Laparoscopic intracorporeal ultrasound cystic duct length measurement: a new technique to prevent common bile duct injuries

The incidence of common bile duct injury remains high. Intracorporeal ultrasound mapping of cystic duct anatomy, prior to laparoscopic cholecystectomy (LC), may assist surgeons in avoiding common bile duct injuries. A technique for intraoperative intracorporeal predissection ultrasound imaging (IIPUI) of the cystic duct length was tested. During LC, gallbladder adhesions were lysed, and with the gallbladder retracted by grasping forceps, the ultrasound examination was performed. Using a 7.5-MHz articulating ultrasound probe, visualization of the extrahepatic biliary tree was obtained in five separate planes. Success in visualizing each plane, time for ultrasound examination, and predissection accuracy of cystic duct length measurement were recorded. Intraoperative cholangiography or direct measurement of the dissected cystic duct was used to determine accuracy of the ultrasound cystic duct length estimates. Forty-three patients underwent IIPUI during LC. The time required to perform the examination varied, with a range of 5 to 17 min (mean 9.5 min). Success of visualization in planes 1 through 5 was 44%, 95%, 98%, 98%, and 70%, respectively. The accuracy rate for cystic duct length ultrasound measurement was 87.1%. No complications related to the examination were observed. In this preliminary study, cystic duct length was determined by predissection intracorporeal ultrasound with a high level of accuracy. Predissection imaging may assist in preventing common bile duct injury during LC.     

Open surgery of choledochus in Denmark

For each of the years 1991-1994 400, 209, 170 and 133 open common bile duct stone extraction were performed in Denmark, corresponding to 35%, 17%, 12% and 5% respectively of patients diagnosed with common bile duct stone. There was only little variation between the 16 hospital counties. The expected decrease in open common bile duct surgery corresponds to the introduction of several non-invasive methods for the treatment of common bile duct stones. To achieve further reduction in open surgery, centralization of the treatment of common bile duct stones is necessary.     

Preoperative diagnosis of laparoscopic cholecystectomy. Is there an indication for routine intravenous cholangiography?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open?

We reviewed our experience with the last 587 laparoscopic cholecystectomies performed between May 1990 and January 1993 to correlate preoperative findings that may predict the conversion of a laparoscopic cholecystectomy to that of an open procedure. The prediction of a need to convert to an open cholecystectomy would allow the surgeon to discuss the higher risk of conversion with the patient and also allow for an earlier intraoperative decision to convert if difficulty was encountered. In addition to routine demographic data, ultrasound reports were available for 526 patients and the following information was recorded: presence of stones, thickened gallbladder wall, common bile duct dilatation, gallbladder sludge, and cystic duct impaction. Overall, a two times higher rate of conversion was found for male patients and patients with a body mass index > 27.2 kg/m2. Additionally, a thickened gallbladder wall on preoperative ultrasound was correlated with a six times higher conversion rate to open cholecystectomy. As expected, the positive intraoperative cholangiogram was associated with a higher incidence of conversion. Additionally, finding a dilated common bile duct on ultrasound was found to be associated with a nearly seven times higher rate of positive intraoperative cholangiogram. No statistical significance was found between conversion and age, previous abdominal operations, the presence of stones, common bile duct dilatation, gallbladder sludge, cystic duct impaction, or a distended gallbladder. Thus, these predictive findings allow the surgeon to preoperatively discuss the higher risk of conversion and allow for an earlier judgment decision to convert if intraoperative difficulty is encountered.     

Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study

A prospective, controlled, randomized trial was conducted in 275 patients with symptomatic gall stone disease, whose history, laboratory data or sonographical findings did not suggest common bile duct stones. Of these patients, 137 did not undergo intraoperative fluoroscopic cholangiography (IOC), but in the remaining 138 patients IOC was attempted. In 111 cases (80.4%) the biliary system was sufficiently visualized. In 3 patients (2.7%) calculi in the cystic or common bile duct were diagnosed, which would have been overlooked without IOC. IOC was false-positive in one case. One year after the operation the patients were asked to return for a follow-up examination. Three patients in the group without IOC had had symptomatic passage of a stone, and one had a common bile duct stone removed by endoscopic papillotomy. A retained stone was discussed as etiology for a pancreatitis in a fifth patient in this group. No patient sustained long-term sequelae from the retained common bile duct stones. None of the patients in the IOC group had evidence of cholangiolithiasis at follow-up. There was no difference between the study groups concerning the incidence of post-operative complications. The operations with IOC lasted significantly longer (92 +/- 31 min vs 77 +/- 28 min). According to our data and those published earlier, the additional financial and logistic expenditure associated with routine IOC is not justified. Patients with the preoperative suspicion of a common bile duct stone should have endoscopic bile duct clearance (ERCP and EPT) prior to cholecystectomy.     

Familial occurrence of congenital bile duct cysts

Congenital bile duct cysts are now a well-documented anomaly of the biliary tree, and have become more common in Japan. Familial occurrence of congenital bile duct cysts, however, is extremely rare, with only six reported cases in the literature. We report a familial pattern of congenital bile duct cysts in a mother and her daughter. A 33-year-old female was admitted for evaluation of right upper quadrant abdominal pain and fever 6 days after an uneventful delivery of her second child. A computed tomography (CT) and ultrasound scan (US) revealed an obstructed biliary tract. Percutaneous transhepatic biliary drainage was then performed, and a cholangiogram revealed a Scholtz type B choledochocele without an anomalous connection of the pancreaticobiliary ducts. Endoscopic US demonstrated that the choledochocele was associated with a stone in the cyst. A pylorus-preserving pancreatoduodenal resection was performed, and a histological study revealed that the choledochocele was lined by biliary mucosa without evidence of malignancy. The newborn infant had an abdominal tumour. An US and CT revealed a congenital bile duct cyst. An operation was performed and the intraoperative cholangiogram showed an Alonso-Lej type I congenital bile duct cyst with an anomalous connection of the pancreaticobiliary ducts. Whether congenital bile duct cysts are hereditary remains to be elucidated.     

The effect of atropine on insulin stimulated gastric secretion and gastrin release

A 28-years-old patient with a palpable mass of two fist's size in the upper abdomen rapidly developed an obstructive jaundice. A pancreatic tumor was suspected and therefore ERCP was carried out. Unusual alterations caused by metastatic lesions of a post mortem diagnosed testicular teratoma narrowing and invading the common bile duct and displacing the main pancreatic duct were visualized.     

Selected versus routine use of intraoperative cholangiography during laparoscopic cholecystectomy

Routine use of intraoperative cholangiography during laparoscopic cholecystectomy is still widely advocated and standard in many departments, however, this is discussed controversially. We have developed a new diagnostic strategy to detect bile duct stones. The concept is based on an ultrasound examination and on a screening for the presence of six risk indicators of choledocholithiasis. 120 consecutive patients undergoing laparoscopic cholecystectomy were prospectively screened for the presence of six risk indicators of choledocholithiasis: history of jaundice; history of pancreatitis; hyperbilirubinemia; hyperamylasemia; dilated bile duct; unclear ultrasound findings. The sensitivity of ultrasound and of intraoperative cholangiography in diagnosing bile duct stones was also evaluated. For the detection of bile duct stones, the sensitivity was 77% for ultrasound and 100% for intraoperative cholangiography. 20% of all patients had at least one risk indicator. The presence of a risk indicator correlated significantly with the presence of choledocholithiasis (p < 0.01, chi-square-test). The negative predictive value of the total set of risk indicators was 100%. Following our diagnostic concept, we would have avoided 80% of intraoperative cholangiographies without missing a stone in the bile duct. This study lends further support to the view that the routine use of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy is not necessary.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Nursing process for health promotion using King''s theory

Laparoscopic ultrasound combines the advantage of diagnostic laparoscopy with intraoperative ultrasonography. This new technique allows visualisation of deep structures that are not palpable. The technical aspects and the application in abdominal surgery are described. The principal indications are detection of common bile duct stones during laparoscopic cholecystectomy and staging of abdominal cancers. The information provided by laparoscopic ultrasound influences therapeutic decisions.     

Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery

BACKGROUND: We set out to analyze the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland. METHODS: Data were collected from 10,174 patients from 82 surgical services. A total of 353 different parameters per patient were included. RESULTS: We found intraoperative complications in 34.4% of patients and had a conversion rate of 8.2%. This rate was significantly increased in patients with complicated cholelithiasis and in those with previous upper-but not lower-abdominal surgery. In most cases, conversions to open procedures were required because of technical difficulties due to inflammatory changes and/or unclear anatomical findings at the time of operation. Bleeding was a common intraoperative complication, that significantly increased the risk of conversion. Patients with loss of gallstones in the peritoneal cavity had increased rates of abscesses. The rate of common bile duct injuries was 0.31%, but it decreased significantly as the laparoscopic experience of the surgeon increased. The rate of common bile duct injuries was not increased in patients with acute cholecystitis or in the 1.32% of patients undergoing laparoscopic common bile duct exploration. Intraoperative cholangiography did not reduce the risk of common bile duct injuries, but it allowed them to be diagnosed intraoperatively in 75% of patients. Local complications were recorded in 4.79% of patients, and systemic complications were seen in 5.59%. The mortality rate was 0.2%. CONCLUSIONS: Although laparoscopic cholecystectomy is a safe procedure, the rate of conversion to open cholecystectomy is still substantial. The conversion rate depends both on the indication and intraoperative complications. There is still a 10.38% morbidity associated with the procedure; however, the incidence of common bile duct injuries, which decreases with growing laparoscopic experience, was relatively low.     

Intraductal ultrasound of the bile ducts

Intraluminal ultrasound with 12.5 and 20 MHz transducer allows precise analysis of the extrahepatic bile ducts and the adjacent structures. Inflammatory and malignant thickening of the bile duct wall can be assessed without difficulty. It is not possible, however, to differentiate between benign and malignant bile duct thickening, and for this purpose biopsy is required in addition. In tumor staging intraluminal ultrasound is superior to conventional ultrasound, because tumor infiltration into the adjacent tissues can be assessed and lymph nodes along the hepaticoduodenal ligament can be detected. Owing to the ultrasound frequencies available, local staging is limited to a circumference of 1.5/2 cm. Intraluminal ultrasound provides additional information that is useful in the diagnosis and therapy of bile duct stones and in different types of palliative tumor therapy. The procedure is simple and not too time consuming, and it involves no risks to the patient.     

Risk of recurrent biliary tract disease after cholecystectomy in patients with duodenal diverticula

OBJECTIVE: To determine if the presence of duodenal diverticula predisposes to the development of common bile duct stones. DESIGN: Cohort study; median follow-up, 10.0 years (25th and 75th percentiles, 5.2 and 16.1 years, respectively). SETTING: Tertiary care center. PATIENTS: One hundred fifty-seven patients with radiologically diagnosed duodenal diverticula who had undergone cholecystectomy from 1950 through 1987 and were asymptomatic at the initiation of follow-up. MAIN OUTCOME MEASURES: All patients were followed up for evidence of recurrent biliary tract disease to the following end points: (1) evidence of choledocholithiasis demonstrated by radiologic surgical, or biochemical means and (2) clinical or biochemical evidence of biliary pancreatitis. RESULTS: Of the 157 patients in the study cohort, 13 patients were categorized as having had recurrent biliary tract disease. Using the Kaplan-Meier survivorship method, the cumulative probabilities of recurrent biliary tract disease in patients with radiologically diagnosed duodenal diverticula were 3.6% at 5 years (95% confidence interval, 0.5-6.9), 5.5% at 10 years (95% confidence interval, 1.5-9.4), and 10.2% at 15 years (95% confidence interval, 3.8-16.7). Age, common bile duct exploration and choledochotomy, and the presence of common bile duct dilatation were not found to be significantly associated with recurrence based on a univariate analysis of risk factors by means of the log-rank statistic. CONCLUSIONS: For patients with radiologically diagnosed, second-portion duodenal diverticula, the risk of developing recurrent bile duct stones after cholecystectomy is lower than has been suggested in previous studies. In the absence of concurrent choledocholithiasis, sphincterotomy or biliary bypass at the time of cholecystectomy seems unwarranted.     

Increased neutrophil function induced by bile duct ligation in a rat model

Neutrophil function was studied in rats with common bile duct ligation. Superoxide production stimulated by phorbol myristate acetate, opsonized zymosan or formyl-methionyl-leucyl-phenylalanine; phagocytosis; and chemotaxis were significantly greater in neutrophils from rats with common bile duct ligation than in sham-operated control rats. Enhanced neutrophil activity was observed within 12 hr of bile duct ligation; it remained increased during the 15-day study. Preincubation of neutrophils from control rats with sera of rats with common bile duct ligation did not increase superoxide generation. This suggests that the high superoxide production observed in neutrophils of rats with common bile duct ligation was not an immediate effect of the serum. Neutrophils of rats with portal vein ligation exhibited normal activity, indicating that portal systemic shunting per se is not the underlying mechanism for increased activity. The elevated levels of AST and alkaline phosphatase, indicating liver damage, that appeared within 12 hr of bile duct ligation correlated with the increased superoxide generation.     

Value of intraoperative cholangiography in laparoscopic cholecystectomy

By introduction of laparoscopic cholecystectomy, an increase of accidental common bile duct injuries up to 1.2% has been reported. In the present study of 325 cholecystectomies we evaluated whether mandatory intraoperative cholangiography (IOC) can reduce the rate of accidental bile duct injuries or, at least, identify them early in order to make an adequate repair possible. In addition 163 patients underwent preoperative intravenous cholangiography (IVC). Both imaging techniques were compared with regard to their sensitivity in the detection of anatomic variations and stones of the extrahepatic bile duct system. Our results demonstrated a great advantage of the IOC. The IOC was feasible in 98.1% of the cases and presented a complete depiction of the extrahepatic bile duct system in 99.3%. IVCs showed the biliary system in 91.4% of the cases but without visualization of the cystic duct in 51.5% and the hepatic confluence in 16%. Anatomic variations of the bile duct system which consecutively influenced the operative management were found in additional 27.6% exclusively by IOC. 71.4% of bile duct stones were not detected by IVC. The intraoperative time consumption of IOC was unimportant. The x-ray-load was clearly lower by a factor of 3.5. There was no complication after IOC. In comparison, 6.1% of patients demonstrated an anaphylactic reaction by IVC. One common duct injury (0.3%) was detected intraoperatively by IOC and at the same operation treated without postoperative complications. In conclusion, we recommend an IOC in addition to a thorough preoperative ultrasound-examination. By this technique intraoperatively identified stones of the common bile duct can be sufficiently treated by postoperative endoscopic extraction and anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.     

Response of tumour cells to hypoxia: role of p53 and NFkB

Laparoscopic ultrasound combines the advantages of diagnostic laparoscopy with peroperative ultrasonography. This new technique allows visualization of deep structures that are not palpable. The technical aspects of this technique and its applications in abdominal surgery are described. The main indications are the search for common bile duct stones during a laparoscopic cholecystectomy and the assessment of the spread of abdominal cancers. The information obtained from laparoscopic ultrasound can influence the therapeutic management.     

An atypical case of atypical pneumonia

A case of anomalous pancreaticobiliary union with ectopic drainage of the common bile duct into the third part of the duodenum was diagnosed in an 86-year-old woman upon evaluation of acute pancreatitis. The role of anomalous pancreaticobiliary unions in the genesis of acute pancreatitis is discussed.     

Endoscopic lithotomy of common bile duct stones with sublingual nitroglycerin and guidewire

OBJECTIVE: In 21 patients, our objective was the endoscopic removal of common bile duct stones by sphincter dilation with the application of sublingual nitroglycerin. METHODS: Nitroglycerin 0.3-0.6 mg was needed for proper dilation of the orifice and for successful cannulation of the Dormia basket into the bile duct. Cannulation of the Dormia basket was simplified by placing the guidewire in the common bile duct beforehand. Because of possible stone impaction, a mechanical lithotriptor was applied smoothly in two patients. RESULTS: Complete stone removal was successful in 18 of the 21 (86%) patients. One patient who developed a mild form of acute pancreatitis recovered in a few days by conservative management with drip infusion of protease inhibitor. Blood pressure dropped transiently in a patient receiving nitroglycerin, but the general condition of the patient was stable. CONCLUSIONS: This procedure was found to be safe, easy, and effective in extracting common bile duct stones.     

Introduction to instrument development: scaling methods

Endoscopic removal of biliary calculi is a safe and effective alternative to surgical exploration of the common bile duct. However, as stones increase in diameter, endoscopic retrieval becomes more difficult and hazardous. Mechanical lithotripsy is an endoscopic technique used to crush common bile duct stones that are too large to be removed by conventional methods. In the 3 years following the introduction of this technique at our institution, 145 patients underwent endoscopic retrograde cholangiopancreatography for symptomatic choledocholithiasis. Endoscopic mechanical lithotripsy improved the overall success rate of common bile duct clearance from 86.2% to 94.5%. No morbidity or mortality was associated with the procedure. Therefore, we recommend mechanical lithotripsy when bile duct stones cannot be removed with conventional techniques.     

Common bile duct stones after laparoscopic cholecystectomy and its treatment. The role of ultrasound and intravenous and intraoperative cholangiography

In the present work we recount our experience in handling common bile duct stones (CBDS) in our first 100 cases of laparoscopic cholecystectomy. In the first 50 cases our diagnostic procedures involved the use of ultrasound exploration and intravenous cholangiotomography 48 h before laparoscopic surgery. We found three cases of residual CBDS. One of the cases was treated by means of ERCP. The other two cases were resolved by carrying out a transparietohepatic cholangiography after the ERCP procedure failed. After this experience, we changed our strategy, introducing the intraoperative cholangiography in the cases with an unclear diagnosis. With this new approach, no residual CBDS occurred in the following 50 cases. These findings demonstrate the following: (1) In our hands, intravenous cholangiography is not more effective than ultrasound exploration in resolving dubious cases. (2) These dubious cases are more effectively diagnosed by means of selective intraoperative cholangiography. (3) When CBDS is treated by transparietohepatic cholangiography it proves to be less uncomfortable for the patient than ERCP and, as we found, even more efficient in removing the stones, although our experience is based on only two cases.