The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis.
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BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution. METHODS: A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998. RESULTS: Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth. CONCLUSIONS: Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary. (+info)
BACKGROUND: Complete absence of a hemidiaphragm or diaphragmatic agenesis in adulthood is rare with only one previous report in the literature. Its significance in relation to performing laparoscopic procedures has not been documented previously. METHODS: We report a case of previously undiagnosed diaphragmatic agenesis in adulthood precluding laparoscopic cholecystectomy and comprehensively review the literature for papers relevant to diaphragmatic agenesis in adulthood. RESULTS: Diaphragmatic agenesis in adulthood may complicate and preclude laparoscopic cholecystectomy. The principles of investigation and management of diaphragmatic agenesis complicating laparoscopic surgery are discussed. CONCLUSIONS: In adults with diaphragmatic agenesis and intrathoracic abdominal viscera precluding laparoscopic cholecystectomy, conservative management is recommended. (+info)
Unretrieved gallstones presenting as a Streptococcus bovis liver abscess.
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We describe a case of a delayed liver abscess presenting two years after a laparoscopic cholecystectomy. At exploration, the patient was found to have an unretrieved gallstone as the nidus for the Streptococcus bovis abscess. (+info)
Successful removal of a stone and an expandable metallic stent from the biliary tract of a patient with acute occlusive pyogenic cholangitis.
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We removed a biliary stone and the metallic stent placed two years previously in a patient with benign biliary strictures. An 80-year-old woman who had been inplanted with an expandable metallic stent (EMS) to prevent obstruction by a large common bile duct stone about two years before as an emergency measure in another hospital, was afficted with acute occlusive pyogenic cholangitis (AOPC) and hospitalized in our hospital. After treating the AOPC, we successfully removed the EMS with a cholangioscope and normal biopsy forceps through the percutaneous transhepatic channel under fluoroscopy. The type of the EMS was Accufulex stent. To remove it was easier than expected. Once it started to unravel, it was removed from the common bile duct within a few minutes. (+info)
Laparoscopic ultrasonographic appearance of the common bile duct mucosa: a predictor of choledocholithiasis.
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Previously we reported on the use of laparoscopic ultrasonography in detecting common bile duct stones during laparoscopic cholecystectomy. The aim of this study is to describe the laparoscopic ultrasonographic appearance of the common bile duct mucosa in patients with choledocholithiasis. Medical records of 44 patients with an increased risk for common bile duct stones undergoing laparoscopic cholecystectomy between 1993 and 1998 were reviewed. In the operating room, the laparoscopic ultrasonographic appearance of the common bile duct mucosa was scored in real time as normal, mild changes (hyperechoic mucosa), or severe changes (hyperechoic with mucosal thickening). Of the 31 patients (70%) with stones or sludge in the biliary tree, 29 (94%) had either severe (58%) or mild (36%) hyperechoic and 2 (6%) had normal-appearing common bile duct mucosa on laparoscopic ultrasonography. Of the 13 patients (30%) with no documented stones or sludge, 11 (85%) had normal and 2 (15%) had mild hyperechoic common bile duct mucosa on laparoscopic ultrasonography. Both of these patients had laboratory values indicating recent passage of common bile duct stones. The association between common bile duct stones and the presence of hyperechoic common bile duct mucosa was statistically significant (P < .0001, Fisher's exact test). This is the first report of hyperechoic common bile duct mucosa demonstrated by laparoscopic ultrasonography as a predictor of common bile duct stones. This finding is evident in the majority of patients with common bile duct stones and also may be associated with recent passage of a stone into the duodenum. (+info)
Studies of the hepatic excretory defects in essential fatty acid deficiency. Their possible relationship to the genesis of cholesterol gallstones.
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Male hamsters were fed normal and essential fatty acid (EFA)-deficient diets for at least 12 wk before bile duct cannulation. With [32P]phosphate, hepatic synthesis of lecithin was similar, but biliary excretion of newly synthesized lecithin was significantly reduced in EFA-deficient compared to that in normal hamsters. Hepatic uptake of intravenously infused taurocholate (TC) and taurochenodeoxycholate (TCDC) were similar in both groups of animals. However, biliary excretion of intravenously infused TC was significantly reduced in EFA-deficient hamsters, whereas that of TCDC-was unchanged. The absolute rate of biliary cholesterol excretion was similar in both groups. Canalicular bile flow, as measured by [14C]erythritol clearance after functional nephrectomy, was significantly lower, with both the bile salt-dependent and independent fractions of this flow being diminished in EFA-deficient hamsters infused with TC. It is concluded that EFA deficiency leads to impaired biliary excretion of taurocholate, lecithin, and water, while cholesterol transport is unaffected, and thus results in supersaturation of bile with respect to cholesterol and production of lithogenic bile. (+info)
Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy.
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OBJECTIVE: To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC. MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, useful strategies for implementing this diagnostic modality for patient evaluation before LC have not been investigated. METHODS: During a 16-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal ultrasonography. Patients were then assigned to one of four groups based on the level of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP and clearance of common bile duct stones; group 2 patients underwent MRC; group 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography. RESULTS: Choledocholithiasis was detected in 43 of 440 patients (9.8%). The occurrence of choledocholithiasis among patients in the four groups were 92.6% (25/27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4, respectively (P <.001). MRC was used for 8.4% (37/440) of patients. Patient triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bile duct stones occurred in six patients (1.4%). CONCLUSIONS: The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratification of risks for choledocholithiasis facilitates patient management with the most appropriate diagnostic studies and interventions, thereby improving patient care and resource utilization. (+info)
Sphincter patency and hepatic BSP uptake after biliary sphincterotomy.
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An attempt has been made to assess the patency and function of the choledochoduodenal junction after biliary sphincterotomy by estimating the first arrival time of injected bromsulphalein (BSP) in duodenal aspirate and the effect of morphine on this. Studies on 49 patients 1--12 years after this operation showed the arrival time to be normal in 47, but in 2 cases there was delay, which suggests that stenosis may develop in time in abot 4 per cent of cases. This had not been detected clinically, radiologically, or by liver function testing. Although it did not effect the BSP arrival time in T-tube bile, morphine was found to prolong the duodenal arrival time in control patients and also after sphincterotomy of the type used, indicating that the protective mechanism of the sphincter region may not have been destroyed by this operation. Abnormal BSP retention in plasma has been reported up to 5 years afte supraduodenal exploration of the bile ducts in 30 per cent of cases. Similarly, in the present study after biliary sphincterotomy plasma BSP levels were above normal in 14 of 49 patients, suggesting that this abnormality reflects the original pathological condition rather than the type of operation used to deal with it. (+info)