Efficacy of endoscopic diagnosis and treatment for postoperative biliary leak

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of endoscopic approaches for the diagnosis and treatment of postoperative biliary leak. METHODOLOGY: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight patients with postoperative biliary leak. Of 8 cases, 6 had biliary leak alone (4 cases with a cystic duct leak and 2 cases with a bile duct leak) and 2 cases with a bile duct leak were associated with a bile duct stricture. Endoscopic sphincterotomy (ES) and endoscopic biliary stenting (EBS) were employed in 5 patients and nasobiliary tube drainage (NBD) without ES was performed in 3 patients. RESULTS: In all the patients, ERCP was successfully performed and could demonstrate exact nature and site of postoperative bile duct injuries. In 2 patients with a concomitant bile duct stricture, repetitive endoprosthesis placements were required. The remaining six patients with biliary leak alone were successfully treated by temporary stenting, i.e., ES and EBS (n = 3), and NBD (n = 3). CONCLUSIONS: The patients with postoperative biliary leaks can be successfully diagnosed by ERCP and treated by temporary endoscopic methods. Among various endoscopic treatments, NBD alone appears to be preferable in treating patients with small bile leaks. However, cases with a concomitant bile duct stricture were intractable and required longer period of stenting.     

Bile leakage after laparoscopic cholecystectomy demonstrated with 99mTc-PMT hepatobiliary scintigraphy

A 41-year-old woman underwent laparoscopic cholecystectomy for the treatment of gallstone and adenomyomatosis. One month after laparoscopic cholecystectomy, hepatobiliary scintigraphy was performed with 99mTc-Sn-N-pyridoxyl-5-methyltryptophan (PMT) to evaluate the presence of a bile leak and/or other complication. A biliary extravasation was noted in the left upper quadrant within 60 minutes. At five hours post injection, a progressive accumulation of 99mTc-PMT was noted in the lesser sac, the right and left paracolic gutter and in the pouch of Douglas. A diagnosis of biliary leakage was made. The patient underwent exploratory laparotomy to repair the leak from the cystic duct stump.     

Bile leakage resulting from clip displacement of the cystic duct stump: a potential pitfall of laparoscopic cholecystectomy

We present the case of a patient who underwent successful endoscopic nasobiliary drainage (ENBD) for bile leakage resulting from clip displacement of the cystic duct stump sustained during a laparoscopic cholecystectomy (LC). This 69-year-old man was admitted with symptomatic cholecystolithiasis. After LC was performed, intraoperative cholangiography (IOC) revealed no abnormal findings. However, postoperatively, bilious material began to appear from the intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage from the end of the cystic duct stump. ENBD was performed. Cholangiography using the ENBD tube 14 days later failed to show a bile leak. The ENBD was subsequently removed. The patient improved rapidly with no complaints. Bile leakage due to clip displacement from the cystic duct stump is a potential pitfall of LC, especially if IOC is normal. We recommend careful cystic duct ligation, combined with the use of superior quality ligation clips, to prevent this complication. ENBD is a useful technique to prevent bile leakage after this complication.     

Endoscopic therapy for patients with a post-operative biliary leak

Twenty-three patients with a post-operative biliary leak were treated by various endoscopic methods and results were analyzed. Leaks occurred at the cystic duct in 13 patients, at the common duct in 6 patients, and at an anomalous branch of the right hepatic duct in 4 patients. Treatments included sphincterotomy alone (4 patients), stent alone (6 patients), sphincterotomy and stent (12 patients), and sphincterotomy and nasobiliary drainage catheter (1 patient). Five patients also had supplemental percutaneous catheter drainage of a biloma. All treatments were completed successfully in the absence of major morbidity, and permanent closure of the leak occurred in 100% of cases. Endoscopic therapy for patients with a post-operative biliary leak is safe and effective and should be recommended before surgical re-exploration.     

Cystic duct syndrome and minimally invasive surgery

Cholecystectomy is an established successful operation which provides total relief of presurgical symptoms in up to 85% of patients. About 5% of patients after cholecystectomy experience severe episodes of upper abdominal pain, similar to those that they had prior to cholecystectomy. These so called postcholecystectomy syndromes may be due to biliary strictures, retained biliary calculi, cystic duct stump syndrome, stenosis or dyskinesis of the sphincter of Oddi. Postcholecystectomy symptoms caused by cystic stump and gallbladder remnant had been described early in this century and several papers have been published on the topic. During recent years laparoscopic cholecystectomy became popular but we have not found in the literature the mention of either that it could cause cystic duct stump syndrome or it could be used for its treatment. During the last seven years in 8 patients we found gallbladder remnants or cystic duct stumps causing their symptoms. Among the 8 patients 3 had laparoscopic and 5 classic cholecystectomies. After incomplete cholecystectomy we usually find that the cystic duct stump and the Calot triangle embedded in inflamed scar tissue. For this reason the surgical risk is to high with laparoscopic surgery to reoperate for these pathological changes. In all 8 cases the pathological cystic duct stumps and gallbladder remnants were removed using 3-4 cm single microlaparotomy incisions. The postoperative stay of these patients were uneventful and they were discharged home 2-3 days after surgery.     

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.     

Complications of laparoscopic cholecystectomy in China: an analysis of 39,238 cases

OBJECTIVE: To investigate the complications of laparoscopic cholecystectomy in China. METHODS: All Chinese articles about laparoscopic cholecystectomy published between April 1994 and November 1995 were identified through CMCC (Chinese Medical Computerized Contents). From more than 600 titles, 105 articles were screened for analysis. Another 21 articles from the 6th Biliary Surgical Congress and 300 cases from the General Hospital of PLA were added. A total of 39,238 cases of laparoscopic cholecystectomy from 91 hospitals were studied. RESULTS: Severe complications of laparoscopic cholecystectomy were identified in 409 (1.04%) patients, including bile duct injury (in 0.32% of patients), postoperative cystic duct leak (0.11%), postoperative bile leak (0.20%), peritoneal abscess (0.07%), bowel injury (0.06%) and postoperative hemorrhage (0.1%). Fourteen postoperative deaths (0.04%) resulted from operative injury. CONCLUSIONS: The data demonstrate that laparoscopic cholecystectomy is an operation associated with low morbidity and mortality rate, but bile duct injury is still a major problem. Complications of laparoscopic cholecystectomy can be minimized by improving operative procedure.     

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.     

Cardiac transplantation in patients aged 60 years or older

The indications and best technique for peroperative cholangiography during laparoscopic cholecystectomy remain unclear, but the operation has been associated with an increased use of preoperative endoscopic retrograde cholangiography. Cystic duct cholangiography, particularly in the hands of the trainee, can be time consuming, and bile duct injury may be caused by attempts to cannulate the cystic duct. This study analyses 113 consecutive patients undergoing peroperative cholangiography through the gallbladder, or cholecystocholangiography. It was successful in 92 (81.4%) patients, the procedure adding less than 10 min to the operating time. There were no cholangiogram-related complications. Common anatomical variations included both short and particularly wide cystic ducts. This information helps to minimize the risk of damage to the common bile duct. This study demonstrates that cholecystocholangiography is a safe, simple, and effective alternative to cystic duct cholangiography with virtually no "learning curve." It provides a "road-map" of biliary anatomy and identifies common bile duct stones prior to the commencement of dissection. Unsuccessful cholecystocholangiography does not preclude the use of cystic duct cholangiography later in the operation. Difficult anatomy is demonstrated prior to dissection. When unsuspected bile duct calculi necessitate open exploration, further laparoscopic dissection is avoided.     

A case of gallbladder adenomyomatosis with pancreaticobiliary maljunction and an anomaly of the cystic duct joined the common channel

A 46-yr-old woman was admitted to our hospital with mild epigastric pain. Ultrasonography and computed tomography revealed an extremely thickened gallbladder wall. Endoscopic retrograde cholangiopancreatography demonstrated that the main pancreatic duct joined the nondilated common bile duct at the outer point of the duodenal wall (P-C type of pancreaticobiliary maljunction), and the cystic duct joined the common channel directly. The intraoperative amylase levels of the bile juices both in the common bile duct and the cystic duct were high. A cholecystectomy was performed. The wall of the gallbladder was markedly thick, yellowish, elastic, and soft. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen. The diagnosis was a generalized type of adenomyomatosis. The pathogenesis of the adenomyomatosis was believed to result from chronic stimulation as a result of pancreatic juice reflux. The etiology of this unusual type of junction was considered to be the result of the combination of pancreaticobiliary maljunction and an anomaly of lower junction of the cystic duct.     

Anatomic variants of the cystic duct and cysticohepatic junction: diagnosis with MR cholangiography

The cystic duct are variable in length, course and site of termination. A knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important in biliary surgery, because failure to recognize anatomic variations may result in a significant ductal injury. Magnetic resonance cholangiography (MRC) is a recently developed technique that demonstrates the biliary tree noninvasively and without injection of contrast material. Anatomic variants of the cystic duct and cysticohepatic junction that may increase the risk of bile duct injury in biliary surgery are frequently identified with MRC. MRC will be a noninvasive and a useful technique in the diagnosis of anatomic variants of the cystic duct and cysticohepatic junction.     

Measurement Techniques for Estimating Local and Total Duct Leakages in Residential Buildings

The paper proposes two measurement techniques for estimating the duct leakage in residential buildings. The first technique determines the “local” leakages using commercially available zone bags and it is called the zone bag-based measurement technique. Zone bags are used to block the flow of air in ducts so that portions of the duct can be isolated and pressurized separately to measure the respective leakages. The thrust of this technique is to locate where these potential leaks are in the duct system and try to provide more cost effective ways to remedy those leaks than what is available currently. The other technique determines the “total” supply and return leakages using a simple model and it is called the model-based measurement technique. The model is based on pressure drop measurements between the return and supply sides. The proposed techniques were evaluated and validated at the air duct leakage laboratory which has two different air duct configurations and a wide range of leakage levels controlled by holes created at several locations of ductwork. Experimental results indicate that the zone bag-based measurement technique estimates the local leakage accurately with a mean absolute difference of 0.26% of total air-handler flow compared to the baseline. It can be inferred that this method gives a better estimate of the total leakage based on the location of the leak than the duct pressurization method that uses the half plenum pressure technique. The results also show that the model-based measurement technique is a good alternative when one cannot use a physical barrier between the return and supply sides. It was found that the total supply or return side leakage was estimated with a mean absolute difference of 0.6% compared to the baseline technique. The future research step is field testing techniques to examine how one can more efficiently sample the duct system by judicially sectioning off the duct at a few points to obtain localized leakage information and obtain enough information to correct leak problems.     

Shaving of the scalp may increase the rate of infection in CSF shunt surgery

Most surgeons use metal clips in laparoscopic cholecystectomy. The aim of this prospective randomized controlled study was to evaluate the efficacy of absorbable clips in elective laparoscopic cholecystectomy. One hundred consecutive patients with symptomatic gallstones without complications were randomized into groups; group T had two metal clips (titan clip ETHICONR), group R (laproclipR Davis and Geck) had one absorbable clip applied on the cystic duct and cystic artery. The patients were followed for one year. There was no difference between the two groups concerning operative time, hospital stay and postoperative complications. The absorbable clips seem to be as effective as metal clips in providing hemostasis in cystic artery and in cystic duct ligation.     

Agenesis of gall bladder--a diagnostic dilemma

Before laparoscopic cholecystectomy, it is important to clarify the anatomy of the cystic duct. This study assessed three-dimensional CT images (3D images) of the cystic duct obtained non-invasively using helical DIC CT and these images were compared with those obtained with ERCP and DIC. The three-dimensional technique using Helical DIC-CT was applied in 168 patients for laparoscopic cholecystectomy. The cystic duct detected by 3D imaging was evaluated for patency, length and bifurcation. Three-dimensional images showed the cystic duct in 157 of 168 cases (93.5%) and in 81 of 89 cases (91%) in which the cystic duct was not clearly visualized on DIC. Among the 23 cases in which were both 3D images and ERCP undergone, 3D images were equal to those of ERCP in detection of the cystic duct in 20 cases, superior to ERCP in two cases, and inferior to ERCP in one. The technique of 3D images proved useful in demonstrating the patency, length and variations in bifurcation of the cystic duct for surgeons performing laparoscopic cholecystectomy and might be substitute ERCP in preoperative assessment.     

Gastric leiomyosarcoma mimicking a cystic tumor at the pancreatic tail--one case report

A 73 year-old female patient suffered from anemia and a palpable abdominal mass. Abdominal ultrasonography and magnetic resonance imaging revealed a lesion with papillary excrescences at the pancreatic tail. Endoscopic retrograde cholangiopancreatography showed a normal pancreatic duct, but a small submucosal tumor was found in the stomach incidentally. Laparotomy disclosed an exophytic tumor arising from the submucosal layer of the stomach. Pathology revealed a gastric leiomyosarcoma with remarkable liquefaction and cystic change. Gastric leiomyosarcoma can be so necrotic as to be mistaken for a cystic tumor. It is critically important to differentiate the peripancreatic cystic lesion because the treatment strategy is totally different.     

A miniature probe enables clear demonstration of the cystic duct during laparoscopic cholecystectomy

We performed intraoperative ultrasonography with a miniature probe to explore the biliary anatomy, especially the cystic duct, during laparoscopic cholecystectomy. By using this radial-type probe introduced into a hard metal sheath with a balloon at the end, the plane containing Calot's triangle can be scanned easily when the gallbladder is extracted to the right side, thereby facilitating the identification of the cystic duct as well as the common ducts. In 30 cases, no common duct stone was found and the cystic duct was clearly identified. This radial-type miniature probe can be used to locate the cystic duct and avoid inadvertant incision or division of the common ducts.     

Cytochrome P-450 complex formation by dirithromycin and other macrolides in rat and human livers

Intraluminal ultrasonography of the common duct was performed in nine patients undergoing laparoscopic cholecystectomy, using a system comprising a 20-MHz crystal in a 95-cm, blunt-tipped 6F sheath, mechanically rotated at 1,800 rpm. The probe was introduced through an incision in the cystic duct and passed into the duodenum. When the catheter was withdrawn, excellent visualization of the common and cystic ducts and lower end of the common hepatic duct was achieved. In seven patients, the biliary tree was normal. A small calculus was discovered in the common duct in one patient. This stone was not seen on a subsequent cholangiogram and was subsequently retrieved. An additional patient had mucus or sludge noted in the duct, which cast no acoustic shadow and thus was distinguished from calculi. The technique was fast, efficient, and easy to perform in this small group of patients and holds promise for screening the common duct pathology during laparoscopic cholecystectomy.     

Immunological aspects of endocarditis

A case is described in which exact localization of a cystic lesion associated with the apices of the maxillary central incisor teeth was sought to aid diagnosis and presurgical planning. The area was imaged using cross-sectional tomographic slices in the sagittal plane produced by a Scanora multimodal tomographic unit (Orion Corporation Soredex, Helsinki, Finland). The images demonstrated the cystic lesion arising within the incisive canal, conforming a diagnosis of naso-palatine duct cyst. Surgery was therefore performed via a palatal approach giving direct access to the cyst. Histological examination of the enucleated cyst confirmed a nasopalatine duct cyst.     

Natural rubella infection with CD8+ T cell expansion and failure to detect viral genome in synovial fluid

We describe the unusual case of a patient who developed recurrent right upper quadrant pain 25 yr after cholecystectomy. A cystic lesion containing a calculus was identified on transabdominal ultrasound, initially suggesting the possibility of gallbladder duplication. Endoscopic retrograde cholangiography identified this lesion as a massively dilated cystic duct stump. Surgical resection led to complete resolution of symptoms. Recurrent cholelithiasis involving the cystic duct stump may lead to massive dilatation, and must be considered in the differential diagnosis of postcholecystectomy syndrome.     

Development of resistance to beta-lactams and other antibiotics of pneumococci isolated from acute otitis media in France: statement of the National Reference Center 1995-1996

BACKGROUND: Visceral pain is characterized by poor pain localization and a referred or radiating pain pattern. Its clinical importance in the abdomen is stressed by the finding that about one-third of patients still complain of abdominal pain after cholecystectomy. A better understanding of symptoms arising from the gallbladder and the underlying pathophysiology is therefore desirable. The aim of the present study was consequently primarily to characterize the symptom patterns after distension of the gallbladder. Secondary aims were to describe the pressure-volume relation in the gallbladder and the cystic duct opening pressure. METHODS: Twelve patients (nine women, three men) treated with cholecystostomy for acute cholecystitis were investigated. Simultaneous cholescintigraphy and measurement of changes in intraluminal gallbladder pressure after injections of saline through a gallbladder catheter were performed. After each injection of saline the localization of pain and the presence of nausea and vomiting were registered. The injections continued until the patient felt abdominal pain necessitating cessation of the investigation or until the cystic duct opened (visualized on cholescintigraphy). RESULTS: Distension of the gallbladder caused pain in 10 of the 12 patients. In 70% the pain was localized under the right costal margin or in the epigastrium. No mathematical formula could describe the pressure-volume relation in the gallbladder. The cystic duct opening pressure varied between 3 and 44 mmHg. CONCLUSIONS: Pain caused by increased gallbladder pressure is localized mostly, but not always, under the right curvature and in the epigastrium. A substantial variation in cystic duct opening pressure was found.