Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrenceassociated risk factors

BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones(EHBDSs)in clinical practice.AIM To explore the curative effect of laparoscopic cholecystectomy(LC)plus common bile duct exploration(CBDE)for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.METHODS Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected.Among them,patients treated with open choledocholithotomy plus LC or open cholecystectomy(OC)were set as the control group(n=40),and those treated with LC plus CBDE served as the observation group(n=42).The surgical outcomes of the two groups were compared,the surgical complications and Gas-trointestinal Quality of Life Index(GIQLI)scores were counted,and the one-year prognostic recurrence was recorded.Independent factors for postoperative re-currence were determined using univariate and multivariate analyses.RESULTS The two groups were comparable in the stone residual rate(P>0.05).The ope-ration time(P<0.05),intraoperative bleeding(P<0.05),and total complication rate(P=0.005)were lower in the observation group than in the control group.The observation group exhibited a marked increase in the GIQLI score,which was higher than the control group(P<0.05).A lower one-year recurrence rate was determined in the observation group vs the control group(P=0.027).Sphincter of Oddi dysfunction[odds ratio(OR)=5.712,P=0.007]and the treatment scheme of open choledocholithotomy plus LC or OC(OR=6.771,P=0.008)were the independent risk factors for one-year recurrence in patients after surgery.CONCLUSION LC plus CBDE for patients with EHBDSs can reduce stone residuals,intraoperative bleeding,complications,and postoperative recurrence.

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.

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.

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.

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.

Hem-o-lok clip migration to the common bile duct after laparoscopic common bile duct exploration:A case report

BACKGROUND Laparoscopic cholecystectomy(LC)and laparoscopic common bile duct exploration(LCBDE)has been widely used for management of gallbladder and common bile duct(CBD)stones.Post-operative clip migration is a rare complication of laparoscopic biliary surgery,which can serve as a nidus for stone formation and cause recurrent cholangitis.CASE SUMMARY A 59-year-old female was admitted to hospital because of fever and acute right upper abdominal pain.She has a history of LC and had a LCBDE surgery 2 mo ago.Physical examination revealed tenderness in the upper quadrant of right abdomen.Computed tomography scan demonstrated a high-density shadow at the distal CBD,which was considered as migrated clips.The speculation was confirmed by endoscopic retrograde cholangiopancreatography examination,and two displaced Hem-o-lok clips were removed with a stone basket.No fever or abdominal pain presented after the operation.In addition to the case report,literature regarding surgical clip migration after laparoscopic biliary surgery was reviewed and discussed.CONCLUSION Incidence of postoperative clip migration may be reduced by using clips properly and correctly;however,new methods should be explored to occlude cystic duct and vessels.If a patient with a past history of LC or LCBDE presents with features of sepsis and recurrent upper quadrant pain,clip migration must be considered as one of the differential diagnosis.

Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis:A systematic review and meta-analysis

Background： Common bile duct （CBD） stones may occur in up to 3%–14.7% of all patients with cholecystectomy.Various approaches of laparoscopic CBD exploration plus primary duct closure （PDC） are the most commonly used and the best methods to treat CBD stone. This systematic review was to comparethe effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC forcholedocholithiasis

Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.

Clinical Application of Primary Suture Following Three-Port Laparoscopic Common Bile Duct Exploration: A Report of 176 Cases

Objective: To investigate the feasibility, safety and the clinical value of primary suture following 3-port laparoscopic common bile duct exploration (LCBDE). Methods: From January 2012 to September 2014, 176 patients suffered from choledocholithiasis were treated with primary suture following 3-port LCBDE and the clinical data were retrospectively analyzed. Results: All cases were operated successfully and none was converted to open surgery. The duration of operation was 92.2 ± 18.8 min and the length of postoperative hospital stay was 4.4 ± 3.7 d. Postoperative bile leakage occurred in 2 cases and these patients recovered by simple drainage for 3 to 7 days without re-operation. All patients recovered smoothly without any serious complications. Conclusions: Primary suture following 3-port LCBDE is safe, effective and mini-invasive, which is worthy of further clinical application.

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.

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.

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.

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.

Cholangioscopy-assisted extraction through novel papillary support for small-calibre and sediment-like common bile duct stones

BACKGROUND To date,endoscopic retrograde cholangiopancreatography has become a wellestablished treatment for common bile duct(CBD)stones.However,it is not suitable for some special patients,such as pregnant women,children or those who cannot stop taking anti-coagulation/anti-platelet agents because of radiation injury and the risk of postoperative bleeding resulting from endoscopic sphincterotomy.To overcome these two problems,this study introduced cholangioscopy-assisted extraction through a novel papillary support for small-calibre and sediment-like CBD stones.AIM To assess the feasibility and safety of cholangioscopy-assisted extraction through a novel papillary support(CEPTS)for small-calibre and sediment-like common bile duct(CBD)stones.METHODS This Retrospective study was approved by the Ethics Committee of the Chinese PLA General Hospital.We designed a covered single dumbbell-style papillary support between 2021 and 2022.Between July 2022 and September 2022,7 consecutive patients with small-calibre(cross diameter≤1.0 cm)or sediment-like CBD stones underwent CETPS procedures in our center.The clinical characteristics and treatment outcomes of these 7 patients were extracted from a prospectively collected database.And the related data were analyzed.Informed consent was obtained from all participating patients.RESULTS A total of 2 patients had yellow sediment-like CBD stones,and aspiration extraction was performed after the insertion of papillary support.Of the 5 patients with clumpy CBD stones(0.4-1.0 cm),2 underwent basket extraction under direct vision for a single stone(0.5-1.0 cm,black and black grey),1 underwent balloon plus aspiration extraction under direct vision for 5 stones(0.4-0.6 cm,brown),and 2 underwent aspiration extraction only for a single stone(0.5-0.6 cm,yellow,none).Technical success,namely,no residual stones in the CBD or left and right hepatic ducts,was achieved in all 7 cases(100%).The median operating time was 45.0 minutes(range 13.0–87.0 minutes).Postoperative pancreatitis(PEP)occurred in one case(14.3%).Hyperamylasaemia without abdominal pain was noted in 2 of 7 patients.No residual stones or cholangitis were found during the follow-up.CONCLUSION CETPS appeared to be feasible to treat patients with small-calibre or sediment-like CBD stones.Patients,especially pregnant women and those who cannot stop anticoagulation/anti-platelet agents,could benefit from this technique.

Expression and functional study of cholecystokinin-A receptors on the interstitial Cajal-like cells of the guinea pig common bile duct

BACKGROUND Many studies have shown that interstitial Cajal-like cell(ICLC)abnormalities are closely related to a variety of dynamic gastrointestinal disorders.ICLCs are pacemaker cells for gastrointestinal movement and are involved in the transmission of nerve impulses.AIM To elucidate the expression profile and significance of cholecystokinin-A(CCK-A)receptors in ICLCs in the common bile duct(CBD),as well as the role of CCK in regulating CBD motility through CCK-A receptors on CBD ICLCs.METHODS The levels of tyrosine kinase receptor(c-kit)and CCK-A receptors in CBD tissues and isolated CBD cells were quantified using the double immunofluorescence labeling technique.The CCK-mediated enhancement of the movement of CBD muscle strips through CBD ICLCs was observed by a muscle strip contraction test.RESULTS Immunofluorescence showed co-expression of c-kit and CCK-A receptors in the CBD muscularis layer.Observations of isolated CBD cells showed that c-kit was expressed on the surface of ICLCs,the cell body and synapse were colored and polygonal,and some cells presented protrusions and formed networks adjacent to the CBD while others formed filaments at the synaptic terminals of local cells.CCK-A receptors were also expressed on CBD ICLCs.At concentrations ranging from 10^(-6) mol/L to 10^(-10) mol/L,CCK promoted CBD smooth muscle contractility in a dose-dependent manner.In contrast,after ICLC removal,the contractility mediated by CCK in CBD smooth muscle decreased.CONCLUSION CCK-A receptors are highly expressed on CBD ICLCs,and CCK may regulate CBD motility through the CCK-A receptors on ICLCs.

Carcinosarcoma of common bile duct:A case report

BACKGROUND Carcinosarcomas of the common bile duct(CBD)are an extremely rare finding in the clinical setting.Based on a review of 12 literatures,3 cases had the imaging features of ossification.Carcinosarcomas are prone to distant metastasis,as they possess clinical features of both carcinoma and sarcoma,and generally have with a poor prognosis.Due to the small number of cases reported,clinical experience in the diagnosis and treatment of the disease is lacking.CASE SUMMARY The patient was a 75-year-old woman who had experienced recurrent chills with nausea and vomiting for 3 mo.Computed tomography,magnetic resonance imaging,endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography led to the diagnosis of malignant tumor of the CBD.The patient ultimately underwent cholecystectomy,CBD resection,and choledochojejunostomy.Postoperative pathological examination revealed carcinosarcoma of the CBD,and the latest follow-up showed that the patient is recovering well.Based on previous case reports,some carcinosarcoma has ossification characteristics in imaging.If it is misdiagnosed as biliary calculi,the use of laser lithotripsy in surgery may lead to tumor diffusion.Choledochoscopy and narrow band staining of mucosa are very important for diagnosis.CONCLUSION We herein present a rare case of carcinosarcomas of the CBD,we found the tumours may have imaging features of polypoid growth and ossification only when the sarcomal components are bone differentiation,while show soft tissue shadow when non bone differentiation.Confirmation of diagnosis depends greatly upon postoperative pathological examination and the adjuvant treatment has not been established,which leads to the poor prognosis.

Severe liver trauma with complex portal and common bile duct avulsion:A case report and review of the literature

BACKGROUND Given its size and location,the liver is the third most injured organ by abdominal trauma.Thanks to recent advances,it is unanimously accepted that the nonoperative management is the current mainstay of treatment for hemodynamically stable patients.However,those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management.Moreover,an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability,thereby imposing therapeutic challenges in the tertiary referral hepato-biliopancreatic centers’setting.CASE SUMMARY We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion,due to a crush polytrauma.The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock,damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery,and hemostatic packing.Afterwards,the patient was referred immediately to our tertiary hepato-bilio-pancreatic center.We performed depacking,a right hepatectomy and Roux-en-Y hepaticojejunostomy.On the 9th postoperative day,the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy.The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure.The follow-up was optimal,with no complications at 55 mo.CONCLUSION In conclusion,the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management,conducted in a tertiary referral hepato-bilio-pancreatic center,where a stepwise and complex surgical approach is mandatory.

Biliary hemorrhage caused by a malignant small round cell tumor in the common bile duct:A case report

BACKGROUND Malignant small round cell tumor(MSRCT)metastasis to the common bile duct associated with recurrent biliary hemorrhage is extremely rare.Thus far,there have been no reports of metastatic small round cell tumors of the common bile duct.CASE SUMMARY Herein,we report the case of a 77-year-old female patient with an MSRCT in the common bile duct.The patient was admitted to hospital due to gastrointestinal hemorrhage and abdominal pain.We found a neoplasm in the common bile duct with active bleeding through a spyglass.We performed biopsy through the spyglass and placed a metal stent to stop bleeding.The pathological result suggested that it was an MSRCT metastasized from the back to the common bile duct.Later,we found using fluorescence in situ hybridization that the SS18 gene break test was negative,ruling out the diagnosis of synovial sarcoma.CONCLUSION MSRCT is a group of tumors with similar cell morphology and diffuse histological structure.Complete tumor resection results in improved survival in patients with MSRCT.Roux-en-Y cholangiojejunostomy was performed.After excision of the common bile duct tumor,the patient felt that the abdominal pain improved and hemorrhage disappeared.The patient underwent routine fecal examination one month after surgery,indicating a negative fecal occult blood test.On May 22,2023,the patient was reexamined by abdominal computed tomography,and no abdominal space occupying lesions or abdominal lymphadenopathy was found.

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.