Joe Ping-Yiu Ha

Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis

Background:Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia. Its classical presentation is repeated attacks of cholangitis with multiple recurrences of bile duct stones. The stones are commonly located in the left lateral segments (2 and 3) and therefore complete clearance is difficult to achieve by either endoscopic retrograde cholangiopancreatography or surgical exploration of the common bile duct. The definitive treatment usually involves resection of the stone-harboring segments. The recent advent in laparoscopic surgery has shown that hand-assisted laparoscopic segmentectomy is a safe and feasible, alternative. This study aimed to compare hand-assisted laparoscopic segmentectomy with open segmentectomy in patients with recurrent, RPC.Methods:This study retrospectively reviewed a prospectively maintained database of both open and laparoscopic treatments for RPC in a single center between 1994 and 2004. During this period, patients with RPC and left intrahepatic (segments 2 and 3) ductal stones not amendable to endoscopic treatment were recruited for analysis. Patients with concomitant gallbladder stones and common bile duct stones were offered left lateral segmentectomy with cholecystectomy and exploration of the common bile duct. Selected patients would have choledochoduodenostomy drainage during the same operation. The operations were performed via either the hand-assisted laparoscopic approach or the open approach using an ultrasonic surgical aspirator. The two cohorts were compared with respect to perioperative parameters to determine whether there would be any advantage in attempting hand-assisted laparoscopic segmentectomy.Results:During the study period from 1994 to 2004, 17 patients underwent left lateral segmentectomy for RPC. Of the 17 patients, 10 had hand-assisted laparoscopic resections, and 7 underwent open resections. All open resections were performed before 1999. Despite the small number of patients and potential type 2 error, there were no differences in age, sex distribution, number of cholangitic attacks, sessions of endoscopic retrograde cholangiopancreatography before surgery, or number of previous operation between the two groups. The median operating time was shorter in the open group (232.5 vs 150 min; p = 0.007), whereas the median blood loss was similar (350 vs 400 ml; p = 0.551). The median postoperative stay was 8 days for hand-assisted laparoscopic group versus 14 days for the open group. This difference was statistically significant (p = 0.019). There was one open conversion in the hand-assisted laparoscopic group because of intraoperative bleeding from the left hepatic vein. Postoperative complication rates were lower in hand-assisted laparoscopic group, but the difference was not statistically significant (20% vs 57%; p = 126). The intramuscular pethidine requirement again was less in hand-assisted laparoscopic group (0 vs 600 mg; p = 0.002). There was no operative mortality in either group of patients. No recurrent cholangitis was noted in either groups during the median follow-up period of more than 3 years.Conclusion:This study not only confirmed the feasibility of hand-assisted laparoscopic segmentectomy for recurrent pyogenic cholangitis, but also showed that this treatment approach is associated with less pain and shorter hospital stay. However, hand-assisted laparoscopic segmentectomy is a lengthier operation and technically more challenging. Nevertheless, the authors believe that with more experience and further improvement of ancillary technology, this procedure can become a standard treatment for recurrent pyogenic cholangitis in selected cases.

Laparoscopic choledochoduodenostomy: an effective drainage procedure for recurrent pyogenic cholangitis.

Background: This article reports the technical aspects of laparoscopic choledochoduodenostomy (LCD) in patients with recurrent pyogenic cholangitis (RPC) and the perioperative results are also evaluated. This is a retrospective review of a prospectively maintained database. Methods: Twelve patients diagnosed to have RPC with the absence of intrahepatic stricture were selected for LCD during the period from 1995 to 2002. The majority of our patients had repeated attacks of cholangitis and had already undergone multiple sessions of endoscopic and operative lithotripsy. The LCD was performed using a five-port approach with the patient lying in the supine position. The stones were first cleared through the longitudinal supraduodenal choledochotomy followed by construction of a side-to-side diamond-shaped anastomosis of at least 15 mm between the bile duct and the first part of the duodenum using 2/0 monocryl in the single-layer method. Results: During the period from 1995 to 2002, 12 patients with RPC underwent LCD. There were 3 male and 9 female patients with a mean age of 62 (40–77). The median operation time was 137.5 min (90–270) and the median postoperative stay was 7.5 days (5–20). All cases were successful using the laparoscopic approach. Average analgesic requirement post operation was 126 mg (50–200 mg) intramuscular pethidine. There was one postoperative bile leak, and this complication was settled by conservative measures. Upon a mean follow-up of 37.6 months (6–91), there was no recurrent attack of cholangitis or any evidence of sump syndrome in this group of patients. Conclusion: LCD is a safe and effective drainage procedure for patients with RPC. Complications are uncommon and postoperative results are promising.

Laparoscopic repair of obturator hernia

Management of patients presenting with bowel obstruction secondary to oburator hernia is difficult due to the rarity of the condition. Herein, two patients with incarcerated obturator hernia are presented, and the role of diagnostic laparoscopy in their management is discussed. A new surgical approach, transabdominal repair with dual mesh, is described.

Combined endo‐laparoscopic approach in managing patients with gallstones and common bile duct stones: An early experience

Gallstones with common bile duct stones is a common condition in Hong Kong. Management still remains a challenge nowadays. Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) is a single‐stage approach which improves patient comfort and is associated with less post‐ERCP pancreatitis. With the new endo‐laparoscopic operating theatre in service, the combined endo‐laparoscopic approach becomes simple and practical. We report here our two early experiences using this approach.

Silent duodenocolic fistula secondary to biliary stent migration

Duodenocolic fistula is mostly caused by colonic malignancy. Other benign inflammatory causes include peptic ulcer, inflammatory bowel disease and cholecystitis. Iatrogenic causes are rare, and mostly related to operative injury to the duodenum or colon. In the era of endoscopic surgery, biliary stenting is increasingly used to treat benign and malignant biliary obstruction. We report a patient with duodenocolic fistula formation that was secondary to a migrating biliary stent. The patient was totally asymptomatic and the diagnosis was made incidentally by computed tomography of the abdomen. The fistula tract was finally resected after removal of the biliary stent.