Removal Of Intrahepatic Stones Research Articles

Hepatobiliary surgery in Taiwan: The past, present, and future. Part I; biliary surgery

Abstract In Taiwan, most surgical services were mainly provided by Japanese or Western surgeons before World War II. Tsuchiya Kunita first reported surgical treatment of gallstone diseases in 1915 in Taiwan. After World War II, experienced Japanese surgeons returned to Japan, and well-trained surgeons moved to Taiwan from different hospitals in Mainland China after 1949. In 1954, Liao had reported surgical gallstone diseases treated by cholecytostomy, cholecystectomy, and cholecystogastrostomy or cholecystoduodenostomy from National Taiwan University Hospital (Formos J Surg. 1954;53:833–4). By using of operative cholangiography, diagnosis and removal of intrahepatic stones could be done through choledochostomy reported first by Lee HC from National Defense Medical Center in 1966 and 1968 (Chin Med J ROC. 1966;13:301–8; Chin Med J ROC. 1968;15:124–34). Wei from the National Taiwan University Hospital reported the first left hepatectomy for treating hepatolithiasis on one patient among his series in 1971 (Formos J Surg. 1971;4:178–96). Treatments of hepatolithiasis were well analyzed by Wen and Lee from Triservice General Hospital and Veterans General Hospital in 1972 (Ann Surg. 1972;175:166–77). Hwang was the first to use choledochofiberscope for removing retained stones since 1974 reported from Show Chwan Memorial Hospital in 1978 (Am J Surg. 1978;139:860–4). The first laparoscopic cholecystectomy was performed by Huang from Taipei Cathay General Hospital in 1990 in Taiwan (J Formos Med Assoc. 1991;90:893–9). Nowadays, Taiwan hepatobiliary surgeons were extensively using either laparoscopic or robotic surgery for treatment of hepatobiliary diseases. In conclusion, we should never forget the great contributions from many clinics in rural villages hosted by Christian or Catholicism organizations in Taiwan hundred years ago. We should express our appreciations to the history of the evolutions of biliary surgical skills. In Taiwan, a great surgeon today is always standing on the shoulders of our ancient giants, our surgical teachers.

Failure Rate of Peroral Cholangiopancreatoscopy in Clinical Practice

Background: Peroral cholangiopancreatoscopy (CP) is an ERCP technique that uses a fiberoptic cholangioscope passed through a therapeutic duodenoscope directly into the biliary and pancreatic ducts. The primary aim of this study was to analyze the failure rate of CP in clinical practice. The secondary aims were to analyze the complication rate, clinical applications and diagnostic yield of CP forceps bite. Methods: It was a retrospective review of all CP procedures performed between 11/01/05 to 11/30/08 at Columbia University Medical Center, NYC by a single experienced endoscopist. The failure was defined as inability to achieve the primary goal that was set before starting the procedure. The diagnostic yield of CP forceps was defined as either positive for malignancy or benign with 6 months follow-up. Results: Out of total 84 procedures, CP failed in 7 (8.3%) cases. The reasons for failure were: equipment related 5 (71.4%), narrowed biliary duct 1, and sphincterotomy bleed 1. There was only one minor complication (1.19%; sphincterotomy-site bleed). The mean age was 64.78 years (range 18-97). Gender: F 46, and M 38 cases. Sedation type: monitored anesthesia care 78 (92.8%), 5 conscious sedation, and 1 general anesthesia. CP was used for diagnostic purpose in 62 (73.8%) and therapeutic in 22 (26.2%) cases. Therapeutic uses were: EHL (electrohydraulic lithotripsy) for stones in 20, and CP forceps for foreign body removal in 2 cases. Biliary findings/applications were (total 79 cases): 31 benign biliary stricture, 27 extrahepatic duct stone removal (size ranging from sludge to 2 cm), 10 malignant stricture, 3 removal of foreign body, 2 intrahepatic stone removal, 1 choledochol cyst, and unremarkable in 5 cases. Pancreatic findings were (total 5 cases): 3 IPMN (intraductal papillary mucinous neoplasia), 1 stone removal, and 1 stent removal. The diagnostic yield of CP forceps was obtained in 34 out of 39 cases (87.2%). Conclusion: We found peroral cholangiopancreatoscopy as a safe and effective technique with very low failure rate of 8.3% and various applications in clinical practice.

3364 Asge guidelines on therapeutic ercp training: are they appropriate?

Introduction: ASGE recommends one year of intensive therapeutic ERCP training for receiving previleges in an academic center. Aims: To examine the outcome of one year of advanced ERCP training on the technical success & complication rate of therapeutic ERCP by one endoscopist during the first year after graduation from advanced endoscopy fellowship training program. Methods & Results: ERCP Training: During 7/98-6/99, the trainee (GSR) participated in 697 ERCPs & shared the ERCP caseload with 4 GI fellows at the BIDMC. The trainee did 50% of the ERCP cases and also assisted in the training of the 3rd year GI fellows. The trainee was encouraged to do multiple stages of each procedure. If cannulation was unsuccessful, the mentor cannulated & gave the endoscope back to the trainee to complete the remaining procedure. Endoscopic sphincterotomy was taught early on & during the latter half of training, the trainee learned precut techniques. During the last quarter, the trainee completed 19 of 21 consecutive therapeutic ERCP cases successfully, without assistance from the mentor. First year after ERCP training: After joining KUMC as a therapeutic endoscopist(GSR) in 7/98, the outcome of consecutive ERCP cases done in first year by GSR was analyzed (n= 100). Classification of the ERCP cases according to the difficulty of the ERCP procedures ( Gastrointest endosc 1999;49:AB148 ): Group 1-Simple diagnostic ERCP: 22/24 (92%); Group 2-Simple therapeutic ERCP: 15/16 (94%) (biliary sphincterotomy, cbd stone ( 3) / large (>1cm) CBD stone removal, CBD stricture dilation, CBD stenting); Group 5-Ultracomplex therapeutic ERCP:13/17 (76%)(needle knife sphincteotomy, CBD stone lithotripsy+ stone removal, intrahepatic stone removal or stricture dilation, & all pancreatic therapy). Complications: pancreatitis: 8; bleeding: 0; perforation: 0; neck infection: 1; cardiac arrest: 1 (revived). Mortality: one patient died 48 hours after the procedure due to a CVA & aspiration. Conclusions: Dedicated therapeutic ERCP training for one year provides the necessary endoscopic skills to perform ERCP successfully with low complication rate. The outcome is comparable to the results published in the literature (Gastrointest endosc 1999;49:AB148). The ASGE guidelines on therapeutic ERCP training appear to be appropriate.

The efficacy of percutaneous transhepatic choledochoscopic removal of intrahepatic stones

The efficacy of percutaneous transhepatic choledochoscopic removal of intrahepatic stones

Congenital bile duct stenosis: Intrahepatic cholangiocholecystojejunostomy (Roux Y) with removal of intrahepatic stones

Congenital bile duct stenosis: Intrahepatic cholangiocholecystojejunostomy (Roux Y) with removal of intrahepatic stones