Duct Fistula Research Articles

Pyloric-preserving Pancreaticoduodenectomy with Duct to Mucosa Pancreatico-gastrostomy Reconstruction: Long-term Follow-up in a Tertiary Center

Background: Duct to mucosa Pancreatico-gastrostomy (DMPG) is a method for reconstruction of pancreatic mass following pancreaticoduodenectomy (PD). There are still controversies about the benefits of this surgical technique compared to the old ones. Objectives: This study aimed to evaluate the long-term outcomes of DMPG reconstruction following PD operation. Method: Through a prospective observational setting, 164 patients, undergoing PD surgery, with diagnosed pancreatic head or peri-ampullary cancer, were enrolled. A pylorus-preserving PD and DMPG were done for all patients to reconstruct the pancreatic mass. Patients were followed up to a mean of 21.06±14.12 months. Demographic data, risk factors, tumoral staging, and postoperative follow-up data were collected for the analytic study. Results: The mean survival of the patients was 21.06±14.23 months after surgery. DGE (delayed gastric emptying) (34.75%), pancreatic fistula (21.34%), bile duct fistula (7.31%), and hemorrhage (5.5%) were recorded as the most important complication in patients. Some post-operative complications were significantly observed in patients with diabetes mellitus (pancreatic fistula, increased amylase, and DGE), Smokers (bile duct fistula, hemorrhage, and increased Amylase), and the elders (bile duct fistula) (p-value 0.05). Conclusions: Although our results indicate that DMPG reconstruction is a safe technique, our findings did not confirm the priority of this method over the older techniques.

Successful Management of the Omphalomesenteric Fistula: About Three Case Reports

The omphalomesenteric duct is an embryologic connection between the midgut and yolk sac, which typically disappears at the 5th to 7th week of gestation. Failure of the obliteration process can lead to omphalomesenteric duct remnants. It usually has a difficult diagnosis, manifested by a variety of cutaneous signs, such as an umbilical mass, granulation tissue, or discharge. This article reports three cases of total persistence of the OMD and reviews the surgical management of those lesions. The first case reports a 6-day-old boy with a patent omphalomesenteric duct fistula opening to the umbilicus presenting with feces sprouting from the umbilical stump. The second one reports a one-month-old infant brought to the hospital with umbilical granuloma, with no response to topical treatment that later started draining feces from the umbilical cord. The third one reports a three-day-old male newborn that manifested a granuloma-like lesion on the umbilical scar with no improvement with topical treatment. A simple catheterization with a relation catheter was performed in all cases showing drainage of a bilious secretion. they were then diagnosed with a persistence of the Vitelline Duct. All infants had a similar surgical approach, with an abdominal elective incision made around the lesion on the abdominal wall. Identification of the fistula trajectory, followed by resection of the bowel segment that contains the fistulae and a formation of a terminal-terminal anastomosis.

Diagnosis and Surgical correction of salivary affections in buffaloes (Bubalus bubalis); a retrospective study

AimThis study aimed to describe the diagnosis and treatment of various surgical salivary affections in buffaloes.Materials and methodsThis study included 135 buffaloes examined at Dakahlia Governorate between 2011 and 2022 suffering from various surgical salivary affections. The recorded surgical affections had salivary fistula (n = 44), ectasia of Stenson’s duct (n = 11), ranula/mucocele (n = 46), and cervical sialocele (n = 34). The buffaloes were sedated using an intramuscular injection of xylazine (0.05 mg/kg) and local infiltration analgesia of lidocaine for specific surgical interventions.ResultsThe salivary duct fistula cases were surgically corrected using a retrograde infusion of povidone-iodine into the duct and its double ligation with Prolene following fistulectomy. Intraoral marsupialization was done in buffaloes suffering from ectasia of the parotid duct. The mucocele /ranula was surgically incised with daily flushing with povidone-iodine. The cervical sialocele was treated by giving an elliptical excision on the sialocele, and sialoadenectomy of the mandibular salivary gland was performed to facilitate dynamic fluid/saliva drainage. A 92.5% of diseased buffaloes showed an uneventful recovery without any postoperative complications after the first treatment, whereas 7.5% of animals tended to recur. The most common and almost equally distributed salivary affections recorded in adult buffaloes were parotid duct fistula, mucocele, and cervical sialocele. The Stenson’s duct ectasia was commonly registered in calves, being congenital.ConclusionRanula was the most common salivary affection encountered in adult buffaloes, closely followed by parotid duct fistulae and cervical sialoceles. Stenson’s duct ectasia was the least encountered salivary affection in calves and was congenital. All salivary affections were corrected easily and safely, with satisfactory outcomes.

Online calculators for predicting the risk of anastomotic stricture after hepaticojejunostomy for bile duct injury after cholecystectomy: a multicenter retrospective study.

Anastomotic stricture is a common underlying cause of long-term morbidity after hepaticojejunostomy (HJ) for bile duct injury (BDI) following cholecystectomy. However, there are no methods for predicting stricture risk. This study was aimed at establishing two online calculators for predicting anastomotic stricture occurrence (ASO) and stricture-free survival (SFS) in this patient population. The clinicopathological characteristics and follow-up information of patients who underwent HJ for BDI after cholecystectomy from a multi-institutional database were reviewed. Univariate and multivariate analyses of the risk factors of ASO and SFS were performed in the training cohort. Two nomogram-based online calculators were developed and validated by internal bootstrapping resamples (n=1000) and an external cohort. Among 220 screened patients, 41 (18.64%) experienced anastomotic strictures after a median follow-up of 110.7 months. Using multivariate analyses, four variables, including previous repair, sepsis, HJ phase, and bile duct fistula, were identified as independent risk factors associated with both ASO and SFS. Two nomogram models and their corresponding online calculators were subsequently developed. In the training cohort, the novel calculators achieved concordance indices (C-indices) of 0.841 and 0.763 in predicting ASO and SFS, respectively, much higher than those of the above variables. The predictive accuracy of the resulting models was also good in the internal (C-indices: 0.867 and 0.821) and external (C-indices: 0.852 and 0.823) validation cohorts. The two easy-to-use online calculators demonstrated optimal predictive performance for identifying patients at high risk for ASO and with dismal SFS. The estimation of individual risks will help guide decision-making and long-term personalized surveillance.

Gastrointestinal Bleeding Because of Hepatic Arteriobiliary Fistula

ABSTRACT Hepatic artery aneurysms are a rare phenomenon, representing 20% of visceral aneurysms. Hepatic artery aneurysm can rarely cause fistulization with the bile duct, also known as common hepatic artery-bile duct fistula. In acute settings, patients present with abdominal pain, jaundice, and gastrointestinal bleeding. Radiographic findings confirm the diagnosis. Given the rarity of this condition, there are no optimal treatment guidelines; therefore, treatment is multidisciplinary and involves definitive surgical and endoscopic management. We present a case of a common hepatic artery-bile duct fistula presenting as gastrointestinal hemorrhage.

Thyroglossal duct diseases: presentation and outcomes

The incidence of thyroglossal duct diseases in the general population is about 7%. We aimed to demonstrate the clinical presentations and management of thyroglossal duct diseases. We conducted a retrospective review of all patients who underwent surgery for histopathologically confirmed thyroglossal duct cyst, sinus, or fistula at a single center. A total of 151 cases were included in this study. There were more female patients (87, 58%) than male patients (64, 42%). The patients' ages ranged from 1 to 63 years old. The most prevalent complaint was painless upper midline neck swelling (93.3%). Most cases were diagnosed as thyroglossal duct cysts (137, 90.7%). Six cases (4%) were associated with carcinoma. All the cases were managed using the modified Sistrunk procedure. There were no procedure-related complications, and five cases of recurrence. Although thyroglossal duct cyst is the most common neck anomaly in children, it may also present with various characteristics later in life. This condition can be managed successfully without complications and with a low recurrence rate.

Postoperative chylothorax after left pulmonary wedge resection without mediastinal lymph node dissection: a case report

Postoperative chylothorax is a rare but serious complication after pulmonary resection. In previous studies, we have found no reports of postoperative chylothorax after left pulmonary wedge resection. Considering the many variations in the route of the thoracic duct, it also has the risk of postoperative chylothorax. We describe a case of refractory chylothorax after left pulmonary wedge resection without mediastinal lymph node dissection. Conservative treatment and supradiaphragmatic thoracic duct ligation did not obtain satisfactory results in this patient. Finally, under the guidance of magnetic resonance-thoracic ductography (MRTD), we successfully ligated the thoracic duct fistula. Thus, MRTD may contribute positively to being used to locate the thoracic duct and its fistula to support precise surgical intervention.

Our Surgery Experience with Thyroglossal Ductus Cyst and Fistules

Objective: In this study, we aimed to analyze the clinical symptoms, examination signs, and treatments of 34 patients who were operated on with the diagnosis of thyroglossal duct cyst, together with the literature. Methods: We retrospectively analyzed the medical reports of 34 patients operated on due to a thyroglossal duct cyst in our clinic. The patient’s age, gender, location of the swelling in the neck region and whether they were fistulized, symptoms, USG results, and pathological results were recorded by us. Results: Of the 34 patients, 20 were male, and 14 were female, and their ages ranged from 6 to 48 years (mean 14.3±11.7 years). The most common symptom was swelling in the middle of the neck (82%). Other symptoms were occasional discharge or fistula in the middle of the neck. Swelling or fistula mouth was in the midline of the neck in 28 patients and the paramedian region (4 on the right and two on the left) in 6 patients. In the symptoms of the cases, we see Fistula mouth in 9 and cyst formation in 25 cases. A neck ultrasound was performed on all patients. All our patients underwent a Sistrunk operation. Thyroglossal duct cysts recurred in only two of our patients, and they have been operated on again. The pathology results of all our patients were thyroglossal duct cysts. Conclusion: Thyroglossal duct cysts and fistulas should not be forgotten in the differential diagnosis of patients presenting with inflammatory discharge and swelling in the middle region of the neck. Surgery should be performed to treat thyroglossal duct cysts because of the risk of cancer transformation. Sistrunk operation is in the first place in the treatment. It is the method with minor repetition.

Professor Leslie H. Blumgart-Pioneering Hepatopancreaticobiliary Surgeon: a Tribute.

Leslie Harold Blumgart was the surgeon behind making Hepatopancreaticobiliary surgery a speciality and his recent demise will always leave a void in that field. He was the person who classified anatomical variations in the biliary tract and devised a special anastomotic technique to decrease the rate of postoperative pancreatic duct fistula after Whipple’s pancreaticoduodenectomy. His contribution in managing hepatobiliary oncology cases with chemotherapy and radiotherapy was also significant. No wonder, he was designated as the “living legend” by the International Hepatopancreaticobiliary Association.

Migration of a Retained Surgical Suture Needle in the Common Bile Duct.

Retained surgical foreign bodies have been a cause of concern since physicians began operating on patients. Retained surgical foreign bodies in the common bile duct (CBD) are rare and may cause cholangitis and jaundice. We report the case of a patient who initially presented with fever and right upper-quadrant abdominal pain. He had received cholecystectomy and choledochojejunostomy 28 years ago and had been well since then. Abdominal computed tomography (CT) revealed left-lobe liver abscess and a linear curve of high-density material. Endoscopic retrograde cholangiopancreatography (ERCP) displayed mild dilatation of the common bile duct (CBD) and choledojejunostomic fistula of the middle CBD. A curved, linear, rusty, metallic surgical suture needle was detected and successfully removed under ERCP.

Complications of robot-assisted thymectomy: A single-arm meta-analysis and systematic review.

BackgroundRecently, thymectomy using minimally invasive approaches has been increasing with the development of robotic video‐assisted thoracoscopic surgery (R‐VATS). Although multimodal approach is effective for robot assisted thymectomy, it is necessary to determine the approach (left, right or subxiphoid) associated with the least complications.MethodsAn electronic retrieval from PubMed, Embase, Web of Science, GreyNet International and The Cochrane Library. The single‐arm meta‐analysis was performed to compare the rate of complications of right‐ and left‐side approaches by R‐VATS.ResultsA total of 21 studies including 930 patients were identified. The pooled incidence of total complications was 12.2% (confidence interval: 10.0%–14.8%) for all studies. The overall complication rate was 17.3% for the right‐side compared with 7.4% for the left side (P < 0.001, odds ratio = 2.484, 1.601–3.852). The pooled incidence of air leak was significantly higher for the right versus left side (5.1% vs. 1.2%, respectively; p = 0.004). The incidence of atrial fibrillation was higher for the right‐side compared with the left‐side approach (4% vs. 1.2%, respectively; p = 0.004). The open conversion rate was significantly higher for the right versus the left‐side (6.5% vs. 2.9%, respectively; p = 0.004). However, there was no significant difference in the pooled incidence of pleural effusion and thoracic duct fistula when comparing the right‐ and left‐side approaches. In subgroup analysis, in the left approach, the incidence of overall complications (28.6% vs. 5.5%, respectively; p = 0.002) and pleural effusion (14.3% vs. 1%, respectively; p = 0.002) was higher for the ‘Old Age’ group compared with the ‘Youth’ group; However, In the subgroup analysis of gender, there was no significant difference in the incidence of complications after thymectomy.ConclusionRobotic video‐assisted thoracoscopic surgery can be performed on the left‐ and right‐sides; however, complications are minimal with the left‐side approach. These data demonstrate that the incidence of overall complications, atrial fibrillation, open conversion ratios, and air leak rate of left‐side R‐VATS thymectomy are lower than those of right‐side. Further subgroup analysis showed that the incidence of postoperative complications was higher in the older group.

Medtronic microvascular plug™: A multipotent device for transcatheter occlusions in children with congenital heart disease

To evaluate our experience with the MVP™ Microvascular Plug system for embolizations of vascular abnormalities in children with congenital heart diseases (CHD). The MVP™ is a recent valuable addition to the armamentarium for vascular embolization. Data on its use in pediatric and congenital cardiology is scarce. Medical records and catheterization reports of all children with CHD who had attempted transcatheter embolizations with MVP™ between April 2015 and September 2020 were retrospectively reviewed. Type of lesions, immediate procedural outcomes, and follow-up data were assessed. A total of 153 patients underwent 172 procedures during which 240 vessel embolizations using 259 MVP™ were attempted. Median age and weight were 34.9 months and 12.5 kg, respectively. Two devices were deployed at the same site in 14 cases. Seven devices were removed before release. Procedural success rate was 99.2%. Target vessels anomalies were systemic arteries ( n = 163), patent arterial duct ( n = 26), venous ( n = 45), and coronaro-cameral fistulae ( n = 6). Mean vessel diameter was 3.3 ± 1.1 mm (1.4 to 9 mm). A detailed device selection chart according to vessel type and diameter was presented based on our experience ( Table 1 ). Complete closure rate was 94.4% at the end of the procedure and increased up to 100% across follow-up. Major complications were limited to one device migration requiring surgery and 4 embolizations treated with percutaneous retrieval. Safety and efficacy of abnormal vessel embolization using the MVP™ were demonstrated in the largest cohort of children with CHD and in a variety of applications. The major advantages of the MVP™ are smooth delivery with high procedural flexibility leading to immediate and stable closure with a single device in most cases, potentially reducing duration, radiation exposure, and decreasing the size of the sheath used in small children.

Percutaneous biopsy and drainage of the pancreas.

Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.

Cholecystohepatic duct fistula (Mirizzi syndrome) in a child

This child suffered three episodes of choledocholithiasis; but what makes her case so interesting is that the stones were passing through an anomalous communication from gallbladder to common hepatic duct. Biliary ductal anatomy is notoriously aberrant, a phenomenon which this case exemplifies.

Prolonged iatrogenic thoracic duct chylous fistula in neck surgery: conservative management or surgery? A literature review.

Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience. The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring. A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation. In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.

Post operative chronic breast seroma with mammary fistula: A case report

Introduction: A breast seroma can develop after trauma to the breast or following procedures such as breast surgery or radiation therapy. Most often, seromas are reabsorbed by the body over a period of several weeks, but in some cases, they can be very troublesome. Also, nipple discharge is very common in women, but a nipple discharge in a previously operated patient for carcinoma can be very alarming. We report a very rare presentation of chronic postoperative breast seroma with mammary duct fistula formation. Presentation of case: A thirty-eight years old female having a 2.1 cm lump in her right breast, presented to us a month after having an excision biopsy of this lump elsewhere. The histopathology report of that excision biopsy showed invasive ductal carcinoma grade III with involved margins. After being discussed in our multidisciplinary team meeting, she underwent re-excision of margins and sentinel lymph node biopsy. This showed no residual carcinoma and negative sentinel lymph nodes. She underwent adjuvant chemotherapy and radiation therapy. But a few months later she presented with pain and swelling in the scar. On her breast ultrasonography, a simple seroma was shown. She was reassured that given time this post-operative seroma should settle. Almost a year later she re-presented with the persistence of a seroma lump along with serous nipple discharge. This nipple discharge would increase on pressing the seroma site suggesting a communication or fistula had formed between the seroma cavity and mammary duct. After a trial of conservative treatment and failing that she was offered surgery. The seroma cavity was excised and the patient’s symptoms were relieved. Discussion: Seroma formation is very common after breast lumpectomies, the incidence being 3 to 85%. Not only it increases morbidity but it may lead to reoperation if not resolved. Also if there is nipple discharge, it should be evaluated thoroughly for its cause as it may represent an underlying serious pathology. Conclusion: Seroma can present with nipple discharge if it has a fistula with one of the mammary ducts. This is a rare entity and so far very few cases have been reported.

S3321 Recurrent Acute Pancreatitis Secondary to Pancreatic Divisum Anomaly

INTRODUCTION: Pancreatic divisum (PD) is a congenital malformation that occurs when the ventral and dorsal ducts of the pancreas fail to fuse. Inadequate drainage of pancreatic secretions from the minor papilla results in ductal distension and recurrent pancreatitis. We present a patient with PD who developed acute necrotizing pancreatitis (ANP) complicated by walled off pancreatic necrosis (WOPN). CASE DESCRIPTION/METHODS: 64-year-old female with history of chronic alcohol abuse and IBD presented with epigastric abdominal pain and emesis. Labs showed normal triglycerides, elevated lipase and amylase. Abdominal US ruled out gallstones. Abdominal CT showed pancreatic inflammation with several cystic-appearing fluid collections. She was treated conservatively. Repeat abdominal CT showed multiple increased peripancreatic fluid collections with mass effect on the stomach (Figure 1). Persistent abdominal pain led to ERCP which displayed complete PD and high-grade pancreatic duct fistula in the body and tail. Ventral and dorsal duct sphincterotomies were done with stent deployment in each duct. EUS revealed 3 peripancreatic fluid collections (consistent with WOPN); the largest was adjacent to the gastric antrum. Purulent drainage was noted after 3 cystogastrostomy incisions. Antibiotics were initiated. Patient eventually had recurrent pancreatitis, requiring repeat minor papilla sphincterotomy with dorsal pancreatic duct stent exchange. DISCUSSION: WOPN is a late complication of ANP, occurring more than 4 weeks after the initial attack. It can cause obstruction and fistula. Due to her PD anatomy, we suspect the patient had previous indolent acute pancreatitis episodes however they were falsely attributed to her IBD. Thus, delaying diagnosis of acute pancreatitis and leading to ANP and WOPN. The lifetime risk of pancreatitis in PD patients is similar to the general population. Consider PD in young, female patients in whom etiologies such as, gallstones and alcohol use, have been excluded. Alcohol abuse in context of her PD anatomy could have amplified our patient’s risk of acute pancreatitis. CT and MRI scans do not reliably detect PD thus ERCP remains the diagnostic test. Minor papilla sphincterotomy, papillary dilatation, stent insertion and pancreatic resection are treatment options. Since recurrent acute pancreatitis can lead to chronic pancreatitis, it is important to detect PD early. Follow up imaging in 3-6 months after pancreatitis resolution is vital, especially in patients with WOPN, to exclude neoplasm.Figure 1Figure 2.: Fig 1. and 2: CT abdomen and pelvis with contrast showing significantly compressed gastric lumen and multiloculated collections surrounding the pancreas, along the fundus of the stomach measuring 8 × 4.3 cm with mass effect, slightly inferiorly along the fundus and body measuring 7.7 × 4.2 cm, and along the antrum measuring 7.9 × 4.3 cm with surrounding fat stranding and mass effect.

A preliminary study on the clinical features of congenital lacrimal fistula

Objective: To summarize the clinical characteristics of congenital lacrimal fistula for reference in its clinical diagnosis and treatment. Methods: Retrospective case series study. The clinical data of 27 patients (32 eyes) with congenital lacrimal fistula admitted to the Lacrimal Center of Third Medical Center of PLA General Hospital from July 2011 to November 2017 were analyzed, including gender, age of diagnosis, left eye or right eye, family history, physical examination, ophthalmic examination, fistula opening location and appearance, symptoms, results of lacrimal duct irrigation, three-dimensional reconstruction of the lacrimal drainage system with CT, lacrimal endoscopy, treatment, outcomes and follow-up. Results: In the 27 patients, the male to female ratio was 1∶2. The age of diagnosis was 1 to 74 years old, and the median was 32 years old. The ratio of unilateral fistula to bilateral fistula was 4.4∶1 (22/5), and the ratio of left eyes to right eyes was 1.2∶1 (12/10). The disease was sporadic in 22 patients, and 5 patients had a family history. Genetic analysis showed that congenital lacrimal fistula presented autosomal dominant inheritance. Fistulas were found on the skin surface of the lacrimal sac area under the medial canthus in 30 eyes, on the lacrimal caruncle in one eye, and on the conjunctiva of the medial canthus in one eye. All the patients presented with epihora, and irrigation liquid outflowed from the fistulas with purulence in 18 eyes. Lacrimal CT of the 27 patients showed contrast agents were left in the lacrimal sac. Lacrimal duct fistula was found open in the common canaliculus with concretions in the lacrimal system in four patients. Eight patients with mild symptoms underwent observation. Three patients underwent lacrimal therapeutic irrigation and probing. Sixteen patients underwent fistulectomy and were cured without recurrence during the follow-up of 1 to 6 years. Conclusions: Congenital lacrimal fistula is usually unilateral, and the opening is mostly located on the skin surface of the lacrimal sac area under the inner canthus ligament. Most cases are sporadic, and some cases are of familial inheritance in an autosomal dominant condition. (Chin J Ophthalmol, 2020, 56: 688-692).

Safe use of vascular stapling devices during laparoscopic cholecystectomy in cases with enlarged cystic canal

Objectives: Bile duct injuries and fistulas due to bile leakage are observed at certain rates in laparoscopic cholecystectomy. In complicated cases, in patients with cholelithiasis cystic duct edema, the cystic canal may be enlarged to the extent that it cannot be closed with a clip in a standard operation. In this study we evaluated the eficiency of stapler closure of cystic canal. Methods: In this retrospective study the cases who had laparoscopic cholecystectomy and cystic canal was closed with stapler between August 2016 and December 2018 were reviewed. Patients' hospital stay and complications were noted. Results: Thirty-three patients who were electively operated and cystic canal closure was performed with vascular staples because of a wide cystic canal during the operation were included in this study. Low bile drainage was observed in only one case and this patient had spontaneous regression with conservative follow-up. Mean duration of hospital stay was 3.7 days. Patients were followed up from 2 months to 28 months postoperatively.Conclusions: Endo-vasculer stapler can be used safely during laparoscopic cholecystectomy with a history of stones in the main bile duct. In this group of patients, it is advisable to make preparations in this direction before the operation.

Endoscopic Ultrasound-Guided Hepaticogastrostomy: Technical Review and Tips to Prevent Adverse Events.

Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.