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Background: Management of acute cholecystitis with emergency laparoscopic cholecystectomy has been established; however, detection and management of concurrent choledocholithiasis are debated. The aim of this study is to develop a more accurate choledocholithiasis predictive model. Materials and Methods: A 9-year audit of emergency cholecystectomies and evaluation of preoperative factors in predictive models. Receiver Operating Curve (ROC) analysis/Youdon Index was used to identify thresholds maximizing these associations for continuous variables. Results: 1601/1828 patients were analyzed. Patients who were diagnosed with choledocholithiasis were more likely to be febrile on admission, have a higher C-reactive Protein, and higher median bilirubin (25.0 μmol/L versus 11.0 μmol/L, P  < .001). When excluding bilirubin, multivariate analysis detected several significant variables, including fever, biliary tree dilatation, or a common bile duct stone seen on ultrasound. When bilirubin was included into the model, bilirubin of 20-39 μmol/L (odds ratio [OR] 2.44, 95% confidence interval [CI]: 1.74-3.44) and ≥40 μmol/L (OR 4.84, 95% CI: 3.40-6.91) were shown to have increased likelihood of choledocholithiasis detection on intraoperative cholangiogram, with the ROC model having a significant C-statistic of 0.796 ( P  < .001). Discussion: A perfect predictive model for concurrent choledocholithiasis in acute cholecystitis does not exist; however, the results from this study are encouraging that high and low predictive groups can be established.

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used in the diagnosis and treatment of pancreaticobiliary system. ERCP is used less frequently in children than in adults due to the rarity of pancreaticobiliary diseases and technical difficulties. However, ERCP is a safe, effective diagnosis and treatment tool for children. Methods: All patients within the age range of 1-19 years, who underwent ERCP between 2010 and 2021 at our endoscopy unit, were retrospectively examined. Patient demographics, use of imaging methods, indications, type of sedation, interventions, success of ERCP, findings, and complications were evaluated. Results: Overall, 105 ERCPs were performed in 66 children (29 male and 37 female). The indications were choledocholithiasis, cyst hydatic, choledochal cyst, biliary atresia or anomaly, liver transplantation-related disorders, and pancreatic disorders, respectively. ERCP was finished as diagnostic ERCP in 20% and as therapeutic in 80%. Therapeutic procedures were sphincterotomy, stent placement or removal, stone or debris extraction, and balloon sweep or dilatation, respectively. The success rate in the procedures was 75.23%. The overall complication rate was 15.23%. Postprocedure pancreatitis occurred in 11.42%, hemorrhage occurred in 2.85%, and aggravation of cholangitis in 0.95%. All complications were managed conservatively. Conclusion: ERCP in pediatric patients is a safe procedure that can be performed by adult endoscopists with high success rates. Since our region is an endemic region for hydatid cyst disease, the most common ERCP indication after choledocholithiasis is procedures related to liver hydatid cyst disease. The most common complication was pancreatitis, and complications were treated medically.

Background: Common bile duct exploration (CBDE) is performed uncommonly. Issues surrounding its uptake in the laparoscopic era include perceived difficulty and lack of training. We aim to determine the success of CBDE performed by "specialist" and "nonspecialist" common bile duct (CBD) surgeons to determine whether there is a substantial difference in success and safety. Methods: A 10-year retrospective audit was performed of patients undergoing CBD exploration for choledocholithiasis. Northern Health maintains an on-call available "specialist" CBD surgeon roster to aid with CBDE. Results: Five hundred fifty-one patients were identified, of which 489/551 (88.7%) patients had stones successfully cleared. Specialists had a higher success rate (90.8% versus 82.6%, P  = .008), associated with a longer surgical time. Method (transcystic or transductal), approach (laparoscopic or open), and indication for operation were similar between groups. There was no significant difference in complications. To be confident of a surgeon having an 80% success rate, 70 procedures over 10 years were required, however, an "in-control" 50% success rate may only require 1 procedure per year. Conclusion: While specialist CBDE surgeons have improved success rates, nonspecialist general surgeons also have a good and comparable success rate with an equivalent complication rate. With realistic annual targets, nonspecialist CBD surgeons should be encouraged to perform CBDE in centers without specialist support.

Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions ( P  = .001); this did not increase the length of hospital stay (LOHS) ( P  = .752) or the rate of complications ( P  = .171). However, doing a preoperative ERCP significantly increased LOHS ( P  = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.

Background: Postcholecystectomy syndrome has been a long-standing source of frustration for surgeons. The objective of this study was to assess the feasibility and safety of laparoscopic remnant cholecystectomy (LRC) and laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) when adopted as the management for gallbladder/cystic duct remnant with stones and choledocholithiasis (GRSC) after cholecystectomy., Patients and Methods: This is a retrospective study of 11 patients who underwent surgeries for GRSC: the first 4 patients (Group 1) underwent open remnant cholecystectomy and CBD exploration, whereas the last 7 patients (Group 2) underwent LRC with LTCBDE successfully. Demographic data and perioperative parameters were analyzed and compared between the two groups., Results: All 11 patients had undergone cholecystectomy for symptomatic gallstone diseases. These patients had a mean age of 62 years. The time interval between cholecystectomy and the diagnosis of GRSC ranged from 4 years to 23 years (mean, 13 years). There was a significant reduction in postoperative hospital stay (5.00±1.41 versus 2.14±1.77 days, P=.034) and blood loss (35.00±10.00 versus 14.29±7.87 mL, P=.011) in Group 2 compared with Group 1. The 30-day morbidity rate was 9.1%. At a mean follow-up of 24 months (range, 6-45 months), no symptoms had recurred, and no mortality was recorded in this study., Conclusions: LRC and LTCBDE for GRSC are safe and feasible and could be offered as a choice in centers performing advanced laparoscopic procedures.

Background: The role of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) remains controversial. This study evaluates the outcomes of a management policy of LC without IOC., Subjects and Methods: Patients with symptomatic cholecystolithiasis were classified regarding their potential risk for choledocholithiasis, and those at low risk received no further investigations, whereas medium- and high-risk patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) with duct clearance. Those who required duct exploration were excluded. LC proceeded without IOC. Data were collected prospectively., Results: Between 2002 and 2011, 717 consecutive patients underwent LC; 168 (23.4%) were classified as medium or high risk, and 57 of those had preoperative duct clearance at ERCP. The conversion rate from LC to open surgery was 4.7%. The morbidity rate was 3.9%, and there were no mortalities. Nineteen patients in the low-risk group were re-admitted, of whom three patients (0.4% of 717 patients) had choledocholithiasis on ERCP. Minor bile duct injury occurred in 3 patients, and a fourth developed ischemic bile duct stricture 7 months following open conversion., Conclusions: The selective use of preoperative MRCP and ERCP to detect and treat choledocholithiasis facilitates the safe application of a policy of LC without IOC. Careful operative technique is necessary to avoid duct injury.

The unique technique of ventral hilum exposure (VHE) was reported that it had excellent surgical outcomes in patients with intrahepatic bile duct stone. The basis of this surgical technique is that all the openings of the 2nd-order bile duct branches are exposed fully. In this article, we describe laparoscopic hemihepatectomy from using the VHE method in a patient with intrahepatic bile duct stone. Our patient was a 70-year-old female who had been diagnosed with an intrahepatic duct stone 30 years prior. Multiple intrahepatic bile duct stones in the left lateral section of the liver were revealed by abdominal computed tomography and magnetic resonance cholangiopancreatography. The patient resumed her oral intake on postoperative day 6. The patient had hyperbilirubinemia (10.3 mg/100 mL) on postoperative day 10. However, her serum bilirubin level decreased to 2.7 mg/100 mL on postoperative day 28. She was discharged without any serious complications on postoperative day 31. Totally laparoscopic left hemihepatectomy, using the VHE method, can be one option of surgical procedure in the near future, although a larger series of cases should be necessary to prove the feasibility of laparoscopic VHE.

Background: Common bile duct stones (CBDS) are present in 3-20% of patients with cholelithiasis. Intraoperative cholangiography has high sensitivity in detecting CBDS but its routine use is associated with increased costs and operating room time. The aim of our study was to define an accurate and simple model for the prediction of CBDS using preoperative variables., Methods: The study consisted of a retrospective analysis followed by a prospective study. Multivariate analysis of the retrospective data was used to create a predictive model for the presence of concurrent CBDS in patients undergoing cholecystectomy. The predictive model was then validated in a prospective series of 160 patients undergoing laparoscopic cholecystectomy., Results: Among the 19 potentially predictive variables for CBDS, only four were found to be statistically significant and independent: X1-alkaline phosphatase levels (UI/L); X2-number of gallbladder stones; X3-total serum bilirubin (mg/dL); and X4-CBD diameter (mm). Using these four variables, the multivariate analysis created the equation: score = 0.002 x X1 + 0.485 x X2 + 0.232 x X3 + 0.220 x X4 - 4.167 to define the risk of CBDS in each patient. The predictive model, tested prospectively in 160 patients undergoing laparoscopic cholecystectomy (LC), showed an elevated index of correlation (r = 0.75) among the predicted and the observed frequencies (chi2 = 126.6; P < 0.0001). The predictive model sensitivity and specificity were 92.9% and 99.3%, respectively., Conclusions: In patients undergoing cholecystectomy, accurate prediction of the risk for concurrent CBDS can be achieved using four preoperative variables. The use of this predictive model can contribute to reducing the number of unnecessary common bile duct explorations.

Situs inversus totalis (SIT) is a rare anomaly that can present technical difficulties during laparoscopic surgery. We report the first case of a combination of SIT and choledocholithiasis in a patient who was treated successfully with a laparoscopic exploration of the common bile duct (CBD). The chest x-ray showed a right-sided heart. An abdominal ultrasound and computerized tomography scan diagnosed the CBD and gallbladder stones as well as the SIT, with the liver and gallbladder on the left side, and the spleen on the right. The surgical techniques were modified in a mirror image fashion in order to provide access to the left upper quadrant. The surgeon and the camera assistant stood on the patient's right side, and the first assistant stood on the left. The ports were introduced in a mirror image of the conventional setup. The SIT was confirmed using a telescope via an umbilical incision. A laparoscopic exploration of the CBD with a cholecystectomy was carried out successfully. The postoperative course was uneventful. This report shows that a CBD stone in a patient with SIT can be treated safely using laparoscopic surgery.