BACKGROUND: Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice.
METHODS: A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches.
RESULTS: Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity.
CONCLUSIONS: In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Fasciolopsis buski, also called the giant intestinal fluke, is the largest intestinal fluke of the zoonotic trematode parasites and found mainly in Southeast Asian countries, including China. Fasciolopsis buski infection was formerly a common health problem in many countries, but it is now rare. Typically, it can be cured by oral drugs, but some infected patients need surgical intervention because of the severity of their condition or because of an unclear diagnosis or even misdiagnosis. Here, we report a case of a 15-year-old girl from Guizhou Province, China, presenting with recurrent upper-middle abdominal pain that was misdiagnosed as a choledochal cyst. Through laparotomy combined with postoperative histopathological examination, the source of the pain was proven to be mechanical biliary obstruction caused by F. buski infection. In the past, mechanical obstruction, especially biliary obstruction, caused by F. buski infection leading to surgery was not uncommon, but it is very rare in modern society. Moreover, delayed treatment and misdiagnosis of parasitic infection can lead to severe consequences. Therefore, we reviewed the previous literature on F. buski infection treated by surgical operation and summarized the characteristics and therapeutic strategies of these cases to raise clinicians\' awareness of this rare infection.

BACKGROUND: Spontaneous perforation of the common bile duct is rare. The cause is usually unknown, although it is sometimes related to the malformation of the bile duct.
METHODS: Female of 1 year, with abdominal distention, hyporexia and fever, tomography with ascites, surgical findings included retroperitoneal bilioma, peritonitis and perforation of common bile duct. Block resection and primary hepato-duodenal anastomosis were performed.
CONCLUSIONS: Spontaneous perforation of the common bile duct tend to evolve insidiously and delay in diagnosis is frequent. Surgical management is decisive, and there are different techniques described.
CONCLUSIONS: A high index of suspicion is important, treatment must be individualized according to each patient.
UNASSIGNED: La perforación espontánea del colédoco es rara. La causa generalmente se desconoce, aunque en ocasiones guarda relación con una malformación de la vía biliar.
UNASSIGNED: Niña de 1 año, con distensión abdominal, hiporexia y fiebre, tomografía con ascitis, se interviene y se encuentra bilioma retroperitoneal, peritonitis y perforación de colédoco. Se realiza resección en bloque y anastomosis hepatoduodenal primaria.
UNASSIGNED: La perforación espontánea del colédoco tiende a evolucionar insidiosamente y el retraso en el diagnóstico es frecuente. El manejo quirúrgico es resolutivo; existen distintas técnicas descritas.
UNASSIGNED: Es importante un alto índice de sospecha. El tratamiento se debe individualizar en cada paciente.

Heterotopic tissue in the bile duct is a very rare condition. There are a few case reports of heterotopic tissue including gastric and pancreatic cells. However, we could not find any data regarding heterotopic chondroid tissue obstructing the common bile duct in the literature. A 56-year-old woman was admitted to our hospital with complaints of progressive jaundice and pruritus. Laboratory test results were within the normal limits except bilirubin and alkaline phosphatase which were 10.8 mg/dL and 256 IU/L, respectively. Endoscopic retrograde cholangiography (ERCP) and computed tomography (CT) revealed a biliary stricture confined to the upper part of the common bile duct. The patient was operated as soon as the bilirubin level dropped below 5 mg/dL by percutaneous transhepatic cholangiography. Despite the lack of a precise confirmation, the patient was prepared for operation considering the possibility of a malignant biliary tumor since the radiographic mass findings together with hyperbilirubinemia were highly suggestive of malignancy. The patient underwent total extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy, and was discharged without any postoperative complications. Histologic examination of the bile duct and the nodule revealed the presence of a well-demarcated chondroid tissue within the subepithelial connective tissue. Herein, we presented the first case, to our knowledge, of heterotopic chondroid tissue of the common bile duct in the literature. It is a benign condition that should be considered in the differential diagnosis of stricture and mass-forming lesions of the bile duct.

BACKGROUND: Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear.
METHODS: Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis.
RESULTS: One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes.
CONCLUSIONS: Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.

Haemosuccus Pancreaticus is defined as upper gastro intestinal (GI) bleeding from the ampula of vater via the pancreatic duct. It is most commonly associated with pancreatic inflammation, erosion of the pancrease by aneurysm or pseudo-aneurysm of the splenic artery. We report a 69 year old man with previous history of acute pancreatitis who was admitted with recurrent haematemesis. Initial upper GI endocopy was normal, while admitted, he collapse with abdominal pain and hypotension. He was resuscitated with blood and intravenous fluid. Repeat upper GI endocopy showed fresh blood in the duodenum, but no active bleeding site was demonstrated. An urgent coeliac axis CT angiogram was done which showed an splenic artery pseudo-aneurysm, which was successfully embolized. Patient is well 9 months after the procedure. This case highlights the importance of considering coeliac axis CT angiogram as part of investigation for obscure GI bleeding.

We describe a 42-year-old man who presented with painless obstructive jaundice, organomegaly and lymphadenopathy. Biopsy of the ampulla of Vater revealed the presence of increased populations of plasma cells which stained positively for immunoglobulin G4. He was treated with prednisolone and demonstrated significant clinical improvement 1 month later. A further case is described and a review of the literature is also provided.

Spontaneous bile duct perforation in infants is rare, with less than 150 cases having been reported worldwide. With a highly variable presentation, diagnosis and treatment can prove challenging, and outcomes are not without significant morbidity. We herewith report the case of an 8-week-old male infant with spontaneous bile duct perforation. He initially presented with abdominal sepsis and septated ascites on ultrasound, which was confirmed as bilious on ascitic tap and at diagnostic laparoscopy. Intraoperative cholangiogram demonstrated a localized leak at the junction of the cystic and common bile duct. Conversion to laparotomy was ultimately required with cholecystostomy, and 2 external intraabdominal drains were placed. He was subsequently managed conservatively with 4 weeks external drainage, with a repeat cholangiogram at 6 weeks, demonstrating successful resolution of the leak. The reported case supports the findings of changing practices in the existing literature. We suggest that, in cases of spontaneous bile duct perforation with no distal obstruction, dissection and surgery to the biliary tree are not always required. Conservative management with simple external drainage can have its complications but, as shown here, can be a successful treatment option in terms of healing of perforation.

Biliary parasitosis is one of the important causes of biliary obstruction in endemic areas, however due to migration and travel the disease is known to occur in non endemic zones as well. The spectrum of biliary fascioliasis ranges from recurrent biliary colics to acute cholangitis. The long term complications are gall stones, sclerosing cholangitis and biliary cirrhosis. We describe fascioliasis as a cause of recurrent biliary colics in a young male necessitating multiple hospitalizations over a period of four years. Investigative profile had been non-contributory every time he was hospitalized for his abdominal pain prior to the current presentation. He never had cholangitis due to the worm in the common bile duct. It was only at endoscopic retrograde cholangiopancreatography (ERCP) biliary fascioliasis was discovered to be the cause of his recurrent biliary colics. After removal of the live Fasciola hepatica from the common bile duct he became symptom free and is attending our clinic for last 11 months now. Clinical spectrum of biliary fascioliasis is discussed in this report.

BACKGROUND: The pancreatoduodenal junction is a small anatomic area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla de Vater, and retroperitoneum converge. Differential diagnosis includes a spectrum of entities that ranges from anatomical variants to malignancies.
OBJECTIVE: The aim of this paper was to review the anatomy and different pathologic conditions, whether tumoral, inflammatory, or congenital in origin, in this specific area that involves the pancreatic head, duodenum, duodenal ampulla, distal pancreatobiliary tract junction, and retroperitoneum.
METHODS: Computed tomography (CT) and magnetic resonance (MR) help us to identify specific radiologic signs that allow to divide the pancreatic-duodenal junction abnormalities into three cathegories: (1) normal variants and congenital anomalies (pancreas divisum, santorinicele, annular pancreas,duodenal duplication cyst, choledocal cyst,...); (2) acquired non-tumoral: traumatic, iatrogenic, inflammatory (duodenal hematoma, duodenal iatrogenic perforation, groove pancreatitis, gastroduodenal artery pseudoaneurysm,...); (3) tumoral (pancreatic head adenocarcinoma, periampullary tumors, neuroendocrine pancreatic tumors, duodenal adenocarcinoma,...). The images illustrate morphologic aspects of these entities.
CONCLUSIONS: CT and MR are the most appropiate imaging modalities to evaluate pancreatoduodenal junction. Knowing the imaging features is crucial to reach the right diagnosis and treatment of the different entities that involve this anatomic area.