Complications of Esophageal Surgery and Trauma
Stephen M. Cohn, Matthew O. Dolich in Complications in Surgery and Trauma, 2014
The overall mortality rate associated with esophageal perforation is 22%, with the break down as follows: cervical perforation is 6%, thoracic perforation is 34%, and abdominal perforation is 29% [8]. Morbidity and mortality is mainly related to anastomotic failure with continued contamination [4]. All published series demonstrate that early diagnosis and treatment lead to better outcomes; morbidity and mortality rates increase when diagnosis and treatment occur more than 24 h after injury. Gouge et al. [17] reviewed the results of a series of 10 primary suture repairs of thoracic perforations; the overall leak rate was 39%, and the overall mortality rate was 25%. In their series review, the overall mortality rate associated with the T-tube technique for draining perforations is 36%, that associated with exclusion and diversion is 35%, and that associated with resection is 26%. The mortality rates associated with T-tube drainage and exclusion may reflect the severity of these patients’ illness.
Basic surgical skills and anastomoses
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie in Bailey & Love's Short Practice of Surgery, 2018
Common bile duct T-tubes should remain in for 10 days. However, once the T-tube cholangiogram has shown that there is free flow of bile into the duodenum and that there are no retained stones, some surgeons like to clamp the T-tube prior to removal. The 10-day period is required to minimise the risk of biliary peritonitis after removal. T-tubes are traditionally and intentionally made of latex to stimulate fibrosis, which results in the formation of a tract to allow the drainage of bile if required. It is important to use an alternative to latex if the patient is allergic, bearing in mind the decreased potential for fibrosis of silicone-based T-tubes. The increase in less invasive means of intervention for bile duct pathology has resulted in fewer T-tubes being used.
General Surgery
Tjun Tang, Elizabeth O'Riordan, Stewart Walsh in Cracking the Intercollegiate General Surgery FRCS Viva, 2020
How would you perform a lap CBD exploration?There are two approaches:Transcystic − small stones <7 mm and fewer than three stones. Can only remove stones below insertion of cystic duct as cannot retroflex into common hepatic duct.Direct supraduodenal CBD exploration − large stones and multiple stones. Avoid if small-calibre CBD due to risk of biliary stricture. Usually laparoscopic CBD exploration is reserved for CBD of at least 8 mm diameter.A longitudinal choledochotomy is made with hooked scissors avoiding the bile duct arteries at 3 and 9 o'clock.Stones are extracted via endoscope or a basket.Completion cholangiogram is performed and choledochotomy is closed. T-tube insertion or primary repair without T-tube/stent are both acceptable.If T-tube is inserted, do a cholangiogram in 5–7 days; tube is clamped if it is clear and there is free flow into duodenum without any filling defects. Remove in OPD in 6 weeks’ time.
Comparison of Patient Outcomes and Safety between Overlapping and Nonoverlapping Surgeries in Patients Undergoing Laparoscopic Common Bile Duct Exploration
Published in Journal of Investigative Surgery, 2022
Xue Zhang, Jinhui Wang, Fubao Liu, Yong Zhao
At our institution, the indicators for laparoscopic transcystic stone extraction were the presence of less than five stones with a size of <9 mm. The indicators for LC were as follows: stone size ≥9 mm, number of stones ≥5, and failure of laparoscopic transcystic stone extraction. In the LC group, patients were assigned to primary closure if the following criteria were met: (1) CBD diameter > 0.8 cm; (2) normal sphincter of Oddi function verified intraoperatively through the flexible choledochoscope; and (3) the absence of residual stone verified intraoperatively through flexible choledochoscopy. Conversely, for patients undergoing other surgical procedures, T-tube drainage was placed following LCBDE in LC. Patients were excluded if the surgery was performed to address a complication from a referring institution. In addition, patients with inadequate information, a prior history of biliary surgery, or those lost to follow-up were excluded from this study. This study was approved by the institutional review board. A written informed consent was obtained from each patient before the surgery.
Perihilar Hepatectomy for Hepatolithiasis with Compressed Hilar Bile Duct Induced by Perihilar Hyperplasia of Liver
Published in Journal of Investigative Surgery, 2020
Guangyu Chen, Feng Tian, Xin Zhao, Yan Chen, Tao Peng, Jingchi Cui, Dajiang Li, Yu He, Shuguang Wang
Each patient underwent intraoperative cholangioscopy through the common bile duct or the biliary-enteric anastomosis to confirm no inflammatory stenosis in the hilar bile duct and no residual bile duct stenosis in the intrahepatic bile duct after hepatectomy. All biliary stones were removed with forceps. Indications of hepaticojejunostomy include Oddis sphincter laxity, manifested by possible passage of urinary catheter (internal diameter >14 Fr) through the Oddis sphincter, which appeared “dead fish mouth” and cannot be closed in the cholangioscopy; and Oddis sphincter stenosis, manifested by inability of the urinary catheter (internal diameter >10 Fr) to pass through the Oddis sphincter [11]. The procedure of hepaticojejunostomy was an end-to-side, mucosa-to-mucosa anastomosis of the extra-hepatic duct with a Roux-en-Y jejunal loop measuring 60 cm long. The anastomosis was interruptedly sutured with absorbable material (Vircyl, 5-0, Johnson Ltd, USA) [12]. A T-tube measuring 3.5–5 mm in diameter was inserted through the biliary-enteric anastomosis or the common bile duct in all patients after performing bile duct exploration for biliary decompression and postoperative cholangiography or cholangioscopic manipulation if necessary.
Novel elbow basket mechanical lithotripter for large common bile duct stone removal
Published in Postgraduate Medicine, 2022
Huahui Zhang, Ying Fang, Jian Huang, Fengdong Li, Xiangrong Qin, Jin Huang
Many techniques can be used for fragmenting stones, for example, digital cholangioscopy-guided laser lithotripsy, surgery treatment, and extracorporeal shock wave lithotripsy [11–13]. With the development of endoscopic techniques, cholangioscopy-guided lithotripsy for stone removal has been widely used in recent years [7]. A multicenter study showed that the success rate of cholangioscopy-guided lithotripsy for CBD stones was 80% in a single procedure [14]. In contrast to ERCP, cholangioscopy is a complex therapeutic endoscopic procedure that will require a longer time to complete the operation. Moreover, the treatment of CBD stones by cholangioscopy is expensive because cholangioscopy-guided laser lithotripsy requires highly skilled providers and expensive equipment [15]. Extracorporeal shock wave lithotripsy is a complex and technically demanding procedure with a low success rate. It is used when conventional techniques have failed to fragment CBD stones or cannot be used [4]. Laparoscopic CBD exploration is traumatic and requires T-tube drainage after surgery, which is generally applied for patients with a suspected bile duct malignancy or ERCP that has failed to remove stones [16].
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