Junji Ishiyama

Common bile duct stones: management strategies in the laparoscopic era.

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.

Xanthogranulomatous cholecystitis: report of a case and literature review on clinical differentiating factors from gallbladder carcinoma

Xanthogranulomatous cholecystitis (XGC) is a rare, benign, destructive inflammatory disease of the gallbladder that is assumed to be a variant of chronic cholecystitis. We herein present a rare case of XGC, which simulates gallbladder carcinoma with extensive involvement of the liver, omentum and the biliary trees. At surgery, total cholecystectomy with partial hepatectomy of the gallbladder bed and excision of adjacent xanthogranulomatous tissue was performed, but bilio‐enteric anastomosis for biliary decompression, which was the procedure preoperatively planned, was impossible to indicate because the common bile duct could not be clearly exposed by its infiltration showing mass formation. Therefore, retrograde transhepatic biliary drainage was eventually indicated for subsequent endoscopic therapy using stent placement to deal with the biliary structure caused by XGC. The patient has been leading a normal life after stent placement in the biliary tract for 6 months duration without any symptoms suggesting biliary stricture. In conclusion, XGC can simulate gallbladder cancer in its clinical presentation, radiological findings and even gross operative features. It is important to make preoperative ultrasound‐guided fine‐needle aspiration cytological diagnosis or intraoperative pathological diagnosis in order to avoid misdiagnosis and unnecessary therapy. Cholecystectomy, excision of adjacent xanthogranulomatous tissue, which often includes partial hepatic resection, are still the best management of XGC.

A Case with Intrahepatic Stones followed up for Over 22 Years after Complete Cholangioscopic Stone Extraction

Abstract: In this paper, we describe the technological know‐how, diagnostic and therapeutic significance of cholangioscopy. In addition, a case who had had recurrent stones after 22 years in the sites different to those of the previous stones was presented, and therapeutic strategy for the management of intrahepatic stones was discussed. The main value of cholangioscopy lies in the fact that retained or unsuspected stones are readily removed with endoscopically‐guided instruments. Moreover, cholangioscopy not only resolves the question as to the presence or the absence of stones, but also indicates inflammation or minute carcinomatous lesions in the biliary tract which would otherwise go undetected. Percutaneous transhepatic cholangioscopy is especially useful for management of intrahepatic stones, because it provides very important information on the location and extent of lesions which is necessary for deciding appropriate therapeutic procedures. The authors firmly believe that better therapeutic results of biliary surgery can be expected if this reliable endoscopic approach becomes more routinely used by surgeons. (Dig Endosc 1999; 11: 169–173)

Laparoscopic Cholecystectomy in Patients with Previous Gastrectomy

Abstract: This study was designed to assess outcome, morbidity and mortality in patients with a previous history of gastrectomy who underwent laparoscopic cholecystectomy at Teikyo University Hospital at Mizonokuchi.