Mean Common Bile Duct Diameter Research Articles

Visibility and Size of the Pancreatic Duct and Common Bile Duct on Routine 2D MRI Sequences in Children Without Pancreaticobiliary Disease.

Background: Pancreatic duct (PD) or common bile duct (CBD) dilatation can indicate ductal pathology, but limited data describe normal pediatric duct measurements on routine 2D MR sequences. Objective: To characterize the visibility and diameter of the PD and CBD on 2D MR images in children without pancreaticobiliary disease. Methods: This retrospective study included patients who underwent abdominal MRI using a rapid protocol (comprised of noncontrast axial and coronal 2D SSFSE sequences) to assess for suspected appendicitis or ovarian torsion in the emergency department setting between January 23, 2023, and September 13, 2023, excluding patients with a pancreatic or hepatobiliary abnormality on MRI or laboratory assessment. Four radiologists independently reviewed examinations. Reviewers recorded PD visibility in each of four segments (head, neck, body, and tail) and CBD visibility, and measured PD diameter in each segment and maximal CBD diameter. Duct measurements by age were characterized by linear regression analyses. Results: The study included 177 patients [112 female, 65 female; mean age, 12.3±3.4 years (range, 5.1-17.7 years)]. The observers reported PD visibility in the head in 32.5-93.5%, neck in 18.4-71.5%, body in 22.3-69.8%, and tail in 7.3-25.7%, and in all four segments in 6.2-22.4%, of patients. Maximum PD diameter in any segment, as a mean across observers, was 1.8 mm (range across observers, 0.7-3.5 mm). Expected maximal PD diameter in any segment, in terms of the 5th and 95th percentile values of observers' mean measurements, was 1.4-2.3 mm; the prediction interval's upper limit increased from age 5 to 17 from 2.1 to 2.5 mm. All observers reported CBD visibility in all patients. Mean CBD diameter across observers was 3.1 mm (range across observers, 2.9-3.4 mm). Expected CBD diameter, in terms of the 5th and 95th percentile values of observers' mean measurements, was 2.3-4.9 mm; the prediction interval's upper limit increased from age 5 to 17 from 3.9 to 5.0 mm. Conclusion: We report expected upper limits for PD and CBD measurements on 2D MR images in children without evidence of pancreaticobiliary disease. Clinical Impact: These findings may aid radiologists' identification of pancreaticobiliary duct abnormalities on routine abdominal MRI examinations.

Sonographic Study of Normal Common Bile Duct Diameter in Saudi Subjects

Background: The aim of this study was to measure the normal parameters of the common bile duct (CBD) in Saudi subjects using ultrasound modality. Methods and Results: This descriptive cross-sectional study was carried out in Alazhar Medical Group (Alqunfoda town, Saudi Arabia) from July 2022 to October 2022. The study included 150 subjects (43 males and 107 females) aged between 10 and 73 years without known biliary/pancreatic disease or surgery. The data was collected using the ultrasound machine Samsung Medison (SonoAce R7) using the lower frequency [2-8 MHz] curvilinear probe. The age, gender, body height, weight, and body mass index (BMI) were also recorded. The mean weight, height, and BMI levels were 71.64±17.32 kg, 165.06±11.7 cm, and 26.19±5.66 kg/m2, respectively. The mean CBD diameter was 3.26±0.82 mm, ranging from 1.8 mm to 5.8 mm. There was no statistically significant difference in CBD diameter between male and female subjects. Our study found that the linear regression model partially predicted the value of the CBD diameter with increasing age and weight. Further research on CBD measurement with a larger population sample and using various body positions is needed for more accurate results.

Evaluation of the Common bile duct (CBD) Diameter After Laparoscopic Cholecystectomy (LC) and Laparoscopic Common Bile Duct Exploration (LCBDE): A Retrospective Study.

Common Bile duct (CBD) measurement is a crucial aspect in the evaluation of the biliary tree. Whether the CBD undergoes any compensatory change in diameter after laparoscopic cholecystectomy or laparoscopic common bile duct exploration is still up for discussion. The aim of this study was to investigate CBD diameter changes after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) on magnetic resonance cholangiopancreatography (MRCP). Our retrospective study is divided into 2 sections. The first part assessing CBD diameter changes after laparoscopic cholecystectomy due to gallstones or gallbladder polyps, involved 85 patients, who underwent MRCP procedures. These patients aged between 30 and 85 were divided into an interval LC group (group A, n=56) and a remote LC group (group B, n=29). In group A, the common CBD diameters were measured at their widest portions on MRCP obtained before and after laparoscopic cholecystectomy. Measurements of the CBD diameters were repeated on MRCP obtained twice after the surgery in group B.Section 2 consisted of 38 patients who had choledocholithiasis and were treated with laparoscopic CBD exploration and T-tube placement. These patients aged 26 to 86 formed the interval LCBDE group (group C). The CBD widest diameters were measured on MRCP before LCBDE and after T-tube cholangiography for these individuals.Patients in groups A and C were further divided into 5 and those in group B into 4 age-related subgroups to facilitate statistical analysis. The Pearson correlation test was performed to find any relationship between CBD diameters and age in groups A and B. Paired sample T test was used to compare the significant difference between the 2 sets of CBD diameters in each study group and their subgroups. In the interval LC group, the post-LC mean CBD diameter was significantly wider when compared with the preoperative mean diameter (P<0.05). There was a significant difference between the first and second post-LC means CBD diameter in the remote LC group (P<0.05). In group C, the mean CBD diameter measured on T-tube cholangiography after LCBDE was significantly smaller than the preoperative dilated mean diameter (P<0.05). This study demonstrated significant dilation occurring in the common bile duct diameter after laparoscopic cholecystectomy. Furthermore, our remote LC group also supported that claim by showing significant dilation between the first and second post-cholecystectomy CBD diameter values. And lastly, our interval LCBDE sample's initial dilation of the CBD diameters was reduced after surgery and stone extraction.

Diagnostic Value of Endoscopic Ultrasonography for Common Bile Duct Dilatation without Identifiable Etiology Detected from Cross-Sectional Imaging.

Background/AimsEndoscopic ultrasonography (EUS) is warranted when cross-sectional imaging demonstrates common bile duct (CBD) dilatation without identifiable causes. This study aimed to assess the diagnostic performance of EUS in CBD dilatation of unknown etiology. MethodsRetrospective review of patients with dilated CBD without definite causes undergoing EUS between 2012 and 2017. ResultsA total of 131 patients were recruited. The mean age was 63.2±14.1 years. The most common manifestation was abnormal liver chemistry (85.5%). The mean CBD diameter was 12.2±4.1 mm. The area under the receiver operating characteristic curve (AUROC) of EUS-identified pathologies, including malignancy, choledocholithiasis, and benign biliary stricture (BBS), was 0.98 (95% confidence interval [CI], 0.95-1.00). The AUROC of EUS for detecting malignancy, choledocholithiasis, and BBS was 0.91 (95% CI, 0.85-0.97), 1.00 (95% CI, 1.00-1.00), and 0.93 (95% CI, 0.87-0.99), respectively. Male sex, alanine aminotransferase ≥3× the upper limit of normal (ULN), alkaline phosphatase ≥3× the ULN, and intrahepatic duct dilatation were predictors for pathological obstruction, with odds ratios of 5.46 (95%CI, 1.74-17.1), 5.02 (95% CI, 1.48-17.0), 4.63 (95% CI, 1.1-19.6), and 4.03 (95% CI, 1.37-11.8), respectively. ConclusionsEUS provides excellent diagnostic value in identifying the etiology of CBD dilatation detected by cross-sectional imaging.

Effect of Ageing on the Common Bile Duct Diameter

Introduction: The aim of the study was to determine if the common bile duct (CBD) diameter increases physiologically with age and investigate whether gallstones lead to changes in CBD diameter. Method: Our study is composed of 721 patients in 2 groups: 517 asymptomatic patients and 204 gallstones patients who underwent MRCP. Their CBD diameter was measured at its widest visible portion on MRCP. Simple linear regression of the average of these measurements was used to investigate the relationship between age and CBD diameter in both populations. Subjects were further divided into 8 subgroups age-wise, respectively, and their means compared decade-wise using ANOVA. Furthermore, each subgroup mean from both populations was compared with each other using a t test. Results: Among the 517 subjects, the mean CBD diameter was 5.3663 mm ± 1.43546 and correlated with age (p < 0.01), dilating at 0.07 mm/year. The mean diameter of our oldest group was 7.9 mm, resulting in a plausible upper limit of 8 mm for the asymptomatic population. The mean CBD diameter of the cholelithiasis population was 5.6738 mm ± 1.40986 and also correlated with age (p < 0.01). The mean CBD diameter of the age groups from the cholelithiasis population was larger than that from the asymptomatic population, but none were statistically significant. Conclusion: Although the CBD increases physiologically with age, there is no significant difference in CBD size between the general population and the cholelithiasis patients at any particular age. Gallstones do not independently dilate the CBD.

S20 Common Bile Duct Dilation After Roux-en-Y Gastric Bypass Surgery

Introduction: As the obesity epidemic continues, surgical interventions to address this issue have become more prevalent. One of the most widely used methods for bariatric surgery is Roux-en-Y gastric bypass (RYGB). A unique problem that has been identified in the post-bariatric surgery population is biliary duct dilation without specific pancreatobiliary pathology. This study aims to evaluate the change in common bile duct (CBD) diameter following RGYB. Methods: This was a single center retrospective study that evaluated patients who had undergone RYGB between 1/1/2010 and 12/31/2020. Adults (>18 years of age) who had CT imaging for non-pancreatobiliary reasons before and after their RYGB were included. Patients with known pancreatobiliary pathology were excluded from analysis. An abdominal radiologist measured the diameters of the CBD in all images at the porta hepatis. Linear regression modeling and t-tests in SPSS were used to analyze data. Results: 46 patients met the inclusion criteria. The average age and BMI at time of RYGB was 48.4 years and 46.4. The average age and BMI at time of post-operative CBD measurement was 49 years and 38.1. The mean CBD diameter of all included patients pre-RYGB was 5.93 mm (SD 1.5) and the mean diameter post-RYGB was 7.0 mm (SD 3.3). Mean diameter change between pre and post RYGB was 1.31 mm (SD 2.8, P < 0.05). Controlling for prior cholecystectomy as well as narcotic use at the time of post-operative imaging, the change in CBD diameter was 1.15 mm (SD 0.6, P value 0.06). Prior cholecystectomy and narcotic usage did not affect in person change of CBD diameter (P 0.9, P 0.6). Conclusion: There are many known causes of non-pathological biliary duct dilation, including age, history of cholecystectomy and narcotic use. Our data shows that biliary dilation can occur after bariatric surgery. This finding is important because endoscopic biliary evaluation with EUS and ERCP in RYGB anatomy is challenging and associated with high failure rates. Other biliary interventions like laparoscopic assisted, percutaneous and trans-gastric procedures are associated with higher risk of complications. Given these issues, it is crucial for patients to have a strong indication for biliary intervention. As physicians treat an increasing number of patients with RYGB anatomy, they must consider that incidentally found biliary dilation might not necessarily indicate the presence of biliary pathology in order to prevent avoidable imaging and interventions.

Laparoscopic Choledochoduodenostomy in Bile Duct Stone Diseases

Common bile duct (CBD) stones are present in 5–15% of patients with gallstones. Some of these patients are candidates for a definitive biliary drainage procedure for prevention of stone recurrence. The aim of our study was to ascertain the outcome of laparoscopic choledochoduodenostomy in choledocholithiasis. After obtaining ethical clearance from the institutional ethical committee, the present prospective and observational study was conducted on 32 patients over a period from September 2017 to September 2020 in the tertiary care hospital. In our study, the total number of patients was 32, of whom 26 (81%) were females. The mean and range of age were 54.44 SD 10.827 and 24–70 years, respectively. The most common presenting feature was jaundice (53.125%). The mean CBD diameter was 24.59 SD 2.564 mm with multiple stones in CBD in 90.625% of our patients. The mean duration of surgery and intraoperative blood loss was 147.94 SD 9.732 and 76.25 SD 12.636 ml, respectively. The mean hospital stay was 6.34 SD 0.827 days with 90.6% of the patients returning to work in the 3rd week. In our study, there was no conversion to open and a single patient developed postoperative ileus which was managed conservatively. There was complete resolution of symptoms on follow-up. Laparoscopic choledochoduodenostomy is safe for benign bile duct diseases. It is physiological, with minimal intraoperative blood loss, less operative time, and fewer postoperative complications and is safe with faster recovery.

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.

Which preoperative findings translate to a positive intraoperative cholangiogram?

Background: The most common investigations used in the preoperative diagnosis of choledocholithiasis are ultrasound and liver function tests (LFTs). These modalities have a low sensitivity for detecting common bile duct stones among the intermediate-risk groups. Aim: The aim of the study is to identify preoperative findings which predict choledocholithiasis in intermediate-risk groups. Describe the implications of a positive intraoperative cholangiogram (IOC). Materials and Methods: A retrospective study of all consecutive laparoscopic cholecystectomies with IOC performed. Data were collected over the past 2 years between January 1, 2015, and December 31, 2016. Standard demographic variables, preoperative symptoms, LFTs, IOC findings, abdomen ultrasound, and postoperative symptoms were included in the study. Results: Of 237 laparoscopic cholecystectomies 23 cases were planned for IOC. The median age was 41 years. Seventeen cases were female. Indications were 12 biliary colic, eight gallstone pancreatitis, two cases of acute cholecystitis, and one case was for ascending cholangitis. Four cases had a positive IOC, and in this group, the median age was 44.5 years with one male. The mean common bile duct diameter was 6.5 mm. Two patients had biliary colic, one patient gallstone pancreatitis, and one acute cholecystitis. One patient had a history of jaundice, and all four cases had elevated gamma-glutamyl transferase (GGT) above 40 mmol/l, three cases had alkaline phosphatase (ALP) above 98 mmol/l. Postoperative, out of 23 cases, five cases had an endoscopic retrograde cholangiopancreaticogram, repeated ultrasound in three cases, persistence symptoms in four cases. Conclusions: GGT was the strongest predictor of choledocholithiasis. A normal GGT seems to be quite good at ruling out Cannabidiol stones. ALP was less accurate. Gallstone pancreatitis is not a good predictor, but it is importance to exclude choledocholithiasis before/during cholecystectomy. There is no relation between the IOC and persistent symptoms.

Measurement of the Diameter of the Common Bile Duct and Pancreatic Duct among Healthy Adult Sudanese Subjects using Magnetic Resonance Cholangiopancreatography

The purpose of our study was to evaluate the common bile duct (CBD) and pancreatic duct (PD) diameter among healthy adult Sudanese subjects using magnetic resonance cholangiopancreatography (MRCP). In addition, this study aimed to determine the effects of age, gender, and body height and weight on the CBD and PD diameters to establish a reference range for these ducts on MRCP, which is very useful in a daily clinical setting where MRCP is commonly performed to evaluate suspected biliary tract disease. Methods and Results: This study included 80 asymptomatic subjects who underwent MRCP. The widest diameter of the CBD and PD was measured perpendicular to their long axes using the electronic caliper. The applied MRCP imaging technique was in line with the guidelines used by Chen et al.(2012) The age, gender, medical history, body height and body weight were recorded. Among the 80 subjects, the mean CBD diameter on MRCP was 6.17±0.69 mm (range of 4-8 mm). There was a significant correlation between the CBD diameter and weight (r=0.407, P&lt;0.001). The mean PD diameter on MRCP was 3.80±0.50mm (range of 2-5 mm). There was also a significant correlation between the PD diameter and weight (r=0.407, P&lt;0.001). In the cohort of 80 subjects, the mean CBD diameter in females was larger than in males(6.50±0.632mm and 5.95±0.677mm, respectively), and this difference was statistically significant (P&lt;0.05). Also, the mean PD diameter in females was statistically larger than in males (6.03±0.66mm and 5.58±0.675mm, respectively), and this difference was statistically significant (P&lt;0.05). Our results demonstrate no significant correlation between the diameter of CBD and PD and participants' height and age. Conclusion: The importance of the current study lies in it’s being one of the few studies whose intention was to use MRCP to bridge the knowledge gap in the literature about the measurement of the CBD and PD diameter among healthy adult Sudanese subjects.

Appraisal of Laparoscopic Common Bile Duct Explorations Using Balloon-Assisted Stone Extraction Method: Seventeen Years Experiences.

Background: Balloon-assisted stone extraction (BASE) can be applied to remove the common bile duct (CBD) stones during laparoscopic CBD exploration (LCBDE). This study aimed to analyze the efficacy of BASE. Methods: A retrospective analysis of patients with CBD stone who underwent LCBDE using BASE from 2001 to 2017 was conducted. The outcomes of BASE and potential factor for failure of technique were also evaluated. Results: A total of 163 patients underwent LCBDE using BASE 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 intrahepatic duct (IHD) (n = 3), and others (n = 6). The overall success rate of stone clearance was 98.2% (160/163). 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). The overall rate of complication related with procedure 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 mortality. Conclusions: BASE for CBD stone is safe and effective technique for the treatment of CBD stones.

Normal ultrasonographic dimensions of the gallbladder and common bile duct in neonates

Background: Ultrasound (US) is the first choice of imaging in neonates presenting with persistent jaundice to exclude surgically correctable causes and differentiate obstructive from nonobstructive causes. Previous studies on normal dimensions of gallbladder (GB) and common bile duct (CBD) recruited adults and children spread across a wide age group. Aims: This study aimed to determine GB and CBD normal dimensions in a large homogeneous neonatal population as well as guide decision regarding pre-US fasting in neonates who require GB evaluation. Materials and Methods: Five hundred and twenty-eight healthy newborns were recruited between May 2009 and May 2011. The widest intraluminal anterior-posterior diameters of GB and CBD were measured. Neonatal age in days, sex, birth weight, weight and height, gestational age at delivery, and time interval since last feed recorded. Results: The mean age was 9.56 ± 7.66 days, and 50.6% were males. The mean CBD diameter was 1.16 ± 1.61 mm while the mean GB diameter was 4.42 ± 2.16 mm. GB and CBD were clearly seen and measurable in 297 (55.8%) neonates and 237 (44.38%) neonates, respectively. There was a significant correlation between CBD diameter and GB diameter (P = 0.04) but no correlation with any demographic parameter. GB visualization was not dependent on time interval from last feed. Conclusion: Mean neonatal values for CBD and GB were established, but neonates have a wider range of GB diameters compared with older children, so GB diameter may not be a reliable parameter for neonatal GB pathologies. GB visualization was not dependent on time interval from last feed; hence, a recent feed should not delay emergency scans, especially in ill neonates

349 Comparison of Common Bile Duct Measurement by Point-of-Care Ultrasound to Radiology-Performed Ultrasound

Exact incidence of common bile duct (CBD) stones is not known, but they have been found in 10-18% of patients undergoing cholecystectomies. They are associated with significant morbidity, resulting in pancreatitis or cholangitis if left untreated. Unfortunately, physical exam and lab tests are unreliable in detecting CBD stones. Limited data exists evaluating the use of point-of-care ultrasound (POCUS) in the emergency department (ED) to evaluate for CBD stones. Our objective was to evaluate the accuracy of CBD diameter measured on POCUS compared to radiology-performed ultrasound. In this retrospective chart review of one academic medical institution, we analyzed 4.5 years of POCUS data to find all cases where CBD dilation was measured and documented by an emergency physician in a POCUS report. We compared these results to radiology-performed ultrasound results of those same patients and compared the two values using paired Student’s T-test to test for significance, mean absolute error (MAE), and Pearson’s correlation coefficient. A total of 126 potential cases of CBD dilation were identified based on POCUS reports that had CBD dilation recorded. Of these, 53 (42%) had radiology imaging studies performed. Thirty-nine (74%) of those included were female. The mean CBD diameter measured on POCUS was 7.61mm (range: 1.3-16.8mm). The mean CBD diameter measured on formal radiology studies for these same patients was 7.34mm (range: 1.0-16.0mm). The two means were not significantly different by paired Student’s T-test (p = 0.63). However, mean absolute error between the two samples was 2.73mm. Pearson’s correlation coefficient was 0.27 (with +1/-1 indicating perfect correlation). While there was not a significant difference between the two samples’ means, there was poor agreement between POCUS and formal radiology US in the evaluation of CBD diameter. We cannot conclude that the two modalities are equivalent in their ability to accurately measure CBD diameter at this time. Limitations of this study include: retrospective chart review with small sample size and no standardization in the qualifications of the physicians performing the POCUS. Future work should include prospective cases and explore how ED providers who receive standardized POCUS training perform versus radiology-performed US for the measurement of CBD diameter.

Predictive factors for extraction of common bile duct stones during endoscopic retrograde cholangiopancreatography in Billroth II anatomy patients.

Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in Billroth II anatomy patients is still a technical challenge and factors affecting stone extraction have not yet been clarified. This study aimed to analyze our experience and evaluate potential factors affecting CBD stone extraction. A retrospective analysis of CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from August 1999 to December 2017, was conducted. The outcomes of ERCP and potential factors affecting stone extraction were examined. A total of 227 patients were enrolled, and 176 patients (77.5%) achieved technical success. The success rate of duodenal ampullary access and selective biliary cannulation was 84.1% (191/227) and 92.1% (176/191), respectively. The mean CBD diameter was 15mm (range 6-35mm), and the largest stone size was 13mm (range 4-36mm). CBD stones were ultimately removed in 137 patients (77.8%), and 105 patients (59.7%) for the first session. Mechanical lithotripsy was used in 17 patients (9.7%). The overall ERCP-related complication rate was 6.3% (11/176), including bleeding in 3 patients (1.7%) and mild pancreatitis in 6 patients (3.4%). The multivariate analysis indicated that CBD stone number ≥ 2 (OR 2.171; 95% CI 1.095-4.306; p = 0.027), and the largest CBD stone size ≥ 12mm (OR 3.646; 95% CI 1.833-7.251; p < 0.001) were patient-related risk factors for failed stone removal; while the use of endoscopic papillary (large) balloon dilation (EPBD/EPLBD) (OR 0.291; 95% CI 0.147-0.576; p < 0.001) was a procedure-related protective factor for successful stone extraction. ERCP is safe and effective for extraction of CBD stones in Billroth II anatomy patients. The number and the largest size of CBD stones, and the use of EPBD/EPLBD are predictive factors for CBD stone extraction.

EVALUATION OF LAPAROSCOPIC ULTRASOUND AS A ROUTINE METHOD FOR ASSESSMENT OF COMMON BILE DUCT PATENCY IN PATIENT WITH HISTORY OF CALCULAR OBSTRUCTIVE JAUNDICE

Intraoperative cholangiogram (IOC) is routinely used during cholecystectomy (either open or laparoscopic) in cases of cholelithiasis with history of obstructive jaundice (OJ). It is performed in such cases with no preoperative imaging that confirms the patency of biliary tree and during exploration of common bile duct. Intraoperative ultrasound (IOUS) has recently become a visualizing tool for anatomy and pathology of biliary tree which is safe, faster and less invasive compared to IOC. This is a prospective controlled randomized trial, conducted on 60 patients undergoing laparoscopic cholecystectomy for cholelithiasis with history of OJ, with no present OJ. It was held in the surgery department in Faculty of Medicine, Menoufia University and Theodor Bilharz Research Institute, from 2014 to 2017. Each patient underwent IOUS then, IOC during laparoscopic cholecystectomy. The study compared between both imaging techniques regarding procedure time, visualization of biliary tree, detection of any common bile duct (CBD) stone, biliary or vascular anomalies, and intra-or postoperative complications in the form of obstructive jaundice or iatrogenic biliary injury. The results showed a significant difference in time of the procedure with a mean time (min) of 9.60±1.224 (3-25) in IOUS and 14.391±1.356 (5-30) in IOC. Mean CBD diameter (mm) is 5.280±0.6957 (2.8-18) in IOUS & 7.010±0.7162 (3.5-22) in IOC without significant differences. IOUS has 100% sensitivity and 96.7% specificity while IOC has 100% sensitivity and 100% specificity. A case with vascular anomaly and one with duct anomaly were detected by IOUS. The vascular anomaly could not be detected with IOC. There was no post-operative complication in the form of missed CBD stones or bile leakage.

Association between common bile duct diameter and abdominal aorta calcium score.

There is evidence of association between aging and increase in the normal upper limit of the common bile duct (CBD) diameter. As aging is a documented risk factor for atherosclerosis, and the possible effect that atherosclerosis can have on the CBD diameter via affecting its smooth muscle contractility and blood flow, we decided to determine the association between CBD diameter and atherosclerosis in the abdominal aorta (AA). A total of 99 asymptomatic patients (53 males and 46 females; age range of 18-88years) without history of cholecystectomy who underwent abdominal contrast-enhanced CT scan were included. The CBD diameter was measured. The atherosclerosis of AA was quantified by Agatston score. Mean (±SD) CBD diameter was 6.14 (±1.95) mm; range=2.4-12.7mm. Agatston score was 0 in 59 patients. In the remaining 40 patients, median (interquartile range, IQR) Agatston score was 497.5 (2026.3). Mean (±SD) CBD diameter in patients with Agatston score>0 was 7.39 (±2.07) mm compared to 5.29 (±1.32) mm in patients without calcification plaque (P<0.001). A moderate correlation was seen between CBD diameter and Agatston score (ρ=0.43; P=0.005). Although the exact cause of increased CBD diameter with advancing age is not understood, a general atherosclerotic process which occurs with aging may affect smooth muscle of the CBD. Whether an upper limit for normal CBD should be defined or not when evaluating dilated CBD for patients with subclinical or clinical atherosclerosis needs further studies.

Retrospective Clinical Study of the Effects of T-Tube Placement for Bile Duct Stricture.

BackgroundT-tube placement in the common bile duct (CBD) is a surgical alternative to bile duct reconstruction in cholecystectomy for cholecysto-choledocholithiasis, or gallstones. The aim of this retrospective clinical study was to investigate the incidence of late complications of T-tube placement.Material/MethodsRetrospective review identified 35 patients who had T-tube placement during cholecystectomy. Clinical data were collected on surgical indications, patient demographics, and clinical symptoms. Ultrasound (US) was used measure the diameter of the common bile duct (CBD), intrahepatic ducts, and presence or absence of stones in the CBD. Data from laboratory investigations included the aspartate aminotransferase-to-platelet ratio index (APRI), which was used as a non-invasive method to evaluate both cholestasis and liver fibrosis.ResultsOf the 35 patients included in the study, 33 (94.3%) underwent open cholecystectomy, CBD exploration, and T-tube placement due to cholecysto-choledocholithiasis. The remaining two patients (5.7%) underwent primary CBD repair and T-tube placement secondary to CBD injury. The mean follow-up period after T-tube placement was 69 months. In patients with T-tube placement, the CBD diameters ranged from 4–21 mm, were normal in 20 patients (57.1%), dilated in 15 patients (42.9%), with the mean CBD diameter being 8.91±4.82 mm. No residual or recurrent CBD calculus and no clinical or laboratory evidence of cholangitis or cholestasis were found.ConclusionsA retrospective clinical study at a single surgical center, showed that T-tube placement during open cholecystectomy and CBD exploration was a safe procedure that did not result in late complications.

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.

Single Stage Management of Concomitant Cholelithiasis and Choledocholithiasis

Concomitant cholelithiasis and choledocholithiasis are commonly managed in two stage procedure, endoscopic management of common bile duct stone followed by laparoscopic cholecystectomy in different time and setting. We perform these two procedures in same sitting in operating room set up. We evaluated the procedure in terms of outcome, feasibility and complications. Prospective cross-sectional study carried out since April 2013 to August 2016 in all patients who had undergone single stage endoscopic and laparoscopic management of concomitant cholelithiasis and choledocholithiasis. Patient's demography, procedural time for different procedure and procedure in total and post-operative complications were recorded and analyzed with suitable statistical methods. Out of 50 cases enrolled, 2 patients were converted to open. Out of 48 patients, 3 needed re-attempt for completion. Majority were female 36 (72%), mean age was 39.48years. Mean common bile duct diameter and mean stone size was 11.43±2.63 cm and 7.99±2.01cm, respectively. Mean of total procedural time was 90.93± 33.68 minutes. In most of the cases, laparoscopic cholecystectomy performed first followed by endoscopic method (66.7%). Total procedural time was less in the patients who underwent laparoscopy first in comparison to endoscopy first. Clinically significant complications like cholangitis, pancreatitis and duodenal perforation occurred in 7 patients. Out of 4 patients who developed pancreatitis, one had severe acute pancreatitis requiring prolonged hospitalization. Single stage management of common bile duct and gall bladder stone by laparoscopic and endoscopic method is feasible in our setup with acceptable results. Endoscopic treatment of common bile duct stone if performed first, is associated with longer procedural time.