Impacted Stones Research Articles

Single-operator cholangioscopy and electrohydraulic lithotripsy for the treatment of Mirizzi syndrome

IntroductionMirizzi syndrome is an infrequent complication of long-standing cholelithiasis. Extrinsic compression of the common hepatic duct is usually caused by an impacted stone in Hartmann's pouch or cystic duct resulting in the development of cholecystobiliary fistula. This syndrome is classified based on the presence and severity of cholecystobiliary fistula. Mirizzi syndrome is challenging to diagnose preoperatively and may require complex biliary surgical procedures for resolution. ResultsWe present three patients with Mirizzi syndrome with different clinical presentations. All were successfully treated by cholangioscopy with electrohydraulic lithotripsy. Endoscopic treatment is a safe alternative with a high success rate. Single-operator cholangioscopy combined with lithotripsy has been shown to have a 90–100% success rate in the treatment of biliary stones. ConclusionHerein, we present our experience treating Mirizzi syndrome with single-operator cholangioscopy guided electrohydraulic lithotripsy. Difficult management of Mirizzi syndrome has led to research of new treatment options to minimize the risk of high-rate complications. Single-operator cholangioscopy in combination with laser lithotripsy is an adequate and safe alternative for the treatment of this condition.

Predictive value of ureteral wall thickness (UWT) assessment on the success of internal ureteral stent insertion in cases with obstructing ureteral calculi.

To evaluate the possible role of ureteral wall thickness (UWT) assessment in the prediction of the success for stent placement in cases with obstructing ureteric stones. 227 adult patients with a single unilateral obstructing ureteral stone requiring internal ureteral stent placement were included. In addition to stone size, the ureteric wall thickness at the impacted stone site and the degree of hydronephrosis were also assigned on CT images. Patients were divided into two subgroups: Group 1: patients in whom internal ureteral stent could not be passed beyond the stone and Group 2: patients in whom an internal ureteral stent was passed successfully. The possible relationship between the UWT values and the success of stent placement, degree of hydronephrosis were comparatively evaluated. The majority of the stones were located in the proximal ureter in Group 1 and the degree of hydronephrosis was also higher in these cases. Moreover, while the mean value of UWT calculated on CT images was 4.3 ± 0.9mm in Group 1, this value was noted to be 2.5 ± 0.8mm in cases of group 2. A cutoff UWT value of 3.35mm was highly predictive for the stent insertion and cases with higher values required additional procedures or percutaneous nephrostomy tube placement. UWT value calculated at the obstructing stone site was found to be predictive enough for the likelihood of internal ureteral stent passage with high sensitivity and specificity. This evaluation may enable the urologist to make the best decision for urinary diversion in such cases.

Laparoscopic ureterolithotomy: bridging the gaps between open surgery and ureteroscopy and/or shock wave lithotripsy

Background Ureteroscopic procedures together with shock wave lithotripsy are the standard of care for patients with symptomatic ureteral stones; in cases with large (>20 mm) and/or impacted stones, laparoscopic ureterolithotomy can be considered an alternative to open surgery, as it is less morbid with high stone-free rates. Patients and methods A retrospective study of patients enlisted for active ureteral stone treatment was conducted. Files of 945 patients were reviewed and analyzed in term of stone size, number, and history of previous stone procedures. A total of 73 patients were included; they had transperitoneal ureterolithotomy for either proximal or distal ureteral stone(s). Results Mean stone size was 31.7±8.5 mm, and median stone number was 1 (1–3). A total of 48 patients had proximal ureteric stones, whereas 25 had distal ones. Mean operative time was 96±19.2 min, stone-free rate was estimated to be 97%, and procedure was aborted in two patients. Complications were reported in 16%, with no grade 3 complications according to Clavian–Dindo classification. Mean hospital stay was 3.2±1.1 days. Conclusion Laparoscopic ureterolithotomy is to be considered for the treatment of large ureteric stone when other minimally invasive modalities are not available; it can bridge the gap between the minimally invasive procedures and conventional open surgery.

Balloon-Assisted Stone Extraction (BASE): An Innovative Method for Lithotripsy during Laparoscopic CBD Exploration

Background: Balloon-assisted stone extraction (BASE) can be applied to remove the common bile duct (CBD) stones during laparoscopic CBD exploration (LCBDE). Aim: This study aimed to analyze the efficacy of BASE. Methods: A retrospective analysis of patients with CBD stone who underwent LCBDE using BASE at our center from 2001 to 2017, was conducted. The outcomes of BASE and potential factor for failure of this technique were also evaluated. Results: A total of 163 patients underwent LCBDE using BASE for CBD stone were enrolled. Success rate of BASE was 88.3% (144/163) and 19 (11.7%) patients with failed BASE underwent Basket for lithotripsy additionally. The reason for aborting BASE were stone impaction (n=6), small stone (n=4), migration into IHD (n=3), and others (n=6). The overall success rate of stone clearance was 97.5% (159/163). The mean CBD diameter was 15.8 mm (range 7-34 mm), and the largest stone size was 13.8 mm (range 3-36 mm). 22 patients had undergone gastrectomy prior to LCBDE. The overall complication rate was 4.9% (8/163), including bile leakage in 2 patients (1.2%), bleeding in 2 patients (1.2%) and pancreatitis in 4 patients (2.4%). There was no procedure related complication. Conclusions: BASE for CBD stone is safe and effective techniques for the treatment of CBD stones.

Comparative evaluation of retrograde intrarenal surgery, antegrade ureterorenoscopy and laparoscopic ureterolithotomy in the treatment of impacted proximal ureteral stones larger than 1.5 cm.

IntroductionThe aim of this article was to compare retrograde intrarenal surgery (RIRS), antegrade ureterorenoscopy (URS), and laparoscopic ureterolithotomy (LU) for impacted proximal ureter stones larger than 1.5 cm in terms of operative data, success, complications, auxiliary treatment rates, and visual analog scale (VAS) scores.Material and methodsMedical records of patients undergoing RIRS, antegrade URS, or LU were retrospectively reviewed. After exclusion criteria, 122 patients were included in advanced analyses. Patients were divided into 3 groups as RIRS (n = 43), antegrade URS (n = 38) and LU (n = 41).ResultsOperation time was shortest in the antegrade URS and hospitalization time was shortest in the RIRS group (p <0.001 and p <0.001, respectively). VAS scores were lowest in the RIRS group and highest in the LU group (p <0.001). Success (complete stone clearance) rates were 83.7%, 97.4%, and 97.5% in the RIRS, antegrade URS, and LU groups, respectively (p <0.001). Auxiliary treatment rates in the RIRS, antegrade URS, and LU groups were 19.1%, 2.6%, and 4.7%, respectively (p <0.001). Although there was no significant difference in terms of general complication rates, grade II complication rate (blood transfusion) was significantly higher in the antegrade URS group and grade IVb complication rate (urosepsis) was higher in the RIRS group according to the modified Clavien-Dindo classification system (p = 0.007 and p = 0.02, respectively).ConclusionsAntegrade URS or LU are more logical options than RIRS for the treatment of large impacted proximal ureter stones. Between antegrade URS or LU, antegrade URS seems to be a more reasonable option due to its less invasive nature.

An unusual finding of Courvoisier sign: Gallstone with locally advanced carcinoma gallbladder

Courvoisier sign is one of the important clinical signs used in the diagnosis of hepatobiliary disease. According to this sign, when the gallbladder is palpable in a jaundiced patient, it is unlikely due to stone. There are exceptions for Courvoisier signs such as double impacted stone, oriental cholangitis, and AIDS-associated cholangiopathy. In our case, there is a gallstone with palpable gallbladder due to concurrent occurrence of gallstone with gallbladder carcinoma compressing the adjacent biliary tree.

Assessment of a Scoring System to Predict Difficult Laparoscopic Cholecystectomy

Introduction Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. It would be useful to have some reliable predictive factors for conversion in LC. Our aim is to predict difficult laparoscopic cholecystectomy preoperatively by using a scoring system.&#x0D; MethodsA total of 136 patients were included. The parameters considered for this study were old age, male sex, history of hospitalization, obesity, abdominal surgery scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone.&#x0D; ResultsAmong 136 cases, 70.6% were easy, 24.3% were difficult and 5.1% were very difficult intraoperatively. The factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4mm and impacted stone were found statistically significant in predicting difficult LC. The preoperative scoring is statistically and clinically a good test for predicting the difficult LC (area under the curve = 0.824) with sensitivity of the test being 82.3% and specificity 72.7%. Conversion rate was 3.67%.&#x0D; ConclusionThe factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4 mm and impacted stone are the preoperative predictors of difficult LC.

Assessment of a Scoring System to Predict Difficult Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. It would be useful to have some reliable predictive factors for conversion in LC. Our aim is to predict difficult laparoscopic cholecystectomy preoperatively by using a scoring system. Methods: A total of 136 patients were included. The parameters considered for this study were old age, male sex, history of hospitalization, obesity, abdominal surgery scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone. Results: Among 136 cases, 70.6% were easy, 24.3% were difficult and 5.1% were very difficult intraoperatively. The factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4mm and impacted stone were found statistically significant in predicting difficult LC. The preoperative scoring is statistically and clinically a good test for predicting the difficult LC (area under the curve = 0.824) with sensitivity of the test being 82.3% and specificity 72.7%. Conversion rate was 3.67%. Conclusion: The factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4 mm and impacted stone are the preoperative predictors of difficult LC.

Live Renal Ultrasonography Facilitates Double-J Ureteral Stent Insertion at the Bedside: A Pilot Study for the COVID-19 Era.

Objectives: To investigate the feasibility and efficacy of live renal ultrasonography to guide Double-J ureteral stent placement at the bedside. Patients and Methods: Between April 12 and June 5, 2020, patients presenting with acute ureteral obstruction requiring decompression were prospectively selected for ultrasound-guided bedside ureteral stent placement. During stent placement, upper tract access confirmed using ultrasound with or without retrograde injection of ultrasound contrast before Double-J stent insertion. A postprocedural abdominal X-ray was obtained for stent position confirmation. Results: Eight patients (four men and four women) were offered bedside ultrasound-guided ureteral stent placement, and all eight consented to proceed. Stents were placed in seven of eight patients. One patient had an impacted ureterovesical junction stone and stricture requiring ureteroscopy and laser lithotripsy in the operating room. All patients tolerated procedures without immediate complications. Conclusion: Live renal ultrasonography can facilitate a high success rate for bedside ureteral stent placement outside the operating room. This approach is an attractive alternative to fluoroscopy-guided stent placement in the operating room and is of particular value in the COVID-19 era when judicious use of these resources is salient.

Novel peroral cholangioscopy-directed lithotripsy using an ultraslim upper endoscope for refractory Mirizzi syndrome

Rationale:Mirizzi syndrome (MS) is an uncommon condition characterized by common hepatic duct (CHD) compression by an impacted gallbladder or cystic duct stones or adjacent inflammation. To date, a standardized therapeutic strategy for MS has not been established yet, owing to its complex clinical presentation. Thus, researchers still have to develop new optimized approaches to solve this problem. Herein, we describe a patient with refractory MS who underwent a successful treatment by novel hybrid anchoring balloon-guided direct peroral cholangioscopy (POC) using an ultraslim endoscope.Patient concerns:A 56-year-old man with a history of biliary stone was referred to our hospital for complaints of discomfort in the right upper quadrant of the abdomen and obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed an 18-mm impacted stone at the level of the cystic duct, which compressed the CHD. The CHD had local stricture, with its upstream and intrahepatic bile duct dilation.Diagnoses:He was diagnosed with type I MS.Interventions:Initially, the patient received an endoscopic major sphincterotomy. However, conventional stone extraction, including mechanical lithotripsy, was unsuccessful. Then, after signing the informed consent form for further treatment, he was successfully treated with novel hybrid anchoring balloon-guided direct POC.Outcomes:The patient had no operative complications and was discharged with cleared ducts. At the 3-year follow-up, he was asymptomatic.Lessons:Our novel hybrid anchoring balloon-guided direct POC may be an effective alternative treatment approach for difficult gallbladder cases, such as refractory MS.

Combined Endoscopic-Transcutaneous Approach for Management of Large Parotid Stones.

Introduction:The aim of this paper is to present our experience with combined endoscopic-transcutaneous approach in terms of effectiveness and safety in patients with large or impacted parotid stones.Materials and Methods:This is a prospective study carried out from August, 2012 to February, 2017 analyzing 21 patients with parotid sialolithiasis. The indication of combined approach was either failed attempt to remove the stone endoscopically, large size (>4mm), or impacted stone. The exact location of the stone was pointed out by endoscopic transillumination and the stone was removed via transcutaneous incision which could be linear incision or a preauricular incision followed by stenting for 3 weeks.Results:We were successfully able to remove the stone in all 21 cases using modified Blair’s incision in 18 cases, while a linear incision was used in remaining 3 cases. Two patients developed stricture in the post-operative period at 5 and 3 months, respectively. The strictures were successfully dilated endoscopically and the patients are asymptomatic ever since. Conclusion:Combined endoscopic-transcutaneous approach is a highly successful approach with few complications for removal of parotid stones and thus resulting in high gland preservation rates in patients of parotid sialolithiasis.

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography.

BACKGROUNDMirizzi syndrome (MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct (CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIMTo evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODSFrom 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed. RESULTSGallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas (P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis (odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).CONCLUSIONGall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: Cross sectional study

IntroductionNumerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically. Patients and methodsThis prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique. ResultsMost patient were middle aged females having multiple gallstones, the mean operation time was 35 min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty.There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, inability to grasp the gall bladder with traumatic forceps, stone ≥1 cm impacted in Hartman's pouch, and bile or pus outside gallbladder (P values: 0.002, 0.000, 0.008 and 0.015) respectively, and no significant correlation with gallbladder adhesions, adhesions from previous upper abdominal surgery, BMI>30, and Time to identify cystic artery and duct >90 min (P values: 0.123, 1, 1, 0.078) respectively. ConclusionNew intraoperative scoring systems are valuable in predicting difficulties and preventing increase operation time and possible injuries. The main points of difficulties are distended or contracted gallbladder, large stone impaction, difficult grasping the wall of the gall bladder and the presence of bile or pus outside the gall bladder.

Stone Formation on Suture Material Following Laparoscopic Pyeloplasty Causing Recurrent Puj Obstruction: A Case Report

Male patient 46 years of age presented with history of Laparoscopic A-H pyeloplasty with DJ stenting for left side hydronephrosis due to PUJ obstruction. After stent removed he experienced intermittent flank pain, discomfort with fullness sensation. On examination there was mild left renal angle tenderness. Urinalysis showed RBC. USG revealed moderate left hydronephrosis. CT urogram showed left side gross HDN with 5 mm PUJ stone. Tc-99m DTPA renal scan revealed partial obstruction. After counseled and exploration founded an impacted PUJ stone. During removal of PUJ stone, identified a suture material embedded by the stone. After removed the stone,PUJ still narrowed. Then A- H pyeloplasty done with placed a D-J stent in situ. The patient had a good post-operative recovery. Bangladesh Journal of Urology, Vol. 21, No. 2, July 2018 p.164-165

Ureteral Avulsion during Semirigid Ureteroscopy: A Single-Centre Experience.

Aims The aim of the study is to present our experience with the management of ureteral avulsions following semirigid ureteroscopy for ureteral stones. This is one of the largest series reported so far. Methods and Materials It is a retrospective and observational study done at Sri Ramachandra Institute of Higher Education and Research over the last 18 years. Results There were seven cases of ureteral avulsion following semirigid ureteroscopy. All patients were males with a mean age of 35.7 years. All had impacted stones, with proximal ureteric location in 6 patients and distal ureteric location in 1 patient. Five cases had two-point avulsions with loss of entire ureter. Two cases had one-point avulsion: one distal ureteric and the other mid-ureteric. Of the five cases with whole length ureteral avulsion, four were managed by classical ileal replacement of ureter and the the fifth case was managed by ileal replacement of ureter by the Yang–Monti technique. Of the two cases with one-point avulsion, one was managed by uretero-neocystostomy and the other by uretero-ureterostomy. All the patients had successful outcome. Conclusions Even though rare, ureteral avulsion can potentially happen especially when dealing with impacted ureteric stones. Being conscious of the possible occurrence of this serious complication during any difficult ureteroscopy and exercising utmost care during the procedure are important preventive measures. However, this catastrophe can be successfully managed by either immediate definitive repair or in a staged manner.

Survey on ureTEric draiNage post uncomplicaTed ureteroscopy (STENT)

ObjectivesTo assess the feasibility of conducting a randomised controlled trial (RCT) to assess whether avoiding ureteric drainage is superior to performing ureteric drainage after Uncomplicated Ureteroscopy and/or Flexible Ureterorenoscopy (URS/FURS) treatment of a urinary tract stone in improving patient reported outcome measures (PROMs) and 30‐day unplanned readmission rates. A secondary objective was to understand current practice of urologists regarding ureteric drainage after uncomplicated URS/FURS (UU).Material and methodsWe undertook an online survey of urologists, circulated amongst members of international urological societies and through social media platforms. Uncomplicated URS/FURS was defined as completion of URS/FURS treatment for a urinary tract stone, with the absence of: ureteral trauma, residual fragments requiring further lithotripsy procedures, significant bleeding, perforation, prior urinary tract infection or pregnancy. The ureteric drainage options considered included an indwelling stent, stent on a string or a ureteric catheter. The primary outcome was to determine the proportion of urologists willing to take part in a RCT, randomising patients after UU to a “no ureteric drainage” arm or ureteric drainage arm. Secondary outcomes included determining in their current practice, the proportion of clinicians performing routine ureteric drainage after UU, the reasons for performing ureteric drainage following UU and their preferred optimal duration for ureteric drainage if it is used. The study was reported according to the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES).ResultsTotal of 468 respondents from 45 countries took part in the survey, of whom 303 completed the entire survey (65%). The majority agreed that they would be willing to randomise patients (244/303, 81%) in the proposed RCT. Perceived lack of equipoise to randomise was the most common reason for not being willing to participate (59/303, 19%).92% (308/335) reported that they use ureteric drainage after UU. This was most often due to wanting to prevent possible complications from post‐operative ureteric oedema (77%) or to aid passage of small fragments (43%). Complexity of the case (i.e. impacted stone 90%) and length of the procedure (46%) were the most important intraoperative factors influencing the decision to use ureteric drainage post procedure. If required, the median stated ideal duration of ureteric drainage was 5 days (IQR: 3–7 days) after UU. If having UU personally, 30% would want no stent postoperatively and over half would prefer a stent on a string.ConclusionWe have highlighted wide variation in practice regarding ureteric drainage after UU. Our results support the feasibility of an RCT evaluating if no ureteric drainage is superior to ureteric drainage in improving PROMs and 30‐day unplanned readmission rates following UU.

S1479 Cystic Duct Stump Stone: A Diagnostic Dilemma of Post Cholecystectomy Syndrome

INTRODUCTION: Post-cholecystectomy syndrome (PCS) is defined as persistent dyspepsia, upper abdominal pain, pancreatitis, or jaundice after cholecystectomy. The symptoms of PCS can be caused by a wide variety of conditions, including biliary, pancreatic, or hepatic, while the rest are extra-intestinal. PCS can be described as early: occurring in the postoperative period or late: occurring months to years later. Here we will focus on endoscopic management of retained biliary stones within the cystic duct stump. CASE DESCRIPTION/METHODS: We present a 72-year-old male with new post-prandial epigastric pain with mild tenderness on deep palpation. Cholecystectomy completed six months prior. Lipase: 82, AST: 72, ALT: 47, Total Bilirubin: 0.7, Direct bilirubin: 0.2. CT Abdomen Pelvis with Contrast: Calculus in the remnant cystic duct stump without any intra or extrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography (ERCP) and fluoroscopy were performed, without visualization of stone. Therefore, Direct Visualization Cholangioscopy was performed, where an impacted stone was noted in the proximal tip of the cystic duct stump. Electrohydraulic Lithotripsy (EHL) was completed, and fragments of the stone were flushed with biliary plastic stent placement. On a three-month follow-up, the patient remained asymptomatic with the removal of the plastic stent. DISCUSSION: It has been demonstrated that ERCP is an adequate alternative to laparoscopic therapy for the diagnosis and treatment of cystic duct stump stones, causing PCS. However, without any head-to-head trials comparing surgical versus endoscopic therapies, selection of therapy becomes anecdotal and based on institutional expertise. We demonstrate a case whereby traditional fluoroscopy with ERCP could not visualize the impacted stone at the proximal tip of the cystic duct stump. Therefore, we question whether the accuracy of diagnostic biliary fluoroscopy decreases in the setting of cystic duct stump. Without cholangioscopy and lithotripsy, the stone likely would have remained, and the patient symptomatic. Therefore, gastroenterologists should recognize the difficulty of fluoroscopic diagnosis of remnant cystic duct stump stones. Additionally, cholangioscopy facilitates selective cannulation of the cystic duct in comparison to contrast fluoroscopy on its own. We are highlighting the importance of the diagnostic and therapeutic role of direct visualization cholangioscopy, in patients with PCS and a suspected cystic duct stump stones.Figure 1.: ERCP and Fluroscopy of cystic duct stump without visualization of cystic duct stump stone.Figure 2.: Direct Visualization Cholangioscopy of impacted stone at the proximal tip of the cystic duct stump.Figure 3.: Clearance of impacted cystic duct stump stone after use of Electrohydraulic Lithotripsy.

S1390 Caroli Disease With Choledochoduodenal Fistula and SUMP Syndrome

INTRODUCTION: Choledochoduodenostomy (CDDS) is a common procedure performed in patients with recurrent, impacted bile duct stones. We present a unique case of a patient with Caroli disease and repeat choledocholithiasis with CDDS presenting with a distal choledochoduodenal fistula (DCDF) and SUMP syndrome. CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of Caroli disease, multiple abdominal surgeries including CDDS, cholecystectomy secondary to recurrent choledocholithiasis presented to the clinic with abdominal pain. Further evaluation with an MRCP revealed filling defects in the distal common bile duct suggestive of choledocholithiasis. She underwent ERCP which revealed DCDF. Multiple small stones were extracted with purulent drainage with failed cannulation of the primary system. She developed severe right upper quadrant pain and nausea shortly after ERCP and presented to the emergency department. Her vitals and labs were unremarkable. Intravenous (IV) antibiotics were started due to concerns of cholangitis. Interventional radiology (IR) placed a percutaneous biliary drainage catheter. A repeat ERCP revealed old choledocho-duodenostomy and internal and external biliary drain within the bile duct, and without cannulation of the intrahepatic duct. Fluid cultures grew Enterococcus faecium and antibiotics were added and discharged home. A biliary catheter was removed two weeks later after gadolinium spillage of contrast into the bowel was seen, showing patency. DISCUSSION: Caroli disease is a congenital disorder presenting with large intrahepatic ductal dilation with an increased risk of hepatic fibrosis. There is bile stagnation leading to recurrent cholelithiasis. CDDS is a procedure performed in recurrent choledocholithiasis leading to gallstone pancreatitis and acute cholangitis despite cholecystectomy. CDDS creates a connection between the proximal common bile duct (CBD) and the 1st portion of the duodenum. The bile no longer drains via the distal CBD, creating a reservoir called a “sump”. Lithogenic bile, debris, or calculi accumulate causes recurrent cholangitis or choledocholithiasis. DCDF occurs at the entrance of the distal CBD into the 2nd part of the duodenum and caused by impacted stones in 90% of the cases. DCDF is a rare complication from CDDS leading to SUMP syndrome. The impacted stone erodes the CBD wall leading fistulation into the duodenum. The diagnosis of DCDF is made with ERCP. Treatment requires fistulotomy, sphincterotomy, stone removal, and biliary drainage.Figure 1.: MR reconstruction of the biliary tree (A) showing a dilated proximal common bile duct (CBD) measuring 11 mm and dilated main pancreatic duct (PD) measuring 4.5 mm. MRCP (B) showing ill-defined intraluminal filling defects are seen in the distal portion of the common duct suggestive of choledocholithiasis.Figure 2.: IR guided percutaneous biliary drainage catheter placement. A: Cholangiogram with gadolinium-based contrast showed mild central biliary dilatation with abnormal anatomy and possible two outflow tracts the bowel (SB). B: An 8.5 Fr. Internal and external catheter (C) was placed.Figure 3.: IR guided percutaneous biliary drainage catheter removal. Prior to the removal of the catheter, a small amount of gadolinium was injected through the existing tube to demonstrate patency. Free spillage of contrast into the bowel (SB) is noted.

A clinical study to determine predictive factors for difficult laparoscopic cholecystectomy

The technique of laparoscopic cholecystectomy (LC) has been standardized and it has become a routine and safe operation. However, there are numerous conditions which make the operation difficult necessitating conversion to open surgery. Preoperative prediction of a difficult cholecystectomy and the risk of conversion is of great help both to the patient who can be counseled appropriately pre-operatively and the surgeon who can also schedule his time and team accordingly. This prospective cross-sectional study was conducted on 118 patients undergoing laparoscopic cholecystectomy in Department of General Surgery, Aditya Birla Memorial Hospital, Chinchwad, Pune, over a period of 18 months from October 2015 to March 2017, to evaluate and correlate the clinical, biochemical and ultrasonography findings with the operative findings for anticipating difficult laparoscopic cholecystectomy. The parameters which were studied are age ≥ 60 years, sex, BMI > 30, history of (h/o) previous upper abdominal surgery, history of gall stone related complications, history of prior biliary intervention, biochemical parameters like Hb, TLC and LFT levels, gall bladder wall thickness (≥ 4 mm), pericholecystic collection, gall bladder size (contracted or distended gall bladder), stone impaction at neck/cystic duct and stone size > 1 cm. The operative parameters taken to assess the difficulty of the LC were total time taken to operate from the insertion of the trocar to the extraction of the gall bladder (more than 90 minutes), change of procedure to subtotal cholecystectomy and conversion to OC. Our study results show that significant predictors for difficult LC are increasing age of patients, h/o gall stone related complications, h/o prior biliary intervention, raised TLC and deranged LFT levels, GB wall thickness ≥ 4 mm, pericholecystic fluid collection, tensely distended/contracted GB and stone size > 1cm. However factors like sex of patient, BMI, history of previous upper abdominal surgery, haemoglobin levels and stone impacted at neck of gall bladder showed no significant relation with operative difficulty.

Outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography versus primary LCBDE for managing cholecystocholedocholithiasis.

ObjectiveThis study was performed to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (ERCP) versus primary LCBDE for managing cholecystocholedocholithiasis.MethodsWe retrospectively analyzed data from 59 patients who underwent LCBDE during laparoscopic cholecystectomy (LC) for managing cholecystocholedocholithiasis from January 2013 to August 2019. The patients underwent either primary LCBDE plus LC (Group I) or LCBDE plus LC after failed ERCP (Group II). The demographics, reason for ERCP failure, perioperative details, and postoperative outcomes were evaluated.ResultsCBD stone removal using preoperative ERCP failed in 31 patients (Group II) because of remaining stones after ERCP (n = 9), failed cannulation (n = 6), failed sedation (n = 6), a periampullary diverticulum (n = 5), previous Billroth II gastrectomy (n = 3), a huge stone (n = 1), and an impacted stone (n = 1). The CBD stone clearance rate was >96% in both groups. The mean operative time, hospital stay, overall complication rate, and open conversion rate were not significantly different between the two groups.ConclusionsWhen extraction of CBD stones by ERCP is likely to be difficult or fail, primary LCBDE is an acceptable alternative treatment for managing cholecystocholedocholithiasis.