Impacted Common Bile Duct Stones Research Articles

EP.FRI.199 Impacted common bile duct stone managed by hepaticoduodenostomy

Abstract The management strategy of common bile duct stone will depend on personal experience, equipment availability, time and the availability of other departmental expertise. For a distally impacted common bile duct (CBD) stone in a low resource setting, an open approach will entail either leaving the stone where it is and carry out a choledochoduodenostomy, or removing the stone through a transduodenal sphincteroplasty. The latter has a significant risk of causing an acute pancreatitis. A case report of a hepaticoduodenostomy performed on a 40-year-old black African man for a retained, impacted distal CBD stone in a low resource setting with a good outcome is presented. The impacted CBD stone had complicated an open cholecystectomy for acute cholecystitis by causing the dehiscence of the cystic duct stump as a result of distal biliary obstruction. A bypass procedure such as a hepaticoduodenostomy may be an alternative to the traditional choledochoduodenostomy in the management of the retained, impacted distal CBD stone especially in the presence of sepsis. A wide side- to-side hepaticoduodenostomy (>3cm d) is a safe and definitive procedure for the decompression of lower CBD obstruction and has good long-term results with infrequent complications including reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis and the ‘sump’ syndrome. This case demonstrates that a hepaticoduodenostomy is safe and effective in rescuing the adverse sequelae of an impacted distal CBD stone in a low resource setting.

Palliative Cholecysto-Jejunostomy for Extra-Hepatic Billiary Obstruction under Local Anaesthesia: A Rewarding Experience

Extra-hepatic billiary obstruction is a common disorder seen in surgical practice, and it greatly affects the quality of life of patients afflicted with such disorder. In its severe form, it may be life threatening due to complications such as, hepatic encephalopathy, Hepato-renal syndrome, fulminant cholangitis and jaundice related coagulopathy. Obstructive Jaundice is the most common presentation following extra-hepatic billiary obstruction and carcinoma of the head of the pancreas and choledocholithiasis are the most common malignant and benign causes. Most patients present with advanced disease where palliation is the only viable option. However, such patients may not be suitable for surgery under General Anaesthesia due to advanced age, poor nutritional state with hypolbuminaemia, extra-abdominal metastasis producing respiratory compromise or a high risk for hepatic encephalopathy. Objectives: We aim to assess the safety and effectiveness of a palliative Cholecysto-Jejunostomy done under local Anaesthesia. Methods: This is a prospective cross-sectional study of total of 54 patients, both males and females, aged 16 years and above, who presented at the General Surgery units of State Specialist Hospital Damaturu and General Hospital Potiskum, both in Yobe State Nigeria; with Obstructive Jaundice. All had clinical and Radiological evidence of extra-hepatic Billiary obstruction and were managed surgically with a palliative Cholecysto-Jejunostomy under local Anaesthesia involving infiltrative cutaneous field block and USS guided Oblique Subcostal Transversus Abdominis Plain Block (OSTAPB). It is a 6-year study done from January 2015-December 2020. Informed consent was obtained from all patients according to Helsinki guidelines and Ethical clearance was granted by the leadership of both hospitals. All data were analysed with SPSS 20.0 software for correlation of outcomes. Results: The study population were 54 patients, 59.3% males and 40.7% females. The mean age is 50.5 years and an age range of 16-75 years. Malignant lesion is the most common cause of extra-hepatic billiary obstruction, with exocrine pancreatic cancer responsible for 48.1% of all causes. Chronic pancreatitis (16.7%) and impacted common bile duct (CBD) stones at 14.8%, are the two most common benign causes. All the patients had an abdominal USS for diagnosis or non-contrast enhanced abdominal CT Scan if there is ambiguity. A total of 77.8% had palliative Cholecysto-Jejunostomy done under local Anaesthesia involving cutaneous field block with Lignocaine with Adrenaline at a standardised dose of 4mg/kg body weight and USS guided Subcostal TAP Block. The remaining had a palliative Cholecystostomy or no surgery done. All abandoned cases were because of an involved or fibrosed Gallbladder. The most common post-operative complications are Surgical Site Infection (SSI) at 24.1%, excessive Primary Haemorrhage and reactionary haemorrhage, at 9.3% each. The total fatality rate was 7.4%. Conclusion: Palliative Cholecysto-Jejunostomy is safe, operative mortality rate is 7.4% and is effective in providing billiary drainage with limited postoperative morbidity.

Endoscopic Interventions for the Early and Remission Phases of Acute Biliary Pancreatitis: What are the More Concrete and Practical Situations for Performing Them?

Background/AimsThe use of endoscopic intervention (EI) for acute biliary pancreatitis (ABP) remains controversial because the severity of biliary obstruction/cholangitis/pancreatitis is not reflected in the indications for early EI (EEI). MethodsA total of 148 patients with ABP were included to investigate 1) the differences in the rate of worsening cholangitis/pancreatitis between the EEI group and the early conservative management (ECM) group, especially for each severity of cholangitis/pancreatitis, and 2) the diagnostic ability of imaging studies, including endoscopic ultrasound (EUS), to detect common bile duct stones (CBDSs) in the ECM group. ResultsNo differences were observed in the rate of worsening cholangitis between the EEI and ECM groups, regardless of the severity of cholangitis and/or the existence of impacted CBDSs. Among patients without impacted CBDSs and moderate/severe cholangitis, worsening pancreatitis was significantly more frequent in the EEI group (18% vs. 4%, <i>p</i>=0.048). In patients in the ECM group, the sensitivity and specificity for detecting CBDSs were 73% and 98%, respectively, for EUS, whereas the values were 13% and 92%, respectively, for magnetic resonance cholangiopancreatography. ConclusionsEEI should be avoided in the absence of moderate/severe cholangitis and/or impacted CBDSs because of the high rate of worsening pancreatitis. EUS can contribute to the accurate detection of residual CBDSs, for the determination of the need for elective EI.

Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery?

Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.

Granulomatous inflammation of gall bladder mimicking an impacted common bile duct stone

The journal is the official publication of the College of Surgeons of Sri Lanka. Its mission is to reach the highest standard of scientific surgical practice by dissemination of high quality scientific information and to foster and promote the growth of scientific surgery in Sri Lanka and in the region. The Sri Lanka Journal of Surgery publishes peer-reviewed leading articles, review articles, scientific articles, perspectives and case reports in the field of surgery and broadly related surgical sciences The journal adheres to the publication ethics as portrayed by the Committee on Publication Ethics (COPE) and is a member of this organisation. It is listed as an ICMJE journal which follow its recommendations (ICMJE recommendations) on Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals.

Rescuing the Rescuer: Fractured Dormia Basket and a Second Basket Rescue Technique.

ABSTRACTMechanical lithotripsy is one of the well-known rescue methods for impacted common bile duct (CBD) stones. A fractured Dormia basket with a captured stone is an unusual complication and poses a special management problem. In the past, surgical intervention was the standard method. Various nonsurgical techniques have been reported. If the impaction is at the level of the papilla, extending the sphincterotomy might be sufficient. Stent insertion, endoscopic mechanical lithotripsy, extracorporeal shock wave lithotripsy, endoscopic laser lithotripsy, and transhepatic choledochoscopic lithotripsy have all been reported. In this case, we used a second basket, which is readily available and less expensive, as a rescue technique.How to cite this articleKhamaysi I, Hajj E. Rescuing the Rescuer: Fractured Dormia Basket and a Second Basket Rescue Technique. Euroasian J Hepato-Gastroenterol 2020;10(1):45–46.

1294 Large Common Bile Duct Stones Creating a Rare Distal Choledochoduodenal Fistula Requiring Unusual Extraction Method

INTRODUCTION: Choledochoduodenal fistulas (CDF) are abnormal connections of the common bile duct to the duodenum separated into proximal and distal. Of the various enterobiliary fistula, the most common is cholecystoduodenal. The rare occurring distal CDF etiologies include cholecystolithiasis, malignancy, peptic ulcers and iatrogenic. In the case presented, common bile duct (CBD) stones were large enough to create a fistula from the common bile duct superior to the sphincter of Oddi requiring unique extraction. CASE DESCRIPTION/METHODS: A 75-year-old Caucasian female with past medical history significant for biliary colic status post cholecystectomy was found to have multiple large CBD stones on abdominal ultrasound outpatient. Physical exam and laboratory analysis was unremarkable. When the ERCP was performed, the papilla was identified and noted be abnormal. The papilla was downward facing. Shockingly, superior to the papilla was a CDF created by an impacted black CBD stone. Subsequently to this unexpected finding, selective deep cannulation of CDF, adjacent to the CBD stone, was done using a sphincterotome with a 0.035 wire. No attempts were made of cannulating the papilla. The cholangiogram showed multiple CBD stones throughout the distal CBD. A 13 mm sphincterotomy superiorly at the CDF, followed by balloon sweeps removing several large yellow cholesterol appearing stones. DISCUSSION: Distal CDF is diagnosed via endoscopy and categorized based on location using the Ikeda classification. Type 1 (distal) fistulas occur along longitudinal fold adjacent to the papilla, often due to an impacted stone. Type 2 (proximal) occurs on the posterior wall of the duodenal bulb. The classification system further separates CDF into type A, opening greater than 2 cm from the papilla, type B, opening within 2 cm from the papilla, and type C, opening on the papillary fold. In this rare case of distal CDF, the diagnosis was likely type 1A (distal and greater than 2 cm from the papilla). Treatment is often based upon the etiology of CDF formation. Given the rare occurrence, it is important for gastroenterologist to be aware of the classifications as it may assist in treatment and safe stone removal.

Cholangioscopy-guided retrieval basket and snare for the removal of biliary stones and retained prostheses.

Background and AimsCertain pancreaticobiliary conditions remain challenging to treat using standard endoscopic techniques. Examples include difficult-to-remove gallstones and foreign objects in the bile ducts. Two tools designed for these purposes are the SpyGlass retrieval basket and the SpyGlass retrieval snare, which are passed through the cholangioscope channel for use under direct visualization. We present 3 cases in which these tools were used successfully.MethodsThree cases using the SpyGlass retrieval basket and retrieval snare were reviewed for efficacy.ResultsPatient 1 had hepatitis C cirrhosis and underwent liver transplantation with T tube placement at the site of biliary anastomosis. Image-guided T tube removal by interventional radiology was unsuccessful. Endoscopic removal with the SpyGlass retrieval snare was completed. Patient 2 presented with cholangitis from an impacted common bile duct stone. Fragmentation with electrohydraulic lithotripsy was performed, and the fragments were removed with the SpyGlass retrieval basket. Patient 3 presented for removal of a migrated biliary stent. The stent was placed a year prior during an ERCP for treatment of choledocholithiasis. Initial removal attempt at an area hospital failed, so the patient was referred to our center, where the Spyglass retrieval snare was used to remove the biliary stent.ConclusionsThis case series demonstrates initial successes treating biliary pathologic conditions with the SpyGlass retrieval basket and retrieval snare, 2 tools designed for use under direct visualization with the cholangioscope.

A new hybrid anchoring balloon for direct peroral cholangioscopy using an ultraslim upper endoscope.

Large impacted or residual invisible common bile duct (CBD) stones after mechanical lithotripsy are challenging. We aimed to evaluate the feasibility and success rate of a new hybrid anchoring balloon-guided direct peroral cholangioscopy (POC) for these conditions using an ultraslim endoscope. Sixty-five patients with large or residual invisible CBD stones for direct POC from July 2012 to July 2016 were identified, including six cases in whom an additional interventional procedure was required. There were altogether 55 cases undergoing a procedure with our new device, with a 0.021-inch guidewire tied to a balloon catheter at its distal end in this single-center retrospective study. Technical success, procedure time, diagnostic and therapeutic efficacy of direct POC, and procedure-related complications were studied. The hybrid anchoring balloon-guided direct POC was successful in 51/55 (92.7%) procedures, including 18 cases in whom the conventional wire-guided method failed within 25min. Mean time for technical success by our method was 12.4±3.4min. In total, of the 43 cases with previous removal of CBD stones, seven (16.3%) were found to have residual stones ≥4mm, excluding three cases in whom direct POC failed. In another 25 cases for difficult stones, 24 lithotripsies were carried out, resulting in 23 complete fragmentations. No significant procedure-related complications were observed. The new hybrid anchoring balloon device performs well in facilitating direct POC using an ultraslim endoscope for evaluation and extraction of residual or large impacted CBD stones.

Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla

AimTo evaluate the efficacy and safety of emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla. MethodsBetween January 2010 and January 2015, 118 cases of acute severe cholangitis with impacted common bile duct stones at the native papilla underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) and early needle-knife precut papillotomy in a tertiary referral center. Precut techniques were performed according to the different locations of stones in the duodenal papilla. Clinical data about therapy and recovery of the 118 patients were recorded and analyzed. ResultsOne hundred and eighteen patients underwent emergency ERCP within 24 h after hospitalization, with a total success rate of 100%. The mean operating time was 6.4 ± 4.1 min. Postoperative acute physiology and chronic health evaluation (APACHE) II scores, white blood cell count and liver function improved significantly. The complication rate was 4.2% (5/118); two with hemorrhage and three with acute pancreatitis. There was no procedure-related mortality. ConclusionEmergency endoscopic needle-knife precut papillotomy is effective and safe for acute severe cholangitis resulting from impacted common bile duct stones at the duodenal papilla.

LABEL procedure: Laser-Assisted Bile duct Exploration by Laparoendoscopy for choledocholithiasis: improving surgical outcomes and reducing technical failure.

Laparoscopic bile duct exploration (LBDE) is recommended in current treatment guidelines for the management of choledocholithiasis with gallbladder in situ. Failure of this technique is common as a consequence of large or impacted common bile duct (CBD) stones. In this series, we present our experience in using holmium laser lithotripsy as an adjunct to LBDE for the treatment of choledocholithiasis. Between 2014 and 2016, eighteen laparoscopic bile duct explorations utilising holmium laser lithotripsy were performed after failure of standard retrieval techniques. Choledocholithiasis was successfully treated in 18 patients using laparoscopic holmium laser lithotripsy (transcystically in 14 patients). There was one failure where a CBD stricture prevented the scope reaching the stone. Two medical complications were recorded (Clavien-Dindo I and II). There were no mortalities or re-interventions. LABEL technique is a successful and safe method to enhance LBDE in cases of impacted or large stones. In our experience, this approach increases the feasibility of the transcystic stone retrieval and may reduce overall operative time.

Management of impacted common bile duct stones during a laparoscopic procedure: A Retrospective Cohort Study of 377 Consecutive Patients

IntroductionTo explore the techniques for managing impacted common bile duct (CBD) stones during laparoscopic common bile duct exploration (LCBDE). MethodsWe retrospectively analyzed 377 consecutive patients undergoing LCBDE from January 2008 to June 2015. Group 1 was defined as patients with impacted CBD stones. Group 2 included patients without impacted CBD stones. The outcomes of LCBDE were compared between the two groups. ResultsThere were 65 patients in Group 1 and 312 patients in Group 2. The incidence of jaundice, abnormal liver function tests, cholangitis and pancreatitis was higher in Group 1. Forty-one patients with small impacted CBD stones were managed using the tipless Nitinol basket. Seventeen patients with large impacted CBD stones and 7 patients with small impacted CBD stones underwent laser lithotripsy via choledochoscopy. None of the patients in Group 1 was converted to open procedures for impacted CBD stones. Operation duration was 13.6 min longer in Group 1 (133.2 min). Postoperative hospital stay was significantly longer in Group 1 (9.7 ± 2.5 d) than in Group 2 (6.3 ± 1.8 d). There was no difference in the overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups. ConclusionRational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones.

Laparoscopic Transcystic Common Bile Duct Exploration: T-Shaped Incision of Cystic Duct with FREDDY Laser Lithotripsy.

Optimal laparoscopic techniques for management of gallstones concomitant with common bile duct (CBD) stones remain under debate. The aim of this study was to evaluate a novel approach to managing gallstones concomitant with large or impacted CBD stones through a modified laparoscopic transcystic CBD exploration (LTCBDE) with frequency-doubled double-pulse neodymium:YAG (FREDDY) laser lithotripsy. This retrospective review includes 32 consecutive patients with gallstones concomitant with large or impacted CBD stones who were offered LTCBDE with FREDDY laser lithotripsy between June 2012 and December 2014. Demographic, perioperative, and follow-up data were collected and analyzed retrospectively. CBD stone clearance was achieved for all patients. There were 13 males and 19 females, among whom there were three patients with a history of abdominal surgery. The diameter of the CBD ranged from 10 to 20 (mean 15.1) mm, and the number of CBD stones ranged from 1 to 5. CBD stones ranged in diameter from 9 to 18 (mean 11.7) mm and 9 patients had stones that were impacted in the CBD. The mean operative time was 123 ± 18 minutes with a range of 72 to 155 minutes. The mean length of postoperative hospital stay was 5.3 (range 4-7) days. All patients recovered normally without morbidity or mortality. The modified LTCBDE with a T-shaped incision of the cystic duct and FREDDY laser lithotripsy is a safe and effective means of managing gallstones concomitant with large or impacted CBD stones.

Laparoscopic Exploration of the Common Bile Duct and T-Tube Drainage in China

Biliary stones that are seen in the Asian population are very different from those seen in the west. It is frequent to see multiple, large, and impacted stones and a hugely dilated Common Bile Duct (CBD). Many of these patients have been managed by open cholecystectomy, even after the advent of Laparoscopic Cholecystectomy (LC) because these large stones pose significant challenges for extraction by endoscopic retrograde cholangio-pancreatography. This study represents an experience of managing intra and extra hepatic bile ducts using a laparoscopic approach. A retrospective data analysis was done during the period of November 2010-April 2015 and correspondingly 85 patients with documented intra and extra hepatic biliary stones were treated laparoscopically at Qilu Hospital under Shandong University, School of Medicine. There were 23 men and 62 women patients with age ranging from 23 to 76 years. The mean diameter of the CBD was 12mm. The number of stones extracted varied from 1 to 35 and the size of the extracted stones from 0.3X0.3X0.3 to 4X3.5X3.5 mm. The average duration of surgery was 170 min. There were 7 conversions to open procedures and 24 patients (29%) had nonfatal postoperative complications. Four patients had retained stones (4.7%). Though patients presented with multiple and impacted CBD stones, laparoscopy presents a unique approach for a minimally invasive procedure with its benefits in the form of laparoscopic intra and extra hepatic bile ducts exploration. &#x0D; JCMCTA 2015 ; 26 (2) : 53 - 61

A rare complication of forming a stent-stone complex after short-term endoscopic biliary plastic stenting in a giant impacted common bile duct stone

Abbreviations: CBD, common bile duct; EPLBD, endoscopic papillary large balloon dilatation; EML, endoscopic mechanical lithotripsy; ESWL, extracorporeal shock wave lithotripsy; LL, laser lithotripsy; EHL, electrohydraulic lithotripsy; ERCP, endoscopic retrograde cholangio-pancreatography; CT, computed tomography; PTCSL, percutaneous transhepatic cholangioscopic lithotripsy; PTBD, percutaneous transhepatic biliary drainage

Percutaneous Approach for Removal of Difficult Common Bile Duct Stones

See Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones by Jae Hyung Lee, Hyung Wook Kim, Dae Hwan Kang, et al., on page 65-70 Bile duct stone disease is one of the most common problems in medical practice. Surgical common bile duct (CBD) exploration was the procedure of choice for the treatment of bile duct stones a few decades ago. However, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy has become the treatment of choice for bile duct stones after the development of ERCP techniques. Development of devices and techniques used in endoscopic sphincterotomy and stone extraction has increased the success rate of stone removal. Meanwhile, endoscopic sphincterotomy may be difficult or impossible in some clinical situations, including duodenal or pyloric stenosis, unusual biliary anatomy, previous gastrointestinal surgery such as Billroth II and Roux-en-Y gastrojejunostomy reconstruction, bilioenteric anastomosis, and patients' intolerance. As a surgical modality, laparoscopic biliary surgery has been widely used. Laparoscopic CBD exploration (transcystic or transcholedochal) is the most commonly used method for managing difficult CBD stones. However, general anesthesia is necessary to perform the surgery and the cost of the procedure is high. The success rate in performing laparoscopic CBD exploration is approximately 86% to 95% with 5% to 18% complication rates.1 Percutaneous transhepatic stone removal is another important technique among the nonoperative managements of bile duct stones. Percutaneous transhepatic stone extraction and expulsion into the duodenum was first reported in 1979.2 Percutaneous transhepatic cholangioscopy (PTCS) can be combined with these techniques. Balloon dilatation of the sphincter of Oddi has been widely used to facilitate stone removal procedure in order to allow biliary stone passage. Several techniques including basket forceps, electrohydraulic lithotripsy (EHL), and laser lithotripsy are now available for fragmentation of large stones.3 Variable major and minor complications of this technique including cholangitis, biliary pleural effusion, and self-limiting hemobilia have been reported. Lee et al.4 reported 100% success rate of PTCS lithotomy for removal of difficult CBD stones in 33 cases. EHL was used in most patients. Complications related with PTCS lithotomy, including fever, pancreatitis, and hemobilia, occurred in 15 patients (45.5%) but were ameliorated with conservative management. The mean procedure number of PTCS lithotomy was 2.8 and the numbers of EHL session were one session in 16, two sessions in nine, three sessions in five, and more than four sessions in two patients. The major indications of PTCS were altered anatomy due to previous stomach surgery (16 cases) and impacted stones (11 cases). Fifteen patients had prior cholecystectomy, but the paper did not mention the presence of gallbladder stone in another 18 patients with intact gallbladder. Because PTCS is an invasive procedure, declining quality of life and requiring additional time for dilatation, maturation and repeated procedure, this procedure should be considered in really difficult cases in which duodenoscope insertion into ampulla is impossible. If biliary cannulation is possible but stone is impacted in CBD, we should know that there are emerging new techniques such as endoscopic biliary lithotripsy using FREDDY laser5 and direct peroral cholangioscopy (POC) with ultraslim endoscopy.6 Holmium laser lithotripsy under direct POC using an ultrathin upper endoscope was also reported as an effective and safe technique for removal of difficult CBD stones.7 Laparoscopic CBD exploration and cholecystectomy are another options if the patients have both gallbladder and CBD stones and medical conditions which are tolerable to general anesthesia. Lee et al.8 reported that laparoscopic CBD exploration is a safe and effective treatment modality for CBD stones not only for younger patients but also for elderly patients (over 70 years). They suggested the laparoscopic CBD exploration as the first treatment strategy for difficult CBD stones as there were no significant differences in mean operation time, postoperative hospital stay, first meal time, recurrence rate, remnant stone, and complication or mortality rates in both groups. Because this study on PTCS lithotomy4 was a retrospective study conducted between 2008 and 2010, new techniques were not considered and PTCS lithotomy was done in cases with impacted CBD stones regardless of biliary cannulation by conventional ERCP. Nevertheless, this paper confirmed that PTCS lithotomy is a safe and effective treatment modality in difficult CBD stones if conventional ERCP with lithotripsy was impossible.

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.

Management of impacted common bile duct stones in late stage pregnancy and immediately post-partum after failed endoscopic stone extraction

Introduction: Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women after acute appendicitis. Extrahepatic biliary obstruction by gallstones during pregnancy remains one of the most challenging management problems in the field of surgery. Although there have been many advancements in the surgical and endoscopic management of gallstone disease, the risks of these interventions and anesthesia to the developing fetus still prevents their routine application during the gestational period. Traditionally, these types of disorders during pregnancy are managed conservatively or via appropriately timed cholecystectomy. However, when the late­term pregnant patient presents acutely with evidence of biliary tract obstruction and sepsis, it represents a medical or surgical emergency. Case report: We present the case management of a 25­year­old late term pregnant female with an impacted www.ijcasereportsandimages.com common bile duct stone and impending biliary sepsis as a result of failed postpartum endoscopic stone extraction. Conclusion: Due to the risk of potential harm to the fetus, this patient subset must be managed in clinically sound and technically proficient manner, which does not allow time for conservative management. Consequently, appropriate management algorithms for conservative therapy versus endoscopic or surgical interventions need to be clearly outlined and defined.

What Are the Risk Factors for Acute Suppurative Cholangitis Caused by Common Bile Duct Stones?

Acute suppurative cholangitis (ASC), a severe form of acute cholangitis, is a life-threatening condition that must be treated with appropriate and timely management. The purpose of this study was to identify the factors that predispose patients to ASC. We retrospectively investigated 181 patients (100 men, 81 women; age, 70.66±7.38 years, mean±SD) who were admitted to Wonkwang University Hospital between January 2005 and June 2007 for acute cholangitis with common bile duct (CBD) stones. All patients underwent endoscopic retrograde cholangiopancreatogram to remove the stones. Variables and factors that could be assessed upon admission were analyzed to identify the risk factors for the development of ASC. Of the 181 patients, 44 (24.3%) presented with ASC. On multivariate analysis, the followings were found to be independent risk factors for the development of ASC: impacted common bile duct stone (p=0.010), current smoker status (p=0.008), advanced age (>70 years; p=0.002), and gallstone (p=0.016). The most commonly isolated organisms in bile culture were Enterococcus species, Escherichia coli, and Klebsiella species. Impacted bile-duct stones, current smoking, advanced age, and gallstones were identified as independent risk factors for the development of ASC in patients with CBD stones. These results suggest that emergency biliary drainage is beneficial in patients with these risk factors.

Laparoscopic management of CBD stones: an Indian experience

Common bile duct stones (CBDS) that are seen in the Asian population are very different from those seen in the west. It is not infrequent to see multiple, large, and impacted stones and a hugely dilated CBD. Many of these patients have been managed by open CBD exploration (OCBDE), even after the advent of laparoscopic cholecystectomy (LC), because these large stones pose significant challenges for extraction by endoscopic retrograde cholangiopancreatography. This series presents the largest experience of managing CBDS using a laparoscopic approach from Indian subcontinent. Between 2003 and 2009, 150 patients with documented CBDS were treated laparoscopically at a tertiary care hospital in New Delhi. Of these, 4 patients were managed through transcystic route and 140 through the transcholedochal route. There were 34 men and 116 women patients with age ranging from 15 to 72 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 139.9 ± 26.3 min and the mean intraoperative blood loss was 103.4 ± 85.9 ml. There were 6 conversions to open procedures, 1 postoperative death (0.7%), and 23 patients (15%) had nonfatal postoperative complications. Three patients had retained stones (2%) and one developed recurrent stone (0.7%). Even in patients with multiple, large, and impacted CBDS, there is scope for a minimally invasive procedure with its attendant benefits in the form of laparoscopic CBD exploration (LCBDE).