Preoperative Magnetic Resonance Cholangiopancreatography Research Articles

ThP4.10 - Outcomes of Transcystic Laparoscopic Common Bile Duct Exploration at the time of Laparoscopic Cholecystectomy in patients with small common bile duct diameter

Abstract Aim Laparoscopic Cholecystectomy with Laparoscopic Common Bile Duct Exploration (LC+LCBDE) is a single stage therapeutic option for management of choledocholithiasis. There have been limited publications regarding the feasibility of transcystic LCBDE in patients with small (≤8mm) common bile ducts (CBD). This study seeks to examine the outcomes for patients with small ducts who underwent LC+LCBDE via a transcystic approach in a district general hospital over a two-year period. Methods Prospectively collected data regarding all patients who underwent LC+LCBDE over a period from January 2022 to December 2023 was retrospectively reviewed. Data concerning indication for surgery, CBD diameter, length of stay, complication rate, and readmission rate were determined from Electronic Care Records. Data were analysed using Microsoft Excel. Results 50 patients were identified. CBD diameter (as measured at pre-operative Magnetic Resonance Cholangiopancreatography [MRCP]) ranged from 3.5mm to 8mm (average 6.25mm). One patient required conversion to open surgery due to difficulties with the LC element of the operation. Median postoperative length of stay was 1 day (range 0-8 days) and readmission rate was 6%. One patient experienced a complication beyond Clavien-Dindo Grade 2, this caused by a superficial wound infection requiring washout under general anaesthetic. One patient required subsequent Endoscopic Retrograde Cholangiopancreatography (ERCP) for management of retained CBD stones. Conclusions LC+LCBDE is a safe and effective management option for patients in the setting of choledocholithiasis with small common bile duct diameter. Small CBD should not necessarily be a deterrent to consideration of LCBDE as a therapeutic option in appropriately selected patients.

Effectiveness of pre-operative routine MRCP in patients scheduled for laparoscopic cholecystectomy

Background: Cholelithiasis is one of the most common surgical diseases worldwide. Laparoscopic cholecystectomy is the gold standard treatment for cholelithiasis, and has become the most common performed gastro intestinal operation. The prevalence is higher in women (7.7%) than in men (3.3%). We aimed to investigate the effectiveness of pre-routine magnetic resonance cholangiopancreatography (MRCP) before performing scheduled Laparoscopic cholecystectomy. Methods: This was a prospective observational study conducted in the Department of General Surgery, Dhaka Central International Medical College, and selected single private Hospital from Dhaka, Bangladesh during the period from January 2021 to January 2023. In our study, we included 90 female patients presented with acute or chronic calculus cholecystitis. All patients were diagnosed with multiple gall stones diseases on USG abdomen after initial clinical evaluation were included in this study. Result: In our study, we found the mean age was 34.97±8.48 years. Among 90 patients USG showed multiple stones in 85(94.44%) patients whereas, MRCP showed stones only in 24 (26.67%) patients. Among patients with normal CBD, MRCP found 25.33 % and USG found 93.33% with stones. There were 3 patients with more than 5 mg/dl. bilirubin who was diagnosed with stones in both findings. Among the patients with 148-220 ALP levels, both USG and MRCP found 90.48% of patients with stones. We found 1 true negative case and 20 true positive cases of multiple stones (with a p value of 0.017). Conclusion: We found that MRCP helps increase the safety of perioperative management in some cases. Preoperative ultrasonography has a low diagnostic accuracy rate when it comes to patients who also have gallstones and CBD stones. So, individuals with gallstones are advised to undergo a normal preoperative MRCP examination.

Preoperative MRCP is not Associated with Lower Complication Rates but Shorter Hospital Stay in Laparoscopic Cholecystectomy

Abstract Background Laparoscopic cholecystectomy is a very common procedure and while preoperative magnetic resonance cholangiopancreatography (pMRCP) is widely used for detection of choledocholithiasis and preoperative planning, the benefits in patients with normal preoperative cholestatic parameters remain unclear. Aims We aimed to investigate a large cohort of patients after laparoscopic cholecystectomy to analyse the impact of pMRCP on complication rates. Methods This retrospective cohort study consecutively includes all patients receiving elective or acute laparoscopic cholecystectomy between 2010 and 2020. Exclusion criteria were conversion to open cholecystectomy and preoperatively elevated cholestatic parameters. Complication rates were recorded and patients stratified depending on the use of pMRCP for preoperative planning. Results 3163 patients underwent laparoscopic cholecystectomy between 2010 and 2020, 2568 of which showed normal cholestatic parameters preoperatively. Of these patients, 684/2568 (27%) were male and 1884/2568 (73%) female. The most frequent indications for laparoscopic cholecystectomy were cholecystolithiasis in 72% (1845/2568) of cases, followed by cholecystitis in 18% (465/2568). The majority of patients (2267/2568, 88%) indeed received pMRCP, while the remaining 301/2568 patients did not. Postoperative complication rates did not significantly differ between the two groups (396/2267 (17%) in the pMRCP group and 58/301 (19%) without pMRCP, p=0.469). One case of pancreatitis occurred in the pMRCP group, versus two reported cases in the other group. Interestingly, the length of hospital stay after cholecystectomy was significantly shorter in the group with pMRCP versus without (4 days (range 1-61 days) versus 7 days (range 1 – 66 days), respectively, p = 0.023). Conclusion Preoperative MRCP seems to not prevent complications in laparoscopic cholecystectomy, since postoperative complication rates were comparable between the two patient groups with and without pMRCP. However, postoperative hospital stay was significantly shorter in patients undergoing pMRCP compared to patients without pMRCP.

Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC

BackgroundIn the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis.MethodsAccording to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups.ResultsAmong the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05).ConclusionsThe preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

How do magnetic resonance cholangiopancreatography findings predict conversion from laparoscopic cholecystectomy for acute cholecystitis to bailout procedures?

BackgroundAcute cholecystitis is one of the most prevalent surgical abdominal conditions. The Tokyo Guidelines describe the management of acute cholecystitis and recommend bailout procedures for “difficult” cholecystitis cases. This study aimed to identify risk factors for conversion from laparoscopic cholecystectomy to bailout procedures in patients with acute cholecystitis. MethodsThis retrospective cohort study was conducted at a single center between January 2017 and December 2021. Patients who underwent laparoscopic cholecystectomy for acute cholecystitis were enrolled and classified into bailout and non-bailout groups. The patients’ characteristics and perioperative data were compared between the 2 groups. ResultsIn total, 161 patients who underwent laparoscopic cholecystectomy for acute cholecystitis were reviewed. Fourteen were excluded because of a lack of preoperative magnetic resonance cholangiopancreatography; thus, 147 patients were enrolled (bailout group, 21; non-bailout group, 126). Age (74 vs 67 years old; P = .048), days from onset to surgery (3 vs 2 days; P = .02), or defect of cystic duct in magnetic resonance cholangiopancreatography (57% vs 29%; P = .02) were significantly associated with conversion to bailout procedures. In the logistic regression analysis, a defect of the cystic duct in magnetic resonance cholangiopancreatography was an independent predictor for bailout procedures (odds ratio, 2.793; P = .04). ConclusionIn this study, defect of the cystic duct in the magnetic resonance cholangiopancreatography can predict conversion to bailout procedures. To the best of our knowledge, this is the first report to describe magnetic resonance cholangiopancreatography finding of the cystic duct as a predictor of surgical difficulty in patients with acute cholecystitis.

Role of Preoperative MRCP in the Management of Biliary Pancreatitis: A Retrospective Study from Saudi Arabia

Background: Gallstones are the leading cause of acute pancreatitis worldwide. Acute biliary pancreatitis occurs when distal common bile duct stones obstruct the ampulla. This can result in severe consequences for some patients, including significant fluid loss, metabolic imbalances, hypotension, and sepsis. Definitive management strategies for choledocholithiasis include laparoscopic cholecystectomy and/or endoscopic retrograde pancreatography. Magnetic resonance cholangiopancreatography (MRCP) has been increasingly used to evaluate bile duct pathology, leading to more frequent pre-operative biliary duct evaluations for patients with acute gallstone pancreatitis. Despite its widespread use, there have been conflicting reports in the literature regarding its effectiveness and impact on hospital stay duration and healthcare-associated costs. Aim: The aim of this study was to compare the impact of performing MRCP in biliary pancreatitis and its utility, measure its cost-effectiveness, and assess the sensitivity and specificity of different laboratory and radiological investigations in diagnosing impacted biliary stones. Methods: This study followed a retrospective design and analyzed, the records of all patients diagnosed with acute biliary pancreatitis during the study period (2015-2019). Data regarding the following variables were obtained and analyzed from patients’ records: age, comorbidities, and previous medications of the patients; BISAP pancreatitis severity score; serum amylase, at the time of admission; serial recordings for biomarkers and liver function test results (for Day, 1, 3, and 6); ultrasonography results; computed tomography results; MRCP and ERCP results; postoperative complications; length of hospital stay in days; and the time waiting for surgery in days. Results: 133 participants were found in the hospital admission registry and included in this analysis, with an average age of 51.73 years. At the time of admission, the average serum amylase level was 1310 units/liter. Regarding the length of hospital stay, 8.9 days was the average among the patients, with a maximum length of stay of 48 days. Our analysis revealed that MRCP has a sensitivity of 77% and a specificity of 64% for detecting CBD stones. Patients who had MRCP stayed longer at the hospital with an average of 9.21 days, although the difference was not statistically significant (p-value: 0.570), compared with International Journal of Surgery &amp; Surgical Techniques 2 Shaher A, et al. Role of Preoperative MRCP in the Management of Biliary Pancreatitis: A Retrospective Study from Saudi Arabia. Int J Surg Surgical Tech 2023, 7(2): 000196. Copyright© Shaher A, et al. an average of 6.15 among patients who did not have MRCP. As for the days to surgery, the average time until surgery was 3.79 (standard deviation 3.73), with a maximum of 16 days until surgery. Patients who had MRCP had to wait for a longer period of time until surgery than their counterparts who waited for less than a day for their surgery (p-value: &lt; 0.001). Conclusion: Our results revealed that patients who underwent MRCP preoperatively had a longer hospital stay and significantly waited longer for surgery than their counterparts. However, more multi-centered, large studies are needed to further support our findings.

Lateral dorsal infundibular approach: an alternative option for the safe completion of difficult laparoscopic cholecystectomy

BackgroundDifficult laparoscopic cholecystectomy (LC) due to acute cholecystitis (AC) increases the risk of bile duct injuries and postoperative complications. Here, we added the lateral dorsal infundibular approach as an initial surgical maneuver during LC to improve outcomes.MethodsWe describe the detailed technical procedure of the lateral dorsal infundibular approach in patients with AC resulting in difficult LC. This technique was developed after nearly 10 years of experience in laparoscopic surgery, and has been routinely used in the past 5 years. We also retrospectively analyzed the perioperative data for 469 patients with difficult LC.ResultsA total of 469 patients with AC received difficult LC between July 2016 and June 2021, of which 438 (93.4%) performed a lateral dorsal infundibular approach. Sixty-four patients (13.6%) had variations of the hepatic bile duct and cystic duct according to preoperative magnetic resonance cholangiopancreatography, 438 patients (93.4%) received elective surgery, 31 (6.6%) received emergency surgery, and 10 (2.1%) underwent conversion. There was no postoperative bile leaks and no bile duct injuries in the described technique.ConclusionDuring difficult LC, the critical view of safety can be gradually achieved by changing the surgical approach to achieve cholecystectomy.

A O02 Few patients with bile duct stones are managed with a one-stage approach: Results from a prospective multicentre cohort study

Abstract Background Bile duct stones (BDS) are present in 10–20% of patients with symptomatic gallstones. They require treatment to reduce the risk of further morbidity. There are two accepted treatment methods. A two-stage approach is most common where preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are followed by laparoscopic cholecystectomy (LC). Less commonly, upfront LC is performed with laparoscopic bile duct exploration (LBDE). Recent evidence suggests patients who undergo ERCP+LC have higher stone clearance rates and a lower rate of bile leakage compared to those who undergo LC+LBDE. However, the latter have lower rates of postoperative pancreatitis and reduced length of stay. Overall morbidity and mortality rates are similar. Although the literature supports the single-stage approach, it is not commonly used across the United Kingdom (UK) or Republic of Ireland (RoI). The reasons for this are not clear. The lack of data on LDBE outcomes from large multicentre studies may be a contributing factor. Most published series are from single institutions and the outcomes of these are difficult to generalise to low-volume centres. This study aimed to analyse the CholeS study dataset to examine LBDE hospital volumes, LBDE-to-LC rates and LBDE outcomes. Methods The CholeS study was a multicentre, prospective population-based cohort study which investigated the variations in practice and outcomes of cholecystectomy. Data were collected from 166 UK/RoI hospitals from the months of March and April 2014. The hospitals were divided into high- and low-volume centres based on the number of LBDEs performed. High-volume centres performed at least two LBDEs per month during the study period and low-volume centres performed less than two per month. Most data were analysed and presented descriptively, using tables, graphs, and percentages for distribution. Where possible, we compared clinically relevant groups using the Chi-squared test to detect differences. A p value of less than 0.05 was considered statistically significant. Results In total, 8820 LCs were performed and 2.9% of patients underwent LBDE. Seventy-seven centres (46.1%) performed at least one LBDE. In these units, 5.4% of patients who underwent LC also underwent LBDE. Almost 90% of the hospitals that performed LBDE carried out less than or equal to five. In contrast, 10.6% of patients underwent ERCP and sphincterotomy. Of the 256 LBDEs, 28.5% underwent preoperative ERCP and 43.8% underwent preoperative MRCP. Eighty seven percent of LBDEs were performed by consultants and 13% by trainees. The laparoscopic-to-open conversion rate was 12.5% and the median operation time was 111 minutes (IQR: 75–155). Among the LBDE cases, the overall postoperative morbidity rate was 21.5% and the bile leak rate was 4.7%. 30-day readmission and 30-day mortality rates were 12.1% and 0.4%, respectively. Bile leak, acute pancreatitis, retained stone and overall morbidity rates following LBDE were compared between the low- and high-volume centres. Bile leak (OR 8.62, 95% CI: 2.26–32.84, p=0.0016) and 30-day morbidity (OR 1.90, 95% CI: 1.05–3.44, p=0.035) were significantly higher in the low-volume units. There was no difference in the rate of postoperative pancreatitis (OR 0.85, 95% CI:0.09–8.3, p=0.8887) or retained stone rate (OR 0.76, 95% CI:0.16–3.68, p=0.7376). Conclusions During the study period, just 2.9% of patients underwent LBDE. The majority of hospitals did not perform this procedure at all and very few were “high-volume” units. Our results suggest that the single-stage management of BDS was underutilised despite the recent evidence which suggests it is a safe and reasonable approach. Our results do not provide any insight into why uptake was low and we suspect the reasons for this are multiple. We argue large retrospective/prospective studies are required to investigate this and hope this information will further guide patient management.

Preoperative three-dimensional magnetic resonance cholangiopancreatography for choledocholithotomy

ObjectiveTo explore the display effect of preoperative three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) for choledocholithotomy. MethodsA total of 156 patients with suspected bile duct calculus in our hospital from June 2019 to June 2021 were collected as the research objects. The patients were divided into the preoperative ultrasonography group and the preoperative 3D-MRCP group (78 cases in each group). The detection rate, location judgment accuracy, and surgical effect were compared between these two groups. ResultsThe detection rate of bile duct calculus by 3D-MRCP was 97.4% (76 cases), which was higher than the preoperative ultrasonography (87.1%, 68 cases, P = 0.016). Taking the results of surgical exploration as the gold standard, the location judgment accuracy by 3D-MRCP was 98.7%, which was higher than the preoperative ultrasonography (91.1%, P = 0.036). The operation time, catheter retention time, postoperative ventilation time, and bowel sound recovery time of the 3D-MRCP group were significantly shorter than those of the ultrasonography group (P < 0.05). The postoperative effectiveness of the 3D-MRCP group was 97.4%, which was significantly higher than the ultrasonography group (86.8%, P < 0.05). ConclusionThe preoperative 3D-MRCP has a high detection rate and anatomical site display rate of bile duct calculus, which can improve the operative effect of choledocholithotomy.

Modified single-port versus multiport laparoscopic choledochal cysts excision and Roux-en-Y hepaticojejunostomy: a retrospective comparative cohort study.

The feasibility, benefit, and safety of multiport laparoscopic choledochal cyst (CDC) excision and Roux-en-Y hepaticoenterostomy (MPCH) have been consistently confirmed. Single-port laparoscopic CDC excision and Roux-en-Y hepaticoenterostomy (SPCH) has advantages of less traumatic and more cosmetic beneficial, it has been reported in some case series, but it is technically challenging. We propose a modified technique to reduce technical difficulty in performing SPCH. The safety and feasibility of modified SPCH were compared with those of conventional multiport laparoscopic CDC excision. A total of 43 consecutive patients who diagnosed with CDC by preoperative magnetic resonance cholangiopancreatography (MRCP) and underwent SPCH (n=24) and MPCH (n=19) for choledochal cyst (CDC) by a single surgeon between January 1, 2018, and January 1, 2021, were enrolled. The baseline clinical characteristics, efficacy and safety outcomes of short-term were compared. The baseline clinical characteristics of the MPCH and SPCH groups are comparable. Average postoperative length of hospital stay was shorter in the SPCH group than in the MPCH group, but the difference was not statistically significant (7.00 vs. 7.58 days; P>0.99). The operation time (281.75 vs. 277.3 min; P=0.58) and the amount of blood loss (9.33 vs. 16.68 mL; P=0.57) were similar in both groups. A significantly greater number of drainage tubes were placed in the MPCH group compared to the SPCH group (11 vs. 5; P=0.01). One patient suffered from hepaticoenterostomy anastomosis stricture in the SPCH group. The short-term outcome of modified SPCH is comparable with MPCH according to our study. It is easily adaptable treatment of CDC.

Evaluating Safety, Effectiveness, and Resource Efficiency in Management Strategies for Intermediate Risk Choledocholithiasis: Defining the Optimal Approach

INTRODUCTION: Optimal management of emergency department patients with intermediate-risk choledocholithiasis (IR-CDL) remains undefined. At a safety-net hospital where timely patient throughput is essential, we hypothesized that forgoing additional preoperative diagnostics and proceeding directly to laparoscopic cholecystectomy (LC) ± intraoperative cholangiogram (IOC) is a safe, effective, and resource-efficient strategy. METHODS: Adults with IR-CDL who underwent cholecystectomy during index hospitalization from 2016 to 2020 were included. IR-CDL was defined as total bilirubin 1.8 to 4.0 mg/dL, common bile duct (CBD) >6 mm, or gallstone pancreatitis on admission. Safety was assessed using the rate of CBD injury, reoperation, readmission, and retained CBD stones within 30 days of discharge. Effectiveness was assessed using the rate of successful endoscopic CBD clearance. Efficiency was measured using hospital length of stay (LOS) and direct and total cost. Patients taken direct-to-operating room (OR) for LC ± IOC were compared with those who received preoperative magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (“additional-workup”). RESULTS: Of 655 patients, 611 (93%) were direct-to-OR and 44 (7%) were additional workup. Demographics were similar between groups. There was no difference in CBD injury, reoperation, readmission, or retained stones after discharge (all p > 0.05; Table). Of direct-to-OR patients who underwent LC+IOC, 34% had choledocholithiasis. Rates of successful endoscopic CBD clearance were similar between preoperative and postoperative ERCP (97% vs 100%, p = 0.96). Direct-to-OR patients had a shorter median hospital LOS by 38.5 hours and lower median direct and total cost by $5,121/patient and $8,535/patient, respectively.TableCONCLUSION: Proceeding directly to the OR for LC ± IOC expedites treatment of IR-CDL at lower cost without compromising safety or efficacy. These findings help clarify optimal management of IR-CDL.

Routine preoperative MRCP in screening choledocholithiasis in acute cholecystitis compared to selective approach: a population-based study.

Choledocholithiasis is more common in acute cholecystitis than in elective situations. Preoperative diagnosis of choledocholithiasis is essential to facilitate adequate planning of CBD (common bile duct) stone removal, preferably performed as a single-stage procedure. The purpose of this study was to test the feasibility of routine preoperative magnetic resonance cholangiopancreatography (MRCP) in acute cholecystitis followed by consequent cholecystectomy. A total of 180 consecutive patients operated for acute cholecystitis between January 2019 and December 2019 were prospectively enrolled. Preoperative routine MRCP was performed for bile duct evaluation when feasible. The control cohort consisted of 180 consecutive patients undergoing emergency laparoscopic cholecystectomy before the study period. Intraoperative cholangiography was used routinely in both groups when technically achievable. We examined the proportion of patients recruited in preoperative MRCP, possible time delay to MRCP and surgery, and the incidence of CBD stones compared to the control cohort. Routine MRCP in acute cholecystitis was achieved in 114/180 (63%) patients compared to 42/180 (23.3%) patients of the control group. The triage time from emergency to MRCP and the operating theatre was similar in both cohorts. The percentage of patients diagnosed with choledocholithiasis in the study group was notably higher (almost 18% vs 11%), p < 0.05. After a median follow-up time of 2.5years in the study group and almost 4years in the control group, recurrent choledocholithiasis was not detected in either group. Routine MRCP in patients with acute cholecystitis can be implemented with a fair execution rate in a population-based setting with minor effects on hospital stay and delays but higher detection of choledocholithiasis. We observed no additional benefit compared to the selective use of MRCP. However, routine preoperative MRCP allows an advantage when considering the appropriate exploration method if choledocholithiasis is detected.

Laparoscopic bile duct plasty for hilar bile duct stenosis (HBDS) in patients with congenital biliary dilatation: Diagnosis of HBDS by preoperative MRCP and laparoscopic strategy to relieve HBDS.

Congenital biliary dilatation (CBD) is a disease associated with pancreaticobiliary maljunction. The most frequent postoperative complication is intrahepatic stones, which are caused by hilar bile duct stenosis (HBDS). We retrospectively reviewed the records of patients who underwent primary surgery for CBD between 2013 and 2021. We evaluated images and videos of HBDS, the laparoscopic technique of releasing the stenosis, and its occurrence rate and compared intraoperative bile duct findings with those of preoperative magnetic resonance cholangiopancreatography (MRCP). There were 87 CBD cases in this study. HBDS occurred in 52% and preoperative MRCP for HBDS showed a 96% sensitivity and 74% specificity in this study. Bile duct plasty was performed in 45% of the cases and videos demonstrated typical methods of laparoscopic bile duct plasty. The mid- to long-term complications were hepatolithiasis in three patients, anastomotic site stricture in three, and postoperative obstruction in two. Our study revealed that preoperative imaging studies are useful for the prediction of HBDS. Our laparoscopic meticulous probing method for finding BDS reveals more intrahepatic BDS through magnification. Therefore, this may reduce the incidence of intrahepatic stones. Preoperative imaging and intraoperative findings can be complemented to plan management that reduces long-term complications.

Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis

PurposeRetained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. MethodsA total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. ResultsRS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. ConclusionsThe presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

Timing of operation in children with a prenatal diagnosis of choledochal cyst: A single-center retrospective study.

There is currently no consensus on the timing of operative correction for patients with a prenatal diagnosis of choledochal cyst (CDC). This study aims to retrospectively analyze patients with prenatally diagnosed CDCs to identify the optimal timing of operative correction and the importance of cyst size as a predictor of the appearance of symptoms related to the CDC. We reviewed 125 patients with a prenatal diagnosis of CDC who were admitted to Guangzhou Women and Children's Medical Center from July 2015 to July 2020. After dividing the patients into a symptomatic group (n=37) and an asymptomatic group (n=88), according to whether they had any clinical symptoms at the time of their operation, we compared their clinical data and postoperative outcomes. The asymptomatic group was divided into a <1month group; a ≥1 month and <4 months group; and a ≥4 months group according to their postnatal age at operation; postoperative complications of the three groups were then compared. We were also interested in the effect of cyst size (width and length) for predicting the development of symptoms related to the CDC. The time of onset of symptoms after birth was mainly concentrated in the first 3 months (48.6%). The median width and length of cysts measured by preoperative magnetic resonance cholangiopancreatography in the symptomatic group were greater than those in the asymptomatic group (43 mm vs 28 mm and 71 mm vs 45 mm, respectively; P < .05). The serum levels of the liver-related enzymes ALT, AST, and GGT, and the serum level of DBIL, were greater in the symptomatic group than in the asymptomatic group (P < .05). The operative time, intraoperative blood loss, and duration of postoperative hospital stay in the symptomatic group were greater than those in the asymptomatic group (P < .05). In the asymptomatic group, there were no statistically significant differences in the surgical data and postoperative complications between the <1 month group, the ≥1 month and <4 months group, and the ≥4 months group. The area under the receiver operating characteristic curve (AUROC) of the length of the cyst in predicting symptoms was 0.747, the best cut-off point was 5.2cm, and the sensitivity and specificity were 78% and 70%, respectively. The AUROC of the width of the cyst was 0.704, the best cut-off point was 4.1cm, and the sensitivity and specificity were 68% and 75%, respectively. We maintain that it is advantageous to receive surgical treatment in the asymptomatic period for patients with a prenatally diagnosed CDC. A cyst size of length >5.2cm and width >4.1cm suggested that clinical symptoms might appear, and that surgery should be carried out as soon as possible, even in the neonatal period.

A Study of Anatomical Variations of Extrahepatic Biliary System by Pre-operative Magnetic Resonance Cholangio-Pancreatography and that Encountered during Laparoscopic Cholecystectomy: A Prospective Observational Study

Introduction: The variations in cystic duct anatomy are of considerable importance during surgical excision of the gallbladder (cholecystectomy). Preoperative MRCP assessment of possible anatomical variations helps the surgeon to formulate appropriate strategies and operative planning. Objective: To assess the usefulness of pre-operative MRCP assessment of anatomical variations of extra-hepatic biliary tree in surgical planning and validate the MRCP findings with surgical findings. Material and Method: A total 120 patients of ultrasonography proven gallstone disease were included in the study, further evaluated preoperatively by magnetic resonance cholangio-pancreatography for delineation of extra-hepatic biliary anatomy and that was compared with findings during Laparoscopic Cholecystectomy performed in the same patients. Seven patients had frozen Calot’s triangle per-operatively and were excluded from the study. Results: Majority of patients was in age group of 51-60 years (28.4%) and females (85.84%). on MRCP, Posterior insertion of Cystic duct was noted in 58.41% patients, Lateral insertion in 35.39% patients while on per-operatively Posterior insertion was noted in 50.44% and lateral insertion in 38.94 % patients. Most common intra-op complication was Bile spill in 19.4% patients, Stone spill in 9.7% patients and there was no bile duct injury noted. Conclusion: There is a definitive role of magnetic resonance cholangio-pancreatography prior to laparoscopic cholecystectomy in gallstone disease for precisely delineating the extra hepatic biliary tree anatomy and predicting difficult surgery thus helping the surgeon to be prepared for the eventualities during surgery and to prevent biliary injury. However still intra-op picture can vary and overall, there is reduction in patient morbidity.

Evaluation of Preoperative Magnetic Resonance Cholangiopancreatography in Acute Cholecystitis to Predict Technical Difficulties in Laparoscopic Cholecystectomy.

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique that provides high-quality visualization of the biliary tree, including the gallbladder. This study aimed to evaluate the useful-ness of preoperative MRCP for acute cholecystitis in predicting technical difficulties during laparoscopic chole-cystectomy (LC). A total of 168 patients who underwent LC with preoperative MRCP were enrolled in this study. Patients were divided into two groups according to preoperative MRCP findings: the visualized group (n = 126), in which the entire gallbladder could be visualized; and the non-visualized group (n = 42), in which the entire gallbladder could not be visualized. The perioperative characteristics and postoperative complica-tions of the two groups were retrospectively analyzed. Operation time was longer in the non-visualized group (median 101.5 vs. 143.5 min; p < 0.001). The non-visualized group had significantly more intraoperative blood loss than the visualized group (median 5 vs. 10 g; p = 0.05). The rate of conversion to open cholecystectomy was significantly higher in the non-visualized group (1.6 vs. 9.5%; p = 0.03). In conclusion, patients in the non- visualized group showed higher difficulty in performance of LC. Our MRCP-based classification is a simple and effective means of predicting difficulties in performing LC for acute cholecystitis.

Application of Embedding Hepaticojejunostomy in Children with Pancreaticobiliary Maljunction Without Biliary Dilatation.

Background: To investigate the effect of embedded hepaticojejunostomy in children with pancreaticobiliary maljunction (PBM) without biliary dilatation. Materials and Methods: The clinical data of 10 patients with nondilated PBM from February 2017 to July 2020 were retrospectively analyzed. Perioperative liver function indexes were compared. Results: All patients were diagnosed by magnetic resonance cholangiopancreatography (MRCP) combined with intraoperative cholangiography. There were 5 cases of Komi type I and 5 cases of type II; the diameter of the common bile duct was 4-9 mm (median: 6 mm); and the length of the common channel was 5-15 mm (median: 9.25 mm). The procedure for one patient with common duct stones was converted to open surgery. Laparoscopic cholecystectomy, common bile duct resection, and embedded hepaticojejunostomy were successfully performed in all 10 cases. The average operation time was 225 ± 96.64 min, and the intraoperative blood loss was 2-5 mL. The mean time to oral intake was 3.5 ± 1.65 days (range: 2-5 days), and the mean hospitalization duration was 6.2 ± 2.44 days (range: 5-8 days). The differences in liver function indexes in the perioperative period were statistically significant (P < .05). The patients were followed-up for 13 to 54 months (median: 40 months). All patients grew well and there was no bile duct dilatation, calculus, or cirrhosis on B-ultrasound examinations. Conclusions: The clinical manifestations of nondilated PBM are often concealed, and preoperative MRCP was important for obtaining a diagnosis. Laparoscopic cholecystectomy, common bile duct resection, and embedded hepaticojejunostomy are feasible for treating nondilated PBM.

A Single Centre Experience With Routine Magnetic Resonance Cholangiopancreatography in the Management of Patients With Gall Stone Disease.

Aim: To evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in detection of common bile duct stone (CBDS) in cases of gall stone disease (GSD).Methods: This is a retrospective study with a prospectively maintained database, carried out in 116 patients who underwent laparoscopic cholecystectomy (LC) for GSD, from October 2017 to September 2020. Preoperative MRCP was performed in all cases.Results: MRCP detected CBDS in 23 out of 116 patients (19.8%) including silent CBDS in seven patients (6%). In situations of normal biochemical parameters and USG abdomen, 30.4% unnoticed CBDS out of all 23 CBDS, were discovered by MRCP. The sensitivity and specificity of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) [positive predictive value (PPV): 24%; negative predictive value (NPV): 81.3%], alkaline phosphatase (ALP) (PPV: 63.2%; NPV: 88.7%), serum total bilirubin (PPV: 57.1%; NPV: 88.4%) and CBD diameter (PPV: 61.5%; NPV: 85.4%) were, respectively, 26.1% and 79.6%, 52.2% and 92.5%, 52.2% and 90.3%, and 34.8% and 94.6%. Cystic duct variations found in nine patients (7.75%). There was no bile duct injury (0%) noted in post operative patients.Conclusion: With normal biochemical and USG parameters, MRCP is a valuable non-invasive investigation to detect the overlooked CBDS. After recognising the cystic duct variants, it may be possible to prevent bile duct injury. Before performing a laparoscopic cholecystectomy (LC) in GSD, a routine preoperative MRCP is highly recommended.

Pure laparoscopic living donor hepatectomy for the right posterior segment graft

The right posterior segment (RPS) graft was introduced as an alternative to expand donor pool. The first LDLT case using an RPS graft was reported in 2001, the RPS graft has not been widely used in LDLT because of lack of donors with suitable anatomical variation, technical challenge for safe donor hepatectomy and surgical difficulties in recipient operation. We present the 3 cases of pure laparoscopic donor hepatectomy with RPS graft. For donor evaluation, we performed laboratory test, abdominal ultrasonography and dynamic computed tomography (CT) scan. Graft selection was determined based on volumetric analysis. In 3 cases of RPS graft, the ratio of the remnant liver volume/whole liver volume was less than 0.3 and left lobe graft was small for metabolic demand of recipients. All 3 donors had type 3 portal vein variation. The Graft Recipient Weight Ratio (GRWR) was 0.72, 0.81, and 1.34 in each case. Preoperative magnetic resonance cholangiopancreatography (MRCP) was performed to evaluate bile duct anomaly. In 3 cases, we had no open conversion, intraoperative and postoperative transfusion. Cut surface bile leakage occurred in one case, but bile leakage decreased without procedure or intervention, the donor discharged at postoperative day 9. He had no more complications. Recipients were recovered uneventfully and discharged. To meet the donor's safety and recipient's metabolic demand, graft selection is one of the important factors in LDLT, the RPS graft is an alternative to expand donor pool. However, thorough preoperative evaluation to understand the anatomical variation is necessary even for experienced transplant surgeons.