Intraoperative Cholangioscopy Research Articles

The role of intraoperative cholangioscopy in determining the resection margins in IPNB

The role of intraoperative cholangioscopy in determining the resection margins in IPNB

Impact of intraoperative cholangioscopy on survival of the patients with intraductal bile duct tumor

Impact of intraoperative cholangioscopy on survival of the patients with intraductal bile duct tumor

Outcomes of laparoscopic choledochotomy using cholangioscopy via percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis: A preliminary Vietnamese study.

Hepatolithiasis and choledocholithiasis are frequent pathologies and unfortunately, with the current treatment strategies, the recurrence incidence is still high. This study aimed to assess the outcomes of laparoscopic choledochotomy using cholangioscopy via the percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis in Vietnamese patients. A cross-sectional study of patients with hepatolithiasis and/or choledocholithiasis who underwent laparoscopic choledochotomy using intraoperative cholangioscopy via percutaneous-choledochal tube at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, from June 2017 to March 2020. A total of 84 patients were analyzed. Most patients were females (56.0%) with a median age of 55.56 years. Among them, 41.8% of patients had previous abdominal operations, with 33.4% having choledochotomy. All patients underwent successful laparoscopic common bile duct exploration followed by T-tube drainage without needing to convert to open surgery. Most patients (64.3%) had both intrahepatic and extrahepatic stones. The rate of stones ≥ 10 mm in diameter was 64.3%. Biliary strictures were observed in 19.1% of patients during cholangioscopy. Complete removal of stones was achieved in 54.8% of patients. Intraoperative complications were encountered in two patients, but there was no need to change the strategy. The mean operating time was 121.85 ± 30.47 minutes. The early postoperative complication rate was 9.6%, and all patients were managed conservatively. The residual stones were removed through the T-tube tract by subsequent choledochoscopy in 34/38 patients, so the total success rate was 95.2%. Laparoscopic choledochotomy combined with cholangioscopy through the percutaneous-choledochal tube is a safe and effective strategy for hepatolithiasis and/or choledocholithiasis, even in patients with a previous choledochotomy.

Surgical diagnosis and management: Emerging role of intraoperative cholangioscopy and pancreatoscopy

Surgical diagnosis and management: Emerging role of intraoperative cholangioscopy and pancreatoscopy

Use of Fiber Optic Bronchoscope as Makeshift Choledochoscope for Intraoperative Cholangioscopy in Management of Hepatolithiasis, a Borrow from Anesthesia Cart – A Case Report

Use of Fiber Optic Bronchoscope as Makeshift Choledochoscope for Intraoperative Cholangioscopy in Management of Hepatolithiasis, a Borrow from Anesthesia Cart – A Case Report

Intraoperative digital single-operator cholangioscopy - extra-anatomical biliary access and insights into severe sclerosing cholangitis in a pediatric patient.

A 3-year-old boy with Downʼs syndrome, born prematurely with atrial septal defect type II and stenosis of the pulmonary artery, presented with hepatopathy and fibrosis. Magnetic resonance imaging (MRI) showed diffuse dilations of the biliary system, with large cystic changes suspicious for Caroli syndrome ([Fig. 1]). Endoscopic retrograde cholangiography (ERC) presented signs of secondary sclerosing cholangitis of the right liver lobe with missing contrast enhancement of the left biliary system ([Fig. 2]). Because there was no communication of the left liver lobe with the central biliary system, the patient underwent surgery to drain the left liver lobe by peripheral hepaticojejunostomy. Access to the biliary system was gained by the open biliary system of segment II and intraoperative cholangioscopy was performed using the newly developed, short digital system (SpyGlass Discover; Boston Scientific Corp., Marlborough, Massachusetts, USA) ([Video 1], [Fig. 3]). Intraoperative cholangioscopy revealed cystic dilated bile ducts, partly filled with biliary casts in accordance with the MRI imaging ([Fig. 4]). These findings further supported the diagnosis of systemic sclerosis due to severe postnatal respiratory insufficiency and circulatory problems.

Surgical management of a patient with biliodigestive anastomosis stricture complicated by multiple intrahepatic lithiasis

A clinical case of surgical management of patient with biliodigestive anastomosis stricture complicated by multiple intrahepatic lithiasis is presented. The patient was 57 years old woman. Anamnesis of the disease: in 2016, biliodigestive anastomosis was performed due to iatrogenic damage of the biliary tract. She was admitted to the hospital with complaints of the right upper abdomen pain, accompanied by chills, jaundice, and fever up to 39°C. The examination revealed a stricture of a previously formed biliodigestive anastomosis complicated by multiple intrahepatic cholelithiasis. Surgical intervention was performed: at the first stage – percutaneous transhepatic cholangiostomy; at the second stage – laparotomy, separation of hepaticojejunoanastomosis, intraoperative cholangioscopy with lithoextraction, resection of a small bowel section with a Brownian anastomosis, post-colon hepaticojejunostomy on a disconnected loop and replaceable transhepatic drains (Smith-Praden-Saypol-Kurian).

Laparoscopic Choledochoduodenostomy

IntroductionToday's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. MethodsWe performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. ResultsA total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4±12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1–7). Mean common bile duct diameter 24.9±7mm. Mean operative time 218.5±74min, estimated blood loss 150 (30–600)mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9±2 days. We found a median of 18 (12–32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. ConclusionsLaparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients.

Colédoco-duodeno anastomosis laparoscópica

IntroductionToday's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. MethodsWe performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. ResultsA total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4±12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9±7mm. Mean operative time 218.5±74min, estimated blood loss 150 (30-600)mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9±2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. ConclusionsLaparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients.

Intrahepatic Biliary Papillomatosis: A Rare Case Report and Literature Review

Background: Biliary papillomatosis (BP) is a rare disease characterized by multiple papillary tumors of variable distribution, involving both the intra hepatic and extra hepatic biliary tract. Till now, its clinical features and outcome are still not well known and the diagnosis is often misdiagnosed for clinical rarity. Case presentation: We experienced a case of biliary papillomatosis of Intra hepatic biliary tract in a 52-year-old man who presented with right upper quadrant abdominal pain. Laboratory tests showed mild elevated bilirubin. Imaging examination (ultrasound, computed tomography and magnetic resonance cholangiopancreatography) demonstrated non-specific intra hepatic duct and common bile duct dilatation. Intraoperative Choledochoscopy showed a dilated bile duct filled with papillary, friable tissue located in left intra hepatic ducts. Thereafter, the patient underwent left lateral lobectomy of liver and the T-tube was positioned. Histology demonstrated papillary lesion characterized by fibro vascular core with overlying mucin-producing columnar epithelial cells dysplasia. Conclusion: Intrahepatic biliary papillomatosis is an extremely rare disorder. Preoperative diagnosis of BP is somehow difficult and often misdiagnosed for its clinical rarity. Taken together, surgical resection is considered the optimal treatment for biliary papillomatosis and intraoperative cholangioscopy is a potential valuable auxiliary instrument for diagnosis and treatment of the disease.

Intraoperative cholangioscopy with an ultrathin endoscope for hemobilia

Intraoperative cholangioscopy with an ultrathin endoscope for hemobilia

Use of preoperative, 3-dimensional magnetic resonance cholangiopancreatography in pediatric choledochal cysts

Standard choledochal cyst (CC) operations involve dilated extrahepatic bile duct excision followed by biloenterostomy. However, biliary variants and associated intrahepatic bile duct (IHBD) stenoses or dilatations triggering postoperative sequelae require additional procedures. The usefulness of preoperative 3-dimensional magnetic resonance cholangiopancreatography (3D MRCP) and virtual cholangioscopy (VES) for observing biliary morphology and pancreaticobiliary maljunction (PBM) was evaluated. In 16 pediatric CC patients (age range, 4 months to 9 years; median, 3 years), visualization of PBM and aberrant bile duct anatomy and IHBD morphology at the hepatic hilum (HH), umbilical portion (UP), and posterior branch (POST) were compared between 3D-MRCP and intraoperative cholangiography (IOC). VES and intraoperative cholangioscopy (IOS) findings were compared. HH, UP, and POST visualization rates were 100%, 94%, and 94%, respectively, by 3D-MRCP, and 100%, 69%, and 69%, respectively, by IOC. IHBD stenosis detection rates at each region were 38%, 13%, and 13%, respectively, by 3D-MRCP, and 25%, 0%, and 9%, respectively, by IOC. IHBD dilatation detection rates at each part were 75%, 47%, and 60%, respectively, by 3D-MRCP, and 88%, 82%, and 91%, respectively, by IOC. PBM was confirmed in 56% and 93% of cases on 3D-MRCP and IOC, respectively. Both 3D-MRCP and IOC showed biliary variants in 5 cases (31%). VES showed membranous strictures at HH, UP, and POST in 6, 2, and 2 cases, respectively, whereas IOS did so at HH in 4 cases and POST in 2. Preoperative 3D-MRCP and VES accurately depict biliary morphology, allowing concrete operative planning in pediatric CC patients, complementing IOC and IOS.

Laparoscopic liver resection for localized primary intrahepatic bile duct dilatation

Background Primary intrahepatic bile duct dilatation (IHBD) may present as a localized form in which resection of the affected liver can prevent immediate and late complications. Laparoscopy has gained large interest in liver surgery. It also allows a safe and efficient exploration of the common bile duct. Methods We performed 10 laparoscopic liver resections for localized IHBD, on 7 women and 3 men (mean age 47 years). Resections were 2 right hepatectomies, 4 left hepatectomies, and 4 left lateral sectionectomies. Three patients had associated common bile duct stones that were treated through intraoperative cholangioscopy. Results The mean operative time was 303.9 minutes. The mean blood loss was 217 mL. None of these patients required hand assistance or conversion to open surgery. One patient suffered a residual collection that was drained percutaneously. The postoperative course was uneventful in the other patients. The mean hospital stay was 5.3 days. No recurrence of cholangitis was observed during the follow-up period. Conclusions The laparoscopic treatment of IHBD is safe and should be performed by teams with expertise in both hepatobiliary surgery and laparoscopy.

Intraoperative cholangioscopy in the management of biliary adenomas

Intraoperative cholangioscopy in the management of biliary adenomas

Papillomatosis Confined to the Distal Biliary Tract ? A Rare Cause of Obstructive Jaundice: Report of a Case

Based on the findings of a patient with recurrent obstructive jaundice due to papillomatosis of the distal bile duct, we herein describe the diagnostic difficulties and therapeutic options in this very rare disease. Endoscopic retrograde cholangiopancreatography and, in particular, cholangioscopy are the imaging procedures of choice if biliary papillomatosis is suspected. Due to the tendency of such patients to demonstrate malignant transformation and develop biliary cirrhosis with septic complications, an early and radical surgical resection is recommended in rare cases of localized papillomatosis. This approach may offer the only chance of a cure although the potential risk of multifocal recurrence cannot be ruled out. When considering a radical resection, intraoperative cholangioscopy is strongly recommended to confirm any localized papillomatosis and rule out any diffuse papillomatosis of the entire biliary tract.

Classification of congenital biliary cystic disease: special reference to type Ic and IVA cysts with primary ductal stricture

Congenital biliary cysts occur not only in the choledochus but also everywhere in the biliary tree, and are frequently accompanied by pancreatobiliary malunion. Alonso-Lej and colleagues first classified choledochal cysts into three types, in 1959. Due to the recognition of intrahepatic involvement, we refined their classification into six types, in 1977, and this has become the reference. However, this classification does not include the concept of pancreatobiliary malunion and has caused some confusion, especially in regard to types Ic and IVA. Type Ic, showing fusiform dilatation, has a pancreatobiliary malunion and often extends continuously to the intrahepatic duct. Type IVA, with intrahepatic involvement, shows primary ductal stricture, especially around the hepatic hilum and umbilicus. The incidence of the stricture is considerably greater than was previously assumed, and upstream intrahepatic ducts often join the dilated duct, with distinct caliber change. Intrahepatic dilatation may develop primarily, due to the stricture, combined with weakness of the duct wall. This stricture can be corrected by portal dissection in the liver to obtain a large anastomosis. In patients with intrahepatic involvement, we should carefully find the stricture by suitable cholangiograms, or by intraoperative cholangioscopy. Detecting the ductal stricture is obviously important, rather than classifying the cyst as type Ic or IVA.

A CASE OF PAPILLARY ADENOMA OF THE LOWER BILE DUCT

A 65-year-old man complaining of right upper quadrant discomfort and fever was seen at the hospital. Serum T. Bil. and transaminases were elevated. Abdominal ultrasonography and CT showed a dilatation of the common bile duct, but no apparent stones or tumors were seen. ERCP revealed a round filling defect in the lower bile duct. A diagnosis of choledocholithiasis was made, and a laparotomy was performed. Choledochotomy and intraoperative cholangioscopy failed to reveal any gallstones, but a papillary tumor was found in the lower bile duct. The histological diagnosis of a biopsy specimen of the tumor was papillary adenoma, and a pylorus-preserving pancreatoduodenectomy was performed. Histological examination of the resected mate-rial showed benign papillary adenoma without invasion or lymph node metastasis. Although benign tumors of the extrahepatic bile ducts are rare, there have been a case of cancer in ade-noma of the lower bile duct and a case of recurrence of lower bile duct adenoma following local resection in the Japanese literature. Thus, we think that adenoma of the bile duct should be resected radically.

PERFORATION OF THE COMMON BILE DUCT -AN ADULT CASE REPORT-

Perforation of the common bile duct can be associated with congenital biliary dilatation in childhood, but it rarely appears in adults. We experienced a case of perforation of the common bile duct with choledocholith in a 68-year-old man. The patient complaining of fever and upper abdominal pain was emergently admitted because upper abdominal CT and ultrasonography revealed calculus of the common bile duct and fluid collection of Morison's pouch. A remission of abdominal symptom was attained by conservative therapy, but an increase in white blood cell count and fever were sustained. The patient was underwent an emergency operation with a diagnosis of choledocholithis and intraabdominal abscess. Upon laparotomy, dense adhesion due to previous gastrectomy and cholecystectomy was present. The abscess cavity was filled with infectious bile and a perforation 3 mm in diameter in the anterior wall of the common bile duct under the confluence was found. Intraoperative cholangioscopy revealed a stone 15 mm in diameter under the site of perforation. The stone was taken out and a T-tube was placed in the hole. He had an uneventful postoperative course and was discharged from the hospital. We think that stone impaction might cause the perforation in this patient.

Multiple intramural cysts of the bile duct

Multiple intramural cysts of the bile duct are extremely rare and we could identify only one report (an autopsy case) in the English literature. 1 Recently, we encountered a patient with this condition who was diagnosed by intraoperative cholangioscopy. Preoperative evaluation of the patient with CT, ultrasonography, and percutaneous trans-hepatic cholangiography revealed findings consistent with gallstones. Intraoperative cholangioscopy revealed these lesions to be multiple intramural cysts that required no treatment. In this. report, we describe the cholangioscopic features of this rare entity.

A CASE OF CHOLESTEROSIS OF THE COMMON BILE DUCT

Cholesterosis of the common bile duct has been thought to be very rare compared with that of the gallbladder. We followed up a case of this disease for 6 years after operation, and assessed the clinical significance of this abnormal findings. A 55-year-old man was admitted to the hospital for operation of a gallbladder polyp. Since DIC showed an irregular filling defect in the lower part of the common bile duct, intraoperative cholangioscopy was performed and yellowish-white multipolypoid cholesterosis was revealed in the same location. This lesion taken by fogarty catheter was proved to have foamy cells in the subepithelial layers histologically. This patient undertook cholecystectomy and T-tube drainage, but this lesion was remained in spite of removing some polyps through T-tube postoperatively. He has been nevertheless symptom-free and normal in laboratory examination while the same DIC findings are still seen. So we should avoid over'surgery for this lesion, which seems to have less significance clinically.