Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.

Histological study of the structural layers around the esophagus in the lower mediastinum

BACKGROUND In Japan,the transhiatal approach,including lower mediastinal lymph node dissection,is widely performed for Siewert type II esophagogastric junction adenocarcinoma.This procedure is generally performed in a magnified view using laparoscopy or a robotic system,therefore,the microanatomy of the lower mediastinum is important.However,mediastinal microanatomy is still unclear and classification of lower mediastinal lymph nodes is not currently based on fascia or other microanatomical structures.AIM To clarify the fascia and layer structures of the lower mediastinum and classify the lower mediastinal tissue.METHODS We dissected the esophagus and surrounding organs en-bloc from seven cadavers fixed in 10%formalin.Organs and tissues were then cut at the level of the lower thoracic esophagus,embedded in paraffin,and serially sectioned.Tissue sections were stained with Hematoxylin-Eosin(all cadavers)and immunostained for the lymphatic endothelial marker D2-40(three cadavers).We observed the periesophageal fasciae and layers,and defined lymph node boundaries based on the fasciae.Lymphatic vessels around the esophagus were observed on immunostained tissue sections.RESULTS We identified two fasciae,A and B.We then classified lower mediastinal tissue into three areas,paraesophageal,paraaortic,and intermediate,using these fasciae as boundaries.Lymph nodes were found to be present and were counted in each area.The dorsal part of the intermediate area was thicker on the caudal side than on the cranial side in all cadavers.On the dorsal side,no blood vessels penetrated the fasciae in six of the seven cadavers,whereas the proper esophageal artery penetrated fascia B in one cadaver.D2-40 immunostaining showed lymphatic vessel connections between the paraesophageal and intermediate areas on the lateral and ventral sides of the esophagus,but no lymphatic connection between areas on the dorsal side of the esophagus.CONCLUSION Histological studies identified two fasciae surrounding the esophagus in the lower mediastinum and the layers separated by these fasciae were used to classify the lower mediastinal tissues.

Distribution of splenic artery lymph nodes and splenic hilar lymph nodes

BACKGROUND Total gastrectomy with splenectomy is the standard treatment for advanced proximal gastric cancer with greater-curvature invasion.As an alternative to splenectomy,laparoscopic spleen-preserving splenic hilar lymph node(LN)dissection(SPSHLD)has been developed.With SPSHLD,the posterior splenic hilar LNs are left behind.AIM To clarify the distribution of splenic hilar(No.10)and splenic artery(No.11p and 11d)LNs and to verify the possibility of omitting posterior LN dissection in laparoscopic SPSHLD from an anatomical standpoint.METHODS Hematoxylin&eosin-stained specimens were prepared from six cadavers,and the distribution of LN No.10,11p,and 11d was evaluated.In addition,heatmaps were constructed and three-dimensional reconstructions were created to visualize the LN distribution for qualitative evaluation.RESULTS There was little difference in the number of No.10 LNs between the anterior and posterior sides.For LN No.11p and 11d,the anterior LNs were more numerous than the posterior LNs in all cases.The number of posterior LNs increased toward the hilar side.Heatmaps and three-dimensional reconstructions showed that LN No.11p was more abundant in the superficial area,while LN No.11d and 10 were more abundant in the deep intervascular area.CONCLUSION The number of posterior LNs increased toward the hilum and was not neglectable.Thus,surgeons should consider that some posterior No.10 and No.11d LNs may remain after SPSHLD.