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Cholangiogram depicting a large amount of intrahepatic duct stones secondary to recurrent pyogenic cholangitis
Source publication
Over 30% of all endoscopic retrograde cholangiography procedures in the US are associated with biliary stone extraction, and over 10–15% of these cases are noted to be complex or difficult. The aim of this review is to define the characteristics of difficult common bile duct stones and provide an algorithmic therapeutic approach to these difficult...
Citations
... A meta-analysis involving 1545 patients suggested [10] that the LCBDE group was superior to the ERCP concurrent LC group in terms of the complication rate, stone recurrence rate and hospitalization cost. Another meta-analysis involving 5 pieces of literature and 860 patients [11] suggested that in addition to the increased bile leakage rate, the LCBDE group was superior to the ERCP concurrent LC group in the rate of stone clearance, complications and enhanced recovery after surgery (ERAS). So why is LCBDE still not the gold standard for the treatment of cholecystolithiasis with extrahepatic cholangiolithiasis? ...
Objective
To compare the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration and lithotomy (LCBDE) in the treatment of cholecystolithiasis combined with bile duct stones.
Methods
From September 2018 to January 2022, 195 patients with cholecystolithiasis complicated with extrahepatic bile duct stones from Department of Department of General Surgery, Shanghai Jiading Central Hospital met the inclusion criteria, including 60 cases in the LC group and 86 cases in the LCBDE group. The general condition, operation success rate, complications and residual stone rate of the two groups were retrospectively analyzed.
Results
In the simultaneous operation group, 58 patients successfully performed ERCP, and the indwelling rate of the abdominal drainage tube (41.7 % vs. 95.3 %) was significantly better than that in the LCBDE group. There was no significant difference in the conversion rate to open surgery, operation time, and intraoperative blood loss between the two groups. In the simultaneous surgery group, 4 patients (6.7 %) developed pancreatitis after ERCP, which was cured by conservative treatment. The pain score at 6 h after operation was significantly lower than that in the LCBDE group (3.9 ± 1.6 vs 6.5 ± 2.4). There were no significant differences in biliary leakage (1.7 % vs. 4.7 %), postoperative cholangitis (5.0 % vs. 5.8 %), incision infection (3.3 % vs. 3.5 %), and bile duct stone residue rate (5.0 % vs 3.5 %) between the two groups. There was no severe pancreatitis, second operation or death. The duration of hospital stay was shortened in the concurrent operation group (5.1 ± 2.3d vs 7.9 ± 3.7d), and the operation cost was significantly higher than that in the LCBDE group (48839.9 ± 8549.5 vs 34635.9 ± 5893.7 yuan).
Conclusion
ERCP combined with LC and LCBDE are both safe and effective methods for the treatment of cholecystolithiasis combined with extrahepatic bile duct stones. The simultaneous operation group has certain advantages in patient comfort and rapid rehabilitation, which can be popularized in qualified units.
... Choledocholithiasis and cholecystolithiasis often cause bile duct obstruction and inflammatory lesions. Approximately 10% to 20% of individuals with gallstones also have concurrent choledocholithiasis [4]. There is a high risk of morbidity and potential mortality from cholangitis or pancreatitis induced by obstructive choledocholithiasis; thus, current guidelines recommend biliary stone extraction for all identified choledocholithiasis, regardless of symptoms [5]. ...
Patient: Female, 79-year-old
Final Diagnosis: Dichlorvo-induced pyloric obstruction
Symptoms: Epigastric pain • mental apathy • vomiting
Clinical Procedure: Braun anastomosis • cholecystectomy • choledocholithotomy • gastrojejunostomy • one-stage suture of common bile duct
Specialty: Gastroenterology and Hepatology • Psychiatry • Surgery • Toxicology
Objective
Unusual clinical course
Background
Pyloric obstruction after dichlorvos poisoning causes repeated vomiting and inability to eat. Choledocholithiasis and cholelithiasis are the common digestive diseases, with high morbidity and relapse in elderly patients. However, the complex situation of these diseases’ coexistence is a clinically intractable problem, and literature on selecting optimal surgical planning is scarce.
Case Report
A thin 79-year-old woman took dichlorvos due to family conflicts. She improved after being urgently sent to local hospital for gastric lavage and detoxification. Over the next 3 months, she presented with intermittent nausea, vomiting, epigastric pain, and mental apathy, and was readmitted. Gastroscopy showed extensive scarring in the antrum, pyloric obstruction, and gastric retention. Magnetic resonance cholangiopancreatography revealed gallstones and choledocholithiasis. Also, she presented with gastric retention, hypertension, moderate anemia, hypoproteinemia, and electrolyte disturbances. After hospitalization, conservative treatment was performed, without improving vomiting, followed by surgical treatment. Gastrojejunostomy, Braun anastomosis, and nasojejunal feeding tube placement were performed for pyloric stenosis; cholecystectomy for cholelithiasis; and choledochotomy, intraoperative choledochoscopy examination, basket stone extraction, and primary suture of common bile duct without indwelling T tube for choledocholithiasis. Patient recovered and was discharged 9 days after surgery. She was recovered well, without vomiting, at 2-month follow-up.
Conclusions
Gastrojejunostomy plus Braun anastomosis is effective treatment of elderly patients with pyloric obstruction formed after pesticide-induced corrosion. Careful selection of choledocholithotomy with primary suture without indwelling T tube reduced postoperative pain and accelerated recovery. This complex case of pyloric obstruction with gallbladder and bile duct stones provides useful considerations for clinical treatment.
... Our case serves as a compelling example of the expanding role of endoscopy in replacing traditional redo-surgical approaches for gastro-intestinal post-surgical complications [1][2][3][4]. While cholangioscopy is a valuable additional treatment option for indeterminate biliary stenosis and biliary stone removal [5][6][7][8][9][10][11][12][13][14][15], its unavailability at our Endoscopy Unit during the procedure necessitated the use of the traditional technique. ...
In all reported cases of foreign body migration or impaction in the biliary tree, there is no mention of the presence of hypereosinophilia among the laboratory findings. This could possibly be attributed to the local tissue reaction caused by the impacted foreign body. Here, we present our experience with the removal of a screw from a surgical retractor that became lodged in the common bile duct (CBD) and migrated in a patient who had previously undergone a left lateral hepatectomy for hepatic hydatidosis. The imaging was not sufficient to make a diagnosis, and the interpretation of hypereosinophilia in such a case could pose a challenge.
... It is a common biliary disease in Gland Surg 2023;12 (5) clinical practice, mainly manifesting as high fever, colic, radiating back pain, chills, and jaundice, etc. It can have a serious impact on patients' quality of life and physical and mental health (17,18). Surgery is still the first choice for clinical treatment of CBDSs (19). ...
Background:
Endoscopic retrograde cholangiopancreatography (ERCP) is an emerging option in the management of common bile duct stones and has a high success rate for biliary stone extraction. However, due to the lack of knowledge and understanding of this technique, some patients often experience varying degrees of anxiety and depression. There is little research on the factors associated with negative emotions. This study aimed to investigate the risk factors for negative emotions in choledocholithiasis patients treated with ERCP and the impact on prognosis to provide a reference for improving patients' prognosis.
Methods:
We analyzed the data of 364 patients with choledocholithiasis treated with ERCP at our hospital between July 2019 and June 2022. Patients' emotional state was assessed using the SAS and SDS scales. The t-test and chi-square test were used to analyze the relationship between patients' negative emotions and prognosis. The patient's prognosis was assessed at one month postoperatively using the SF-36 scale. Binary logistic regression and multiple linear regression were used to analyze the independent risk factors for negative emotions and prognosis in patients.
Results:
In this study, the prevalence of anxiety was 10.4%, the prevalence of depression was 8.8% and the prevalence of negative emotions was 15.4%. Binary logistic regression analysis showed that gender [odds ratio (OR) =0.379, P=0.023], fertility status (OR =0.164, P=0.032), monthly household income (OR =0.180, P=0.001) and so on were independent risk factors for the anxiety. Fertility status (OR =0.173, P=0.038), marital status (OR =0.210, P=0.043), TBIL on the first postoperative day (OR =1.079, P=0.002) and so on were independent risk factors for depression. Multiple linear regression analysis revealed that the presence of negative emotions (P=0.001) was an important risk factor for prognosis.
Conclusions:
Patients with choledocholithiasis treated with ERCP are prone to anxiety, depression and other psychological disorders. Therefore, clinical work should not only focus on the patient's condition, but also pay attention to the patient's family situation and emotional changes, and give timely psychological counselling and prevent complications, reduce the patient's suffering and improve the patient's prognosis.
... 1,5 > OBJETIVOS Ao final da leitura deste capítulo, o leitor será capaz de ■ descrever as estratégias atuais disponíveis para o tratamento cirúrgico dos casos considerados difíceis ou complexos de coledocolitíase; ■ discutir as opções de tratamento cirúrgico de coledocolitíase; ■ descrever as abordagens a respeito das situações nas quais todos os recursos não operatórios -colangiopancreatografia retrógrada endoscópica (CPRE), radiointervenção, litotripsia, coledocoscopia etc. -já foram tentados e não lograram êxito, ou, então, não se encontram prontamente disponíveis para utilização no contexto em questão. 13 Outra questão que não pode ser menosprezada refere-se à disponibilidade da CPRE, que não é geograficamente homogênea, uma vez que o acesso a esse tipo de procedimento é comumente mais simples em grandes centros urbanos em detrimento de localidades mais distantes. Estima-se que, no Brasil, sejam realizados cerca de três procedimentos de CPRE por 100 mil habitantes a cada ano, índice muito abaixo do ideal. ...
Ao final da leitura deste capítulo, o leitor será capaz de
■ descrever as estratégias atuais disponíveis para o tratamento cirúrgico dos casos
considerados difíceis ou complexos de coledocolitíase;
■ discutir as opções de tratamento cirúrgico de coledocolitíase;
■ descrever as abordagens a respeito das situações nas quais todos os recursos não
operatórios — colangiopancreatografia retrógrada endoscópica (CPRE), radiointervenção,
litotripsia, coledocoscopia etc. — já foram tentados e não lograram êxito, ou, então, não
se encontram prontamente disponíveis para utilização no contexto em questão.
Aim
Vulvar dermatoses are heterogeneous group consisting of inflammatory
infectious malignant lesions and pigmentary changes For all these reasons diagnosis
and classification of vulvar lesions pose difficulties for both gynecologists and
dermatologists The aim of this study is to determine the relative frequency of vulvar
lesions confirmed by histopathologic examination of biopsy samples in our clinic
Methods
In this retrospective study the data of 579 patients who underwent vulvar
biopsy in Izmir Kâtip Celebi University University Atatürk Training and Research
Hospital between 2012 2022 were evaluated Vulvar dermatoses were classified
according to histopathological results
Results
The most common vulvar lesion was lichen sclerosus et atrophicus 19 3
followed by condyloma acuminata 18 6 lichen simplex chronicus 9 8 and
squamous hyperplasia 9 1 Nonspecific histopathological findings like
hyperkeratosis and acanthosis were detected in 7 5 of the cases
Conclusion
Clinical diagnosis of vulvar dermatoses and differential
diagnosis of neoplastic and inflammatory diseases may be compelling for
clinicians Since vulvar benign and malignant diseases have similar
symptoms such as itching histopathological diagnosis revealed by vulvar
biopsy in the differential diagnosis of these cases is important in the
management and treatment of cases For this reason pathologists who
specialized in the diagnosis of vulvar pathologies play a critical role in the
management of vulvar diseases
The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.
Common bile duct stones (CBDS) are the most common cause of acute cholangitis. Removal by endoscopic retrograde cholangiopancreatography became the standard of care after endoscopic sphincterotomy was introduced. On the other hand, it is still difficult to remove 10-15% of CBDS completely in the first attempt for various reasons. This review describes the methods for the complete endoscopic clearance of CBDS, including difficult cases, reflecting the latest knowledge and techniques.
