Residual Gallstones Research Articles

Outcome of surgical treatment for recurrence of biliary stones

Background: Cholelithiasis is one of the most common digestive disease, a chronic recurrent hepatobiliary disease whose pathological bases are impaired cholesterol, bilirubin and bile acid metabolism. Management of recurrent biliary stones is difficult because of the precense of deepseated intrahepatic ductal stones and ductal strictures, which are often multiple. Purpose: The objective of this study is to evaluate the efficacy and safety of surgical treatment for recurrence of biliary stone patients. Patients and Methods: Prospective analyses of the patients of recurrent biliary stones (common bile duct and intrahepatic) at Department of GI Surgery, Hue Univesity of Medicine and Pharmacy Hospital and Department of GI Surgery, Hue Central Hospital from 01/2019 to 06/2022. We evaluated the data according to outcome measures, characteristics and treatment results of recurrent cholelithiasis patients. Results: 52 patients were included into the study, mean age of the patients was 53.6±16.5 years. 44 patients (84.6%) had previous choledocholithotomy and T tube drainage during 24 months. Common bile duct stones were 69.2%, intrahepatic gallstones were 65.4%. Type of surgery included: choledocholithotomy and T tube drainage were 55.8%, left hepatectomy plus drainage were 32.6%. There was no operative mortality. Complication occurred in 13.4% of patients and half the complications involved wound ìnfection. With regard to residual stones after operation by cholangiography, there are 6 patients obviously showed residual gallstones. Follow-up examination during 3-6 months showed 90.1% of patients with good results. Conclusion: Surgical management of recurrent biliary stones (common bile duct and intrahepatic) were safe and effective. Key words: Gallstones, residual gallstones, relapse gallstone.

Laparoscopic completion cholecystectomy for patients with residual gallstone disease: a single-center experience

Background The incidence of residual gallbladder after cholecystectomy procedures may reach 2.5%. That remnant part of the gallbladder may harbor or develop stones, leading to recurrent symptoms. Surgical excision is recommended in such patients. Herein, we describe our experience regarding laparoscopic management of patients with residual gallbladder or cystic duct stump stones. Patients and methods We retrospectively reviewed the data of 24 patients with previous diagnosis, who were managed by laparoscopy in our tertiary-care setting. Relevant preoperative, intraoperative, and postoperative data were collected. Results The time interval since the previous cholecystectomy ranged between 3 and 120 months. Most patients had previously undergone an open cholecystectomy (75%), while the remaining cases were performed through laparoscopy. The laparoscopic assessment revealed residual gallbladder and cystic duct stump stones in 87.5% and 12.5% of cases, respectively. Conversion to the open approach was needed only in two cases (8.3%). Operative time ranged between 60 and 130 min (mean = 108.83), while intraoperative blood loss had a mean value of 111.88 mL (range, 50–150). The duration of hospitalization ranged between 1 and 4 days (median = 1). Postoperative morbidity occurred in eight patients (33.33%). Wound infection, gallbladder bed collection, and pulmonary embolism occurred in 16.7, 16.7, and 4.2% of patients, respectively. No specific risk factors for postoperative morbidity were identified. Conclusion Laparoscopic completion cholecystectomy is considered a safe and effective procedure in experienced hands for managing patients with symptomatic gallbladder residuals .

Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study.

Remnant cystic duct stump calculi are an uncommon but important cause of 'post-cholecystectomy syndrome'. High index of suspicion is needed to diagnose this condition in a symptomatic post-cholecystectomy patient. We present our experience with the surgical management of this condition. This prospective study included 19 patients with residual gallstone disease who underwent completion cholecystectomy between August 2016 and October 2021. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analysed. The study included 14 women and 5 men. The mean age was 42.1 years (range, 14-80 years). The median duration between index surgery and completion cholecystectomy was 36 months (range, 2-178 months) (interquartile range, 105 months). The follow-up duration was 2 months. The initial surgery was open cholecystectomy in 17 and laparoscopic cholecystectomy in 2 patients. All patients with residual stump stone presented with pain, while 10 out of 19 patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 16 cases, whereas 3 patients underwent open surgery. The mean operative time was 80 min (range, 55-140 min), and the mean blood loss was 100 ml (range, 50-160 ml). The mean hospital stay was 3 days (range, 2-10 days). No post-operative mortality or major morbidity was recorded in any of our patients. Laparoscopic excision of the cystic duct stump is feasible and safe even after previous open cholecystectomy. It is increasingly becoming the treatment of choice where expertise is available.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis. Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection. Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

Feasibility of transgastric endoscopic gallbladder-preserving surgery for benign gallbladder diseases (with video)

With the increasing realization of the importance of gallbladder function, choledochoscopic gallbladder-preserving surgery has been advocated for benign gallbladder diseases. However, limited information is available regarding the use of endoscopic gallbladder-preserving surgery (EGPS) for patients with benign gallbladder diseases. The aim of this study was to evaluate the feasibility of EGPS for benign gallbladder diseases. Between June 2020 and January 2021, 22 patients with gallbladder stones and/or gallbladder polyps were treated with EGPS. The main outcome measures included the rate of complications, residual gallbladder stones, and gallbladder stone recurrence. In this study, transgastric EGPS was successfully performed in 22 patients (13 female, 9 male) with benign gallbladder diseases, and included 8 cases of multiple gallstones, 4 cases of gallbladder polyps with gallstones, 6 cases of multiple gallbladder polyps, 2 cases of single gallstone, and 2 case of singe gallbladder polyp. The median time of transgastric EGPS was 118min. During hospitalization, 4 patients suffered localized peritonitis (4/22, 18.2%), and these patients successfully recovered after conservative medical treatment. None of the patients experienced massive bleeding, delayed bleeding, diffuse peritonitis, or any other serious complications. During the median follow-up of 4months, 1 patient suffered residual gallstone, while no gallstone recurrence or deaths related to transgastric EGPS occurred in any patients. Transgastric EGPS appears to be a feasible treatment method in selected patients with benign gallbladder diseases. However, as it is a new technique, further studies are needed to explore the long-term effectiveness of transgastric EGPS.

The second 'gallbladder operation'.

Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

The comparison of different drip cholangiography: a randomised trial.

This study investigated the advantages and disadvantages of contrast media administration by gravity drip and manual push injection during cholangiography. A total of 100 patients who presented to the Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, for a cholangiography between June 2019 to June 2020 were enrolled in this study. Patients were randomly divided into 2 treatment groups. One group of patients with manual injection of contrast (the N group, n=50), received the contrast agent via the traditional manual injection method whereby the doctor injects 50 mL of prepared contrast agent into the right side of the patient while continuously observing the effects on the bile duct. The other group of patients with gravity drip administration of contrast media (the O group, n=50), received the contrast agent via gravity drip at a rate of 80 drops per minute, and both clinicians and radiologists monitored the entire cholangiography process from a safe distance. Patients were followed up and angiographic satisfaction was assessed after two weeks. All 100 patients completed cholangiography without allergic reaction to the contrast medium. In the traditional injection group (N group), nine patients experienced upper abdominal discomfort with nausea, abdominal pain, chills, high fever, and other symptoms, and residual gallstones were observed in 12 patients. In patients in the gravity drip group (O group), four patients felt upper abdominal discomfort accompanied by nausea, abdominal pain, chills, high fever, and other symptoms, with residual gallstones detected in six patients. Patients who underwent gravity drip cholangiography had significantly reduced adverse reactions compared to patients who underwent traditional manual infusion cholangiography. Furthermore, gravity drip cholangiography resulted in clearer images and reduced X-ray exposure for medical staff. Thus, increased implementation of gravity drip cholangiography in the clinical setting should be considered. Chinese Clinical Trial Registry ChiCTR1800018202.

S2515 Where Did You Come From, Where Did You Go? A Tall Tale of Bouveret’s Travels

Introduction: Bouveret syndrome (BS) refers to a gastric outlet obstruction (GOO) secondary to an impacted gallstone in the pylorus or proximal duodenum. Our case describes BS with migrated gallstone to the distal jejunum causing a small bowel obstruction (SBO) successfully treated with prompt interventional endoscopic (IE) intervention. Case Description/Methods: 86-year-old male presented with nausea, vomiting, and hiccups for the past 3weeks. CT revealed dilated stomach, possible GOO. Urgent endoscopy revealed dilated stomach, 1 large completely obstructing, non-bleeding cratered duodenal ulcer, and large impacted gallstone at the distal duodenal bulb. IE consultation prompted repeat EGD 3 days later showed 1cm fistula in the duodenal bulb to the gallbladder remnant, no evidence of residual gallstone in the bulb, second and third portion of duodenum were normal. CT showed SBO with a transition point in left hemiabdomen. Subsequent double-balloon enteroscopy identified 4cm gallstone in distal jejunum causing SBO. Electrohydraulic lithotripsy successfully fragmented the stone (Figure 1). Patient advanced diet and fully recovered. Discussion: Bouveret's syndrome, described in 1770, represents 2–3% of all gallstone-related GOO and 1–4% of all SBOs. Morbidity and mortality rates, about 60% and 30% respectively, are reported in cases where a patient is a nonsurgical candidate due to comorbidities. Large stones typically require surgical intervention and have high mortality (12-27%). Our case describes treatment success with IE.Figure 1.: First EGD: A, severe LA Grade D esophagitis, B-H shows large completely obstructing, non-bleeding cratered duodenal ulcer 30mm, and large gallstone impacted at the distal end of duodenal bulb. Second EGD: I-K Duodenal Fistula, L-N Fistulous connection to Gallbladder Double Balloon Enteroscopy: O, Large impacted gallstone in distal jejunum. P-U electrohydraulic lithotrpsy performed on impacted gallstone, U-V Clearance of broken particles with aggressive flushing, W-Y Fluoroscopic images showing radiolucent defect, Z Resolution of defect on fluoroscopy.

The postoperative choledochoscopy in the management of the residual hepatolithiasis involving the caudate lobe: A retrospective study.

To reveal the role of the postoperative choledochoscopy in treating the residual calculi in the caudate lobe (CL) of the liver.We recruited 66 patients with T-tube/percutaneous transhepatic cholangioscopy tract who still had residual gallstones in the CL at least 6 weeks after the operation. Imaging examinations determined the gallstones’ locations in the patients, and all of them underwent the postoperative choledochoscopic examination through the T-tube/percutaneous transhepatic cholangioscopy tract for therapeutic intervention.Among the 66 patients, the residual gallstones were mostly located in the Spiegel lobe (48/66, 72.7%), and the residual gallstones that located in the origin of the CL bile branches were successfully determined in the 57 patients (57/66, 86.4%), the remaining 9 patients were unclear because the proximal ducts were severely narrow or even atresia. The mean frequency of the postoperative choledochoscopy was 3.6 (range, 1–10) times. There were 9 patients with complications, and no mortality occurred. In the origin-proved 57 patients, 6 patients failed to remove the gallstones altogether, and the final residual gallstone clearance rate was 77.3% (51/66). There was no significant difference between the Spiegel lobe and the other parts of the CL in determining the bile duct's origins, gallstone clearance rate, and complications. However, the frequency of choledochoscopy in the other parts of the CL was more than in the Spiegel lobe.The postoperative choledochoscopy, an essential method for treating the residual gallstones in the CL, commands high efficiency for calculi extraction and fewer complications. The main reasons for failing to remove the residual gallstones are that the bile duct's origins could not be determined, and the distal bile ducts are atretic in the CL.

Percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract.

PurposeIn the present study, the effectiveness and safety of minimally invasive percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract were assessed.Material and methodsBetween 2000 and 2015, 12 patients (seven women and five men, mean age 78 ± 8 years) after open cholecystectomy with common bile duct exploration and T-tube drainage underwent percutaneous extraction of residual gallstones through the T-tube tract.ResultsThe intervention was successful in 92% (11/12). In seven patients complete extraction of the retained gallstones was achieved, and in four cases partial extraction combined with passage of small residual fragments to the duodenum was obtained. In one case the extraction attempt was ineffective. Mild haemobilia was observed in two patients. No mortality or major complications were observed.ConclusionsOur findings are consistent with literature data and confirm that percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract is an effective and safe treatment method. Although the presented technique is not a novel approach, it can be beneficial in patients unsuitable for open surgery or laparoscopic intervention when ERCP attempt occurs ineffective or there exist contraindications to ERCP.

Feasibility of per-oral cholecystoscopy and advanced gallbladder interventions after EUS-guided gallbladder stenting (with video)

The recent development of EUS-guided gallbladder drainage (EGBD) with a lumen-apposing stent has made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of per-oral cholecystoscopy and the types of gallbladder interventions that can be performed. This was a retrospective review conducted in the Prince of Wales Hospital from June 2012 to March 2016. All patients who had acute cholecystitis with EGBD were included. Cholecystoscopy was performed 1 to 3 months after stent insertion. Patients' demographic data, technical success, types of intervention, and adverse events were recorded. Twenty-nine cholecystoscopies were performed in 25 patients. Twenty-seven of 29 cholecystoscopies were successful (93.1%). Magnifying endoscopy was performed in 10 patients, confocal endomicroscopy and EUS in 1 patient, and endocytoscopy in another patient. Fourteen patients (56%) had spontaneous stone passage. Eleven patients (44%) had residual gallstones on cholecystoscopy, and removed in 8. Overall stone clearance rate was 88% after a mean (standard deviation) number of 1.25 (0.46) sessions of cholecystoscopy. Per-oral cholecystoscopy and advanced gallbladder interventions were feasible and safe. This opens up exciting possibilities for endoscopic treatment of gallbladder pathologies.

Laparoscopic Nephrotomy to Removal of Staghorn Calculus in a Canine

Background: Renal urolithiasis is the third most common disease of the urinary tract of dogs. In humans, staghorn lithiasis affects 1 to 1.5% of the population, often women over 50 years old. In veterinary medicine, this type of lithiasis has been little reported, and there are few descriptions of treatment, both in small and large animals. The objective of this work is to report a rare case of renal staghorn stones treated by laparoscopic nephrotomy.Case: A six-year-old female schnauzer with 6 kg body weight was evaluated clinically in order to spay. According to the owner, the animal showed polydipsia. Additional tests such as blood count, serum biochemistry, radiography and abdominal ultrasound were done, showing hematological examinations within the standards for the species. After the ultrasound we noticed an asymmetric kidneys with the right kidney with preserved cortical layer and hyperechoic line corticomedullary interface, with posterior acoustic shadow and left kidney with relative/corticomedullary differentiation and pelvis preserved without alteration; this evocative image of kidney stones in kidney right. In abdominal radiographs was possible to visualize radiopaque mass in the right kidney compatible with renal staghorn stones. Excretory urography was done, which demonstrated evident excretion of contrast material in the left kidney and the right kidney doubtful. Based on these findings, we opted for exploratory laparoscopy followed by laparoscopic nephrectomy or nephrotomy for removal of urolithiasis, depending of the lesions visualized during the procedure. All procedure were performed using a minimally invasive approach without the need for conversion to open or videoassisted procedures. The most complex and delicate step was the nephrorrafy, due the little time for suturing to avoid renal ischemia. Eight months after the surgery, the owner is contacted, and it said that the animal was well, without clinical signs of kidney disease. After returning and performing ultrasound and excretory urography revealed that the right kidney had atrophied, but there was still draining contrast shown by excretory urography.Discussion: Although the use of laparoscopy is increasing worldwide is still considered an underexplored approach to renal calculi in veterinary medicine. Our choice in this case was due the numerous potential advantages that have minimally invasive compared to open technique, as demonstrated in medicine and veterinary medicine studies. At the beginning of laparoscopy was possible to elect the procedure (nephrectomy or nephrotomy) to be performed; the anatomic changes presente as renal artery patency /coloring kidney and wrist, observed by laparoscopic visualization, with amplification, showed the possibly of renal preservation. This is an advantage associated with videosurgical access. Laparoscopic view allowed to discard residual gallstones as well as to promote the correct synthesis of renal tissue. All steps of the nephrotomy were performed by minimally invasive access. It was not possible to directly correlate with the histological analysis technique renal disorder before and after the surgery, because the kidney was already reduced in size in the first operation and biopsy was not done in that occasion. The present report demonstrates that laparoscopic surgery can be considered viable for the management of renal staghorn stones in dogs.Keywords: surgery, nephrolity, canine.

Diagnosis and analysis of residual gallbladder stone with choledocholithiasis

Objective To investigate the diagnosis/misdiagnosis reason/treatment of residual gallbladder stone with choledocholithiasis. Methods The clinical data of 34 patients with residual gallbladder, 16 cases of them suffered from choledocholithiasis additionally were retrospective analyzed. Results 14 cases were treated by residual cholecystectomy + choledochotomy + T-tube drainage, 2 cases were were treated by choledochotomy + T-tube drainage.Preoperative misdiagnosis of residual gallstones rate was 56.3%(9/16), 7 cases were found residual gallstones during operation.The other 2 cases were misdiagnosed residual gallstones.The rate of intraoperative and postoperative misdiagnosis was 12.5%(2/16).18 cases with residual gallstones, 16 cases underwent residual cholecystectomy, 2 cases who were suspected with choledocholithiasis underwent residual cholecystectomy + choledochotomy, T-tube drainage.18 cases had no preoperative and postoperative misdiagnosis. Conclusion The clinical symptom of residual gallbladder stone with choledocholithiasis was similar to residual gallstones, often characterized by upper abdominal pain, fever, chills, jaundice, abdominal distension and other symptoms.It is difficult for preoperative imageological diagnosis that less than 3 cm residual gallbladder and small stones.When choledocholithiasis at the same time, needing more intraoperative careful dissect cystic duct and common bile duct, completes the cystic duct and common bile duct exploration, reducing misdiagnose residual gallstones. Key words: Gall stone; Choledocholithiasis; Diagnosis; Treatment

Residual gallbladder stones after cholecystectomy: A literature review.

BACKGROUND:Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy.MATERIALS AND METHODS:Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up.RESULTS:Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct.CONCLUSION:Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.

Outcome evaluation of 10,317 laparoscopic cholecystectomies: a 17-year experience at a single center.

This study is an analysis of the large series of laparoscopic cholecystectomies and compare our results with those reported in the literature concerning complications. From December 1993 to September 2010, 10,317 patients with gallstone disease underwent laparoscopic cholecystectomy. Previously operated patients were also included in the study. We analyzed the successfulness of the results, intraoperative and postoperative complications, conversions in open cholecystectomy, mortality and reoperation rate. We registered 23.28% complications. Intraoperative complications were bleeding in 9.84%, gallbladder perforation in 8.63%, stone loss in 1.37%, common bile duct injury in 0.24% and injury of intraabdominal organs in 0.07% of cases. Postoperative complications were bleeding in 1.12%, wound infection in 0.59%, bile leakage in 0.5%, incisional umbilical hernias in 0.37%, subhepatal collection in 0.33%, residual gallstones in choledocus in 0.09%, urine retention in 0.08% and biliary peritonitis in 0.01% of patients. Conversion to open cholecystectomy was necessary in 2.13%. Reoperation was performed in 0.27%. The mortality rate was 0.019%. Our results on large number of patients are similar to other series in the newer literature but the rate of complications should be decreased. The incidence of complications decreases with growing laparoscopic experience.

Disease spectrum and use of cholecystolithotomy in gallstone ileus

Gallstone ileus is a heterogeneous and highly morbid condition that suffers from a lack of consensus regarding the timing and approach to management of the biliary tree and associated fistula. We report three cases that demonstrate the spectrum of gallstone ileus with classical examples of both Barnard's and Bouveret's syndromes. Clinical presentation, diagnostic imaging, surgical technique and outcome are discussed. One patient with Barnard's syndrome presented with recurrent gallstone ileus. To minimize the risks of complex, definitive biliary surgery and avoid further recurrent episodes, a cholecystolithotomy was performed with effect. Two cases of Bouveret's syndrome were successfully managed with enterolithotomy/cholecystectomy and multivisceral resection respectively, thus highlighting the diverse nature of this disease and management options. Following enterolithotomy, potentially morbid, definitive one-stage surgery in typically compromised, elderly patients needs to be weighed against the risk of recurrence and ongoing biliary pathology. We suggest the use of open cholecystolithotomy for the removal of residual gallstones when the patient is not suitable for definitive biliary surgery.

Recurrent Gallstone Ileus

Mechanical small bowel obstructions caused by gallstones account for 1% to 3% of cases. In these patients, 80% to 90% of residual gallstones in these patients will pass through a remaining fistula without consequence. Recurrent gallstone ileus has been reported in 5% of patients. We report the case of a woman, aged 72 years, who presented with mechanical small bowel obstruction caused by gallstone ileus. After successful surgical therapy for gallstone ileus, the patient's symptoms recurred, and she was diagnosed with recurrent gallstone ileus requiring a repeat operation. While management of gallstone ileus can be achieved through a single-stage operation including enterolithotomy and cholecystectomy with repair of biliary-enteric fistula or by enterolithotomy alone, the literature supports enterolithotomy alone as the treatment of choice for gallstone ileus due to decreased mortality and morbidity. However, the latter approach does not obviate potential recurrence. We present this case of recurrent gallstone ileus to elucidate and review the pathogenesis, presentation, diagnosis, and consensus recommendations regarding management of this disorder.

Lithiase biliaire du nourrisson, de l’enfant et de l’adolescent

The prevalence of cholelithiasis is estimated within 0.13% and 2% of children under 19 years of age. Pigment stones are the commonest type of gallstones in children, without recognizable predisposing factors in infants or secondary to a predisposing disease such as chronic hemolysis and ileal disease in children. In adolescents, idiopathic cholesterol gallstones accounts for the majority, such as in adults. Gallbladder stones are found in 80 to 90% of cases and common bile duct stones in 10 to 20% of cases. When common bile duct stones are found, a choledocal cyst with anomalous pancreatobiliary duct junction needs to be excluded. Magnetic resonance cholangiopancreatography should be performed in first line. Cholecystectomy is not indicated for silent gallstones, except in children with a predisposing disease such as chronic hemolysis. Treatment of common bile duct stones includes interventional radiologic, endoscopic or surgical procedures. Stone extraction may be performed at endoscopic retrograde cholangiopancreatography with or without sphincterotomy, combined with laparoscopic cholecystectomy. In children without a predisposing disease or no residual gallstones indicating a cholescystectomy, conservative management (percutaneous cholangiography with biliary drainage) may be proposed in specialised centers, especially for infants. A hepaticojejunostomy is indicated in cases of choledocal cyst with anomalous pancreatobiliary duct junctions.

Residual gallstone disease - Laparoscopic management.

A few patients who continue to suffer antecedent symptoms following laparoscopic cholecystectomy (LC) may harbor residual gallstones. The incidence of residual gallstones following cholecystectomy is <2.5%. Many of these patients require a completion cholecystectomy to ameliorate their symptoms. We reviewed our experience of laparoscopic re-intervention for residual gallstones over a period of 10 years from January 1998 to December 2007. Twenty six patients underwent Laparoscopic completion cholecystectomy (LCC) for residual gallstone disease. Twelve patients had a previous LC (2 patients - subtotal cholecystectomy) and 9 patients had a previous open cholecystectomy (7 patients - subtotal cholecystectomy). Five patients had previously undergone a cholecystostomy. Diagnostic investigations included abdominal ultrasound, endoscopic ultrasound (EUS), magnetic resonance cholangio-pancreatography (MRCP) and endoscopic retrograde cholangio-pancreatography (ERCP). Findings included a remnant gallbladder in 3 patients, long cystic duct stump with impacted stone in 18 patients and a contracted gallbladder in 5 patients. All procedures were successfully completed laparoscopically. The mean operative time was 62 minutes and mean blood loss 50cc. Ten patient required abdominal drains postoperatively. Two patients had bilious drainage lasting 9 days and 11 days respectively. One patient died a week following surgery of acute myocardial infarction. Another patient died 6 months later of unrelated causes. The remaining patients have remained symptom free at a mean follow up of 3.2 years (range 7 months to 9 years). The possibility of residual gallstones increases with subtotal cholecystectomy and inadequate dissection of the Calot's triangle in the presence of acute inflammation. Laparoscopic re-intervention for treating residual gallstone disease is feasible and can be safely performed in centers of expertise.

Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy?

We investigated routinely the bile ducts by magnetic resonance cholangiopancreaticography (MRCP) prior to cholecystectomy. The aim of this study was to analyze the rate of clinically inapparent common bile duct (CBD) stones, the predictive value of elevated liver enzymes for CBD stones, and the influence of the radiological results on the perioperative management. In this prospective study, 465 patients were cholecystectomized within 18 months, mainly laparoscopically. Preoperative MRCP was performed in 454 patients. With MRCP screening, clinically silent CBD stones were found in 4%. Elevated liver enzymes have only a poor predictive value for the presence of CBD stones (positive predictive value, 21%; negative predictive value, 96%). Compared to the recent literature, the postoperative morbidity in this study was low (0 bile duct injury, 0.4% residual gallstones). Although MRCP is diagnostically useful in the perioperative management in some cases, its routine use in the DRG-era may not be justified due to the costs.