No abstract available.
Choledochostomy*

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 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

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 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

Xanthogranulomatous cholecystitis(XGC) is a rare, benign, destructive, inflammatory process of the gallbladder that is believed to be a variant of chronic cholecystitis. The gross and microscopic appearances are characteristic with multiple intramural nodules composed of foamy histiocytes and inflammatory cells. Clinically, radiologically and morphologically, XGC sometimes is confused with a malignant neoplasm. In a retrospective twelve year study, 20 cases of XGC were found in 2007 gallbladders (0.99%) and we have been reviewed the characteristic features of it. In 8 patients(40%) XGC sufficiently resembled carcinoma of the gallbladder for the radiological study and surgeon. Gallstones were found in 14 cases(70%). Associated malignancy were 2 cases : one in distal CBD and one in head of pancreas but, there was no coexisted carcinoma of the gallbladder. Complete cholecystectomy was done in 12 cases(60%) and partial cholecystectomy was performed in 7 cases(35%). One underwent T-tube choledochostomy only for suspectd carcinoma of the gallbladder, which subsequently proved to be XGC. In conclusion, appearances often mimicked carcinoma of the gallbladder at laparotomy with xanthogranulomatous tissue extending to adjacent structures. So the possibility should be considered that an `inoperable tumor' of the gallbladder may be in fact XGC, a benign condition that frozen-section biopsy may confirm. If XGC was suspected at operation or confirmed at frozen-section biopsy, coincident carcinoma may still be present. Management of XGC should therefore include choloecystectomy and excision of adjacent xanthogranulomatous tissue and any fistula.
Biopsy ; Cholecystectomy ; Cholecystitis* ; Choledochostomy ; Fistula ; Gallbladder ; Gallstones ; Head ; Histiocytes ; Laparotomy ; Pancreas ; Retrospective Studies

Choledochal cyst has only rarely been encountered in association with pregnancy. The clinical manifestations are nonspecific and variable that makes it difficult to differentiate from physiologic changes in pregnancy. Consequently, diagnosis is often delayed until patients present with life-threatening complications. During pregnancy, symptoms of choledochal cyst may be developed by hormonal changes and the enlarged uterus. Because of the risk of fetal mortality and maternal morbidity, definitive surgical treatment should be delayed and step-by-step management should be carefully implemented to avoid complication until delivery. Herein, we report a case of enlarged, symptomatic choledochal cyst that developed in a 26-year-old pregnant woman. The temporal relationship between pregnancy and symptom development, as well as the biliary sludge formation in the enlarged cyst, suggest that the choledochal cyst was influenced by pregnancy. In order to buy time for fetal maturation, endoscopic ultrasonography-guided choledochoduodenostomy was performed for biliary decompression as a bridge to surgical excision.
Adult ; Bile ; Choledochal Cyst* ; Choledochostomy* ; Decompression ; Diagnosis ; Endosonography ; Female ; Fetal Mortality ; Humans ; Pregnancy* ; Pregnant Women ; Uterus

Percutaneous transhepatic biliary drainage (PTBD) is an established procedure for biliary obstruction. However, duodenobiliary or jejunobiliary reflux of the intestinal contents through a PTBD catheter sometimes causes recurrent catheter obstruction or cholangitis. A 64-year-old female patient with a history of choledochojejunostomy was referred to our department with acute cholangitis due to choledochojejunal anastomotic obstruction. Emergent PTBD was performed, but frequent obstructions of the catheter due to the reflux of intestinal contents complicated the post-PTBD course. We therefore introduced a catheter with an antireflux mechanism to prevent jejunobiliary reflux. A commercially available catheter was modified; side holes were made at 1 cm and 5 to 10 cm (1 cm apart) from the tip of the catheter, and the catheter was ligated with a nylon thread just proximal to the first side hole. Using this novel "antireflux PTBD technique," jejunobiliary reflux was prevented successfully, resulting in a longer patency of the catheter.
Catheter Obstruction ; Catheters ; Cholangitis ; Choledochostomy ; Dioxolanes ; Drainage ; Female ; Fluorocarbons ; Gastrointestinal Contents ; Humans ; Nylons

Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy.
Bile Ducts ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Choledochostomy ; Dioxolanes ; Drainage ; Fluorocarbons ; Hand ; Humans

PURPOSE: After performing pylous-preserving pancreaticoduodenectomy, there are several methods of performing pancreaticojejunostomy for preventing pancreatic leakage. The purpose of this study was to compare the results of two methods of jejunal anastomosis after pancreaticojejunostomy. METHODS: We retrospectively evaluated the clinical results of 49 patients who had received pancreaticojejunostomy for pylous-preserving pancreaticoduodenectomy. One method is the Billroth-I type, that is, choledochojejunostomy and pancreaticojejunostomy after anastomosis of one jejunum loop to the duodenum. The other method is the Roux-En-Y (R-Y) type. Choledochojejunostomy and pancreaticojejunostomy are done with an isolated jejunum loop. Then gastrojejunostomy is fashioned between the stomach and the distal jejunal segment. Finally, the end-to-side jejunojejunostomy is created. RESULTS: The Billroth-I type was used in 17 patients and the R-Y type was used in 32 patients. The median operation time was 397 min and 431 min, respectively. The median postoperative hospital day was 27.6 days and 22.1 days, respectively. The postoperative complications were 10 cases in 17 patients (58.8%) and 11 cases in 32 patients (34.4%), respectively. Leakage of the pancreaticojejunostomy was the most common complication in each group (23.5% and 15.6%, respectively). Most complications required no need surgical intervention. But two cases of Billroth-I type complications needed total pancreatectomy because of leakage of the pancreaticojejunostomy. CONCLUSION: Not only were there fewer complications for the R-Y type than for the Billroth-I type, but there was no need for operation to treat the complications of the R-Y type because of the isolated jejunal loop.
Choledochostomy ; Duodenum ; Gastric Bypass ; Humans ; Jejunum ; Pancreatectomy ; Pancreaticoduodenectomy ; Pancreaticojejunostomy ; Postoperative Complications ; Retrospective Studies ; Stomach