Objective: Ultrasonography remains the initial imaging modality in the management of biliary disease. This study is designed to evaluate the accuracy of transabdominal ultrasonography in diagnosing biliary pathology in patients with choledocholithiasis. Methods: This was a retrospective study of a continuous sample of patients over a period of 3 years ending in January 2016; these patients were referred for endoscopic management of choledocholithiasis to a tertiary care hospital in Colombo, Sri Lanka. Ultrasound reporting was carried out by different consultant radiologists at both the index and the referring hospitals. The findings of endoscopic retrograde cholangiograms were compared with the ultrasound scan (USS) results. Results: A total of 247 patients were included in the study. USS was 97.4% accurate in detecting intrahepatic duct dilatation (IHDD). Stone counts and the location of stone(s) in the USSs correlated strongly with the number of stones delivered during endoscopic removal and their location in cholangiograms (P < 0.001). The difference in mean diameter of the common bile duct (CBD) of patients with choledochal cysts (CCs) (18.57 mm) and of patients without them (12.39 mm) is statistically significant (P < 0.001). At 14.5 mm, the negative predictive value for a CC is 99.02%. Conclusion: Ultrasonography is a reliable tool in predicting IHDD, stone count, and the location of stones in the biliary tree, particularly in a resource-poor setting. A CBD diameter of 14.5 mm in transabdominal ultrasound scan can be used as a cutoff for predicting extrahepatic CC.

Backgrounds/Aims Published data on choledocholithiasis in Sri Lanka is scarce. This study was conducted to determine epidemiological, clinical and endoscopic characteristics of choledocholithiasis in Sri Lanka. Methods This was a retrospective study of consecutive patients for a period of three years until April 2016. The sample included patients from many parts of the island. Patients were selected from the endoscopy database of the unit and the data were collected from the records of the patients. Results A total of 253 patients were included in the study. The mean age of the patients was 53.6 years. Patients presented with obstructive jaundice (58.5%), cholangitis (25.3%), biliary colic or upper abdominal pain (14.2%) and acute biliary pancreatitis (1.8%). There were 26 (10.3%) post cholecystectomy patients. Concomitant gallbladder stones were found in 173 patients (68.4%). Juxta-papillary diverticula were found in 36 patients (14.2%). Twenty-one (8.3%) and nine patients (3.6%) were found to have choledochal cysts and common bile duct strictures, respectively. Stones were commonly found in the distal common bile duct (68.4%). A majority of the patients had a single stone (47.8%). In 209 patients (79.6%), the size of the largest stones measured between 0.5–1.5 cm. Conclusions Choledocholithiasis is a disease affecting middle-aged population with predominance among females in Sri Lanka. Patients with symptomatic choledocholithiasis commonly present with obstructive jaundice. In the present study, most of the stones were formed in anatomically normal biliary systems. Stones were predominantly distal, single and measured 0.5–1.5 cm in size. The observed features were favorable features for successful endoscopic clearance. None of the patients included in the study had primary CBD stones according to the available criteria.

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Three consecutive patients undergone robotic reoperation by daVinciÒ SI, and by the same team were reported. Patients were positioned in reverse Trendelenburg. For all patients, five trocars were used (3 of 8 mm and 2 of 12 mm), and surgical specimens were removed through Pfannestiel incisions. Results: From November 2016 to December 2017, three cases of IGBC were performed. Clinicopathological, operative and postoperative data are summarized in the table. Briefly, all patients underwent bisegmentectomy IVb/ V (1 anatomical and 2 non-anatomical) plus hilar lymphadenectomy; they were pT1b, and neither presented residual liver disease nor positive node at final pathology. Neither Pringle maneuver nor blood transfusions were necessary. All discharges from ICU and hospital were on second and third postoperative days, respectively. No complications at 30-days were recorded. Conclusion: Our initial experience suggests that robotic reoperation seems to be safe, and simplifies both hilar lymphadenectomy as well as intrahepatic control of pedicles allowing anatomic resections. The putative benefits of its approach are the articulate arms facilitating traction and dissection of hilar structures with precise movements and tridimensional view. Both articulate mono and bipolar scalpels helped to work bi-axially on the liver wedge necessary to remove segments IVb/V with their pedicles.