Flexible Choledochoscope Research Articles

Laparoscopic Management of Common Bile Duct Stones using Semi-rigid Ureteroscope- a Single Centre Prospective Observational Study

Background: Minimally invasive and endoscopic techniques are increasingly being used by surgeons nowadays in the management of patients with cholelithiasis and choledocholithiasis. However, there is a high failure rate in the extraction of large impacted stones using the conventional flexible choledochoscope by the laparoscopic approach. Improvisation of this technique will reduce the failure rate. The present study explored the safety, feasibility, and efficacy of a semirigid ureteroscope (SRUS) in the laparoscopic management of common bile duct (CBD) stones. Methods: A prospective observational clinical study was carried out in an experienced GI surgical unit from January 2020 to December 2021. It included 36 patients diagnosed with radiologically proven gallstone disease with bile duct calculi who underwent Laparoscopic CBD exploration (LCBDE) and stone extraction using SRUS with lap cholecystectomy (LC) as a single-stage procedure. The success rate in terms of complete CBD clearance is the primary outcome measure. Post-procedure complications, 24 hr pain score, in-hospital stay, and patient satisfaction score are the secondary outcome measures. Results: Mean age of the study subjects was 50.45±9.12 years. The most common clinical symptom was biliary colic followed by jaundice. The primary outcome measure of complete CBD clearance was achieved in 94%. A complication following surgery was bile leak in one patient (3%). There were no surgical site infections or T-tube related complications. The average WHO 24-hour pain score was 4.9±1.9. The mean in-hospital stay was 3.3±1.4 and the mean patient satisfaction score was 2.42±0.3. Conclusion: Laparoscopic approach avoids the complications of endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy/sphinteroplasty and keeps the sphincter of Oddi (SOD) intact. LCBDE with SRUS is a safe and effective single-stage approach without any radiation hazards. The pneumatic lithotripter with its pneumatic ballistic effect is more efficacious, cost-effective, and safe as compared to other lithotripsy techniques. This lithotripter is capable of dealing with different varieties of stones regardless of their composition, size and degree of impaction. However, future comparative studies are needed to prove the superiority of this technique.

3D Laparoscopic common bile duct exploration with primary repair by absorbable barbed suture is safe and feasible

Endoscopic retrograde cholangiopancreatography (ERCP), with interval laparoscopic cholecystectomy (LC), is the most common treatment approach for common bile duct (CBD) stones. However, recent studies show that single-stage laparoscopic CBD exploration (LCBDE) is safe and feasible. Three-dimensional (3D) laparoscopy enhances depth perception and facilitates intracorporeal suturing. The application of 3D technology for LCBDE is emerging, and we report our case series of 3D LCBDE. We audited the 27 consecutive 3D LCBDE performed from July 2017 to January 2020. We have a liberal policy for magnetic resonance cholangiopancreatography (MRCP) in patients with deranged liver function tests (LFT). All CBD explorations were done through choledochotomy with a 5 mm flexible choledochoscope and primarily repaired with an absorbable barbed suture without a stent or T-tube. The mean age of patients was 68 (range 44-91) years, and 12 (44%) were male. The indications for surgery were choledocholithiasis 67% (n=18), cholangitis 22% (n=6), and gallstone pancreatitis 11% (n=3). About 67% (n=18) had pre-operative ERCP. About 37% (n=10) had pre-operative biliary stent. Pre-operative MRCP was done in 74% (n=20), and the mean diameter of CBD was 14.5 mm (range 7-30). The median operative time was 160 (range 80-265) min. The operative drain was inserted in 18 patients. One patient each (4%) had a bile leak and a retained stone. There was no open conversion, readmission, or mortality. 3D LCBDE with primary repair by an absorbable barbed suture is safe and feasible. This paper emphasized that one stage LCBDE should be a treatment option which is comparable with two stage ERCP followed by LC to treat CBD stones. In addition, 3D technology and barbed sutures use in LCBDE are safe and useful.

Khâu kín ống mật chủ sau phẫu thuật nội soi cắt túi mật và sỏi ống mật chủ kết hợp nội soi đường mật ống mềm

Tóm tắt Đặt vấn đề: Nghiên cứu nhằm đánh giá kết quả sớm điều trị bệnh nhân sỏi túi mật và ống mật chủ (OMC) được phẫu thuật nội soi (PTNS) kết hợp kiểm soát OMC (KS-OMC) bằng nội soi ống mềm tại Bệnh viện HN Việt Đức. Phương pháp nghiên cứu: 12 bệnh nhân (Nam/Nữ: 5/7) được khâu kín OMC sau PTNS cắt túi mật và lấy sỏi OMC có dùng nội soi đường mật ống mềm. Kết quả: Thời gian phẫu thuật trung bình: 145 ± 45 phút, lượng máu mất 70 ± 50ml (Lượng máu mất từ: 50ml tới 150 ml); các biến chứng trong mổ: không, biến chứng rò mật sau mổ: không, biến chứng nhiễm trùng vết mổ: 1 trường hợp; thời gian nằm viện trung bình 8 ± 1,5 ngày (Thời gian từ: 6 tới 10 ngày) Kết luận: Khâu kín OMC sau phẫu thuật nội soi cắt túi mật và lấy sỏi OMC có kiểm tra bằng nội soi đường mật ống mềm là an toàn và hiệu quả. Abstract Introduction: The objectives of study were to evaluate the early result of treatment patients with concomitant gallbladder stones and common bile duct (CBD) stones by laparoscopic surgery in using flexible fiberoptic choledochoscope. Material and Methods: There were 12 patients enrolled (male/female: 5/7) who are sutured bile duct after laparoscopic cholecystectomy and removing stones in common bile duct with cholangioscopy. Results: Average surgery time: 145 ± 45 min, blood loss 70 ± 50 ml, no postoperative complications related to the procedure. There is no bile leak. There is one surgical site infection, mean hospital stay of 8 ± 1,5 days (6 to 10 days). Conclusion: The current study suggests that laparoscopic surgery and using cholangioscopy to controlling bile duct for the management of cholecysto-choledocholithiasis is a safe and effective technique. Keywords: Gallstones, bile duct stones.

Lấy sỏi mật qua đường hầm ống Kehr bằng ống soi mềm

Tóm tắt Đặt vấn đề: Còn sỏi sau mổ sỏi đường mật là một vấn đề thường gặp và là một vấn đề khó khăn đối với các phẫu thuật viên gan mật. Mục tiêu: Đánh giá hiệu quả của lấy sỏi mật qua đường hầm ống Kehr với ống soi mềm, kết hợp tán sỏi điện thủy lực. Phương pháp nghiên cứu: Nghiên cứu can thiệp, tiến cứu, không nhóm chứng. Chúng tôi sử dụng ống soi mềm đường mật 5mm, kết hợp với tán sỏi điện thủy lực. Kết quả: Từ tháng 01 năm 2010 đến tháng 01 năm 2013, chúng tôi thực hiện trên 164 bệnh nhân. Tuổi trung bình là 50. Tất cả các trường hợp (TH) đều có sỏi trong gan. Trong đó có 63 bệnh nhân có sỏi ống mật chủ kèm theo. Số lần lấy sỏi trung bình là 4,5 lần (từ 1 đến 10 lần). Có 139 TH (84,8%) phải tán sỏi điện thủy lực vì sỏi to hay dính chặt vào đường mật. Tỉ lệ hết sỏi sau khi lấy qua đường hầm ống Kehr trên cả 3 phương tiện bao gồm nội soi đường mật, siêu âm và X quang sau mổ là 90,9%. Nguyên nhân không lấy hết sỏi do đường mật nhỏ, gập góc hay có hẹp đường mật. Tỉ lệ hẹp đường mật là 34,8% (57 TH). Không có tai biến và biến chứng nặng. Thời gian nằm viện trung bình là 10 ngày. Kết luận: Lấy sỏi mật qua đường hầm ống Kehr kết hợp với tán sỏi điện thủy lực là cách giải quyết sỏi sót và sỏi đường mật trong gan rất hiệu quả và an toàn với tỉ lệ hết sỏi cao và không có biến chứng nặng. Đây là phương pháp tối ưu cho những bệnh nhân còn sỏi sau mổ có mang ống Kehr. Abstract Introduction: Retained biliary stones remain a common clinical problem in patients after surgery and a challenge for hepatobiliary surgeons. Objectives: The aim of this study is to evaluate the efficacy of biliary stone extraction via T-tube tract using a flexible fiber optic choledochoscope and electrohydraulic lithotripsy. Material and Methods: This is a prospective, interventional case series study. A 5mm flexible fiber optic choledochoscope was used in accompanied with electrohydraulic lithotripsy. Results: From January 2010 to January 2013, there were 164 included in this study. The mean age was 50. All of the patients had intrahepatic stones. Among them, 63 patients had common bile duct stones. Stone extractions on average were 4.5 (from 1 to 10 times). Electrohydraulic lithotripsy was necessary in 139 patients (84.8%) because of large or impacted stones. Complete clearance rate was 90.9% consisting of cholagioscopic, ultrasonographic and cholangioghaphic clearances. The most common factors related to failure of stone extraction are small associated with angulated intrahepatic bile ducts and biliary strictures. Biliary strictures were noticed in 57 patients (34.8%). There were no major accidents and complications. The mean hospital stay was 10 days. Conclusion: Biliary stone extraction via T-tube tract with electrohydraulic lithotripsy is a safe and efficient procedure for retained biliary stones and intra-hepatic stones with a high complete clearance rate and no major complications. This is the method of choice for treatment of retained biliary stones in patients with a T-tube in situ. Keywords: Biliary stone extraction, T tube tract.

Role of Flexible choledochoscopy in present era – for difficult billiary stones.

Introduction: Several studies have concluded that Laparoscopic Common bile duct exploration (LCBDE) procedures are superior to sequential endo-laparoscopic treatment in terms of both clinical and economical outcomes. Method: In all the cases of LCBDE Calot’s triangle was dissected and cystic duct & artery were clipped before Laparoscopic CBD exploration (Intra-operative Flexible choledochoscopy was done with help of a Olympus (6mm) Flexible Choledochoscope (CYF-5A) via Choledochotomy approach rather than transcystic appreoach). After removal of CBD stones with dormia basket, irrigation & ballon sweep, check completion choledochoscopy of both lower CBD & CHD was performed in all the cases. CBD was closed primarily in all the LCBDE cases over a stent in situ (Infant feeding tube No-7/8). Result: A total of 82 patients underwent LCBDE and 8 patients underwent open CBD exploration (criteria dilated CBDE >20mm with intrahepatic stones) between the periods of 2011 to 2018. Age of the patients ranged from 22 to 76 years. The mean age is about 42.30 years. Peroperatively 14(17.07%) cases had only choledocholithiasis (had previous history of cholecystectomy), 52(63.41%) cases had cholelithiasis with choledocholithiasis, 12(14.63%) cases had associated hepatolithiasis and 2(0.024%) cases had retained cystic duct stump stones with choledocholithiasis. Of eight open CBD exploration patients five and three patients underwent choledochoduodenostomy and Roux-en-Y hepaticojejunostomy respectively. In this series Mechanical lithotripsy with a rigid scope was used in 18 patients after failure to remove large stones by instrumental exploration and percentage of residual stone in this study was 0%. Two cases of LCBDE was converted to open procedure (due to presence of large impacted intrahepatic stones in one case and difficulty in defining Calot’s triangle in another case). Conclusion: Examination of the bile ducts under direct vision with a choledochoscope seems a certain method of ensuring that there are no residual stones.

Laparoscopic Common Bile Duct Exploration Use of a Rigid Ureteroscope: A Single Institute Experience.

Laparoscopic common bile duct exploration (LCBDE) is used to treat choledocholithiasis. Flexible choledochoscopy is usually performed; however, this instrument is fragile and liable to breakage. Data were collected and reviewed retrospectively from a prospectively maintained database. All cases of attempted LCBDE with the rigid ureteroscope at the institution since January 2014 were included. Demographic characteristics, preoperative attempted endoscopic retrograde cholangiopancreatography (ERCP), size of the bile duct, findings at laparoscopy, use of drain or T-tube, conversions, and morbidity or mortality were documented. A total of 37 patients were identified. The median age was 51 years (32-71). The male to female ratio was 1:5. Twenty-eight patients had failed ductal clearance at ERCP (75.7%). The mean common bile duct (CBD) diameter was 11.4 mm (10-13.5). There were five conversions. Cirrhosis in 2 patients, bleeding in 1 patient, impacted stone in 1, and equipment failure in 1. T-tubes were placed in 5% of cases. N = 8 (21.6%) of the patients had a Mirizzi syndrome. Average hospital stay was 4 days (3-7). Two patients had complications postoperatively-bleeding and collections. LCBDE using the rigid ureteroscope is feasible. It can be performed with acceptable morbidity. Use of the rigid ureteroscope represents a good alternative to the flexible choledochoscope with high duct clearance rates. One disadvantage is cirrhosis where the scope may not be negotiated into the CBD due to a stiff liver. It is a viable option when preoperative ERCP has failed to clear the CBD.

Utilization of the flexible adult bronchoscope for performing intraoperative choledochoscopy during open common bile duct exploration for choledocholithiasis: a cost effective utilization of resources

Intraoperative evaluation of the common bile duct is required for assessment of completeness of stone clearance following common bile duct exploration for management of choledocholithiasis. This is usually done by performing an Intraoperative cholangiography. However, intraoperative cholangiography can miss radio-lucent stones, and can be confusing if air is present in the biliary system. Intraoperative choledochoscopy allows direct visualization and confirmation of completeness of stone clearance. It also permits instrumentation to clear retained stones and to directly obtain mucosal biopsies. However, in most hospitals the flexible choledochoscope is not easily available because of its limited scope of utilization, but the flexible bronchoscope due to its wider use by various departments and specialties, is usually available. Since 2003, we have used the flexible adult video Bronchoscope to perform choledochoscopy in 49 patients undergoing open common bile duct exploration. In 18 patients, retained stones were removed by using the bronchoscope grasping forceps. Mucosal biopsies were performed in 7 patients. We now routinely perform choledochoscopy in all patients undergoing common bile duct exploration by using the bronchoscope. Along with the data, a short video clip is also being presented.

The Role of Choledochoscopy in Hepatopancreatobiliary Diseases.

Advances in choledochoscopy technology lead to an improvement in the diagnosis and treatment of hepatopancreatobiliary diseases. The aim of this study is to reveal the role of choledochoscopy in hepatopancreatobiliary pathologies. Choledochoscopy was used under general anesthesia in operation rooms. Flexible choledochoscope inserted via a vertical choledochotomy line, which was closed by primary closure, T-tube application, or choledochoduodenal anastomosis. Olympus CHF T 20 flexible choledochoscope and related endoscopic instruments were used for the procedures. The records were evaluated retrospectively. This study presents the findings of 235 intraoperative choledochoscopy procedures. The most common indications were suspected common bile duct stone in 96 patients (40.9%), serum cholestatic enzyme increase without jaundice in 52 (22.1%), obstructive jaundice and/or serum bilirubin increase in 46 (19.6%), and presence of dilated choledoch in 42 (17.9%). Additional endoscopic diagnostic and/or therapeutic procedures were performed 156 times in 125 patients (53.2%), and endoscopic biliary stone removal was the most used procedure (87 patients, 37.0%). The mean choledochoscopy duration was 8.5 minutes (range: 5-25 minutes). Choledochoscopy confirmed preliminary diagnosis in 117 patients (49.8%), while different data were elicited in 68 (28.9%), and normal findings were found in 50 (21.3%). In this series, no choledochoscopy-related mortality was seen, and some complications occurred in 4 patients (1.7%). Intraoperative flexible choledochoscopy is a proper technique in the diagnosis and treatment of hepatopancreatobiliary disorders.

Laparoscopic Choledocholithotomy with Rigid Nephroscope

Apart from the required expertise, a major deterrent to laparoscopic common bile duct (CBD) lithotomy (LCDL) remains the relatively prohibitive cost of the flexible choledochoscope, and it also has a shortcoming of not being effective in removal of large impacted CBD stones. All patients presenting with CBD stones were treated, without exclusion, by laparoscopic cholecystectomy plus transdochal LCDL after relevant investigations. LCDL was performed using a rigid nephroscope. The CBD was closed either with running 3-0 polyglactin acid (Vicryl; Ethicon) sutures without a stent or around a T tube in a few patients. Perioperative parameters were recorded in all patients. Transdochal LCDL was performed on 172 consecutive patients. Five patients had a prior open cholecystectomy, 26 patients presented with acute cholecystitis, 5 patients presented with mild acute pancreatitis, and 12 patients presented after failed endoscopic retrograde cholangiopancreatography. Twenty-eight (16.28%) patients had multiple stones, 2 had biliary sludge, and no stone was found in 3 patients. Stone size varied from 4 to 12 mm. The average operative time was 68 minutes (range, 45-127 minutes). Primary repair was performed with 3-0 Vicryl continuous sutures, and the T tube was left in place in 13 (7.56%) patients. Conversion to an open procedure was required in 8 patients (4.65%). Postoperatively, mild acute pancreatitis occurred in 1 patient, and biliary peritonitis occurred in 5 patients. Rigid scope transdochal LCDL is feasible, probably easier, better for impacted large CBD stones, and definitely more affordable.

Balloon Catheter Pulmonary Embolectomy Under Direct Visual Control Using a Choledochoscope

Acute massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. To salvage critically ill patients, complete clot extraction without arterial wall injury is essential. In this study, we performed balloon catheter embolectomy under direct visual control by using a flexible choledochoscope. For clear visualization, we introduced deep hypothermic circulatory arrest, and cold normal saline solution was flushed through the irrigation channel. From our experience, we believe that balloon catheter embolectomy with a choledochoscope allows easy access to the secondary and tertiary pulmonary branches and enables complete clot extraction.

Use of Rigid Nephroscope for Laparoscopic Common Bile Duct Exploration—A Single‐Center Experience

Increasingly, laparoscopic biliary surgeons are undertaking laparoscopic cholecystectomy and laparoscopic common bile duct exploration for patients with cholelithiasis and choledocholithiasis. In laparoscopic common bile duct exploration a flexible choledochoscope is ordinarily used, and with this instrument the surgeon usually fails to remove large impacted stones. In contrast with use of a rigid nephroscope it is possible to remove all common bile duct stones irrespective of size and degree of impaction. The present study evaluates the efficiency of rigid nephroscope for managing common bile duct stones laparoscopically. In the present study laparoscopic common bile duct exploration for stones was performed in 80 patients via standard laparoscopic cholecystectomy port sites. Patients with a common bile duct diameter >10 mm were included in this study. The rigid nephroscope was passed through the epigastric port and negotiated into the common bile duct through a choledochotomy. Stones were removed with graspers. Large hard stones were fragmented by pneumatic lithotripsy. Of the 80 patients treated in this manner, 72 (90%) had multiple common bile duct calculi, and 8 (10%) had a solitary common bile duct calculus. Mean common bile duct diameter was 15.3 mm (range: 10-37 mm). Conversion to open common bile duct exploration was necessary in 1 case (1.25%) because of difficult dissection secondary to extensive dense adhesions. In 7 patients (8.75%) a pneumatic lithotripter was used to fragment stones. Choledochotomy was managed by placing a T-tube in 21 (26.25%) patients, by effecting primary closure in 58 (72.5%) patients, and by choledochoduodenostomy in 1 (1.25%) patient. The mean operative time in this series was 83 min (range: 53-135 min). The mean postoperative hospital stay was 4.2 days (range: 3-19 days). One patient (1.25%) developed cholangitis 5 months after laparoscopic common bile duct exploration; the cause was a residual common bile duct stone. A rigid nephroscope can be used for managing all types of common bile duct calculi irrespective of site, size, composition, or degree of impaction. Its use can be expected to become the standard for laparoscopic common bile duct exploration, especially for removing large calculi from a dilated common bile duct.

Percutaneous transhepatic cholangioscopy. A new method for the diagnosis of bile duct malignancies

Percutaneous transhepatic cholangioscopy combines the advantages of endoscopic and radiological examinations. It makes it possible to assess the intraluminal spread of bile duct disease as well as histological and cytological examination of biopsies obtained under vision. Eight PTCs were performed without complication in seven patients with cancer of the bile duct. In four, the histology and extent of the tumour was defined endoscopically before any surgical intervention. In three others the results of treatment were objectified. A flexible choledochoscope, as used intraoperatively, was employed (CHF-P10). A stepwise dilatation of the percutaneous access-route was undertaken in several sessions in order to avoid bleeding complications. The procedure is done without general anaesthesia.

Safe Modification of the Liver-Hanging Maneuver by Endoscopic-Assisted Dissection of the Retrohepatic Tunnel

As a safer approach to right hepatectomy, Belghiti et al. (J Am Coll Surg 193:109-11, 2001) described a liver-hanging maneuver. However, this procedure is performed blind, with the risks of damaging the small retrohepatic veins and consequential bleeding. To overcome this problem, we modified the procedure so that, instead of performing blind dissection using a long vascular clamp, we use a flexible choledochoscope to dissect the retrohepatic space filled by loose alveolar tissue anterior to the inferior vena cava (IVC). The avascular path is identified by a combination of saline irrigation and gentle movement of the tip of the choledochoscope. Cotton tape can then be passed around the liver parenchyma to elevate the liver away from the anterior surface of the IVC. This modification of Belghiti's liver-hanging maneuver allows direct vision along the plane anterior to the IVC, thus avoiding injury to the retrohepatic veins.

Percutaneous flexible choledochoscopy: A simple method for retained common bile duct stone removal

Conventional methods of treatment of retained common bile duct stones found on T tube cholangiography after common bile duct exploration include percutaneous extraction under fluoroscopic control and endoscopic sphincterotomy. Four cases of percutaneous stone extraction under direct vision using the flexible choledochoscope are described. Clearance of the bile ducts was achieved at one sitting in three cases and four sittings in one case. Follow-up tube cholangiography was performed in two cases and confirmed complete clearance. Percutaneous endoscopic stone extraction can be performed by any surgeon with experience of flexible choledochoscopy and offers the advantages of a minimally invasive procedure without the use of specialized equipment.

Operative choledochoscopy: Common bile duct exploration is incomplete without it

This paper reviews the reported experience of operative choledochoscopy. Development of choledochoscopes to the currently available rigid and flexible instruments is described. The collected results of both rigid and flexible choledochoscopy are reported. Retained stones occurred in 97 of 2712 stone-positive explorations with the rigid choledochoscope (3.6 per cent) and in 35 of 1726 stone-positive explorations with the flexible choledochoscope (2.0 per cent). Choledochoscopy should now be a mandatory part of common bile duct exploration.

Laparoscopic treatment of intrahepatic duct stone.

Between October 1998 and November 1999, 12 patients with IHD stones, without severe ductal stricture, adhesion due to previous exploration, intrahepatic abscess or suspicious malignancy, were in the subjects of this study. A 4-port-technique was performed, with a 4-way flexible choledochoscope, via a choledochotomy, for removal of the stones. The postoperative follow-up for recurrent stones was performed with a cholangiogram and an ultrasonogram, and the quality of life was evaluated by a questionnaire for the symptoms. The mean operating time was 288.3 (150-420) minutes. There was only one postoperative complication, but no intraoperative transfusions or perioperative mortality. Remnant stones were detected in 1 patient on the final T-tube cholangiogram, which was removed by percutaneous choledochoscopy, through the tract matured by the T-tube. There were no cholangitis or recurrent stones during the mean follow-up period of 31.4 (10-45) months. With increasing demand for minimal invasiveness, the laparoscopic treatment of IHD stones could be an effective option.

Evolution of a percutaneous fetoscopic access system for single-port tracheal occlusion

Background/Purpose: Prenatal tracheal occlusion currently is being assessed as a treatment modality for congenital diaphragmatic hernia (CDH). The development of a totally percutaneous fetoscopic access system would help avoid the need for maternal laparotomy and reduce the morbidity rate of fetal surgical procedures for the mother. Laparoscopic radial expansion sheaths and Seldinger technique–based vascular catheters both have been advocated as means of achieving amniotic cavity access. The authors have investigated these 2 systems in an attempt to develop a reliable method for achieving safe percutaneous fetoscopic access and present the first successful attempt to deploy an intratracheal balloon using an entirely percutaneous approach through a single port in an ovine model. Methods: A number of prototype systems were evaluated sequentially over a 3-year period in an ovine model: (1) the radially expanding InnerDyne step port system, (2) a new rigid cannula with a bulbous/sharp end preloaded onto the radially expanding InnerDyne port, (3) a conical removable addition to the rigid cannula in 2, (4) a modified bulbous/sharp ended cannula incorporating a circumferential protective insert, (5) a rigid split sheath with the radially expanding port placed through the lumen of the split sheath, (6) a flexible introducer and dilator with the split sheath (used in the Seldinger placement of central lines), and (7) a 2-needle approach using a superelastic shape-memory alloy Nickel-Titanium wire with the flexible dilator and sheath, incorporating a side perfusion port. For balloon tracheal occlusion, live anaesthetized time-mated pregnant ewes were used at 110 days' gestation. Tracheobronchoscopy was achieved using a 3-mm 0° telescope, and the cutaneotracheal tract was secured by a 3.3-mm sheath incorporating a side-perfusion port. The rigid telescope was replaced by a flexible choledochoscope preloaded with a silicone balloon. The balloon was deployed 2 cm above the carina proximal to the right upper lobe bronchus. Results: The many problems encountered in the evolution of the preferred system related mainly to separation and tenting of the chorioamniotic membranes in the ovine uterus and inconsistent access to the fetal parts of interest. Each resulted in significant modifications to our approach. Furthermore, the use of rigid access devices commonly caused fetal injury. Successful access to the intrauterine cavity and cannulation of the trachea was achieved consistently with minimal trauma, irrespective of fetal position by method 7. Multiple port placement allowed visualization of the entry of all components of the system confirming minimal chorioamniotic membrane separation and tenting. Single port tracheal occlusion was undertaken first on 6 cadavers before being performed successfully on 3 live anaesthetized ewes. Fetoscopic access and cannulation of the trachea was achieved consistently in all live animals irrespective of fetal position. Conclusions: This modified Seldinger technique using the unique properties of the memory-shaped alloy wire for initial uterine access offers a safe method for the percutaneous placement of fetoscopic ports in the ovine model for prenatal intervention. Successful placement of a tracheal balloon entirely through a single percutaneously placed port represents a further advance in prenatal therapy for CDH. J Pediatr Surg 38:45-50. Copyright 2003, Elsevier Science (USA). All rights reserved.

Reinventing the culdoscope.

The purpose of this study was to reassess culdoscopic visualization of the female pelvis using a small flexible fiberoptic choledochoscope introduced via a disposable trochar system. A disposable 5-mm retractable laparoscopic trochar was used to gain access to the peritoneal cavity via the posterior fornix of the vagina. A 4.9-mm flexible choledochoscope then was introduced through this trochar to visualize the pelvic organs. The initial procedures were performed with the patient under general anesthesia using direct laparoscopic visualization of the cul-de-sac. Subsequent procedures were performed on women who were awake, using local anesthesia and sedation with the patients in a knee-chest position. In this study, 18 women taken to the operating room for a planned transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy underwent flexible culdoscopy. Three procedures were performed with the patients under general anesthesia using direct laparoscopic visualization, and 15 procedures were performed in a blind fashion with the patient awake in a knee-chest position. The average Quetelet Index was 31.2 (range, 22.8-43.1). Of the 18 procedures, 16 were successful in adequately visualizing the pelvic organs. There were no significant complications from the procedures, and no injury to adjacent organs. Culdoscopy with a small flexible scope can be performed safely in awake patients, providing adequate visualization of the female pelvis.

7161 Long-term results of percutaneous cholecystolithotomy using flexible choledochoscope for acute calculous cholecystits.

Aims: To evaluate outcomes of long-term follow up after percutanesous cholecystolithotomy using choledochoscope for acute calculous cholecystitis. Methods: Medical records of 72 patients with acute calculous cholecystitis undergoing percutaneous cholecystolithotomy from March 1989 to November 1999 were retrospectively reviewed. Stone removal was performed by a flexible choledochoscope via the matured fistra track around the drainage catheter using either basket catheter or electrohydraulic lithotriptor. To determine combined gallbladder cancer, frequent bile cytology were performed and biopsies were endoscopically obtained. The drainage catheter was withdrawn after endoscopic confirmation of complete stone removal. After successful treatment, patients were followed up with bimonthly interview and ultrasound every six months up to the detection of stone recurrence or subsequent cholecystectomy. Adjuvant bile acid therapy was administered to them. Results: With one exception, complete stone removal was successfully achieved (success rates; 98.6%). One patient underwent cholecystectomy due to perforation of cystic duct by electrohydraulic lithotripsy. Three patients underwent cholecystectomy right after stone removal; gallbladder cancer was identified in two and pancreatic cancer was in one.With these four exceptions, 68 patients were followed up during a mean of 54 months (1 to 120 months). Of these, 13 cases were died (4; myocardial infarction, 4; stroke, 2; heart failure, 1; lung cancer, 1; gallbladder cancer, 1; unknown), 6, no contact due to address change, and 5, underwent cholecystectomy for other diseases (2; gastric cancer, 2; CBD stone, 1; gallbladder cancer) without stone recurrence up to their end points. Stone recurrence was observed in 10 patients (14.7%). Six of the 10 patients with recurrent calculi were asymtomatic. Gallbladder cancer developed in 3 patients (4.4%). The periods of detection of gallbladder cancer from complete stone removel were 12, 42, and 60 months. There is no procedure related mortality. Procedure related complication was observed in the only one patient (1.4%) as cystic duct perforation. Conclusion: Percutaneous stone removal for acute calculous cholecystitis is safe and effective with low recurrence rates in long-term follow up. However, there is the risk of developing gallbladder cancer even after stone removal. Therefore, perecutaneous gallstone removal is beneficial in patients with surgical high risk.

Role of hepatic resection in surgery for bilateral intrahepatic stones

Hepatic resection is the treatment of choice for unilateral intrahepatic stones. The availability of the flexible choledochoscope has greatly changed the management of intrahepatic stones. Little has been reported regarding hepatic resection for bilateral intrahepatic stones. Fifty-nine (15.1 per cent) of 392 patients with bilateral intrahepatic stones underwent hepatic resection. The indications and results were reported. Surgical outcome and long-term follow-up were analysed, and results were compared with those in patients not undergoing hepatectomy. Fifty-nine patients underwent hepatic resection because of destruction of the left liver by repeated infection (n = 40), multiple cholangitic liver abscesses (n = 18) or associated intrahepatic cholangiocarcinoma (n = 1). The hospital mortality rate was 1.7 per cent. The majority of complications were wound infection (9 per cent), haematobilia (5 per cent) and biliary fistula (3 per cent). The incidence of residual stones after surgery was 60 per cent. One year after postoperative choledochoscopic stone extraction, the rate of complete stone clearance was 84 per cent. In patients who did not have hepatectomy the respective rates were 90.1 and 52.9 per cent. The recurrence rate for stones in the hepatectomy and no-hepatectomy groups was 12 and 33.0 per cent respectively. Compared with patients not undergoing hepatectomy, those having hepatic resection had similar operative risks, fewer residual stones and a low incidence of recurrent stones (P < 0.05).