance cholangiopancreatography revealed type I Mirizzi syndrome in the presence of a 21 mm cystic duct stone. During endoscopic retrograde cholangiopancreatography, hemobilia was identified. Subsequent triple phase computed tomography imaging identified a 12 mm cystic artery pseudoaneurysm. Angiography with successful coiling of the cystic artery was accomplished. Cholecystectomy was performed, confirming type I Mirizzi syndrome. This case demonstrates the importance of considering ruptured pseudoaneurysm in patients presenting with evidence of upper gastrointestinal bleeding in the setting of biliary stone disease. Transarterial embolization, followed by surgical management, is effective in both the diagnosis and management of ruptured cystic artery pseudoaneurysm with associated hemobilia.

OBSERVATIONAL STUDY ON CHOLEDOCHODUODENOSTOMY AND T-TUBE DRAINAGE IN CHOLEDOCHOLITHIASIS PATIENTS WITH RISK FACTORS OF POST-OPERATIVE MISSED STONE

Choledocholithiasis means stones in bile duct it is estimated that choledocholithiasis is present in 1-15% of patients with cholelithiasis and 29.7% patients with post cholecystectomy patients. Common bile duct stones (CBDS) is still challenging to surgeon despite advances in surgery which is commonly performed in conjunction with cholecystectomy. In patients with symptomatic cholelithiasis the incidence of CBDS varies widely between 5% and 33% according to (1-5) age .CBDS can either be primary (originating within the CBD) or secondary (originating in the gallbladder) and pass into the CBD through cystic duct or bile duct stones within intrahepatic biliary tree, termed primary hepatolithiasis, and may also lead to secondary 6 choledocholithiasis . Abdominal sonography and magnetic resonance cholangiopancreatography (MRCP) are the most common non7 invasive pre-operative imaging modalities for detection of CBDS .

Delayed Cholecystectomy Management for Mirizzi Syndrome.

Mirizzi syndrome is defined as a common hepatic duct obstruction from a cystic duct stone, which results in a severe inflammatory reaction that distorts biliary anatomy and makes surgical intervention challenging. Most case reports describe an open subtotal cholecystectomy as the most common surgical technique with few reports detailing successful laparoscopic interventions. This case involves an 11-year-old African American female who presented with right upper quadrant abdominal pain and imaging consistent with Mirizzi syndrome. She was taken for a laparoscopic cholecystectomy that was quickly aborted due to extensive inflammation. She subsequently underwent endoscopic decompression of her biliary tree by gastroenterology. She returned to the operating room six weeks later for a successful interval cholecystectomy. This case illustrates a unique report of delayed cholecystectomy for management of Mirizzi syndrome, which highlights a potential management strategy that avoids technically difficult laparoscopic cholecystectomy in the acute inflammatory period.

EVALUATION OF PANCREATOBILIARY PATHOLOGIES USING MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY

Introduction: Pancreato-biliary diseases are commonly observed in the population that can have adverse outcome if not diagnosed or managed correctly and in time. It is divided into intraductal and extraductal obstruction. Biliary strictures, choledocholithiasis, malignant strictures as well as conditions such as primary sclerosing cholangitis constitute the most signicant reasons of intraductal obstruction. Extraductal reasons for obstruction consist of compression of biliary channels by neoplasms, cystic duct stones and pancreatitis. Benign as well as malignant biliary obstructions are not easy to distinguish with only imaging clinical correlation is also important. A total of 70 patients were enrolled Methodology: in the study. MRI was done with 3 Tesla GE machine using body coil. T2-weighted and diffusion-weighted sequences were routinely obtained. Examination was performed after the patient has fasted for minimum 4 hours to promote gall bladder lling. Males were Result And Discussion: slightly more in proportion than females (52.86% vs 47.14%) in study, The commonest clinical feature noted in the study was abdominal pain (55.71%), followed by jaundice (17.14%) and epigastric pain in 10% cases. The common ndings noted were calculus cholecystitis (21.43%), cholelithiasis (18.57%), choledocholithiasis (17.14%), IHBR dilatation (15.71%) and benign stricture in (14.29%). Acute and chronic pancreatitis was noted in 8 cases each (11.43% each). Pseudocyst of pancreas and hepatic cysts or abscess was also noted in 10% and 7.14% cases respectively. Overall, 11% of the cases had neoplastic or malignant nding on MRCP assessment. MRCP was found to be 93 % accurate in Conclusion: identifying the pancreaticobiliary disorders with its underlying cause in present study. The present study shows that MRCP is excellent modality of choice for the detecting of pancreaticobiliary pathologies in the symptomatic patients. Thereby helping in quick diagnosis, treatment planning and better prognosis

Length of the Remnant Cystic Duct and Bile Duct Stone Recurrence: a Case‒Control Study

BackgroundSince the introduction of the Critical View of Safety approach in laparoscopic cholecystectomy, exposure of the common bile duct, and common hepatic duct is not recommended, therefore, the length of the cystic duct remnant is no longer controlled. The aim of this case‒control study is to evaluate the relationship between the length of the cystic duct remnant and the risk for bile duct stone recurrence after cholecystectomy. MethodsAll MRIs with dedicated sequences of the biliary tract taken between 2010 and 2020 from patients who underwent prior cholecystectomy were reviewed. The length of the cystic duct remnant was measured and compared between the patients with and without bile duct stones using multivariate logistic regression analysis. ResultsA total of 362 patients were included in this study, 23.5% of whom had bile duct stones on MRI. The cystic duct remnant was significantly longer in the patients with stones than in the control group (median 31 mm versus 18 mm, P < 0.001). In the MRIs performed > 2 years after cholecystectomy, the cystic duct remnant was also significantly longer in the patients with bile duct stones (median 32 mm versus 21 mm, P < 0.001). A cystic duct remnant ≥ 15 mm in length increased the odds of stones (OR = 2.3, P = 0.001). Overall, the odds of bile duct stones increased with an increasing cystic duct remnant length (≥ 45 mm, OR = 5.0, P < 0.001). ConclusionsAn excessive cystic duct remnant length increases the odds of recurrent bile duct stones after cholecystectomy.

S2880 Transpapillary Cystic Duct: A Rare Novel Genetic Variant

Introduction: Patients with cholecystitis often present with abdominal pain, nausea and vomiting. The treatment for cholecystitis often is a cholecystectomy. Pathogenesis of cholecystitis entails blockage of the cystic duct resulting in inflammation up-stream from the site of obstruction. Stones are often the cause of this obstruction, and can often enter the bile duct, causing bile duct obstruction. Cystic duct often merges with the common hepatic duct in the extrahepatic but non-pancreatic portion. Imaging such as Ultrasound and MRI in such cases would reveal a filling defect within the bile duct. We present a case where the cystic duct opened directly at the ampulla. Case Description/Methods: A 68 year-old female presented with abdominal pain, nausea and vomiting. Laboratory testing revealed normal AST, ALT and Alkaline phosphatase. Bilirubin was elevated. Ultrasound imaging revealed findings of cholecystitis. A magnetic resonance cholangiopancreatography was performed (Figure a) that revealed a normal common bile duct (CBD), and a dilated cystic duct with a filling defect consistent with a stone. Interestingly, it revealed cystic duct insertion close to the ampulla. During laparoscopic cholecystectomy, an intraoperative cholangiogram (Figure b) with contrast injection into the cystic duct revealed multiple filling defects in the cystic duct with contrast draining into the small bowel through the papilla. ERCP with cholangioscopy confirmed the cystic duct opening into the ampulla. Treatment entailed ERCP with cholangioscopy and lithotripsy. Discussion: Recognizing anatomical variants and considering these in the differential can help in understanding unusual clinical presentations of biliary pathologies.Figure 1.: a: MRCP images showing stones (green arrow) in cystic duct with cystic duct opening at the ampulla; b: Intraoperative cholangiogram confirming cystic duct stones with cystic duct opening at the ampulla.

S1841 The Curious Case of CA 19-9 in Mirizzi Syndrome

Introduction: Mirizzi Syndrome (MS) is a rare complication of gallstone disease, caused by an obstructing stone in the cystic duct or the gallbladder neck, leading to obstruction of the common hepatic duct. This case discusses the utility of EUS in improving diagnostic yield of MS and the importance of cancer screening in these patients. Case Description/Methods: A 44-year-old male with a history of gastritis presented with right upper quadrant (RUQ) abdominal pain, jaundice, and scleral icterus for one week. On exam, the patient was afebrile with mild RUQ abdominal tenderness. Labs showed a total bilirubin of 5.4 mg/dL, AST of 66 U/L, ALT of 228 U/L, and a total alkaline phosphatase of 159 U/L. Ultrasound demonstrated intra- and extrahepatic biliary dilation with suggestion of a shadowing stone within the common bile duct (CBD). The gallbladder wall was thickened with trace pericholecystic fluid. MRCP showed a 15 mm calculus presumed to be in the CBD, with a 16 mm CBD dilation. ERCP showed a filling defect in the midportion of the CBD, and a CBD stent was placed. Due to these findings, a CA 19-9 antigen was drawn, measuring 3038 U/mL. EUS was then performed, which visualized a cystic duct stone partially extending into the CBD– a finding consistent with MS. An enlarged lymph node was visualized in the porta hepatis region. FNA of the lymph node as well as CBD brushings from the ERCP were both negative for malignant cells. The patient was discharged and underwent a cholecystectomy two weeks later. Surgical findings were consistent with MS and a 20 mm stone was removed with the gallbladder. The intraoperative frozen section of the gallbladder was negative for malignant cells. (Figure) Discussion: Initial evaluation for MS should include an ultrasound or CT scan, followed by MRCP. The pooled sensitivity of MRCP for detecting CBD stones is around 87%. While MRCP is often used to diagnose MS, the anatomy may not be well visualized due to the proximity of the cystic duct to the CBD. EUS has a pooled sensitivity of 97% in detecting a CBD stone and can better visualize the biliary tract anatomy, aiding in diagnosis. Diagnosis of MS prior to surgery can be helpful in avoiding biliary tract injuries. MS evaluation should also include screening for malignancy, as MS has an association with gallbladder cancer. While elevated CA 19-9 levels are concerning for malignancy, they can also be seen in chronic benign biliary obstruction. It is important to obtain a CA 19-9 level when suspecting MS, both before and after stone removal.Figure 1.: A. MRI: A T2-weighted image showing a 15 mm filling defect (white arrow) within the cystic duct, partially extending into the common bile duct, consistent with an obstructing stone. Intrahepatic and extrahepatic biliary dilation is also seen. B. Endoscopic ultrasound: An ovoid, hyperechoic structure, measuring 11 mm x 15 mm, with shadowing suggestive of a gallstone at the level of the cystic duct and compression of the common bile duct. C. Endoscopic ultrasound: An irregularly contracted gallbladder (black arrow) with adjacent dilated common bile duct. D. Endoscopic ultrasound: Fine needle aspiration of an enlarged lymph node with well defined margins in the porta hepatis region, measuring 20 mm x 15 mm in maximal cross-sectional diameter. Color Doppler imaging was utilized prior to needle puncture to confirm a lack of significant vascular structures within the needle path.

Management of cystic duct stone(s) during laparoscopic cholecystectomy

Background and objective: Although cholecystectomy relieves symptoms in the majority of cases, still a significant number of patients suffer from the post-cholecystectomy syndrome. Cystic duct remnant calculi is a causative factor of the post-cholecystectomy syndrome. Cystic duct stones are not infrequently encountered during laparoscopic cholecystectomies. This study aimed to present our experience of patients with calculi of the cystic duct that successfully dealt with laparoscopically. Methods: This study was conducted on 4000 cases of chronic calculous cholecystitis at Rizgary Teaching Hospital from January 2010 to November 2020. Results: Cystic duct stones were detected in 397 cases. A single stone was found within the cystic duct in 301 patients (75.8%) and multiple stones in 96 patients (24.2%). The cystic duct was reported to be wider than normal in 368 cases (92.7%) and near to normal in 29 cases (7.30%). We recorded two cases (0.5%) of concomitant common bile duct stones with cystic duct stones. Our procedure for dealing with cystic duct stone was successful in 372cases (93.7%). Milking the stone back to the gall bladder was successful in 15 cases (3.80%). In eight cases (2.00%), we were obliged to convert the procedure to open cholecystectomy. Since peroperative cholangiography and choledcoscopy are not available in our hospital, the associated common bile duct stone in two cases (0.50%) was postponed and dealt with later on. Post-operative recovery was uneventful, apart from one patient who developed features of acute cholangitis. Conclusion: Cystic duct stones are not infrequent, as was believed earlier. Their preoperative detection may be difficult, but it can be detected easily peroperatively. Its detection and retrieval are mandatory to decrease the incidence of post-cholecystectomy phenomena. Keywords: Gall bladder; Laparoscopy; Cholecystectomy; Cystic duct stones.

Outcome of Digital Cholangioscopy and Laser Lithotripsy for Impacted Biliary Stones

Abstract Background and Aims Impacted stones in the bile duct are difficult to extract, and are predictor of failure of conventional endoscopic retrograde cholangiopancreatography techniques including mechanical lithotripsy and large balloon dilatation. Intracorporeal lithotripsy may be an effective technique for these stones. The aim of this study is to report the efficacy and safety of intracorporeal laser lithotripsy for impacted stones in the bile duct. Method This study is retrospective analysis of prospectively collected data. Patients with impacted stones in the bile duct underwent cholangioscopy with spyglass DS system and laser lithotripsy. Outcome measures were proportion of patients with complete clearance of bile duct after the first session, number of sessions required for complete clearance, and the complications. Results Forty-three patients (27 female) with mean age of 56.12 ± 15.16 years underwent digital cholangioscopy and laser lithotripsy. Mean bilirubin value was 1.8 ± 1.6 mg/dL, 20 (46.51%) patients had single stone, 35(81.39%) patients had only bile duct stones, and 8(18.61%) patients had additional stones in cystic duct or intrahepatic biliary radical. Mean size of largest stone was 16.2 ± 4.4mm. Average duration of the procedure was 69.11 ± 28.12minutes, and complete clearance was achieved in 41/43 (95.34%) patients after the first session. Mean number of sessions required for complete clearance was 1.02 ± .26. Postprocedure cholangitis occurred in one patient. Conclusion Intracorporeal laser lithotripsy is an effective and safe modality for the clearance of impacted bile duct stones.

Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis

PurposeRetained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. MethodsA total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. ResultsRS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. ConclusionsThe presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

What makes acute cholecystitis recur after removing the percutaneous cholecystostomy tube?

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment option for acute cholecystitis. However, the disease may recur after PTGBD catheter removal. This study aimed to evaluate the role of endoscopic sphincterotomy and other risk factors in reducing the recurrence of cholecystitis.We retrospectively analyzed data from 1088 patients who underwent PTGBD for cholecystitis at Kyungpook National University Hospital, Republic of Korea, between January 2011 and April 2018.A total of 115 patients were enrolled in the study. The recurrence rate of cholecystitis was 17.4% (n = 20) during a median follow-up period of 1159 (range, 369–2774) days. Endoscopic biliary sphincterotomy did not significantly affect the recurrence rate of cholecystitis (P = .561). In multivariable analysis, cystic duct stones (P = .013) and PTGBD catheter migration before the prescheduled removal time (P = .002) were identified as independent risk factors for cholecystitis recurrence after PTGBD.To reduce post-PTGBD recurrence in cholecystitis, caution must be exercised to avoid inadvertent dislodging of the PTGBD catheter. In cases of cholecystitis with cystic duct stones, cholecystectomy should be considered only after careful assessment of postoperative risks. Instead, transluminal endoscopic gallbladder drainage could represent a promising option for the prevention of recurrent cholecystitis.

Assessment of postoperative common bile duct stones after endoscopic extraction and subsequent cholecystectomy.

Common bile duct stones (CBDSs) occasionally cause serious diseases, and endoscopic extraction is the standard procedure for CBDS. To prevent biliary complications, cholecystectomy is recommended for patients who present with gallbladder (GB) stones after endoscopic CBDS extraction. However, CBDS can occasionally recur. To date, the occurrence of CBDS after endoscopic CBDS extraction and subsequent cholecystectomy is not fully understood. Hence, the current study aimed to evaluate the incidence of postoperative CBDSs. This retrospective observational study included consecutive patients who underwent postoperative endoscopic retrograde cholangiography after endoscopic CBDS extraction and subsequent cholecystectomy between April 2012 and June 2021 at our institution. After endoscopic CBDS extraction, a biliary plastic stent was inserted to prevent obstructive cholangitis. Endoscopic retrograde cholangiography was performed to evaluate postoperative CBDSs after cholecystectomy until hospital discharge. The outcomes were the incidence of postoperative CBDSs and CBDSs/sludge. Moreover, the predictive factors for postoperative CBDSs were evaluated via univariate and multivariate analyses. Of eligible 204 patients, 52 patients (25.5%) presented with postoperative CBDSs. The incidence rate of CBDS/sludge was 36.8% (n = 75). Based on the univariate analysis, the significant predictive factors for postoperative CBDSs were ≥ 6 CBDSs, presence of cystic duct stones, and ≥ 10GB stones (P < 0.05). Moreover, male sex and < 60-mm minor axis in GB might be predictive factors (P < 0.10). Based on the multivariate analysis, ≥ 6 CBDSs (odds ratio = 6.65, P < 0.01), presence of cystic duct stones (odds ratio = 4.39, P < 0.01), and ≥ 10GB stones (odds ratio = 2.55, P = 0.01) were independent predictive factors for postoperative CBDSs. The incidence of postoperative CBDS was relatively high. Hence, patients with predictive factors for postoperative CBDS must undergo imaging tests or additional endoscopic procedure after cholecystectomy.