Cases Of Cholelithiasis Research Articles

Laparoscopic Approach In Patient With Situs Inversus Totalis And Colelithiasis: A Case Report

Title: Laparoscopic Approach in Patient with Situs Inversus Totalis and Colelithiasis: a Case Report. 
 Background: Situs Inversus Totalis is a rare clinical condition that gives a mirror aspect to the position of the organs. It is a congenital condition and though it does not affect normal health or longevity, it may be a challenge in cases requiring surgical intervention. 
 Case: The authors report a case of cholelithiasis in a patient with previous diagnosis of Situs Inversus Totalis. The patient presented abdominal pain, related to eating and associated with nausea and vomiting. After the image exams, it was performed the surgical procedure, without intercurrences. 
 Conclusion:Situs Inversus Totalis is a challenge for surgical approach because of the mirrored configuration of the organs, which can lead to misdiagnosis. Using image exams anda complete evaluation of the patient helps the correct management in caso of surgical procedures, and consequently influence in the prognosis.

Cholelithiasis in an intrahepatic gallbladder

Intrahepatic gall bladder (GB) is an uncommonly encountered condition in clinical practice characterized by ectopic location of GB within the hepatic parenchyma. This condition not only produces difficulty in clinical diagnosis of various GB diseases especially cholecystitis and carcinoma but also in their management including cholecystectomy. An ectopic partial intrahepatic GB can make cholecystectomy hazardous, when indicated. A case of cholelithiasis in an intrahepatic gallbladder with concurrent choledocholithiasis is reported. The patient initially presented with pain over the right upper abdomen. The diagnosis was made during intraoperative laparoscopic cholecystectomy. This article discusses about difficultly faced during cholecystectomy and rarity of the presentation.

Factors determining conversion of laparoscopic to open cholecystectomy

Background and objectives: Laparoscopic cholecystectomy (LC) has virtually replaced conventional open cholecystectomy (OC) as the standard procedure of treatment for cholelithiasis and cholecystitis. However, OC sometimes becomes a necessity considering the feasibility and safety of the surgical procedure. But the factors that demand conversion from LC to OC differ widely. The present study aimed to determine the prevalence of conversion from LC to OC and to assess the causes of conversion and risk factors related to conversion.Methods: The study was conducted in a referral hospital – ‘Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM)’ from September 2014 to September 2016. Cases of cholelithiasis with or without cholecystitis, and other gall bladder pathology were included in the study. A team of experienced surgeon performed LC of all selected cases. The causes of conversion to OC were systematically recorded by the surgical team and the risk factors (age, sex, obesity, history of previous abdominal surgery, gallbladder thickness) related to conversion from LC to OC was investigated.Results: A total of 261 (M / F = 87 /174) patients were considered eligible for the study. The mean age of all patients was 43 (±1.75) years. For the male and female groups the mean ages were 44±1.9 and 42±1.6 years respectively. Of the total 261 cases, 210 (80.5%) patients had cholelithiasis with chronic cholecystitis, 47 (18.0%) had gallbladder stone plus acute cholecystitis and 4 (1.5%) had gallbladder polyp. Open conversion was required in case of 19 patients. Thus, overall conversion rate was 7.3%. The common causes of conversion were a) difficulty in defining Calot’s triangle (42.1%), b) injury to cystic artery (21.1%) and c) injury to bile duct (15.8%). Both male and female had equal risk for conversion. The investigated risk factors like history of previous abdominal surgery, preoperative ERCP, acute cholecystitis, obesity, increased gallbladder-wall thickness and older age showed no significant association with conversion.Conclusion: The study revealed that a very few patents (7.5%) needed conversion from LC to OC. The commonest cause of conversion was difficulty in defining Calot’s triangle, injury to cystic artery and bile duct. The risk factors like previous abdominal surgery, preoperative ERCP, gallbladder wall thickness, obesity and old age were not found associated with conversion to OC.IMC J Med Sci 2017; 11(2): 32-35

Characteristic Features Of Gall Bladder Topography In Women Of Different Somatotypes And Those With Abdominal Obesity (Based On Results Of Spiral Computed Tomography)

Актуальность Распространенность желчнокаменной болезни и значительные затраты общества на ее лечение являются одной из проблем современной медицины. До 10 - 15% взрослого населения страдают данным заболеванием. Ежегодно в России регистрируется 800000 новых случаев желчнокаменной болезни (ЖКБ). Особую трудность в лечении представляют пациенты с абдоминальным ожирением III ст, так как увеличение толщины слоя подкожной жировой клетчатки ведёт к появлению значительных технических трудностей во время оперативного вмешательства, увеличивает объём оперативной травмы и ухудшает результаты лечения данной категории больных.Цель исследования Уточнить особенности топографии у женщин с различными типами телосложения страдающих абдоминальным ожирением. Материалы и методы В статье описаны результаты прижизненного топографо - анатомического исследования желчного пузыря (по результатам спиральной компьютерной томографии и 3D-моделирования) у лиц женского пола с различными типами телосложения в условиях абдоминального ожиренияРезультаты и их обсуждение Произведена оценка визуализации (по результатам спиральной компьютерной томографии) анатомических структур брюшной стенки и органов брюшной полости, находящихся в правом подреберье у лиц женского пола в зависимости от типа телосложения и наличия абдоминального ожирения. Предложенная методика 3D-моделирования позволяет провести математические измерения, которые могут послужить основой для расчёта критериев оптимального оперативного доступа при выполнении холецистэктомии.Выводы Наличие абдоминального ожирения не вызывает изменений в топографо-анатомических характеристиках желчного пузыря, однако глубина его расположения существенно увеличивается из-за значительного увеличения толщины подкожной жировой клетчатки.Ключевые слова желчный пузырь, тип телосложения, абдоминальное ожирение

Clinical reappraisal of vasculobiliary anatomy relevant to laparoscopic cholecystectomy.

Background:Laparoscopic cholecystectomy (LC) has many advantages as compared to open cholecystectomy. However, vasculobiliary injuries still continue to be a matter of concern despite advances in laparoscopic techniques. Misidentification and misperception of vasculobiliary structures is considered to be a pivotal factor leading to injuries. Although many studies since time immemorial have stressed on the importance of anatomy, an insight into laparoscopic anatomy is what essentially constitutes the need of the hour.Objective:To assess the frequency and the relevance of anatomical variations of extrahepatic biliary system in patients undergoing LC.Materials and Methods:The present study is an observational study performed for a period of 2 years from August 2014 to August 2016. It included all diagnosed patients of cholelithiasis undergoing routine LC performed by a single surgeon by achieving a critical view of safety. During dissection, vascular and ductal anomalies were noted and assessed for their relevance in LC.Results:Seven hundred forty cases of cholelithiasis, irrespective of pathology, comprising 280 (37.83%) men and 460 (62.16%) females with a mean age of 39.85 ± 18.82 years were included in the study. Photodocumentation and operative recordings were available in 93% of cases. Operative findings revealed 197 (26.62%) vascular anomalies and 90 (12.16%) ductal anomalies. A single cystic artery was seen in 340 cases, and a normal cystic duct was seen in 650 cases. Variations in ductal anatomy were fewer than variations in vascular anatomy.Conclusion:Extra-biliary anatomy relevant to LC is unpredictable and varies from patient to patient. Vascular anomalies are more frequent than the ductal anomalies, and surgeon should be alert regarding their presence.

Intrahepatic Rupture Of Gall Bladder In A Case Of Chronic Cholecystitis.

We present, a 69 years old gentleman, known case of cholelithiasis, who presented in septic shock, with history of severe right upper quadrant abdominal pain since 3 days. CT scan of his abdomen showed intrahepatic rupture of gall bladder with peripherally enhancing lesion in liver communicating with the gall bladder lumen suggestive of empyema gall bladder. Few gall stones appeared to have migrated into the liver parenchyma. He underwent ultrasound guided percutaneous cholecystotomy with a plan for elective cholecystectomy at a later date.

Does ‘open’ surgery remain the gold standard in rectal cancer surgery?

Department of GI Surgery, University College London Hospital, 235 Euston Road, London, UK *Author for correspondence: manish.chand@uclh.nhs.uk **Author for correspondence: alec.engledow@uclh.nhs.uk Let us start by defining the term ‘gold standard’. According to the Oxford Dictionaries’ definition, gold standard is defined as “a thing of superior quality which serves as a point of reference against which other things of its type may be compared.” In everyday parlance, this is fairly self-explanatory statement but in the context of scientific literature it takes on a more vague meaning. Commonly, the gold standard is used to validate new techniques which can be measured against a known reference. But in regard to surgery, the term becomes more fluid and only loosely associated with the original definition. The gold standard as relates to a surgical technique can be seen as the universally accepted technique but in many cases, one which has not been scientifically validated. This process of evolving the reference standard and the issue of validation can be demonstrated using cholecystectomy and hemorrhoidectomy as examples. In modern day practice, laparoscopic cholecysectomy has found itself as the gold standard for excision of the gallbladder for cases of cholelithiasis. This has been a transition from ‘open’ cholecystectomy which has occurred over the last 25 years due to a gradual accumulation of evidence in favor of laparoscopy. But to contrast, there are several ‘unvalidated’ but seemingly safe surgical techniques on offer to treat hemorrhoids with not one laying claim to the gold standard. So with that in mind, what is the current gold standard for rectal cancer surgery? There is little dispute that total mesorectal excision (TME) as popularized by Heald [1] is the accepted optimal, oncological surgical technique for rectal cancer excision. The modern surgical discussion revolves around approach rather than technique. Currently, there are four recognized approaches to TME – open, laparoscopic, robotic and transanal (taTME). The latter two are more novel and have yet to gain universal acceptance although taTME in

Cholelithiasis Fortunately Removed by Endoscopic Retrograde Cholangiopancreatography

Stones in the common duct occur in 10% to 15% of patients with cholelithiasis. In our case, coexistent cholelithiasis and choledocholithiasis were diagnosed by endoscopic retrograde cholangiopancreatography. The stone basket was easily introduced into the gallbladder and common bile duct, then fortunately removed stones. However, endoscopic retrograde cholelithiasis removal is known to be difficult because of the anatomical approach. We herein present a rare case of cholelithiasis successfully treated by retrograde endoscopic removal.

Comparison of Early Outcomes and Costs Between Laparoscopic and Open Cholecystectomy for Mild and Moderate Cases of Cholelithiasis in Rural Morocco: A Retrospective Comparative Study

Background: Laparoscopic cholecystectomy (LC) was first introduced in the late 80’s, replacing open cholecystectomy as the standard surgical approach for cholelithiasis in developed countries. In contrast, there were initially many controversies in developing countries regarding the laparoscopic techniques. Objectives: This study aimed to compare the early outcomes and costs between laparoscopic and open cholecystectomy for cholelithiasis in a rural hospital in a developing country. Patients and Methods: This retrospective study included all consecutive patients who underwent cholecystectomy for mild and moderate symptomatic gallstone, in the Marche Verte hospital, in the Boulemane province in Morocco between January and December 2011. Demographics, postoperative outcomes, and costs were compared between laparoscopic and open surgery groups. Duration of hospital stay was calculated from the time of operation to the time of discharge. The total costs for each patient included the sum of: the average hospitalization costs per day; the average operating room costs; and material and medications costs. Chi-square test or Fisher’s exact test and student or Mann-Whitney U tests were used for comparison, as appropriate. Results: During the study period, 95 patients were included; among them, 53 patients underwent laparoscopic surgery and 42 laparotomy. There were no statistical differences between the two groups concerning age, gender distribution, American society of anesthesiologists (ASA) classification, and number of acute cholecystitis. Rate of conversion to open surgery was 5.6% (3 patients). Patients in the laparoscopic group had shorter hospital stay (2.9 vs. 4.7 days, P = 0.0001), lower rates of infectious complications (3.7% vs. 16.6%, P = 0.04), and lower costs (169 vs. 231.62 US dollars, P = 0.0001). Conclusions: The results of the present study showed that, in a rural hospital setting in a developing country, laparoscopic cholecystectomy for symptomatic cholelithiasis was associated with shorter hospital stay, less infectious morbidity rates, and reduced costs, compared to open surgery. Thus, laparoscopic cholecystectomy should be advised as a routine technique for management of cholelithiasis in rural areas of developing countries.

Expression of CCK Receptors in Carcinoma Gallbladder and Cholelithiasis: A Pilot Study.

Gastrin and cholecystokinin (CCK) receptors are trophic for various gastrointestinal malignancies. Their role in gallbladder cancer has not been widely studied. To identify expression of CCK-A and CCK-B receptors in the tissue and blood of patients suffering from carcinoma (CA) gallbladder and gallstone disease and to compare expression of CCK A and B receptors in the gall bladder tissue and blood of healthy individuals and patients of CA gallbladder, and gallstone diseases. Forty nine subjects of both genders were recruited, comprising of 22 patients of CA gall bladder, 19 cases of cholelithiasis and, 8 normal gallbladders obtained from patients operated for trauma of the biliary system or Whipple's procedure. RNA extraction and cDNA formation for CCK-A and CCK-B receptors were carried out. Real Time PCR was performed on cDNA and threshold cycle (Ct) value of each sample was obtained and ΔCt was calculated. Chi-square test for comparing two groups and ANOVA test for comparing multiple groups were applied and if p<0.05 then Dunnett-C test was performed. Both CCK-A and CCK-B receptors were expressed irrespective of its origin in all tissues and blood samples studied; be it normal, Cholelithiasis or CA gallbladder and there was no difference among them (p>0.05). This preliminary study showed higher expression of CCK-A receptors in patients of cholelithiasis and decreased expression of CCK-A receptors in patients of CA gallbladder as compared to normal gallbladder although it did not rise to statistical significance.

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass in obese patients: a prospective study

BackgroundAlthough the risk of cholelithiasis (CL) increases in patients after Roux-en-Y gastric bypass (RYGB), no prospective study has yet assessed the incidence of CL after sleeve gastrectomy (SG). ObjectivesTo compare, prospectively, the incidence and predictive factors for CL after both procedures. MethodsA postoperative abdominal ultrasound follow-up was proposed to all patients with an intact gallbladder and who underwent RYGB or SG in Hôpital Louis Mourier from 2008 onward. ResultsAt least one ultrasound was performed on one hundred and sixty patients between 6 and 12 months postsurgery, 43 after SG and 117 after RYGB. Age, gender, initial body-mass index, co-morbidities were similar in both groups. Weight loss (WL) at 6 months was significantly lower after SG than after RYGB (26.9±9.2 and 31.3±7.5 kg, respectively = .001). The incidences of CL after SG and RYGB were similar (28% versus 34% respectively, P = .57). Most cases of CL occurred in the first year post surgery. During the follow-up, 12% and 13% of patients who underwent SG and RYGB, respectively, became symptomatic. WL of>30 kg at 6 months was a risk factor for CL after bariatric surgery, but we did not find any preoperative predictive factor for gallstone formation. ConclusionsDespite lower WL after SG, the incidence of CL after SG and RYGB was similar at 2 years. Our results suggest that rapid WL is the main element leading to gallstone formation after both procedures.

Consumption of heme iron: A major factor in pigment gallstone formation

Objective: To study the various risk factors responsible for pigment gallstone formation. As there is not any reported medicine which can dissolve pigmented gallstone. Design: Study of 526 cases of cholelithiasis and 526 control cases was done. Query forms were filled with various risk factors like age, gender, BMI, diabetes, genetics, diet, smoking, etc. Collected data and hypothesis were statistically analysed. ICP-OES was done to know the elementary composition of gallstone. Statistical Analysis: Univariate and multivariate were done using SPSS to conclude the risk factors for gallstone disease. Chi-square was applied for the relation between types of stone and age while ANOVA and post hoc ANNOVA, Least significant difference (LSD) were use for the analysis of variance between prevalence of different types of stone with risk factors. Results: In our study, non-veg diet and ground water rich in iron beyond the permissible limit, as a drinking source were at higher risk factor for the gallstone disease (p<0.0001). Non-veg diet as a rich source of heme iron and supplementation of iron from drinking water source may led to pigmented gallstone formation. Conclusion: Controlled dietary habit and use of supply water may reduce the chance for pigmented gallstones.

Determinaton of eligibility for laparoscopic cholecystectomy of elective patients

We defined possible complications and difficulty grade of surgery at frequent symptomatic cholelithiasis cases and laparoscopic cholesistectomy surgeries which is accepted exclusive cure technique with evaluating a number of preoperative parameters. Fifty patients who applied to Ataturk University Medical Faculty Department of General Surgery with cholelithiasis diagnosis and planned to undergo laparoscopic cholesistectomy were included in this study. These patient’s volume of gallbladder, the extreme dimensions, thickness of wall, count of gallstone and dimensions of the biggest stone, length of cystic canal, measured by magnetic resonance cholangiopancreatography; preoperative ages, genders and preoperative endoscopic retrograde cholangiopancreatography story were recorded.To detect difficulty of patients’ surgery, a grading system was established based on surgery time, count surgery port, difficulty of Callot dissection, difficulty of bad dissection, intraoperative injury of bile duct, intraoperative gallbladder perforation, applying drainage and passing to open procedure parameters. The statical relationship of preoperative data and surgery points were analysed. The difficulty of surgery was not statically related with age, gender, thickness of wall of gallbladder, count of gallstone and dimensions of the biggest stone, length of cystic canal, and preoperative endoscopic retrograde cholangiopancreatography story (p>0.05). A meaningful relationship was found between surgery difficulty and gallbladder volume over 30 cm³ or extreme dimension over 40 mm (p<0.05). In conclusion, it is discovered that surgery difficulty degree increases when gallbladder volume is over 30 cm³ or it’s extreme dimension is over 40 mm. We suggest that surgeans must be careful at laparoscopic surgeries on gallbladders which have high volume or extreme dimention to decrease possible complications. J. Exp. Clin. Med., 2013; 30:331-334

Ultrasound training in surgical residency: Is it feasible?

Purpose: Ultrasound training for the surgical residents is not a common practice in India. This study was undertaken to prepare a working model for surgical trainees and assess its effectiveness by training a single surgical resident. Materials and Methods: This was a prospective study of 238 patients with pain abdomen. Training was given in abdominal ultrasound for a period of 2 months. Ultrasound scans were performed independently by a radiology resident and surgery resident. Inter-rater agreement between both residents was assessed using Kappa coefficient. Ultrasound results were compared with clinical diagnosis and final diagnosis. Results: The kappa agreement was 0.53, 0.56, 0.8 and 1 for urolithiasis, appendicitis, pancreatitis and urinary tract infection, respectively. Almost all cases of cholelithiasis were identified by the surgery resident. There was improvement of 21%, 31% and 100% in patients of urolithiasis, acute appendicitis and liver abscess, respectively, in the second 10 months of the study. Conclusions: Ultrasound scans can be performed by a surgery resident with similar results as that of a radiology resident. Training of the surgery resident is possible with satisfactory results.

Changes in Plasma Levels of Vasoactive Factors in Patients Undergoing Abdominal Surgery

Background: To investigate the changes in plasma levels of endothelin (ET), nitric oxide (NO), prostacyclin (PGI2) and thromboxane A2 (TXA2) in patients undergoing abdominal operation. Materials and Methods: Thirty cases of abdominal surgery (14 males, 16 females; mean age 48 ± 11 years, ranging from 24 to 70) were prospectively recruited: Twenty-four cases of cholelithiasis and cholecystitis, 2 cases of peptic ulcer and 4 cases of portal vein hypertension. At five different time points (1-3 days after hospitalization (T1), at surgery beginning, after anesthesia (T2) and at the first (T3), third (T4) and fifth day (T5) after surgery), plasma levels of ET-1, NO2-, NO3-, 6-keto-PGF1α and thromboxane B2 (TXB2), the latter two being stable metabolites of PGI2 and TXA2 respectively, were measured. Results: ET-1 levels increased significantly after anesthesia and surgery (T1 = 69.2 ± 10.7 vs. T2 = 82.4 ± 14.7 vs. T3 = 96.6 ± 22.8 pg/ml, p 2 levels before surgery were significantly lower than that after (T2 = 67.5 ± 52.7 vs. T3 = 157.6 ± 21.8 pg/ml, p 1α were significantly higher than that after anesthesia and surgery (T1 = 180.5 ± 17.8 vs. T2 = 132.1 ± 32.6 vs. T3 = 110.9 ± 31.9 pg/ml, p 2) increased significantly after surgery, while vasodilatory factors (NO and PGI2) decreased significantly after operation. Imbalance in vasoactive factors encourages hypercoagulability and then may play a role in the pathobiology of post-surgery complications, such as deep venous thrombosis (DVT).

Response of Gallstone Ileus to Conservative Therapy

We report a case of cholelithiasis followed by gallstone ileus, documented with serial computed tomography (CT) scans, that responded to conservative therapy. An 80-year-old woman was admitted because of abdominal pain and vomiting. Six months previously, she had presented with abdominal pain and nausea of sudden onset. A CT scan showed thickening of the gallbladder wall and a gallbladder stone. She refused cholecystectomy, and the abdominal pain gradually improved in response to conservative treatment. On admission, plain abdominal radiographs showed obstruction of the proximal small bowel. A CT scan revealed disappearance of the gallbladder stone, fluid-filled bowel loops, and the presence in the small bowel of an impacted stone (major axis, 45 mm; minor axis, 23 mm). We diagnosed gallstone ileus. Because the gallstone was not large, we inserted a stomach tube and administered conservative treatment. One day after admission, CT showed that the impacted stone had migrated to the transverse colon. Four days after admission the impacted stone was not seen on plain abdominal radiography. Five days after admission, follow-up CT revealed pneumobilia but no impacted stone. Because the symptoms had improved the patient resumed oral intake of liquids The patient was discharged 14 days after admission and is doing well.

Effect of longacting somatostatin analogue on kidney and cyst growth in autosomal dominant polycystic kidney disease (ALADIN): a randomised, placebo-controlled, multicentre trial

Autosomal dominant polycystic kidney disease slowly progresses to end-stage renal disease and has no effective therapy. A pilot study suggested that the somatostatin analogue octreotide longacting release (LAR) could be nephroprotective in this context. We aimed to assess the effect of 3 years of octreotide-LAR treatment on kidney and cyst growth and renal function decline in participants with this disorder. We did an academic, multicentre, randomised, single-blind, placebo-controlled, parallel-group trial in five hospitals in Italy. Adult (>18 years) patients with estimated glomerular filtration rate (GFR) of 40 mL/min per 1·73 m(2) or higher were randomly assigned (central allocation by phone with a computerised list, 1:1 ratio, stratified by centre, block size four and eight) to 3 year treatment with two 20 mg intramuscular injections of octreotide-LAR (n=40) or 0·9% sodium chloride solution (n=39) every 28 days. Study physicians and nurses were aware of the allocated group; participants and outcome assessors were masked to allocation. The primary endpoint was change in total kidney volume (TKV), measured by MRI, at 1 year and 3 year follow-up. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov, NCT00309283. Recruitment was between April 27, 2006, and May 12, 2008. 38 patients in the octreotide-LAR group and 37 patients in the placebo group had evaluable MRI scans at 1 year follow-up, at this timepoint, mean TKV increased significantly less in the octreotide-LAR group (46·2 mL, SE 18·2) compared with the placebo group (143·7 mL, 26·0; p=0·032). 35 patients in each group had evaluable MRI scans at 3 year follow-up, at this timepoint, mean TKV increase in the octreotide-LAR group (220·1 mL, 49·1) was numerically smaller than in the placebo group (454·3 mL, 80·8), but the difference was not significant (p=0·25). 37 (92·5%) participants in the octreotide-LAR group and 32 (82·1%) in the placebo group had at least one adverse event (p=0·16). Participants with serious adverse events were similarly distributed in the two treatment groups. However, four cases of cholelithiasis or acute cholecystitis occurred in the octreotide-LAR group and were probably treatment-related. These findings provide the background for large randomised controlled trials to test the protective effect of somatostatin analogues against renal function loss and progression to end-stage kidney disease. Polycystic Kidney Disease Foundation.

Common bile duct stones, an experience in Ondokuz Mayis University

Common bile duct stones, obstructive jaundice, cholangitis and acute pancreatitis are diseases that can lead to serious complications. In our clinic between May 1993 and October 2011 the results of 101 patients who underwent surgery for common bile duct stone were retrospectively evaluated. Among 101 patients who were included in the study, 45 had symptomatic gallstones accompanied by common bile duct stone, 27 had mechanical icterus, 15 had common bile duct stone and 8 had cholangitis (five patients with suppurative cholangitis), six had acute cholecystitis. Thirthy one patients with common bile duct stones were treated with endoscopic retrograde cholangiopancreatography (ERCP). Surgical procedures were as follows; choledochoduodenostomy in 50 cases, T-tube drainage in 17 patients and transduodenal sphincteroplasty in three patients. Synchronous cholecystectomies were performed in all patients who had not undergone biliary surgery before. Early postoperative mortality was 3.9%. In this study, we detected choledocholithiasis in 11.31% of the all symptomatic cholelithiasis cases. Since our clinic provide tertiary healthcare, this rate becomes 9.85% by excluding those who underwent cholecystectomy for common bile duct stones at other hospitals. Given that the patients who referred to our clinic are in high-risk group, the actual rate of choledocholithiasis in our society is expected to be slightly below that value.

Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding

BackgroundRapid weight loss after bariatric surgery has been a factor of inducing gallstones postoperatively. Many studies have reported increased gallstone formation after laparoscopic Roux-en-Y gastric bypass (LRYGB). However, not many studies have compared symptomatic gallstone frequencies between LRYGB, laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). The aim of our study is to evaluate symptomatic cholelithiasis cases requiring cholecystectomy after each bariatric procedure. MethodsBetween January 2009 and August 2011, a total of 937 patients underwent bariatric surgery at our institution. Of these patients, 598 had primary LRYGB, 197 had LSG, and 142 had LAGB. We excluded patients with previous cholecystectomy or concomitant cholecystectomy at the time of bariatric procedure. A retrospective review of a prospectively collected database was performed for all patients. ResultsOf 367 LRYGB patients, 5.7% (n = 21) had symptomatic gallstones. Of 115 LSG patients, 6.1% (n = 7) required cholecystectomy, and of 104 LAGB patients, .0% (n = 0) developed symptomatic gallstones. The differences in the occurrences of symptomatic gallstones between LRYGB and LSG were not statistically significant (P>.88). However, statistical significance was present between LRYGB and LAGB (P<.02), as well as between LSG and LAGB (P<.02). Mean percentage of excess weight loss (%EWL) at 24 months was 85.7%, 58.8%, and 38.3% in LRYGB, LSG, and LAGB patients, respectively. There was no complication related to the cholecystectomy procedure. ConclusionsFrequency of symptomatic gallstones after LRYGB and LSG was not significantly different and after LAGB was significantly lower. Slow and less amount of weight loss would have contributed to the low rate of symptomatic gallstone formation in the LAGB patients. (Surg Obes Relat Dis 2013;0:000–00.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Impact of pancreatobiliary reflux in normal pancreatobiliary junction on gallbladder

Objective To explore the impact of pancreatobiliary reflux （PBR） in normal pancreato- biliary junction on gallbladder. Methods A total of 54 patients receiving cholecystectomy for gallbladder diseases underwent uhrasonography to evaluate the thickness of gallbladder wall, inner layer and gallbladder wall blood flow before operation. The bile juice was sampled during ERCP in 45 patients with common bile duct stone and during cholecystectomy in 9 patients to detect amylase level. All patients with normal panere- atobiliary junction enrolled in the study were assigned into PBR group （ n = 24 ） and controlled group （ n = 30） according to their bile amylase level. Resected gallbladder specimens were examined histopathologically and then tested for expression of COX2, Ki-67 and p53 immunohistochemically. Results PBR group in- eluded 20 cases of cholelithiasis and 4 gallbladder polyp, among which 23 were occult PBR （OPBR） and 1 high confluence of pancreatobiliary ducts （ HCPBD）, which was similar to pancreatobiliary maljunction （PBM） pathologically. The control group recruited 28 cases of cholelithiasis and 2 gallbladder polyp. There were no differences in frequency of inflammation, hyperplasia, metaplasia or expression of p53 between the two groups （ p 〉 0.05 ） , while higher presence of dysplasia and higher expression of COX2 and Ki-67 were seen in PBR group （ p 〈 0.05）. Conclusion In patients with OPBR, although hyperplasia and metaplasia in gallbladder epithelium were similar to those induced by cholelithiasis, dysplasia and active proliferation might relate to progress to malignancy. Key words: Gallbladder; High confluence of pancreatobiliary ducts; Occult ancreatobiliary reflux; Biliary amylase