BACKGROUND:Common bile duct (CBD) stones are a common condition with high recurrence rates of stone and cholangitis. However, whether stone type influences recurrence remains unclear. METHODS:We retrospectively analyzed 190 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones between January 2014 and December 2023. Patients were categorized into two groups: brown pigment stone (n = 127) and black pigment stone (n = 63). Clinical characteristics were compared and recurrence risk factors were analyzed. This study was approved by the Institutional Review Board of Peking University Third Hospital (Approval No. M2024869) and conducted in accordance with the Declaration of Helsinki (2013 revision). RESULTS:Baseline characteristics were similar between groups, except the brown pigment group had higher rates of prior ERCP (33.1% vs. 17.5%), larger CBD diameter (15 mm vs. 12 mm), and more multiple stones (69.3% vs. 49.2%) (all p < 0.05). Recurrence of CBD stones (35.4% vs. 9.5%) and cholangitis (21.3% vs. 4.8%) was significantly higher in the brown pigment group (p < 0.05), with shorter median stone-free survival (67.0 vs. 82.0 months) and cholangitis-free survival (70.0 vs. 82.0 months). Multivariate analysis identified brown pigment stones (HR = 3.162, 95% CI: 1.337-7.482, p = 0.009) and prior ERCP (HR = 3.254, 95% CI: 1.798-5.888, p < 0.001) as independent risk factors for stone recurrence, while stone diameter ≤ 10 mm was protective (HR = 0.412, 95% CI: 0.220-0.773, p = 0.006). Brown pigment stones (HR = 3.434, 95% CI: 1.026-11.489, p = 0.045) and prior ERCP (HR = 2.398, 95% CI: 1.111-5.173, p = 0.026) also independently predicted cholangitis recurrence. CONCLUSION:Brown pigment stones carry higher risks of stone and cholangitis recurrence, and ERCP may not be the preferred treatment.

Laparoscopic transcystic biliary drainage (LTCBD) combined with cholecystectomy have been explored as a treatment for cholecystocholedocholithiasis, but early dislodgment of the drainage tube remains a major challenge. We developed a modified laparoscopic transcystic biliary drainage approach and aims to evaluate its safety and efficacy by comparing it with the conventional approach. From April 2020 to December 2023, a total of 81 patients with cholecystocholedocholithiasis underwent LTCBD. In the early phase of the study, the conventional LTCBD (c-LTCBD) approach was performed, while in the later phase, a modified LTCBD (m-LTCBD) approach was implemented. The safety and efficacy of these two techniques were compared. Among the 81 patients, c-LTCBD was performed in 14 patients, while the remaining 67 patients underwent m-LTCBD. There were no significant differences between the two groups in age, sex, presence of jaundice, cystic duct diameter, common bile duct diameter, number of stones, or the requirement for emergency treatment. Further analysis revealed that no significant differences were observed between the two techniques on surgical outcomes including surgical duration, complication rates, extended functions, C-tube removal time, or mean maximum drainage volume. Importantly, the hospital stay duration was shorter in the m-LTCBD compared to the c-LTCBD group (t = 3.206, P = 0.002). Additionally, 9 cases of C-tube related adverse events (C-tube dislodgement /displacement) were observed, with the incidence significantly lower in the m-LTCBD group (5/67 vs. 4/14, respectively; χ2 = 5.224, P = 0.022). m-LTCBD is a safe and effective technique for external drainage and therapeutic access, offering a viable alternative for managing cholecystocholedocholithiasis.

BACKGROUND:Choledocholithiasis is a common benign disease of the biliary tract. We identified a particular type of choledocholithiasis characterized by sudden narrowing of the common bile duct at the site of impaction, which caused a marked increase in surgical difficulty and risk compared to treatment for typical choledocholithiasis. This phenomenon has not been described in previous studies. AIM:To propose the ice-breaking sign and evaluate its influence on treatment strategies for choledocholithiasis. METHODS:Using a retrospective case-control study design, patients who were diagnosed with common bile duct stones and admitted to the Emergency Department of Peking University Third Hospital between January 2018 and December 2023 were included. Propensity score matching was used to match cases and controls. Univariate analysis was conducted to assess the differences in clinical data between the two groups of patients. RESULTS:There were no significant differences in the baseline data between the two groups, except for higher incidence of jaundice, alkaline phosphatase and total bilirubin in the ice-breaking sign group. Compared to the control group, the ice-breaking sign group had lower success rates for endoscopic retrograde cholangiopancreatography (25.0% vs 81.8%, P = 0.006) and laparoscopic common bile duct exploration (69.4% vs 93.8%, P = 0.007), longer operation time (148.04 ± 60.55 minutes vs 106.15 ± 35.21 minutes, P = 0.001), higher likelihood of T-tube placement (62.2% vs 31.3%, P = 0.016) and using lithotripsy techniques during surgery (29.7% vs 0%, P = 0.001), more intraoperative bleeding [25.0 (20.0-50.0) mL vs 10.0 (10.0-20.0) mL, P < 0.001] and longer postoperative hospital stay [6.50 (5.0-9.0) days vs 5.50 (3.0-6.50) days, P = 0.002]. The ice-breaking sign group showed significantly more dilatation in the proximal than distal bile duct. CONCLUSION:The ice-breaking sign, a newly identified radiological phenomenon, may influence therapeutic decisions in choledocholithiasis, suggesting laparoscopic common bile duct exploration as the preferred approach over endoscopic retrograde cholangiopancreatography in patients exhibiting this sign.

INTRODUCTION:Several techniques are used for laparoscopic treatment of gallstone disease with biliary duct stone, but each approach has indications and shortcomings. We have developed a modified laparoscopic transcystic biliary drainage for the management of cholecysto-choledocholithiasis. The hypothesis is that the modified laparoscopic transcystic biliary drainage will reduce morbidity from around 15% to less than 5%. The aim of this study is to assess the safety and efficacy of the modified laparoscopic transcystic biliary drainage. METHODS AND ANALYSIS:This is a prospective single-arm clinical trial to evaluate the safety and efficacy of the modified laparoscopic transcystic biliary drainage. The recruited 310 patients will be from Peking University Third Hospital. (Here, patients who meet the inclusion criteria will be included in the study, all patients will undergo laparoscopic cholecystectomy with concomitant laparoscopic exploration of the common bile duct and a modified laparoscopic transcystic drainage.) The primary endpoint is the postoperative morbidity and bile leakage. The secondary endpoints of the study are anchoring time of the C-tube, average daily drainage volume, early dislodgement of the C-tube, removal time of the C-tube, pancreatitis, residual stones and postoperative hospital stay. Recurrent stones and biliary stricture will be recorded during 6 months of follow-up. A two-tailed p<0.05 was considered statistically significant. SPSS for Windows V.21.0 (SPSS) software was used. ETHICS AND DISSEMINATION:This clinical trial was approved by the Medical Science Research Ethics Committee of Peking University Third Hospital (No. M2023223). TRIAL REGISTRATION NUMBER:NCT06011941. PROTOCOL VERSION:V.2, 23 November 2023.

BackgroundHepatolithiasis frequently presents with recurring cholangitis and complications. Oddi sphincter-preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS), introduced in 1993, has shown favorable long-term results. Endoscopic sphincterotomy (EST) is commonly used, but its impact on OSPCHS outcomes remains unclear.MethodsFrom January 1993 to June 2021, 254 patients with hepatolithiasis underwent OSPCHS. A total of 31 patients had prior EST (group with EST, n = 31), while 223 did not (group without EST, n = 223). Perioperative and long-term outcomes were compared, and risk factors for stone and cholangitis recurrence were analyzed using a Cox regression model.ResultsThe immediate and final stone clearance rates were 67.3% and 81.9%, respectively. Patients with prior EST had higher rates of stone recurrence (57.7% vs. 35.7%, p = .031), shorter stone-free duration (median: 51.5 vs. 112.0 months, p = .001), higher cholangitis recurrence (45.2% vs. 25.6%, p = .023), and shorter cholangitis-free duration (median: 71.0 vs. 134.0 months, p = .006). Multivariable analysis identified bilateral intrahepatic stones (HR: 1.815, p = .010) and prior EST (HR: 3.157, p = .000) as independent risk factors for stone recurrence, whereas combined hepatectomy was a protective factor (HR: 0.448, p = .001). For cholangitis recurrence, male gender (HR: 2.308, p = .001) and EST (HR: 2.241, p = .009) were independent risk factors, while complete stone clearance reduced recurrence risk (HR: 0.423, p = .002).ConclusionPrior EST adversely affects the long-term outcomes of OSPCHS. Therefore, in the management of hepatolithiasis, emphasis should be placed on preserving the Oddi sphincter.

Background Bilateral hepatolithiasis is an intractable disease and repeated attacks of acute cholangitis seriously threaten patient health. The surgical approaches evolve along with gradually greater understanding of its pathophysiology. Methods This is a retrospective cohort study for bilateral hepatolithiasis from January 1958 to December 2018. Before May 1993 (Group A, n = 70), three surgical approaches were adopted: 37 patients with common bile duct exploration (CBDE), 29 with choledochoenterostomy (CE) and four with partial hepatectomy (PH). After June 1993 (Group B, n = 150), 101 patients underwent Oddi sphincter-preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS), and 16 with CBDE, 21 with CE, 12 with PH. The perioperative and long-term outcomes were compared. Results After 1993, the cholangitis recurrence rate significantly decreased from 49.2% to 20.9%, and the stone recurrence rate from 76.3% to 37.1% (both P < .001). Also, the stone-/cholangitis-free durations were prolonged significantly (median: 50.8 vs 26.4/49.6 vs 16.2 months, both P < .001). Preoperative cholangitis was an independent risk factor for stone recurrence (hazard ratio [HR] = 1.863, P = .018), and residual stone for cholangitis recurrence (HR = 2.838, P < .001). OSPCHS and PH were protective surgical approaches for recurrent stone (CBDE: reference; OSPCHS: HR = .469, P = .016, PH: HR = .219, P = .018) and cholangitis (CBDE: reference; OSPCHS: HR = .421, P = .010, PH: HR = .283, P = .093). Conclusions For bilateral hepatolithiasis, the management should focus on hepatobiliary lesion eradication and Oddi sphincter function preservation.

OBJECTIVE:To explore the feasibility and efficacy of laparoscopic transcystic drainage and common bile duct exploration in the treatment of patients with difficult biliary stones.METHODS:Between April 2020 and December 2021, eighteen patients with difficult biliary stones received laparoscopic transcystic drainage (C-tube technique) and common bile duct exploration. The clinical characteristics and outcomes were retrospectively collected. The safety and effectiveness of laparoscopic transcystic drainage and common bile duct exploration were analyzed.RESULTS:Among the eighteen patients with difficult biliary stones, thirteen patients received traditional laparoscopic transcystic drainage, and the remaining five received modified laparoscopic transcystic drainage. The mean surgical duration were (161±59) min (82-279 min), no bile duct stenosis or residual stone was observed in the patients receiving postoperative cholangiography via C-tube. The maximum volume of C-tube drainage was (500±163) mL/d (180-820 mL/d). Excluding three patients with early dislodgement of C-tube, among the fifteen patients with C-tube maintained, the median time of C-tube removal was 8 d (5-12 d). The duration of hospital stay was (12±3) d (7-21 d) for the 18 patients. Five C-tube related adverse events were observed, all of which occurred in the patients with traditional laparoscopic transcystic drainage, including two abnormal position of the C-tube, and three early dislocation of the C-tube. All the 5 adverse events caused no complications. Only one grade one complication occurred, which was in a patient with modified laparoscopic transcystic drainage. The patient demonstrated transient fever after C-tube removal, but there was no bile in the drainage tube and the subsequent CT examination confirmed no bile leakage. The fever spontaneously relieved with conservative observation, and the patient recovered uneventfully with discharge the next day. All the 18 patients were followed up for 1-20 months (median: 9 months). Normal liver function and no recurrence of stone were detected with ultrasonography or magnetic resonance cholangiopancreatography (MRCP).CONCLUSION:Laparoscopic transcystic drainage combined with common bile duct exploration is safe and feasible in the treatment of patients with difficult biliary stones. The short-term effect is good. Modified laparoscopic transcystic drainage approach may reduce the incidence of C-tube dislocation and bile leak.

回顾性分析7例胆肠吻合术后吻合口狭窄行腹腔镜下重建手术患者的临床资料。6例顺利完成腹腔镜下胆肠吻合口重建，手术时长（232±73） min，出血（22±15） ml，术后住院时间（7±2） d，术后无严重并发症，仅1例发生无症状胆瘘。所有患者术后半年肝功恢复正常，4例患者肝内胆管恢复正常，2例患者肝内胆管回弹不良，其中1例再发肝内胆管结石行开腹胆肠吻合口重建及空肠盲襻皮下埋置术。本研究结果表明腹腔镜胆肠吻合口重建及取石术应用于胆肠吻合术后狭窄患者安全可行，近期效果良好。

Background: Surgical resection has been proposed for curable gallbladder cancer (GBCA); however, optimal preoperative evaluation and resection planning methods remain unestablished. The aim of this study was to establish the types of CT tumour radiological appearances in GBCA with a focus on its association with clinicopathologic features and its prognostic impact in curable GBCA. Methods: In all, 118 patients surgically treated for GBCA were identified and CT tumour radiological appearances were reviewed. Models were established and internally validated. Clinicopathologic variables and prognostic impact were analysed for correlation with tumour radiological appearance. Results: The classification and distribution of tumour radiological appearance in these patients was Type 1 (n = 14), Type 2 (n = 60), Type 3 (n = 21), Type 4 (n = 18), and undetermined (n = 5). Among the 113 patients, a higher tendency of T stage and incidence of lymph node metastasis was observed from Type 1 to Type 4. Most Type 1 patients were T1 stage, they have no lymph node involvement or recurrence. With a median follow-up of 25 months (range, 1-135 months), a clear prognostic difference was observed among the 4 types after surgical treatment (p < 0.001). Type 1 patients showed 100% 5-year survival rate. Among the 66 T2 tumours, both tumour location and tumour radiological appearance effectively stratified patient prognosis (p < 0.001, p = 0.007). Introducing tumour radiological appearance into tumour location enabled further prognostic stratification of the 35 T2h tumours (p < 0.001). Conclusions: Type of CT tumour radiological appearance is a predictor of tumour biology. It may improve preoperative evaluation and resection planning. (C) 2020 Published by Elsevier Ltd.

OBJECTIVE:To explore the feasibility and to compare the merits and demerits of laparoscopic and endoscopic approach in removing common bile duct stones in patients with gastrojejunostomy after gastrectomy.METHODS:Between January 2012 and December 2016, 25 patients with common bile duct stones after gastrojejunostomy received laparoscopic or endoscopic treatment in our centers. They were divided into laparoscopic group and endoscopic group based on treatment approaches for common bile duct stones, including 15 patients in laparoscopic group and 10 in endoscopic group. The clinical characteristics and outcomes between the two groups were retrospectively analyzed.RESULTS:Among the 25 patients with gastrojejunostomy, the method of reconstruction was Billroth II in 21 patients and Roux-en-Y in 4 patients. Six patients received laparoscopic or endoscopic treatment during the acute cholangitis state. Among the laparoscopic group, 5 patients with stones more than 1 cm, 7 patients with multiple stones, while in the endoscopic group, 3 patients with stones more than 1 cm and 4 patients with multiple stones. Fourteen patients in the laparoscopic group with coexisting gallbladder stones, and 6 of their common bile duct stones were successfully removed by transcystic approach without T tube drainage. Stone removals were successful in 4 patients of the endoscopic group by a single performance, including 3 patients with single small stone and one patient with multiple small stones. Two patients in the laparoscopic group were converted to open surgery for severe adhesion and one patient in the endoscopic group turned to laparoscopic operation for failing of finding papilla in the Roux-en-Y anastomotic status. The median hospital stays were 12 d and 10 d, respectively in the laparoscopic and endoscopic group. There were 3 patients with postoperative complications, including one patient with paralytic ileus in the laparoscopic group and 2 patients with biliary pancreatitis or bacteremia in the endoscopic group, and all of them recovered uneventfully with conservative treatment.CONCLUSION:Both laparoscopic and endoscopic approaches are feasible for removing stones in the common bile duct in patients with gastrojejunostomy after gastrectomy, and they complement each other. In addition, both techniques are difficult to conduct, and a technical competence should be considered in selection of each method.

Introduction: To investigate the feasibility and safety of laparoscopic hepatectomy combined with choledochoscopy without T-tube drainage in the treatment of intrahepatic and common bile duct stones. Method: From January 2014 to May 2018, 18 patients with hepatolithiasis in the left intrahepatic duct and common bile duct stones underwent laparoscopic hepatectomy combined with choledochoscopy and stone extraction. Of which 12 patients have left lateral heatic calculi, 6 patients have left hepaic calculi, all patients were complicated with common bile duct stones.After laparoscopic hepatectomy ,common bile duct stones were removed under video-assisted choledochoscopy through the left hepatic duct without choledochotomy and T-tube drainage. Result: Twelve patients underwent successfully laparoscopic left lateral lobectomy,six patients underwent successfully laparoscopic left hemihepatectomy, all 18 patients with common bile duct stones were explored by choledochoscope through hepatic cross section.5 patients were used laser lithotripsy due to incarceration of common bile duct stones. The mean operation time was 148 min (range ,108∼212 min), the mean intraoperative blood loss was 160ml (range,80∼320ml).There was one case of bile leakage, which was resolved by conservative treatment.The mean postoperative hospital stay was 5 days(range,3-9 days).Over follow-up of 6 months to 60 months,mean 26 months,no residual or recurrent stone formation were found. Conclusion: Laparoscopic hepatectomy combined with choledochoscopy without T-tube drainage for the treatment of intrahepatic and common bile duct stones is safe and effective in selected patients. This procedure has advantages of reapid rehabilitation and short postoperative hospital stay.

Our study was aimed at finding the ultrasound (US) features of xanthogranulomatous cholecystitis (XGC) and evaluating the usefulness of US in differentiating XGC from gallbladder carcinoma (GBC). Through use of an electronic medical record system and the picture archiving and communication system, 31 cases of XGC and 52 cases of GBC with both sonograms and pathologic results were identified. Sonographic features of the abnormal gallbladder were evaluated. The smooth and intact interface between gallbladder lumen and mucosa was observed in most XGC cases (23/31, 74.2%) but in no GBC cases. XGC featured hyper-echoic foci, small hypo-echoic nodules and a layered appearance in the lesion, which were more frequently seen in the XGC group than in the GBC group. In conclusion, US may prove useful in the differential diagnosis of XGC and GBC, but more studies are required.

Introduction: Second radical resection is recommended for incidental gallbladder cancer (IGBCA). Laparoscopic surgery has received acceptable outcomes for the management of suspected gallbladder cancer, but few studies have demonstrated the oncologic outcomes of laparoscopic second surgery for IGBCA. This study was undertaken to determine the safety and feasibility of a laparoscopic second radical resection for IGBCA based on our 10 years experience. Method: Retrospective analysis of IGBCA patients (detected after a postoperative pathological examination) who underwent laparoscopic second radical resections between July 2007 and March 2017 were conducted. The results were compared with IGBCA patients who underwent open radical resections during the same period. Result: 17 patients with IGBCA underwent second radical resections, and residual disease was identified in 5 patients. Among the 17 patients, 8 patients who underwent laparoscopic second radical resections formed the study group (Group 1), including 1 T1bN0 and 7 T2N0; the remaining 9 patients who underwent open second radical resections formed the control group (Group 2), including 2 T1bN0, 6 T2N0 and 1 T2N1. The median operating time and blood loss were no difference between the two groups. Only one patient in each group had post-operative morbidity. The median lymph node yield was 5 (1–11) in Group 1, and was comparable to that in Group 2 (P = 0.593). During a median follow-up of 41 (6–125) months, no patient in Group 1 developed a recurrence, 2 patients in Group 2 developed recurrence and 1 of them died for recurrence. Conclusion: Laparoscopic second radical resection is safe and feasible in selected patients with IGBCA, and the results were comparable to open surgery.

Objective: To explore the feasibility of laparoscopic treatment for incidental gallbladder cancer(IGBCA) and analyze the factors influencing prognosis. Methods: A retrospective study of 71 patients with IGBCA received laparoscopic treatment at Department of General Surgery, Peking University Third Hospital from January 2007 to December 2016 was conducted,the clinicopathological data and prognosis were analyzed. There were 18 males and 53 females,aged 23 to 81 years. They were divided into two groups based on the presence of intraluminal mass in the gallbladder. Sixty-five of the 71 patients received laparoscopic radical resection, the prognosis of them were compared with 14 patients with open radical resection. Results: Among the 71 patients,65 patients received radical resection,3 patients simple gallbaldder resection and 3 patients palliative resection. Postoperative complications occurred in 6 patients. IGBCA were detected by frozen section in 57 patients,with the accuracy of 96.5%,while the accuracy of T stage is 43.8% in the 48 patients received T stage evaluation during frozen section examination. The T stages based on final pathology were Tis(n=6),T1a(n=5),T1b(n=10),T2(n=46),and T3(n=4).The number of harvested lymph node was 4.7±2.9(range:2-12).There are 14 patients with lymph node metastasis. The 50 patients with intraluminal gallbladder mass include 21 patients with ≤T1b stage and 29 patients with ≥T2 stage, while the 21 patients without intraluminal gallbladder mass are all with ≥T2 stage. The median survival time of the 71 patients was 33 months, with the 5-year cumulative survival rate 67.3%. The 5-year cumulative survival rate is 78.5% for the 65 patients who received radical resection,comparable with those who received open radical resection(P=0.485).Univariate analysis demonstrated that T stage, lymph node metastasis, G grade, lymphovascular invasion, neural invasion, acute cholecystectomy, bile spillage, gallbladder mass and preoperative CA19-9/CEA were the most important prognostic factors(P<0.05). Conclusions: Laparoscopic treatment for IGBCA is feasible, especially for those with intraluminal gallbladder mass. The accuracy of frozen section examination in evaluating T stage is low.

Objective To explore the feasibility and safety of laparoscopic transcystic common bile duct stone extraction and cholecystectomy in pregnant patients with choledocholithiasis.Methods A retrospective analysis of 4 pregnant patients with choledocholithiasis was performed.The clinicoradiologic,perioperative and follow up data were analyzed.Results The 4 patients were admitted for acute cholangitis at their second trimester of pregnancy.Preoperative MRCP demonstrated that the diameter of the common bile duct stone was less than that of the cystic duct.Laparoscopic transcystic common bile duct stone extraction and cholecystectomy were successfully conducted.Plasma shock wave lithotripsy was applied in one patient with impacted gallstone,intraoperative cholangiography was conducted in one patient with suspected residual stone.There was not major post-op complications nor stone recurrence in the follow up postoperatively.They all delivered a healthy baby on the expected date of childbirth.Conclusions Simutaneously laparoscopic transcystic common bile duct stone extraction and cholecystectomy in pregnant patients with choledocholithiasis is feasible and safe.

Objective To evaluate the effect of endoscopic sphincterotomy ( EST ) for intra-and extra-hepatic stones . Methods Clinical materials of 28 patients with intra-and extra-hepatic stones undergoing EST in our hospital from January 2005 to December 2015 were reviewed retrospectively .There were 27 cases of cholangitis and 1 case of abdominal pain .The cholangitis rate and clinical outcomes after EST were followed up . Results The stones were completely cleared in 8 patients and residual stones existed in 20 patients.Complicated intrahepatic and extrahepatic bile duct stricture occurred in 10 cases, two of which were given stent implantation.After EST there were 25 cases of recurrent cholangitis (25/28, 89.3%).Twelve patients received EST again and 13 patients underwent open operations .Finally, 18 patients were asymptomatic , as compared with 5 patients suffering from cholangitis , 1 patient with abdominal pain and 4 patients fatal. Conclusions EST has a high residual stone rate and a high recurrent cholangitis rate for hepatolithiasis .It can not correct biliary stricture radically .Most cases of hepatolithiasis receiving EST have to receive surgery . Therefore, EST is not an optimal and definitive procedure for hepatolithiasis .

Objective To analyze the prognostic factors of hepatolithiasis with cholangiocarcinoma. Methods Clinical data of hepatolithiasis with(case group,n=26)and without(control group,n=386)cholangiocarcinoma in our hospital from January 2006 to February 2017 were reviewed.Univariate analysis and logistic regression analysis were applied to analyze the prognostic factors of hepatolithiasis with cholangiocarcinoma. Results Univariate analysis showed that there were significant differences between the two group in hepatic abscess,liver cirrhosis,portal hypertension, morbid hepatectomy, clearance of stones, and correction of biliary stricture(P<0.05).The was no significan difference in the incidence of biliary stricture between the two groups[the case group:55.7%(15/26)vs.the control group:38.3%(148/386),χ2=3.815,P=0.051].Logistic regression analysis illustrated that liver cirrhosis(OR=4.873,95%CI:1.310-18.126,P=0.018)and residual stones(OR=27.579,95%CI:6.275-121.214, P=0.000)were independent prognostic factors.The biliary stricture correction(OR=0.018,95%CI:0.092-0.564,P=0.000)was an independent protective factor. Conclusions For the hepatolithasis management, every effort should be made to achieve early detection and treatment,which could prevent liver abscess,liver cirrhosis and portal hypertension.Clearance of stones, correction of stenosis,and morbid hepatectomy should be applied during the operation.

Objective: Although laparoscopic treatment of gallbladder cancer (GBC) has been explored in the last decade, long-term results are still rare. This study evaluates long-term results of intended laparoscopic treatment for suspected GBC confined to the gallbladder wall, based on our experience over 10 years. Methods: Between August 2006 and December 2015, 164 patients with suspected GBC confined to the wall were enrolled in the protocol for laparoscopic surgery. The process for GBC treatment was analyzed to evaluate the feasibility of computed tomography (CT) and/or magnetic resonance imaging (MRI) combined with frozen-section examination in identifying GBC confined to the wall. Of 159 patients who underwent the intended laparoscopic radical treatment, 47 with pathologically proven GBC were investigated to determine the safety and oncologic outcomes of a laparoscopic approach to GBC. Results: Among the 164 patients, 5 patients avoided further radical surgery because of unresectable disease and 12 were converted to open surgery; in the remaining 147 patients, totally laparoscopic treatment was successfully accomplished. Extended cholecystectomy was performed in 37 patients and simple cholecystectomy in 10. The T stages based on final pathology were Tis (n= 6), T1a (n= 2), T1b (n= 9), T2 (n= 26), and T3 (n= 4). Recurrence was detected in 11 patients over a median follow-up of 51 months. The disease-specific 5-year survival rate of these 47 patients was 68.8%, and rose to 85% for patients with a normal cancer antigen 19-9 (CA19-9) level. Conclusions: The favorable long-term outcomes demonstrate the feasibility of combined CT/MRI and frozensection examination in the selection of patients with GBC confined to the gallbladder wall, confirm the oncologic safety of laparoscopic treatment in selected GBC patients, and favor measurement of preoperative CA19-9 in the selection of GBCs suitable for laparoscopic treatment.

OBJECTIVETo explore the surgical strategies for the treatment of T1b gallbladder cancer patients diagnosed intraoperatively or postoperatively.METHODSA retrospective analysis of 42 patients with T1b gallbladder cancers was performed. There were 14 patients diagnosed intraoperatively and 28 patients diagnosed postoperatively. The reevaluations of T stages were conducted in the 28 T1b gallbladder cancer patients diagnosed postoperatively by the professional pathologist. After T stage reevaluation, 25 confirmed T1b patients with complete follow-up data were divided into simple cholecystectomy group and ra-dical resection group, and the clinicopathologic characteristics between the two groups were analyzed.RESULTSOnly 2 of the 14 T1b gallbladder cancer patients diagnosed by the intraoperative frozen specimen proved to be T1b on postoperative paraffin pathology, and for the remaining 13 patients, T2 was in 11 patients, and T3 in one patient. The rate of misdiagnosis was 85.7% by the intraoperative frozen specimens, postoperative T stages were equal or higher than intraoperative T stages. Two of the 28 postoperatively diagnosed T1b patients were proved to be T2 after reevaluation, the rate of misdiagnosis was 7.1%, the reevaluated T stages were equal to or higher than the previous stages. Twenty-five confirmed T1b gallbladder cancer patients had complete follow-up data, 11 of whom underwent simple cholecystectomy and the remaining 14 radical resections. No patient had vessel or perineural invasion on pathology in the 25 confirmed T1b patients. Metastasis was absent in all the 30 lymph nodes examined, which achieved from 14 patients with radical resection. The survival rate after simple cholecystectomy was comparable to that after radical resection (P=0.361). Only one patient with radical resection had abdominal cavity implantation relapse, who received gallbladder compression during operation and 2 years later died from metastasis.CONCLUSIONIntraoperatively diagnosed T1b gallbladder cancer should receive radical resection. Reevaluation of the T stage is necessary and the initial step for postoperative diagnosed T1b gallbladder cancer patients. The pros and cons of radical surgery for definitive T1b patients should be carefully evaluated, and systemic chemotherapy is recommended for those with bile spillover.

Objective To investigate the efficacy of laparoscopic gallbladder type Oddi sphincter-preserved cholangioplasty with hepaticosubcutaneous stoma ( OSPCHS) for hepatolithiasis. Methods From January 2011 to May 2016, 17 hepatolithiasis cases had undergone totally laparoscopic gallbladder type OSPCHS in our hospital. With the preservation of the Oddi sphincter, the hepatic duct was opened to make a basin at the porta and repaired by the cholecyst, the fundus of which was set subcutaneously. At the same time, the portion of the damaged liver was resected. Results The complete stone clearance rate was 82. 4% (14/17). The mean follow-up was 38. 5 months (range, 11 -67 months) in the 17 cases. One patient (5. 9%, 1/17) suffered from recurrent cholangitis postoperatively. Three patients (21. 4%, 3/14) had stone recurrence, and were treated by cholangioscopy through the hepatico-subcutaneous stoma. Conclusion Laparoscopic gallbladder type OSPCHS is safe, effective and minimally invasive for hepatholithiasis, achieving a satisfactory medium-term results.