T-tube Cholangiography Research Articles

Diagnostic value of T-tube cholangiography and choledochoscopy in residual calculi after biliary surgery

BackgroundT-tube cholangiography and choledochoscopy are commonly used techniques for detecting residual bile duct stones after biliary surgery. However, the utility of routine cholangiography before T-tube removal needs further investigation. This study aims to evaluate the diagnostic efficacy of various methods for detecting residual calculi following biliary surgery.MethodsWe retrospectively analyzed the clinical data of 287 adult patients who underwent common bile duct exploration with T-tube drainage, followed by T-tube cholangiography and choledochoscopy, at the Department of General Surgery, Xuanwu Hospital, Capital Medical University, between 2017 and 2022. Exclusion criteria were patients with bile duct tumors, incomplete medical records or loss to follow-up, and patients with contraindications to T-tube or choledochoscopy. McNemanr test and Kappa test were used to compare the results and consistency between choledochoscopy and T-tube cholangiography. All patients underwent both cholangiography and choledochoscopy six to eight weeks after laparoscopic cholecystectomy combined with common bile duct exploration and T-tube drainage. The results of T-tube cholangiography and choledochoscopy for each patient were recorded, analyzed, and compared.ResultsAmong the 287 patients, T-tube cholangiography detected residual stones in 38 cases, which were confirmed by choledochoscopy in 29 cases. Conversely, of the 249 patients without evidence of residual stones on T-tube angiography, 11 patient was later found to have retained stones through choledochoscopy. There was no significant difference between the results of T-tube cholangiography and choledochoscopy (P = 0.82), indicating a high level of agreement between the two methods (Kappa value: 0.70) (95% CI, 0.65–0.76).ConclusionThere is no significant difference in the diagnostic accuracy between T-tube cholangiography and choledochoscopy for detecting residual bile duct stones after surgery (P = 0.82). The two methods demonstrated a high level of consistency (Kappa value: 0.70) (95% CI, 0.65–0.76). The choice of diagnostic method for postoperative residual bile duct stones should be based on the specific condition of the patient.

Anatomical Variation of the Cystic Duct: A Case Report

During a cholecystectomy, cystic duct anatomical variation mostly transpires might experience. Understanding the complex anatomy of the cystic duct and cholecystitis junction is crucial before undergoing biliary surgery to prevent severe ductal damage. This article highlights two unusual cases of irregular cystic duct, i.e., cystic duct narrow-wide and low lateral insertion. The first case was of a 66-year-old male patient having chronic cholecystitis and cholelithiasis. The aberrant cystic duct entry was thought to be rapid and heading into the correct hepatic duct during surgery. Multiple calculi were discovered after more investigation of the common and proper hepatic ducts. Following the completion of the cholecystectomy, the standard and right hepatic ducts were drained using T-tubes. The two T-tubes were found in the cystic and common hepatic ducts, respectively, according to postoperative T-tube cholangiography. The distal choledochus residual stones were removed six weeks later by cholangioscopy through the T-tube's sinus tract. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the second case of a 44-year-old woman exposed to a lengthy cystic duct with a small and bent-in lumen. The cholecystectomy was done openly on the patient. Both of the patients recovered. The approach described by the authors for identifying structural changes in the cystic duct is preoperative or MRCP or ERCP, as well as intraoperative cholangiography or cholangioscopy.

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.

Surgical strategies for Mirizzi syndrome: A ten-year single center experience.

BACKGROUNDMirizzi syndrome (MS) remains a challenging biliary disease, and its low rate of preoperative diagnosis should be resolved. Moreover, technological advances have not resulted in decisive improvements in the surgical treatment of MS. Complex bile duct lesions due to MS make surgery difficult, especially when the laparoscopic approach is adopted. The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.AIMTo analyze preoperative diagnostic methods and the safety, effectiveness, prognosis and related factors of surgical strategies for different types of MS.METHODSThe clinical data of MS patients who received surgical treatment from January 1, 2010 to December 31, 2020 were retrospectively reviewed. Patients with malignancies, choledochojejunal fistula, lack of data and lost to follow-up were excluded. According to preoperative imaging examination records and documented intraoperative findings, the clinical types of MS were determined using the Csendes classification. The safety, effectiveness and long-term prognosis of surgical treatment in different types of MS, and their interactions with the clinical characteristics of patients were summarized.RESULTSSixty-six patients with MS were included (34 males and 32 females). Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) showed specific imaging features of MS in 58 cases (87.9%), which was superior to ultrasound scan (USS) in the diagnosis of MS and more sensitive to subtle biliary lesions than USS. The overall laparoscopic surgery completion rate was 53.03% (35/66), where the completion rates of MS type I, II and III were 69.05% (29/42), 42.86% (6/14) and zero (0/10), respectively. Thirty-one patients (46.97%) underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients, and 25 of these patients underwent bile duct exploration, repair and T-tube drainage. In addition, 25 patients underwent intraoperative choledochoscopy and T-tube cholangiography. Overall, 21 cases (31.8%) were repaired by simple suturing, and 14 cases (21.2%) were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy. The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time, bleeding volume and cost. Gender, acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach. Age had no effect on the classification of MS, but it influenced the final surgical approach, hospital stay and cost. A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications, and no mortality was observed during the follow-up period of 36.5 ± 26.5 mo (range 13-76, median 22 mo).CONCLUSIONMRI/MRCP can improve the preoperative diagnosis of MS. The Csendes classification can reflect the difficulty of treatment. The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

Fluoroscopic Evaluation of the Bile Ducts: Anatomic Variants, Benign and Malignant Pathologies and Bile Leaks: Part I

Direct cholangiography (DC) includes endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), T-tube cholangiography (TTC), and percutaneous transhepatic cholangiography (PTC). Radiologists need to understand how each technique is performed and how to interpret each study. In many institutions, radiologists do not interpret ERCPs. Currently, common duct explorations are rarely performed; therefore, radiologists are not interpreting TTCs as frequently as they did in the past. In addition, many institutions are using alternative techniques to replace IOC. Therefore, our radiology residents are not being trained to perform and interpret DC. This presentation describes the important aspects of the performance and interpretation of DC.

Fluoroscopic Cholangiography: Anatomy, Pathology, and Intervention

Direct intraoperative cholangiography, endoscopic retrograde cholangiopancreatography, T-tube cholangiography, and percutaneous transhepatic cholangiography are routine procedures performed by interventionalists. Radiologists must understand how to interpret direct cholangiography to facilitate multidisciplinary communication, correlate findings with magnetic resonance cholangiopancreatography, and improve patient care.

Diagnosis and treatment of biliary pancreatic duct dilatation

Diagnosis and treatment of biliary pancreatic duct dilatation

A Novel Remote-Controlled Injection Device for T-Tube Cholangiography: A Feasibility Study in Canines.

BackgrounThe purpose of this study was to develop a remote-controlled injection device for T-tube cholangiography to avoid occupational exposure.Material/MethodsThe remote-controlled injection device has 3 major components: an injection pump, a pressure sensor, and a wireless remote-control panel. The feasibility and effectiveness of this device for T-tube cholangiography was evaluated in ex vivo porcine livers using a laparoscopic training platform and in in vivo canine experiments.ResultsThe contrast dye was successfully injected into the biliary tracts of the ex vivo porcine liver and canines by the designed device. The X-ray images clearly showed the anatomical structure of the bile ducts. No obvious adverse reaction was observed in the dogs during or after the procedure. All steps were controlled remotely, avoiding ionizing radiation exposure to the surgeons.ConclusionsThis novel remote-controlled injection device for T-tube cholangiography can assist operators in completing cholangiography remotely and protecting them from occupational exposure.

Application value of choledochoscopy and imaging examination in the diagnosis and treatment of residual bile duct stones

Objective To investigate the application value of choledochoscopy and imaging examination in the diagnosis and treatment of residual bile duct stones. Methods The retrospective descriptive study was conducted. The clinical data of 618 patients who underwent choledochoscopy and imaging examination after operation of hepatolithiasis in the First Affiliated Hospital of Zhengzhou University between April 2014 and September 2018 were collected, including 300 males and 318 females, aged from 19 to 89 years, with an average age of (58±12)years. Observation indicators: (1) situations of residual bile duct stones diagnosed by choledochoscopy and imaging examination; (2) stone extraction situations of patients with hepatolithiasis. Measurement data with normal distribution were represented as Mean±SD, and measurement data with skewed distribution were described as M (range). Count data were represented as absolute number or percentage, and analyzed using the chi-square test or Fisher exact propability. Results (1) Situations of residual bile duct stones diagnosed by choledochoscopy and imaging examination: all the 618 patients underwent choledochoscopy, and 505 of them underwent the imaging examination before choledochoscopy. ① Of patients undergoing single imaging examination, 72 received ultrasonography, with false-negative rate of 29.17%(21/72); 37 received CT examination, with false-negative rate of 10.81%(4/37); 33 received T-tube cholangiography, with false-negative rate of 39.39%(13/33). ② Of patients undergoing combined two imaging examinations, 61 received ultrasonography+ CT, with false-negative rate of 8.20%(5/61); 129 received ultrasonography+ T-tube cholangiography, with false-negative rate of 12.40%(16/129); 52 received CT+ T-tube cholangiography, with false-negative rate of 5.77%(3/52). ③ There were 121 receiving ultrasound+ CT+ T-tube cholangiography, with false-negative rate of 7.44% (9/121). There were statistically significant differences in the false-negative rates of combined two or three examinations of ultrasound+ CT+ T-tube cholangiography and single imaging examination (χ2=40.83, P 0.05). There were statistically significant differences in the combined three examinations of ultrasound+ CT+ T-tube cholangiography and ultrasound and T-tube cholangiography examination respectively (χ2=16.23, 21.62, P 0.05). There was no statistically significant difference in the combined three of imaging examinations and combination of ultrasound+ CT examinations and combination of ultrasound+ T-tube cholangiography (χ2=0.33, 1.71, P>0.05). Seventy-one patients without residual bile duct stone by preoperative imaging examination were detected residual bile duct stones by intraoperative choledochoscopy, and residual bile duct stones of 36, 31 and 4 patients are respectively distributed around the distal common bile duct, small intrahepatic bile duct, left and right hepatic ducts, common hepatic duct and remaining common bile duct. (2) Stone extraction situations of patients with hepatolithiasis: of 618 patients, cases with 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 times of residual bile duct stones clearance were respectively 392, 116, 48, 39, 9, 6, 3, 2, 2 and 1. Residual bile duct stones clearance frequency of patients was an average of 1.73 times. There were 63.43%(392/618) and 96.28%(595/618) of patients had stone clearance with once and ≤ 4 times of stone extraction, respectively. Conclusion The negative results of preoperative imaging examinations cannot be as standards of bile duct stone clearance before choledochoscopy, and the best choice is to detect whether there are residual bile duct stones and remove the stones combined with choledochoscopy. Key words: Hepatolithiasis; Residual stones; Choledochoscopy; Preoperative examinations

Trans-T-tube Biliary Drainage; an Alternative Treatment Option for Intractable Postoperative Biliary Fistula after Choledochotomy

Introduction: Persistent biliary fistula after biliary operation is not common, but sometimes it is very difficult problem, especially in case of friable common bile duct (CBD). Herein, we report a case of intractable postoperative biliary leakage treated with trans-T-tube biliary drainage (TTBD). Method: A 65-years-old man visited because of CBD stone and multiple left intrahepatic bile duct (IHBD) stones. After the left hemihepatectomy and choledocholithotomy, primary closure of CBD was performed because there was endoscopic retrograde biliary drainage (ERBD) catheter inserted already. On postoperative day 7, covered stent insertion in right hepatic artery was performed due to bleeding from hepatic artery branch. On the 5th day after the intervention, bile leakage was observed from drain and re-operation was performed. There was necrosis of CBD wall around choledochotomy site and debridement and T-tube insertion was performed. Persistent bile leakage was observed with average amount of 500ml/day even though well-functioning T-tube until 30 days after re-operation. And two times of ERBD tries were failed. T-tube cholangiography revealed bile leakage from CBD more proximal portion to T-tube insertion site. A drainage catheter through T-tube was inserted with positioning the catheter tip in right IHBD. Result: Two days after the procedure of TTBD, the amount of bile from drain was dramatically decreased and the drain was removed after 6 days after TTBD. Four weeks after the TTBD, T-tube and TTBD catheter were removed without any problem. Conclusion: For intractable persistent biliary fistula after choledochotomy, TTBD could be considered for useful alternative treatment option.

Trans-T-tube biliary drainage; an alternative treatment option for intractable postoperative biliary fistula after choledochotomy

Introduction: Persistent biliary fistula after biliary operation is not common, but sometimes it is very difficult problem, especially in case of friable common bile duct (CBD). Herein, we report a case of intractable postoperative biliary leakage treated with trans-T-tube biliary drainage (TTBD). Methods: A 65-years-old man visited because of CBD stone and multiple left intrahepatic bile duct (IHBD) stones. After the left hemihepatectomy and choledocholithotomy, primary closure of CBD was performed because there was endoscopic retrograde biliary drainage (ERBD) catheter inserted already. On postoperative day 7, covered stent insertion in right hepatic artery was performed due to bleeding from hepatic artery branch. On the 5th day after the intervention, bile leakage was observed from drain and re-operation was performed. There was necrosis of CBD wall around choledochotomy site and debridement and T-tube insertion was performed. Persistent bile leakage was observed with average amount of 500ml/day even though well-functioning T-tube until 30 days after re-operation. And two times of ERBD tries were failed. T-tube cholangiography revealed bile leakage from CBD more proximal portion to T-tube insertion site. A drainage catheter through T-tube was inserted with positioning the catheter tip in right IHBD. Results: Two days after the procedure of TTBD, the amount of bile from drain was dramatically decreased and the drain was removed after 6 days after TTBD. Four weeks after the TTBD, T-tube and TTBD catheter were removed without any problem. Conclusion: For intractable persistent biliary fistula after choledochotomy, TTBD could be considered for useful alternative treatment option.

Development of Biliary Contrast Agents Remote Pushing Device

A biliary contrast agents pushing device, including a syringe pushing system and a remote controller is introduced. The syringe pushing system comprises an injector card slot, a support platform and an injection bolus fader. A 20 mL syringe can be fitted on the syringe pushing system and kept with the ground about 30 degree. This system can perform air bubble pumping back and contrast agents bolus injection as well as speed adjustment. Remote controller is an infrared remote control which can start and stop the syringe pushing system. With this device, the remote controlled cholangiography technology can be achieved, which can not only protect doctors from X-ray radiation but also improve the traditional T-tube cholangiography and the contrast effect, reduce postoperative complications in patients as well. The application of this device will improve the current diagnosis and treatment system, the device will benefit the majority of doctors and patients.

Application value of percutaneous sinus-tract cholangioscopy in the diagnosis and treatment of residual intra- and extra-hepatic bile duct stones: a report of 1 045 cases

Objective To investigate the application value of percutaneous sinus-tract cholangioscopy in the diagnosis and treatment of residual intra- and extra-hepatic bile duct stones. Methods The retrospective cross-sectional study was conducted. The clinical data of 1 045 patients with intra- and extra- hepatic bile duct stones who underwent percutaneous sinus-tract cholangioscopy or stone extraction in the Second Affiliated Hospital of Zhejiang University from January 2003 to June 2016 were collected. Patients received percutaneous sinus-tract cholangioscopy or stone extraction at 6-8 weeks after T tube drainage. Observation indicators: (1) diagnosis and stone extraction situstions: cases with residual stones, stone extraction frequency and clearance rate; the critics of clearance rate are no residual stone during operation combined with B ultrasound or T-tube cholangiography; (2) postoperative complications: incidence and management of postoperative complications, prognosis and Clavien-Dindo classification for postoperative complication; (3) follow-up situation. T-tube was removed when there was no residual stone. Patients were followed up by outpatient examination up to April 2017. B ultrasound reexamination was performed to detect the recurrence of stone once every 3-6 months. Results (1) Diagnosis and stone extraction situstions: among 1 045 patients, results of cholangioscopy showed 147 wihout bile duct stones and 898 with bile duct stones.Of 898 patients, 2 618 times cholangioscopic explorations for stone extraction were performed, with a maximum frequency of 16 times, and 851 had stones clearance, with a overall clearance rate of 94.77%(851/898). The clearance rates of extra- and intra- hepatic bile duct stones were 100.00%(221/221) and 93.06%(630/677). Of 47 patients with residual stones, 16 didn′t receive cholangioscopy due to branches stricture or occlusion of intrahepatic duct, 13 failed to take out stone due to T-tube dislodgement (9 cases) and improper placement (4 cases) induced closed T-tube sinus tract, 7 had T-tube sinus tract duodenal fistula, 6 gave up stone extraction, 3 was due to longer sinus tract induced bending and 2 was due to T-tube sinus tract fracture. (2) Postoperative complications: among 1 045 patients, 297 had level Ⅰ-Ⅱ mild complications and 13 had level Ⅲ and above severe complications. The common complications included fever, vomiting, diarrhea and so on; the special complications included T-tube sinus tract duodenal fistula of 13 patients, T-tube sinus tract fracture of 4 patients, rupture of broken stones pole of 3 patients, massive hemobilia of 2 patients, acute pancreatitis of 2 patients and cardiac arrest of 1 patient. The above complications were improved by symptomatic and supportive treatments. (3) Follow-up situation: among 1 045 patients, 558 received long-term follow-up, with follow-up time of 10-171 months and a median time of 79 months. Eight-four patients had stone recurrence. Of 13 patients with recurrence of extrahepatic bile duct stones, 7 took out stones by endoscopic retrograde cholangio pancreatography (ERCP) and 6 underwent reoperations. Of 71 patients with recurrence of intrahepatic bile duct stones, 43 underwent reoperations and 28 received conservative treatment. Conclusions Percutaneous sinus-tract cholangioscopy for residual intra- and extra-hepatic bile duct stones is safe and effective, with good diagnosis and treatment values and a high clerance rate. The integrity of T-tube sinus-tract is a key of complete stones removal. Key words: Hepatolithiasis; Residual stones; Cholangioscopy; Efficacy

Biliary Drainage catheter insertion via T-tube for intractable biliary fistula from friable common bile duct

Persistent biliary fistula is one of difficult problems, especially in friable CBD due to severe inflammation. Herein, we report an intractabel bile leakage, despite of T-tube, successfully treated with trans-T-tube biliary drainage (TTBD). A 65-years-old man visited our hospital with recurrent CBD stone. CT scan demonstrated multiple intrahepatic duct stones in left IHBD. A left hemihepatectomy was performed. Because there was a ERBD catheter, we repaired primarily the choledochoscpe insertion site. On POD7, an emergency angiography and a covered stent insertion in right hepatic artery were performed due to bleeding from hepatic artery branch. The patient recovered from shock, however, bile juice was observed from drain on 5 days after the intervention. On the finding of re-operation, the repaired choledochoscope insertion site was necrotized. A T-tube was inserted, but tight sutures were impossible because of friable tissues. Persistent bile leakage was observed from drain, despite of well-functioning T-tube. 30 days later from re-operation, bile leakage (500 cc/day) was persistent. 2 Time of ERCP were failed. T-tube cholangiography revealed bile leakage from more proximal portion than T-tube insertion site. A catheter was inserted through T-tube and the tip was placed in right IHBD. 2 Days after TTBD, the amount of drained bile was dramatically decreased. 6 Days after the TTBD, abdominal ultrasonography showed no abnormal fluid collection, and the drain was removed. 4 Weeks after the TTBD, no more bile leakage was observed, and the TTBD and T-tube was removed. An intractable biliary fistula was successfully managed with T-tube and TTBD catheter.

Enhanced recovery after surgery combined with laparoscopic common bile duct exploration in the treatment of choledocholithiasis: a prospective study

Objective To investigate the application value of perioperative enhanced recovery after surgery (ERAS) combined with laparoscopic common bile duct exploration (LCBDE) in the treatment of choledo-cholithiasis. Methods The clinical data of 84 patients with choledocholithiasis who were admitted to the Yijishan Hospital from January 2011 to December 2013 were prospectively analyzed. A single-blind, randomized, controlled study was performed in the 75 patients who were allocated into the control group and the enhanced recovery after surgery group (ERAS group) based on a random number table. All the patients underwent LCBDE, the patients in the control group received conventional perioperative management and the patients in the ERAS group received perioperative management according to enhanced recovery rehabilitation program. All the patients were followed up by outpatient interview till postoperative month 6. The clinical features, liver function and residual stones in the patients were observed. The operation time, postoperative complications, postoperative intestinal function recovery, duration of hospital stay and hospital expenses in the two groups were compared. Measurement data with normal distribution were presented as ±s.Comparison between groups were evaluated with an independant sample t test. Count data were analyzed using the chi-square test. Results All the 75 eligible patients undergoing successful operation were randomly divided into the control group (35 patients) and the ERAS group (40 patients). The operation time and volume of intraoperative blood loss in the control group and the ERAS group were (185±46) minutes and (124±28) mL, (178±37) minutes and (114±32) mL, respectively, with no significant difference (t =0. 729, 1. 431, P >0.05). There were 12, 14 and 10 patients in the control group and 5, 6 and 4 patients in the ERAS group with postoperative incision pain, vomit and infection, showing a significant difference (χ2=5. 054, 5. 966, 4. 241, P 0.05). The postoperative first flatus day, time of food intake, time of postoperative infusion and duration of hospital stay were (42±13) hours, (45±14) hours, (6.8±2.3) days and (11.3±4.5) days in the control group, and (35±11) hours, (19±7) hours, (4.2±1.8) days and (9.6±2.4) days in the ERAS group, with a significant difference between the 2 groups (t = 2. 741, 10. 524, 5. 485, 2. 077, P <0.05). The total hospital expenses was (18 729±3 127) yuan in the control group, which was significantly greater than (16 981±2 756) yuan in the ERAS group (t =2. 574, P <0.05). The liver function of all the patients was recovered at the postoperative month 1. Four patients with residual stones in the 2 groups were detected by T-tube cholangiography, and were cured by removal of gallstones by choledochos-copy. There were no complications of the abdominal pain, jaundice and fever in all the patients till the end of follow-up. Conclusion ERAS combined with LCBDE for the treatment of choledocholithiasis is safe and feasible, with the advantages of low morbidity, quick recovery, short duration of hospital stay and less hospital expenses. Key words: Cholelithiasis, common bile duct; Enhanced recovery after surgery; Common bile duct exploration; Laparoscopy

Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration.

AIM:To assess the feasibility, safety of rigid tubal ligation scope in laparoscopic common bile duct (CBD) exploration.MATERIALS AND METHODS:Rigid nephroscope was used for laparoscopic CBD exploration until one day we tried the same with the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stone that were removed using endoscopic retrograde cholangiopancreaticography (ERCP) basket. This serendipity led us to use this scope for numerous patients from then on. A total of 62 patients, including male and female, underwent laparoscopic CBD exploration after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All the patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. A total of 48 patients were given T-tube through choledochotomy and closed, and the remaining 14 patients had primary closure of choledochotomy.RESULTS:There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Post-operatively graded clamping of T-tube was done and was removed after 15 days in the patients who were given T-tube. None had retained the stone after T-tube cholangiography, which was done before removing the tube. Mean duration of follow up was 6 months. No patients had any complaints during the follow up.CONCLUSION:Laparoscopic CBD exploration is also feasible with rigid tubal ligation scope. With experienced surgeons, CBD injury is very minimal and stone clearance can be achieved in almost all patients. This rigid tubal ligation scope can be an alternative to other rigid and flexible scopes.

Postoperative bile leakage induced by pancreaticobiliary maljunction complicated with aberrant bile ducts upon gallbladder bed

Laparoscopic cholecystectomy is the gold standard for the treatment of gallstones and chronic cholecystitis.A patient with gallstone was admitted to the 88th Hospital of PLA in August 2012 and received laparoscopic cholecystectomy.She had bile leakage after operation,and had to accept reoperation.Pancreaticobiliary maljunction and aberrant duct upon gallbladder bed were found postoperatively by T-tube cholangiography and pancreatic amylase test in the bile,which led to a complicated treatment and a tortuous recovery.This article analyzed the treatment process for this disease and explore the proper diagnosis and treatment. Key words: Cholecystolithiasis ; Pancreaticobiliary maljunction ; Aberrant duct ; Bile leakage

Clinical Analysis and Significance of Cholangiography for Biliary Cast/Stone After Orthotopic Liver Transplantation

Cholangiography is an important method for the diagnosis of biliary complications after orthotopic liver transplantation. The cholangiography after orthotopic liver transplantation presents special challenges, especially in patients with biliary cast/stone and biliary stenosis. We described the T-tube cholangiography combined therapeutic fibro-choledochoscopy for the diagnosis and treatment of biliary cast following after orthotopic liver transplantation. Fourteen patients who developed biliary cast/stone after liver transplantation were analyzed retrospectively. The complications were divided into three temporal stages, early, medium, and late. Hepatic functions and the characteristics of the bile duct were observed by T-tube cholangiography and endoscopy. The biliary cast after liver transplantation was divided into three categories: Solitary, multiple, and columnar. Three months after liver transplantation, bile ducts appeared fuzzy by T-tube cholangiography, but no evidence of biliary cast was found. The bile duct was feculent with flocculation during the middle stage 3-6 months after liver transplantation. At six months after transplantation, bile ducts (especially intrahepatic bile ducts) were distended; cholangiectasis was obvious with biliary cast. The intrahepatic bile duct stricture was observed on occasion by T-tube cholangiography and the intrahepatic bile duct could be thin and distended, and resembled withered branches or strings of beads. The intrahepatic bile ducts even disappeared at this stage; hepatic functions were usually unacceptable and the icterus gradually aggravated. Four cases were diagnosed earlier according to the categories of stone and stage. Curative therapy was performed promptly and the clinical outcome was acceptable. Biliary tracts of the transplanted livers could be observed by T-tube channels and biliary complications were treated effectively by therapeutic fibro-choledochoscopy. It is necessary to combine T-tube cholangiography with fibro-choledochoscopy for the diagnosis and treatment of biliary complications after orthotopic liver transplantation.

Biliary complications after liver transplantation: The role of MR imaging using different hydrographic sequences in patients with biliary-enteric and duct-to-duct biliary anastomosis

To aim of this study was to assess the diagnostic performance of the state-of-the-art magnetic resonance cholangiography (MRC) comprising several 2D and 3D hydrographic sequences in patients after liver transplantation with biliary-enteric and duct-to-duct biliary anastomosis. Retrospective analysis included MRC examinations of 42 patients (21 men, 21 women) performed from 18 days to 86 months (average, 18.9 months) after liver transplantation. Studies were carried out on 1.5 T units, using 4 hydrographic (turbo spin echo, TSE) sequences. The analysis included accuracy of MRC in detecting biliary complications, as well as frequency of specific complications in patients with biliary-enteric anastomosis (n=15) and duct-to-duct biliary anastomosis (n=27). In 34 patients the results were correlated with endoscopic retrograde cholangiopancreatography ERCP (n=9), ERCP and CT (n=5), ERCP and percutaneous cholangiography (n=2), ERCP and T-tube cholangiography (n=1), ERCP, PTC, and histopathology (n=1), PTC (n=1), PTC and CT (n=1), PTC and histopathology (n=1), T-tube cholangiography (n=4), T-tube cholangiography and CT (n=1), fistulography (n=1), CT (n=4), and histopathology (n=3). In the remaining 8 patients other imaging studies (US, CT, follow-up MRC), laboratory liver function tests, and clinical status were the standard of reference. Results MRC yielded 94.6% sensitivity in detecting biliary complications in patients after liver transplantation. In patients with biliary-enteric anastomosis, disseminated biliary strictures were more frequent than in patients with duct-to-duct biliary anastomosis (20% vs. 7%). Less frequently, the biliary-enteric anastomosis was accompanied by anastomotic strictures (40% vs. 56%) and the presence of stones/sludge (20% vs. 37%), but the differences did not show statistical significance. MRC allowed accurate diagnosis of biliary complications in patients after liver transplantation and therefore can be used as a safe alternative to invasive diagnostic procedures such as ERCP and PTC, especially in patients with biliary-enteric anastomosis, in which invasive diagnostic procedures are technically challenging. The main limitation of MR hydrography is its low accuracy in distinguishing bilomas from other fluid collections.

Obstructive jaundice and melena caused by hemocholecyst: A case report

A hemocholecyst (HC) is a clot-filled gallbladder caused by bleeding into its lumen. Obstructive jaundice caused by the compression of HC to the hilar biliary tract is likely to be misdiagnosed as cholangiocarcinoma and is extremely rare. We herein report a case of obstructive jaundice and melena caused by HC. A 57-year-old male patient presented with right upper quadrant pain associated with icteric sclera and melena was suspiciously diagnosed as having malignant cholangiocarcinmoa by abdominal ultrasonography, computed tomography and magnetic resonance imaging. Laparotomy found a hematoma in the gallbladder. The hematoma spread to the left hepatic lobe forming an exogenous mass which compressed the hilar biliary tract. Radical cholecystectomy and bile duct exploration with T-tube drainage were performed. Histopathological examination revealed massive necrosis of the gallbladder mucosa with inflammatory cells infiltration as well as intraluminal hematoma formation. One month after operation, a T-tube cholangiography revealed a normal biliary tree. We suggest that HC should be considered in patients with obstructive jaundice and melena after common causes are ruled out.