No abstract available.
Choledochostomy*

Postoperative biliary stricture is a relatively rare but serious complication of biliary surgery. Although Rouxen-Y hepaticojejunostomy or choledochojejunostomy are well-established and fundamental therapeutic approaches, their postoperative morbidity and mortality rates have been reported to be up to 33% and 13%, respectively. Recent studies suggest that percutaneous transhepatic intervention is an effective and less invasive therapeutic modality compared with traditional surgical treatment. Compared with fluoroscopic intervention, percutaneous with cholangioscopy may be more useful in biliary strictures, as it can provide visual information regarding the stricture site. We recently experienced two cases complete membranous occlusion of the bilioenteric anastomosis and successfully treated both patients using percutaneous transhepatic cholangioscopy.
Choledochostomy ; Cholestasis ; Constriction, Pathologic ; Humans ; Postoperative Complications

PURPOSE: The feasibility of a rat choledochojejunostomy (CJ) training model was investigated, as an introductory model to microsurgery for general surgeons. METHODS: Roux-en-Y CJ was performed on 20 rats. Interrupted 10-0 prolene sutures were used to perform CJ. The animals were observed for 7 days and sacrificed and examined. RESULTS: The rats were divided into 2 groups of 10 based on surgical order. The CJ time showed a significant decrease from 36.2 ± 5.6 minutes in group 1 to 29.4 ± 5.7 minutes in group 2 (P = 0.015). The bile leakage rate was 40% in group 1 and 10% in group 2. The survival time was 5.4 ± 2.2 days in group 1 and 7 days in group 2 (P = 0.049). CONCLUSION: The rat CJ training model is a feasible introductory model for general surgeons with no previous experience in microsurgery.
Animals ; Bile ; Choledochostomy* ; Microsurgery ; Polypropylenes ; Rats* ; Sutures

BACKGROUNDIt is difficult and time-consuming for carrying out conventional hand-sewn bilioenteric anastomosis, especially for small bile duct anastomosis and laparoscopic procedure. In order to simplify it, we have developed a novel procedure of sutureless bilioenteric anastomosis with an intraluminal degradable stent. This study aimed to evaluate the feasibility and safety of this technique with cholangioduodenostomy in dog model.

METHODSA patent intraluminal degradable stent tube for sutureless choledochoduodenostomy in dog model was made with polylactic acid in diameter of 3 mm or 4 mm. Thirty-eight dogs were randomly divided into to a stent group (SG, n = 20) and a control group (CG, n = 18). Dogs in the SG underwent sutureless choledochoduodenostomy with intraluminal stent, while the CG underwent conventional choledochoduodenostomy (single layer discontinuous anastomosis with absorbable suture). Dogs of each group were divided into 4 subgroups according to time of death (1, 3, 6, and 12 months postoperatively) to evaluate the healing of anastomosis. Operation time, intraoperative tolerance pressure of anastomosis, rate of postoperative bile leakage, bursting pressure of anastomosis were compared between the two groups. Anastomosis tissue was observed afterwards by pathology evaluation, hydroxyproline content, serum bilirubin, liver enzyme level and magnetic resonance cholangio-pancreatography (MRCP) to assess the stricture.

RESULTSAll procedures were completed successfully. The surgical time of the SG was significantly less than the CG (SG: (19.2 ± 4.3) minutes, vs. CG: (29.2 ± 7.1) minutes, P = 0.000). One bile leakage was occurred in either group. No significant difference of intraoperative tolerance pressure of anastomosis, rate of bile leakage and postoperative bursting pressure of anastomosis, anastomotic stricture, hydroxyproline content, serum bilirubin and liver enzyme level was found between the two groups. MRCP showed no anastomosis stricture and obstruction during months of follow-up.

CONCLUSIONThe technique of sutureless choledochoduodenostomy with a degradable intraluminal stent is feasible and a safe procedure in this dog model.

PURPOSE: The purpose of this study was to develop a porcine training model for laparoscopic choledochojejunostomy (CJ) that can act as a bridge between simulation models and actual surgery for novice surgeons. The feasibility of this model was evaluated. METHODS: Laparoscopic CJ using intracorporeal sutures was performed on ten animals by a surgical fellow with no experience in human laparoscopic CJ. A single layer of running sutures was placed in the posterior and anterior layers. Jejunojejunostomy was performed using a linear stapler, and the jejunal opening was closed using absorbable unidirectional sutures (V-Loc 180). RESULTS: The average operation time was 131.3 +/- 36.4 minutes, and the CJ time was 57.5 +/- 18.4 minutes. Both the operation time and CJ time showed a steady decrease with an increasing number of cases. The average diameter of the CBD was 6.4 +/- 0.8 mm. Of a total of ten animals, eight were sacrificed after the procedure. In two animals, a survival model was evaluated. Both pigs recovered completely and survived for two weeks, after which both animals were sacrificed. None of the animals exhibited any signs of bile leakage or anastomosis site stricture. CONCLUSION: The porcine training model introduced in this paper is an adequate model for practicing laparoscopic CJ. Human tissue simulation is excellent.
Animals ; Bile ; Choledochostomy* ; Constriction, Pathologic ; Humans ; Laparoscopy ; Running ; Sutures ; Swine

Endoscopic ultrasonography (EUS) combines endoscopy and intraluminal ultrasonography, and allows imaging with a high-frequency transducer over a short distance to generate high-resolution ultrasonographic images. EUS is now a widely accepted modality for diagnosing pancreatobiliary diseases. EUS-guided fine-needle aspiration (EUS-FNA) using a curved linear-array echoendoscope was initially described more than 20 years ago, and since then many researchers have expanded its indications to sample diverse lesions and have also used it for various therapeutic purposes. EUS-guided biliary drainage (EUS-BD) is one of the therapeutic procedures that has been developed using a curved linear-array echoendoscope. Technically, EUS-BD includes rendezvous techniques via transesophageal, transgastric, and transduodenal routes, EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS). Published data have demonstrated a high success rate, albeit with a comparatively high rate of nonfatal complications for EUS-CDS and EUS-HGS, and a comparatively low success rate with a low complication rate for the rendezvous technique. At present, these procedures represent an alternative to surgery or percutaneous transhepatic biliary drainage (PTBD) for patients with obstructive jaundice when endoscopic biliary drainage (EBD) has failed. However, these procedures should be performed in centers with extensive experience in linear EUS and therapeutic biliary ERCP. Large prospective studies are needed in the near future to establish standardized EUS-BD procedures as well as to perform controlled comparative trials between EUS-BD and PTBD, between rendezvous techniques and direct-access techniques (EUS-CDS and EUS-HGS), and between EBD and EUS-BD.
Biopsy, Fine-Needle ; Cholangiopancreatography, Endoscopic Retrograde ; Choledochostomy ; Dioxolanes ; Drainage ; Endoscopy ; Endosonography ; Fluorocarbons ; Humans ; Jaundice, Obstructive ; Transducers

Patients with pancreatic cancer frequently suffer from both biliary and duodenal obstruction. For such patients, both biliary and duodenal self-expandable metal stent placement is necessary to palliate their symptoms, but it was difficult to cross two metal stents. Recently, endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) was reported to be effective for patients with an inaccessible papilla. We report two cases of pancreatic cancer with both biliary and duodenal obstructions treated successfully with simultaneous duodenal metal stent placement and EUS-CDS. The first case was a 74-year-old man with pancreatic cancer. Duodenoscopy revealed that papilla had been invaded with tumor and duodenography showed severe stenosis in the horizontal portion. After a duodenal uncovered metal stent was placed across the duodenal stricture, EUS-CDS was performed. The second case was a 63-year-old man who previously had a covered metal stent placed for malignant biliary obstruction. After removing the previously placed metal stent, EUS-CDS was performed. Then, a duodenal covered metal stent was placed across the duodenal stenosis. Both patients could tolerate a regular diet and did not suffer from stent occlusion. EUS-CDS combined with duodenal metal stent placement may be an ideal treatment strategy in patients with pancreatic cancer with both duodenal and biliary malignant obstruction.
Aged ; Choledochostomy ; Constriction, Pathologic ; Diet ; Duodenal Obstruction ; Duodenoscopy ; Humans ; Middle Aged ; Pancreatic Neoplasms ; Stents

BACKGROUND/AIMS: The long-term results of Roux-en-Y procedure as a treatment for choledochal cyst or cholelithiasis were compared and analyzed. METHODS: A retrospective analysis was carried out for 70 patients (38 type 1 or type 4A choledochal cysts, 33 cholelithiasis) with ages ranging from 17 to 74 years who had undergone hepaticojejunostomy or choledochojejunostomy in a Roux-en-Y manner, with or without hepatectomy. RESULTS: Late complications related to the surgical procedure include cholangitis, recurrent stone, malignancy, abscess, and peptic ulcer disease. The late complication rate was 37.8% in the choledochal cyst group, and 27.3% in the cholelithiasis group. Cholangitis were found in 8.1% of the choledochal cyst group, and in 12.1% of the cholelithiasis group. Recurrent stones were found in 10.8% and 18.2%, respectively. A malignant tumor was found in each group, and both of them were not resectable. Peptic ulcers or erosions were found in 5 patients (13.5%) of the choledochal cyst group, but no one in the cholelithiasis group (p=0.056). CONCLUSION: Late complications after Roux-en-Y procedure in choledochal cyst or cholelithiasis are not uncommon and relatively serious. Long-term follow-up for the patients is mandatory, with attention being given to not only biliary symptoms, but also symptoms related to peptic ulcer disease.
Abscess ; Cholangitis ; Choledochal Cyst* ; Choledochostomy ; Cholelithiasis* ; Follow-Up Studies ; Hepatectomy ; Humans ; Peptic Ulcer ; Retrospective Studies

Sump syndrome is a rare late complication of choledochoenteric anastomosis, and this caused by the accumulation of food debris, choledocholithiasis, bile sludge and cholesterol crystals in the distal common bile duct. This syndrome is characterized by symptoms such as abdominal pain and fever. The treatment modality for this syndrome has been surgery in the past. However, endoscopic treatment such as endoscopic sphinterotomy is currently regarded as the primary therapeutic approach for this condition. We experienced a patient with a history of choledochoduodenostomy and who developed sump syndrome as a complication of the surgery. Endoscopic sphinterotomy was performed for treatment, but this only produced the recurrence of the disease. The recurrent sump syndrome was eventually successfully controlled by performing endoscopic papillary balloon dilatation.
Abdominal Pain ; Bile ; Choledocholithiasis ; Choledochostomy ; Cholesterol ; Common Bile Duct ; Dilatation ; Fever ; Humans ; Postcholecystectomy Syndrome ; Recurrence ; Sewage

PURPOSE: We recently experienced 3 consecutive cases of bile peritonitis due to tract rupture following T-tube removal at about 6 weeks after choledocholithotomy with using a new tube (1.1% silica-filled rubber). These unexpected cases of bile peritonitis have raised questions related to the tube material factor for the rupture. The aim of this study was to compare three kinds of T-tubes [ (100% silicone (SIL), 1.1% silica-filled rubber (SFR), and 100% rubber (RUB) ] from the point of view of fistula maturation as is related to the physicochemical properties of the tube materials. METHODS: SIL, SFR and RUB tubes were implanted into the subcutaneous space in rats. Histologically, the degree of fistula maturation was estimated by an inflammation score, the thickness of inflammation and the fibrosis. The physical properties of the tube materials were estimated by their modulus and elasticity. RESULTS: SFR and RUB tube had no statistically significant difference for the thickness of the inflammation and fibrosis. Yet there were difference in their modulus and elasticity. The modulus, elasticity, thickness of the inflammation and the fibrosis were difference in the SIL versus SFR and the SIL versus RUB. CONCLUSION: There were no statistically significant differences in the degree of fistula maturation between the SFR and RUB tubes. The rubber tube tended to show a more severe inflammatory reaction and better maturation of the fistula. Moreover, the flexibleness of the RUB tube make easy to experience collapse of the tube. The degree of maturation mostly depends upon the chemical property of the tube materials. However, the tract rupture that happens is due to the physical properties rather than the chemical properties of the tube. We recommend RUB for the T-tube to prevent the tube related complication such as tract rupture.
Animals ; Bile ; Choledochostomy ; Elasticity ; Fibrosis ; Fistula* ; Inflammation ; Latex ; Peritonitis ; Rats ; Rubber ; Rupture ; Silicones