Background and Aims:Complex choledocholithiasis often coexists with stenosis of the ampulla of Vater,which increases the difficulty and complexity of treatment.If only the stones in the bile duct are removed without addressing the ampullary stenosis,the disease is prone to recurrence.Previously,most treatments involved the use of endoscopic retrograde cholangiopancreatography(ERCP)to guide the wire for sphincterotomy and stone extraction,followed by laparoscopic cholecystectomy.However,ERCP has limitations in handling complex cases.In response,our team pioneered a new method of treating choledocholithiasis combined with stenosis of the ampulla of Vater via a transabdominal approach.This study was performed to investigate the feasibility and efficacy of this method,aiming to provide a new therapeutic option for clinical practice.Methods:A randomized controlled study was conducted with 120 patients treated at Chengdu Second People's Hospital from 2021 to 2023 for gallbladder stones and choledocholithiasis with stenosis of the ampulla of Vater.Patients were divided into an observation group and a control group,with 60 cases in each group.The observation group underwent laparoscopic cholecystectomy with choledochotomy for stone extraction,followed by retrograde guidance of duodenal papillary sphincterotomy through the opened bile duct,simultaneously treating gallbladder,bile duct stones,and stenosis of the ampulla of Vater.The control group underwent traditional ERCP approach for sphincterotomy,stone extraction,and laparoscopic cholecystectomy.Perioperative variables were collected for both groups and the surgical outcomes were compared.Results:Among the 120 patients,54 were male and 66 were female.There were no statistically significant differences between the two groups in terms of stone extraction success rate,intraoperative blood loss,postoperative 24-h total bilirubin,direct bilirubin,transaminases,white blood cell count,jaundice relief time,or incidence rates of bile leakage,retroperitoneal bleeding/infection,and severe pancreatitis(all P>0.05).The observation group had significantly shorter average operative time and postoperative hospital stay compared to the control group(98.67 min vs.110.8 min,P<0.05;3.81 d vs.5.61 d,P<0.05).Additionally,the observation group had a significantly lower incidence of postoperative hyperamylasemia and/or hyperlipasemia and mild pancreatitis(1.67%vs.25.00%,P<0.001;0 vs.10%,P=0.027).Conclusion:The novel transabdominal approach is superior to the ERCP approach in terms of reducing surgery time and hospitalization time,and it carries a lower risk of postoperative mild pancreatitis and hyperamylasemia and/or hyperlipasemia.The stone extraction success rate is comparable to that of ERCP,making it a viable alternative treatment option.

Objective To compare the clinical efficacy of modified multi-side hole nasobiliary drainage(MHND)via the percuta-neous transhepatic cholangiography(PTC)route with traditional percutaneous transhepatic cholangial drainage(PTCD)for palliative treatment of patients with advanced obstructive cholangiocarcinoma.Methods A retrospective analysis was conducted on the data from 66 patients with advanced cholangiocarcinoma who underwent biliary drainage.Results Both groups normalize temperature and alleviate symptoms of acute cholangitis within 24 h post-puncture.There was no statistically significant difference in laboratory indicators such as white blood cell(WBC),total bilirubin(TBiL),alanine transaminase(ALT),aspartic transaminase(AST)at 48 h post-operation,and in the incidence of bile leakage,biliary peritonitis,and cholangitis during the postoperative hospital stay(P>0.05).However,the incidence of postoperative electrolyte disorders,gastrointestinal symptoms,and the recurrence rate of gastrointestinal symptoms during the follow-up period were significantly higher in the PTCD group compared to the MHND group,while the recur-rence rate of biliary tract infections was slightly higher in the MHND group compared to the PTCD group.The differences between the two groups were statistically significant(P<0.05).Conclusion Modified MHND shows better clinical efficacy in the treatment of patients with advanced tumor jaundice.Compared with traditional PTCD,it not only effectively reduces jaundice and relieves acute cholangitis but also significantly reduces gastrointestinal symptoms during the postoperative period,thereby improving the quality of life for patients.However,it is noteworthy that it may also increase the risk of biliary tract infections.

Background and Aims:Complex choledocholithiasis often coexists with stenosis of the ampulla of Vater,which increases the difficulty and complexity of treatment.If only the stones in the bile duct are removed without addressing the ampullary stenosis,the disease is prone to recurrence.Previously,most treatments involved the use of endoscopic retrograde cholangiopancreatography(ERCP)to guide the wire for sphincterotomy and stone extraction,followed by laparoscopic cholecystectomy.However,ERCP has limitations in handling complex cases.In response,our team pioneered a new method of treating choledocholithiasis combined with stenosis of the ampulla of Vater via a transabdominal approach.This study was performed to investigate the feasibility and efficacy of this method,aiming to provide a new therapeutic option for clinical practice.Methods:A randomized controlled study was conducted with 120 patients treated at Chengdu Second People's Hospital from 2021 to 2023 for gallbladder stones and choledocholithiasis with stenosis of the ampulla of Vater.Patients were divided into an observation group and a control group,with 60 cases in each group.The observation group underwent laparoscopic cholecystectomy with choledochotomy for stone extraction,followed by retrograde guidance of duodenal papillary sphincterotomy through the opened bile duct,simultaneously treating gallbladder,bile duct stones,and stenosis of the ampulla of Vater.The control group underwent traditional ERCP approach for sphincterotomy,stone extraction,and laparoscopic cholecystectomy.Perioperative variables were collected for both groups and the surgical outcomes were compared.Results:Among the 120 patients,54 were male and 66 were female.There were no statistically significant differences between the two groups in terms of stone extraction success rate,intraoperative blood loss,postoperative 24-h total bilirubin,direct bilirubin,transaminases,white blood cell count,jaundice relief time,or incidence rates of bile leakage,retroperitoneal bleeding/infection,and severe pancreatitis(all P>0.05).The observation group had significantly shorter average operative time and postoperative hospital stay compared to the control group(98.67 min vs.110.8 min,P<0.05;3.81 d vs.5.61 d,P<0.05).Additionally,the observation group had a significantly lower incidence of postoperative hyperamylasemia and/or hyperlipasemia and mild pancreatitis(1.67%vs.25.00%,P<0.001;0 vs.10%,P=0.027).Conclusion:The novel transabdominal approach is superior to the ERCP approach in terms of reducing surgery time and hospitalization time,and it carries a lower risk of postoperative mild pancreatitis and hyperamylasemia and/or hyperlipasemia.The stone extraction success rate is comparable to that of ERCP,making it a viable alternative treatment option.

Objective To compare the clinical efficacy of modified multi-side hole nasobiliary drainage(MHND)via the percuta-neous transhepatic cholangiography(PTC)route with traditional percutaneous transhepatic cholangial drainage(PTCD)for palliative treatment of patients with advanced obstructive cholangiocarcinoma.Methods A retrospective analysis was conducted on the data from 66 patients with advanced cholangiocarcinoma who underwent biliary drainage.Results Both groups normalize temperature and alleviate symptoms of acute cholangitis within 24 h post-puncture.There was no statistically significant difference in laboratory indicators such as white blood cell(WBC),total bilirubin(TBiL),alanine transaminase(ALT),aspartic transaminase(AST)at 48 h post-operation,and in the incidence of bile leakage,biliary peritonitis,and cholangitis during the postoperative hospital stay(P>0.05).However,the incidence of postoperative electrolyte disorders,gastrointestinal symptoms,and the recurrence rate of gastrointestinal symptoms during the follow-up period were significantly higher in the PTCD group compared to the MHND group,while the recur-rence rate of biliary tract infections was slightly higher in the MHND group compared to the PTCD group.The differences between the two groups were statistically significant(P<0.05).Conclusion Modified MHND shows better clinical efficacy in the treatment of patients with advanced tumor jaundice.Compared with traditional PTCD,it not only effectively reduces jaundice and relieves acute cholangitis but also significantly reduces gastrointestinal symptoms during the postoperative period,thereby improving the quality of life for patients.However,it is noteworthy that it may also increase the risk of biliary tract infections.

ObjectiveTo establish an ischemia-reperfusion model in cynomolgus macaques and to analyse the effects of edaravone intervention. MethodsA total of fifteen adult male cynomolgus macaques were randomly divided into three groups: sham operation (Sham group, n=3), ischemia-reperfusion model (Model group, n=6) and edaravone treatment (Edaravone group, n=6). Ischemic-reperfusion model of cynomolgus macaques was established by clamping the M1 branch of the left cerebral artery for 1 h. After 2 h of reperfusion, the animals in Edaravone group were injected with 0.5 mg/kg edaravone intravenously for intervention treatment, while the animals in Sham and Model groups were injected with an equal volume of normal saline intravenously, twice a day, from the 2nd to 7th day. The behavioral video recordings, clinical observations and neurological deficit scores of cynomolgus macaques were obtained, and brain edema volume and cerebral ischemia volume were statistically analyzed. ResultsCompared with the Sham group, the animals in Model group showed typical symptoms of ischemic stroke, with a significant increase in the neurological deficit score， the volumes of edema and infarct of brain tissue (all P＜0.01). Compared with Model group, the neurological deficit score, the volumes of edema and infarct of brain tissue were significantly reduced in Edaravone group (all P＜0.05). ConclusionAn animal model of ischemia-reperfusion in cynomolgus macaques was successfully established, and edaravone was confirmed to alleviate the damage caused by ischemia-reperfusion.

Objective To analyze our experience in primary closure of common bile duct after laparoscopic bile duct exploration.Methods From June 1992 to March 2018,2 740 patients underwent primary closure of common bile duct after laparoscopic common bile duct exploration in the Second People's Hospital of Chengdu.Results The operations were successfully carried out in 2 534 (92.4％) out of 2 740 patients,of whom 15 patients (0.6％) were converted to open common bile duct exploration.Bile leakage occurred in 113 patients (4.1％).Residual stones were found in 29 patients (1.1％).One patient (0.1％) who had a pancreatic carcinoma died on postoperation day 15.48 patients (1.8％) developed other complications.The total postoperative complication rate was 7.0％ (191/2 740).Conclusion In suitable patients,laparoscopic bile duct exploration with primary closure was feasible,safe and effective.

OBJECTIVETo summarize the clinical features, biochemical change and genetic mutations of a neonate with congenital bile acid synthesis disorder type 2.

METHODSClinical features, blood biochemical index, gene analysis and treatment of the patient were reviewed.

RESULTSThe patient presented with the symptoms of jaundice 3 days after birth but without skin itching. Pale stool was noted. Subsequently, he presented with hepatomegaly, blood coagulation disorders, left cochlear nerve damage, liver cirrhosis and remarkable growth retardation. Serum biochemistries showed that bilirubin and transaminase were elevated, while γ -GT and total bile acid was normal. Abdominal ultrasonography indicated decline of gallbladder contraction. Cholangiography showed normal extra- and intrahepatic bile ducts and patent biliary tract. Liver biopsy showed intrahepatic cholestasis. Gene testing has identified a homozygous mutation in AKR1D1 gene.

CONCLUSIONCongenital bile acid synthesis disorder should be suspected when a neonate has presented with jaundice, elevated bilirubin and transaminase, normal or reduced TBA and γ -GT. Genetic testing and urine mass spectrometry analysis can diagnose congenital bile acid synthesis disorder. Early therapy is crucial to patients with congenital bile acid synthesis disorder.

Objective To investigate the clinical efficacy of primary closure in laparoscopic common bile duct exploration (LCBDE).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 2 429 patients who underwent primary closure in LCBDE in the Second Hospital of Chengdu City from March 1992 to December 2017 were collected.Patients underwent laparoscopic cholecystectomy (LC) + stone extraction using LCBDE or extracorporeal shock wave lithotripsy (ESWL),laparoscopic endoscopic sphincteropapillotomy (LEST) was performed selectively,then underwent laparoscopic endoscopic nasobiliary drainage (LENBD) or laparoscopic transabdominal antegrade-guide common bile duct stent implantation,finally underwent primary closure of common bile duct.Observation indicators:(1) surgical situations;(2) postoperative recovery;(3) postoperative short-term complications;(4) follow-up situation.Follow-up using outpatient examination and telephone interview was performed to observe long-term surgical complications once every 3 months up to 1 year postoperatively.Measurement data with normal distribution were represented as (x) ± s.Measurement data with skewed distribution were described as M (range).Results (1) Surgical situations:of 2 429 patients,2 251 underwent successful stone extraction using LCBDE,relief of the obstruction and primary closure of common bile duct,with depletion of stones;15 underwent stone extraction using conversion to open surgery,with depletion of stones;163 had residual stones or surgery-related complications.Of 2 429 patients,1 144,898,223,110 and 54 were respectively detected in grade N or 0,1,2,3 and 4 of laparoscopic distal of the common bile duct smooth classification (LDSC);599 underwent LEST,367 underwent LENBD,207 indwelled urinary catheter through cystic duct stump,125 underwent laparoscopic transabdominal antegrade-guide common bile duct stent implantation and 1 131 underwent primary closure in LCBDE only.Number of removing the stones,diameter of common bile duct,volume of intraoperative blood loss and operation time was (2.5±0.2)per case,(0.7±0.4)cm,(22.4±2.6)mL and (100±12) minutes,respectively.(2) Postoperative recovery:time of postoperative gastrointestinal function recovery,duration of hospital stay and treatment expenses were respectively (2.5±0.5) days,(7.3± 1.2) days and (2.7±0.3) × 104 yuan.Of 2 429 patients,367 removed nasobiliary catheter at 3-7 days postoperatively,207 removed urinary catheter at 3-6 weeks postoperatively,and 125 removed common bile duct stent through duodenoscope port at 1-4 months postoperatively.(3) Postoperative short-term complications:incidence of postoperative short-term complications in 2 429 patients was 6.711％ (163/2 429).① Ninety-four patients with bile leakage were cured after drainage and symptomatic and supportive treatment.② Of 29 patients with residual stones:25 with residual stones of common bile duct were cured by stone extraction using endoscopic sphincterotomy of duodenal papilla,and 4 with residual stones of intrahepatic bile duct didn't receive treatment.③ One patient died at 15 days after surgery for pancreatic cancer.④ Of 39 with postoperative other complications:2 with postoperative hemorrhage were cured by laparoscopic reoperation;12,19 and 3 were respectively complicated with postoperative inflammatory stenosis of duodenal papilla induced to short-term obstructive jaundice,mild acute pancreatitis and stress ulcer bleeding of upper digestive tract,and they were improved by endoscopy or non-operation treatment;2 with stenosis of bile duct didn't receive treatment;1 had a miss ligation at bending section of front zone of nasobiliary catheter,and ligation was removed by endoscopic retrograde cannulation of the pancreatic at 19 days postoperatively.(4) Follow-up situation:of 2 429 patients,1 749 were followed up for 3-12 months,with a median time of 6 months.During the follow-up,of 1 749 patients,2 had mild stenosis in the primary closure area of common bile duct incision and 1 had stenosis of duodenal papilla,they were not treated,and other patients didn't have related complications.Conclusion Controlling strictly the operative indication,primary closure of common bile duct in LCBDE is safe and feasible,with satisfactory clinical outcomes.

Objective To assess the safety, effectiveness and predictive factors of endoscopic balloon dilatation for the treatment of esophageal stricture and esophageal achalasia in children. Methods 28 patients with esophageal stricture and esophageal achalasia treated by endoscopic balloon dilatation from January 2012 to November 2014 were included. All the patients were divided into two groups, 22 in group A (esophageal stricture) and 6 in group B (esophageal achalasia). All procedures were performed under tracheal intubation and intravenous anesthesia using the 3rd grade controlled radial expansion (CRE) balloon with gastroscope. Outcomes, including success, complications and recurrence data were recorded, and predictors for outcomes were analyzed. Results A total of EBD 57 sessions (1 to 5 per patient, 2.00 ± 1.15) were performed on 28 patients in this study. 22 patients were diagnosed with esophageal stricture (78.57%) and 6 with esophageal achalasia (21.43%). The median age was 25 months (range 0 ~ 150), and female/ male ratio was 12/16. EBD was successful in all the 28 cases. The total success rate was 100.00%. Complications occurred in 6 patients during the dilatation, and no complication in 22 patients. Completely remission of symptoms was seen in 82.14% cases (n = 23), relief in 14.28% (n = 4), non-response in 3.57% (n = 1), and recurrence in 3.57% (n = 1). The stricture diameter before EBD was (6.28 ± 1.77) mm (range 3.0 ~ 10.0 mm), and it was (10.85 ± 2.51) (range 6 ~ 15 mm) after the last EBD. The difference was significant (P < 0.01). There was no significant difference in success, effectiveness, complications and recurrence among the two groups (P > 0.05). The effectiveness of EBD was significantly associated with the diameter and number of strictures (P < 0.05), more complications were seen in the patients with multiple and/or smaller strictures (P < 0.05). In group A, the longer interval between surgery and the first EBD was related to more dilatation in the patients with anastomotic esophageal strictures (P < 0.05). The age and the interval between symptom onset and the first EBD were not the predicting factors for treatment in group B (P > 0.05). Conclusions The results of this study indicated that EBD under general anesthesia was an effective primary treatment in children with esophageal stricture and esophageal achalasia. The diameter and number of stricture were the most important predictive factors for successful clinical outcomes, while the interval between surgery and the first EBD was the most risk factor for EBD sessions in the patients with anastomotic esophageal strictures.

Objective To evaluate laparoscopic balloon nasobiliary biliary drainage (LBNBD),vs ureteral catheter drainage in one stage laparoscopy,choledochoscopy and duodenoscopy choledocholithotomy and primary closure of the small calibered common bile duct (diameter 0.3-0.8 cm).Methods During the period of Apr 2010 to Nov 2016 102 cases were enrolled including 50 cases receiving LBNBD and 52 cases using ureteral catheter drainage.Results Between the two groups,LBNBD was superior to ureteral catheter drainage in all the following parameters:the operation time,intraoperative blood loss,postoperative liver function,blood amylase and other laboratory indicators,gastrointestinal function recovery time,gastrointestinal symptoms and electrolyte imbalance,postoperative hospital stay,and bile duct drainage time with all differences statistically significant (P ＜ 0.05).Bile drainage differences during the postoperative first 3 days (averagely 200-400 ml a day) were not statistically different (P ＞ 0.05).Postoperative pancreatitis,bile leakage,and hemobilia were not statistically different (P ＞ 0.05).Conclusions The use of LBNBD is safe and effective in endoscopic choledocholithotomy in cases of small calibered common bile duct.