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.

Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation

AIM: To investigate the possibilities and advantages of laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct compaired with traditional open operation.METHODS: Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation were performed in two groups of patients who had gallstones in the left lobe of liver and in the common bile duct. The hospitalization time, hospitalization costs, operation time, operative complications and post-operative liver functions of the two groups of patients were studied.RESULTS: The operation time and post-operative liver functions of the two groups of patients had no significant differences, while the hospitalization time, hospitalization costs and operative complications of the laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration in the common bile duct group were significantly lower than those in the traditional open operation group.CONCLUSION: For patients with gallstones in the left lobe of liver and in the common bile duct, laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct can significantly shorten the hospitalization time, reduce the hospitalization costs and the post-operative complications,without prolonging the operation time and bringing about more liver function damages compared with traditional open operation. This kind of operation has more advantages than traditional open operation.

Percutaneous transhepatic extraction and balloon dilation for simultaneous gallbladder stones and common bile duct stones:A novel technique

AIM To evaluate the clinical efficacy and safety of an innovative percutaneous transhepatic extraction and balloon dilation(PTEBD) technique for clearance of gallbladder stones in patients with concomitant stones in the common bile duct(CBD).METHODS The data from 17 consecutive patients who underwent PTEBD for clearance of gallbladder stones were retrospectively analyzed. After removal of the CBD stones by percutaneous transhepatic balloon dilation(PTBD), the gallbladder stones were extracted to the CBD and pushed into the duodenum with a balloon after dilation of the sphincter of Oddi. Large stones were fragmented using a metallic basket. The patients were monitored for immediate adverse events including hemorrhage, perforation, pancreatitis, and cholangitis. During the two-year follow-up, they were monitored for stone recurrence, reflux cholangitis, and other longterm adverse events.RESULTS Gallbladder stones were successfully removed in 16(94.1%) patients. PTEBD was repeated in one patient. The mean hospitalization duration was 15.9 ± 2.2 d. Biliary duct infection and hemorrhage occurred in one(5.9%) patient. No severe adverse events, including pancreatitis or perforation of the gastrointestinal or biliary tract occurred. Neither gallbladder stone recurrence nor refluxing cholangitis had occurred two years after the procedure.CONCLUSION Sequential PTBD and PTEBD are safe and effective for patients with simultaneous gallbladder and CBD stones. These techniques provide a new therapeutic approach for certain subgroups of patients in whom endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy or surgery is not appropriate.

Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones

AIM To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct(CBD) stones.METHODS From April 2014 to May 2016, 15 consecutive patients(6 men and 9 women) aged 45-86(mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder. RESULTS All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain(n = 1), abdominal distension(n = 1), and fever(n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred. CONCLUSION For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.

Undifferentiated high-grade pleomorphic sarcoma of the common bile duct:A case report and review of literature

BACKGROUND Undifferentiated pleomorphic sarcoma(UPS)is a rare malignant mesenchymal tumor with a poor prognosis.It mainly occurs in the extremities,trunk,head and neck,and retroperitoneum regions.Owing to the lack of specific clinical manifestations and imaging features,UPS diagnosis mainly depends on pathological and immunohistochemical examinations for exclusive diagnosis.Here we report an extremely rare case of high-grade UPS in the common bile duct(CBD).There are limited available data on such cases.CASE SUMMARY A 70-year-old woman was admitted to our department with yellow eyes and urine accompanied by upper abdominal distending pain for 2 wk.Her laboratory data suggested significantly elevated hepatorenal function levels.The imaging data revealed calculous cholecystitis,intrahepatic and extrahepatic bile duct dilation with extrahepatic bile duct calculi,and a space-occupying lesion at the distal CBD.After endoscopic biliary stenting and symptomatic support therapy,CBD exploration and biopsy were performed.The frozen section indicated malignant spindle cell tumor of the CBD mass,and further radical pancreaticoduodenectomy was performed.Finally,the neoplasm was diagnosed as a high-grade UPS combined with the light-microscopic morphology and immunohistochemical results.CONCLUSION This extremely rare case highlighted the need for increasing physicians'vigilance,reducing the odds of misdiagnosis,and providing appropriate treatment strategies.

Results of Surgical Management of Malignant Obstruction of the Common Bile Duct in Yaoundé

Introduction: In Cameroon, surgery remains the only approach in malignant obstructions of the common bile duct (MOCBD) even in palliative situations. The aim of this work was to describe the modalities of surgical treatment of MOCBD, evaluate the results and detect the factors associated with postoperative morbidity and mortality. Patients and Methods: We conducted an analytical observational study, with retrospective data collection from the files of patients operated upon for MOCBD. This was done in four referral hospitals in the city of Yaoundé for a 42-month period spanning from January 1, 2020 to June 30, 2023. Demographic data, clinical presentation, surgical data, and 30-day postoperative outcomes were collected. Results: We collected 71 files. The sex ratio was 1.4 and the mean age was 56 ± 11 years. Fifty-three (53) patients (74.6%) were overweight or obese and 10 patients (14.1%) were hypertensive. A clinical cholestasis syndrome was present in 69 patients (97.2%). Fifty-five (55) patients (77.5%) had a cancer of the head of the pancreas, 8 patients (11.3%) had an extra-hepatic cholangiocarcinoma and 8 patients (11.3%) had an ampullary adenocarcinoma. Eight (8) resections (11.3%) with curative intent had been carried out and in 63 cases (88.7%), surgery was palliative. Postoperative morbidity was 55.7%, influenced by advanced WHO stage (p = 0.02). Postoperative mortality was 25.7%, associated with a high ASA score (p = 0.01). Conclusion: Pancreatic head cancer is the main etiology of malignant obstructions of the common bile duct in Cameroon. Surgical treatment is most often palliative. Postoperative morbidity and mortality are high, influenced by high WHO and ASA scores.

Risk factors for recurrence of common bile duct stones after surgical treatment and effect of ursodeoxycholic acid intervention

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal.Additionally,ursodeoxycholic acid(UDCA)can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concen-tration in bile.Despite these treatment options,there are still patients who experience stone recurrence.The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People’s Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected.According to the post-ERCP treatment plan,100 patients were classified into UDCA(n=47)and control(n=53)groups.We aimed to assess the clinical efficacy and rate of relapse in the two patient populations.We then collected information(basic demographic data,clinical characteristics,and serum biochemical indicators)and determined the factors contributing to relapse using logistic regression analysis.Our secondary goal was to determine the effects of UDCA on liver function after ERCP.Compared to the control group,the UDCA group demonstrated a higher clinical effectiveness rate of 92.45%vs 78.72%(P<0.05).No significant differences were observed in liver function indices,including total bilirubin,direct bilirubin,gamma-glutamyl transpeptidase,alanine aminotransferase,alkaline phosphatase,and aspartate aminotransferase,between the two groups before treatment.After treatment,all liver function indices were significantly reduced.Comparing the control vs UDCA groups,the UDCA group exhibited significantly lower levels of all indices(55.39±6.53 vs 77.31±8.52,32.10±4.62 vs 45.39±5.69,142.32±14.21 vs 189.63±16.87,112.52±14.25 vs 149.36±15.36,122.61±16.00 vs 171.33±22.09,96.98±10.44 vs 121.35±11.57,respectively,all P<0.05).The stone recurrence rate was lower in the UDCA group(13.21%)in contrast with the control group(44.68%).Periampullary diverticula(OR:6.00,95%CI:1.69-21.30),maximum stone diameter(OR:1.69,95%CI:1.01-2.85),stone quantity>3(OR:4.23,95%CI:1.17-15.26),and positive bile culture(OR:7.61,95%CI:2.07-27.91)were independent factors that influenced the relapse of common bile duct stones after ERCP(P<0.05).Furthermore,postoperative UDCA was identified as a preventive factor(OR:0.07;95%CI:0.08-0.09).CONCLUSION The intervention effect of UDCA after ERCP for common bile duct stones is adequate,providing new research directions and references for the prevention and treatment of stone recurrence.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND The incidence of cholelithiasis has been on the rise in recent years,but the choice of procedure is controversial.AIM To investigate the efficacy of laparoscopic cholecystectomy(LC)combined with endoscopic papillary balloon dilation(EPBD)in patients with gallbladder stones(GS)with common bile duct stones(CBDS).METHODS The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC+EPBD group(n=50)or an LC+endoscopic sphincterotomy(EST)group(n=52)according to surgical methods.Surgery-related indexes,postoperative recovery,postoperative complications,and expression levels of inflammatory response indexes were compared between the two groups.RESULTS Total surgical time,stone free rate,rate of conversion to laparotomy,and successful stone extraction rate did not differ significantly between the LC+EPBD group and LC+EST group.Intraoperative hemorrhage,time to ambulation,and length of hospitalization in the LC+EPBD group were lower than those of the LC+EST group(P<0.05).The rate of total complications of the two groups was 9.80%and 17.65%,respectively,and the difference was not statistically significant.No serious complications occurred in either group.At 48 h postoperatively,the expression levels of interleukin-6,tumor necrosis factor-α,high-sensitivity Creactive protein,and procalcitonin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).At 3 d postoperatively,the expression levels of aspartate transaminase,alanine transaminase,and total bilirubin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).CONCLUSION LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS,in which LC combined with EPBD is beneficial to shorten the patient’s hospitalization time,reduce the magnitude of elevated inflammatory response indexes,and promote postoperative recovery.

Safety and efficacy of percutaneous transhepatic balloon dilation in removing common bile duct stones:A systematic review

BACKGROUND Endoscopic sphincterotomy(EST) is widely regarded as the first choice in the management of common bile duct(CBD) stones. However, for some patients, this treatment is not possible. The percutaneous transhepatic balloon dilation(PTBD)technique has been suggested as an alternative but has yet to gain wide acceptance.AIM To review cases of PTBD for removing CBD stones and explore the safety and efficacy of this treatment.METHODS We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched EMBASE,PubMed, and Web of Science for cases of PTBD that underwent CBD stone removal from 1981 to January 2019. We analyzed all relevant articles available in full text. We extracted data on patient's age, gender, overall technique success rate, reasons for technique failure, and the presence and type of major and minor complications. We analyzed the data and reported the results in a table and text.Altogether, we retrieved 12 case series and 6 case reports, for a total of 1347 patients. Thirty cases were excluded due to a lack of patient data.RESULTS The overall technique success rate for removing a CBD stone was 98.5%(1327/1347) and 98.1%(109/111) for removing concurrent CBD and gallbladder stones. Based on available data(n = 1312), mean age of all patients(687 males and625 females) was 68.9 years. The total number of procedures in the remaining 1317 patients(after exclusion) was 3237(average 2.4 procedures per patient). The total number of failures for eliminating a CBD stone was 20, and the reasons for failure included: Stone impaction(n = 10), intrahepatic bile duct stricture(n = 5),large stone(n = 2), severe CBD dilation(n = 1), multiple stones(n = 1), and duodenal perforation(n = 1). Various major complications related to the procedure were reported, but the incidence rate was low(1.4%). No pancreatitis or procedure related mortality was reported. Minor complications including transient hyperamylasemia, nausea, vomiting, abdominal pain, fever, and mild hemobilia were reported. For 218 patients(88 patients with unsuccessful endoscopic removal due to anatomical change and large or impacted stone and130 cases who refused endoscopic procedure due to poor general condition or other additional disease), the CBD stones were successfully pushed into the duodenum by performing the PTBD procedure.CONCLUSION PTBD is a safe and effective approach in the nonoperative management of CBD stones. PTBD provides an alternative treatment when endoscopic procedures fail or are unsuitable for the patient.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones(CBDS)recommend stone removal,with endoscopic retrograde cholangiopan-creatography(ERCP)being the first treatment choice.When deciding on ERCP treatment for asymptomatic CBDS,the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared.The incidence rate of ERCP-related complications,particularly of post-ERCP pancreatitis for asymptomatic CBDS,was reportedly higher than that of symptomatic CBDS,increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases.Although studies have reported short-to middle-term outcomes of natural history of asymptomatic CBDS,its long-term natural history is not well known.Till date,there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not.No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach,suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS.Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Double common bile duct: A case report

Double common bile duct （DCBD） is a rare congenital anomaly in which two common bile ducts exist. One usually has normal drainage into the papilla duodeni major and the other usually named accessory common bile duct （ACBD） opens in different parts of upper gastrointestinal tract （stomach, duodenum, ductus pancreaticus or septum）. This anomaly is of great importance since it is often associated with biliary lithiasis, choledochal cyst, anomalous pancreaticobiliary junction （APBJ） and upper gastrointestinal tract malignancies. We recently recognized a rare case of DCBD associated with APB3 with lithiasis in better developed common bile duct. The opening site of ACBD was in the pancreatic duct. The anomaly was suspected by transabdominal ultrasonography and finally confirmed by endoscopic retrograde cholangiopancreatography （ERCP） followed by endoscopic sphincterotomy and stone extraction. According to the literature, the existence of DCBD with the opening of ACBD in the pancreatic duct is most frequently associated with APB3 and gallbladder carcinoma. In case of DCBD, the opening site of ACBD is of greatest clinical importance because of its close implications with concomitant pathology. The adequate diagnosis of this rare anomaly is significant since the operative complications may occur in cases with DCBD which is not recognized prior to surgical treatment.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy

Bile duct injuries(BDIs)are difficult to avoid absolutely when the biliary tract has a malformation,such as accessory hepatic duct.Here,we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9/146),1.37%(2/146),6.85%(10/146),and 0%(0/146),respectively;the mean postoperative hospital stay was 7.7±2.7 d.After propensity score matching,184 patients remained,and all preoperative covariates except diameter of CBD stones were balanced.Postoperative bile leak occurred in 11 patients overall(5.98%),and no difference was found between the small CBD group(4.35%,4/92)and the large CBD group(7.61%,7/92).The incidence of CBDS recurrence did not differ significantly between the small CBD group(2.17%,2/92)and the large CBD group(6.52%,6/92).CONCLUSION LC+LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with choledocholithiasis patients with large CBD.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery:An algorithmic approach

AIM:To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. METHODS:During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. RESULTS:Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). CONCLUSION:Management of major biliary fistulaethat are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Extrahepatic right hepatic duct diverticulum: a rare entity

BACKGROUND:Douglas described choledochal cysts in 1852 and Todani proposed an anatomy-based classification in 1977. The classification is the most extensively used,but does not include some rare variations.We present a case of hepatic duct diverticulum,one of the variations,and discuss its diagnosis and treatment. METHODS:A 57-year-old woman presented with upper abdominal pain and discomfort associated with nausea and vomiting.She was finally diagnosed with cholelithiasis and right hepatic duct diverticulum. RESULT:The patient underwent resection of the hepatic duct diverticulum and cholecystectomy,and was asymptomatic 26 months after surgery. CONCLUSIONS:Hepatic duct diverticulum is a rare form of choledochal cyst,not included in Todani’s classification. Todani’s classification including this and other uncommon variations of choledochal cysts must be reviewed.The best diagnostic imaging methods and treatment for choledochal cysts must be defined.

Should we redefi ne large common bile duct stone?

The definition of large stones is not clear ranging from 10 mm to 15 mm and does not include the lower common bile duct (CBD) diameter. Three hundred and four patients who underwent endoscopic retrograde cholangiopancreatography and stone extraction were retrospectively analyzed over a 1-year period. Sixteen patients were different from others in that 10 patients with large stones had stone extraction with a wire basket or a balloon catheter and 6 patients with small stones had stone extraction with mechanical lithotripsy. The defi nition of large stones should include diameter of the lower CBD and any stone in lower CBD with its diameter greater than 2 mm.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients:A technical review

Situs inversus(SI)is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs.Since the 1990s,more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy.In these cases,the major problem is to overcome is the left-right condition for right-handed surgeons.Laparoscopic common bile duct exploration(LCBDE),an alternative to treat patients with bile duct stones,has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography.Recent updated meta-analyses revealed that a shorter postoperative hospital stay,fewer procedural interventions,cost-effectiveness,a higher stone clearance rate,and fewer perioperative complications are additional advantages of LCBDE.However,the technique is technically demanding,even for skilled laparoscopic surgeons.Conducting LCBDE in patients with difficult situations,such as SI,is more complex than usual.We herein review published SI patients with choledocholithiasis treated by LCBDE,including our own experience,and this paper focuses on the technical aspects.