Gallstones

animals of this species sampled) were seropositive and 1 of them was in an active stage of illness. Of 172 terrestrial rodents tested none had monkeypox-specific antibodies. The samples from 51 F anerythrus squirrels collected in 1979 have recently been tested by RIAA in Atlanta; 5 had monkeypox-specific antibodies. F anerythrus seems to be a priority species in the research on the host reservoir of monkeypox virus. Kima A. A human infection caused by monkeypox virus in Basankusu Territory, Democratic Republic of the Congo. Bull WHO 1972; 46: 593-97. 2. Breman JG, Bernadou J, Nakano JH. Poxvirus in West African nonhuman primates: Serological survey results. Bull WHO 1977; 55: 605-12. 3. Gispen R, Brand-SaathofB, Hekker AC. Monkeypox-specific antibodies in human and simian sera from the Ivory Coast and Nigeria. Bull WHO 1976; 53: 355-60.

Spice bioactive compounds, capsaicin and curcumin, were both individually and in combination examined for antilithogenic potential during experimental induction of cholesterol gallstones in mice. Cholesterol gallstones were induced by feeding mice a high-cholesterol (0.5%) diet for 10 weeks. Groups of mice were maintained on a lithogenic diet that was supplemented with 0.015% capsaicin/0.2% curcumin/0.015% capsaicin + 0.2% curcumin. The lithogenic diet that contained capsaicin, curcumin, or their combination reduced the incidence of cholesterol gallstones by 50%, 66%, and 56%, respectively, compared with lithogenic control. This was accompanied by reduced biliary cholesterol and a marginal increase in phospholipid in these spice-fed groups. Increased cholesterol saturation index and cholesterol : phospholipid ratio in the bile caused by the lithogenic diet was countered by the dietary spice compounds. The antilithogenic influence of spice compounds was attributable to the cholesterol-lowering effect of these dietary spices in blood and liver, as well as a moderate increase in phospholipids. Decreased activities of hepatic glutathione reductase and glutathione-S-transferase caused by the lithogenic diet were countered by the combination of capsaicin and curcumin. The increased lipid peroxidation and the decreased concentration of ascorbic acid in the liver that was caused by the lithogenic diet was countered by the dietary spice compounds, individually or in combination. Thus, while the capsaicin and curcumin combination did not have an additive influence in reducing the incidence of cholesterol gallstones in mice, their combination nevertheless was more beneficial in enhancing the activity of hepatic antioxidant enzyme ─ glutathione reductase in the lithogenic situation. The antioxidant effects of dietary spice compounds are consistent with the observed reduction in cholesterol gallstones formed under lithogenic condition.

Cholecystectomy is a common procedure. Abnormalities in the anatomy of the biliary system are common but an abnormal location of the gallbladder is much rarer. Despite frequent pre-operative imaging, the aberrant location of the gallbladder is commonly discovered at surgery. This article presents a case of a patient with the gallbladder located to the left of the falciform ligament in the absence of situs inversus totalis that presented with right upper quadrant pain. A laparoscopic cholecystectomy was performed and it was noted that the cystic duct originated from the right side. The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. The spectrum of unusual positions and anatomical gallbladder abnormalities is reviewed in order to facilitate elective and emergent cholecystectomy as well as other hepatobiliary procedures. With proper identification of the anatomy, minimally invasive approaches are still considered safe.

Seven patients with radiolucent stones in the gallbladder and two patients with radiolucent stones in the biliary tree were treated with oral cholic acid and purified soya-bean lecithin for 6 months. In two patients the stones disappeared and in one patient the stones were reduced in size. In five patients fasting bile samples were obtained before and during treatment and assayed for cholesterol, bile acid, and phospholipid. In all five patients the lithogenic index of bile was reduced during treatment. The biliary deoxycholic acid concentration was increased and chenodeoxycholic acid concentration decreased during treatment.

This is a case report of an 85-year old patient who presented with abdominal pain, nausea and vomiting associated with altered liver function test. The plain X-rays and CT scan showed pneumobilia with an ectopic gallstone. The patient was diagnosed with Bouveret syndrome and managed surgically. The report is followed by a discussion about Bouveret syndrome.

Background and Aim:  Gallstone formation is characterized by the abnormal regulation of cholesterol trafficking and solubilization. The prevalence of gallstone disease (GSD) differs between ethnic groups sharing the common environment. These differences can be explained by a genetic predisposition to gallstone formation. Studies have identified single nucleotide polymorphisms (SNP) D19H and T400K in the cholesterol transporter gene ATP-binding cassette, subfamily G, member 8 (ABCG8) in patients with cholesterol gallstones. The aim of this study was to analyze the relationship between D19H and T400K polymorphisms in the ABCG8 gene and GSD in an Indian population, and the effects of these polymorphisms on cholesterol levels in sera and bile.Methods:  A total of 226 patients with GSD were analyzed for their lipid profile in plasma and bile. A total of 289 controls were recruited, and their plasma lipid profile was analyzed by standard protocols. The genotype of SNP D19H and T400K of ABCG8 was analyzed in 226 patients and 222 control samples. SNP D19H was analyzed by direct sequencing, and SNP T400K genotyping was assayed by the amplification refractory mutation system–polymerase chain reaction.Results:  There was no significant difference in the allelic distribution of SNP T400K between the GSD and gallstone-free groups (P > 0.05), but the distribution of the SNP variant, D19H, was significantly higher (P = 0.017, odds ratio = 2.274) in patients compared to controls. The analysis of serum and bile cholesterol followed a strong association with genotypes.Conclusion:  SNP D19H, but not SNP T400K, in the ABCG8 gene is significantly associated with GSD in an Indian population.

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed.

Background: Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices. Methods: Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident's first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors.

Gallstone ileus is a rare disease and accounts for 1%-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We report two cases of gallstone ileus. The first was a 78-year old woman who had a 2-d history of vomiting and epigastralgia. Plain abdominal film suggested small bowel obstruction clinically attributed to adhesions. Later on, gallstone ileus was diagnosed by abdominal computed tomography (CT) based on the presence of pneumobilia, bowel obstruction, and an ectopic stone within the jejunum. She underwent emergent laparotomy with a one-stage procedure of enterolithotomy, cholecystectomy and fistula repair. The second case was a 76-year old man with a 1-wk history of epigastralgia. Plain abdominal film showed two round calcified stones in the right upper quadrant. Fistulography confirmed the presence of a cholecystoduodenal fistula and gallstone ileus was also diagnosed by abdominal CT. We attempted to remove the stones endoscopically, but failed leading to an emergent laparotomy and the same one-stage procedure as for the first case. The postoperative courses of the two cases were uneventful. Inspired by these 2 cases we reviewed the literature on the cause, diagnosis and treatment of gallstone ileus.

Background: There is a high prevalence of gallstone disease in Western countries as a consequence of genetic, biochemical, and environmental factors. Animal and clinical studies have explored the importance of dietary elements. Overwhelming but conflicting information has been reported about the relationship between specific dietary components and gallstone disease. Although the detailed biochemical pathways have been described in experimental models, human studies are mainly epidemiological. Methods: We performed a Medline search with the terms "diet", "gallstones", "cholesterol", "risk factors", including results from 1965 to 2006 and the author's personal library to review the relationship between dietary factors and cholesterol gallstone disease. Results: We identified over 150 references and present their results with respect to the author's criteria. Conclusions: The best delineated relationship between cholesterol gallstones and diet was found in the studies that analyzed total calorie intake, refined sugars and fiber. The possible mechanisms are discussed in base of experimental studies.

Most surgeons in general surgical practice in NSW who encounter common bile duct (CBD) stones at laparoscopic cholecystectomy (LC) prefer not to explore the CBD laparoscopically (A. Das, unpubl. data 1999). We suspect that this finding reflects a geographically widespread sentiment. A combination of two strategies can usually be used to avoid the need for laparoscopic CBD exploration: (i) selective preoperative endoscopic retrograde cholangio-pancreatography (ERCP) for suspected stones; and (ii) postoperative ERCP when unexpected stones are found at operative cholangiography (OC). The problem with this approach is that: (i) many patients have a negative and, therefore, unnecessary preoperative ERCP with the attendant risks; 1-7 and (ii) conventional postoperative ERCP (i.e. without a stent) carries the risks of failure to cannulate, pancreatitis, perforation and bleeding. Even a surgeon who is enthusiastic for laparoscopic transcystic or direct choledochoscopic exploration of the CBD, will not always be able to perform these procedures on certain patients and in certain circumstances. Ultimately, the optimum management of choledocholithiasis depends on the setting in which it is discovered, the resources of the institution, and the skill and experience of the attending surgeon. 14 Over the past 3 years, we have evaluated a combined approach to take advantage of the strengths and avoid the weaknesses of both the laparoscopic and endoscopic techniques, with the aim of finding a surgical technique to deal with CBD stones that is applicable to all general surgeons. In some settings, the facilitated ERCP might need to be performed elsewhere.

Background: The debate for and against the routine use of intraoperative cholangiography (IOC) continues. One of the main arguments against the routine use of the technique during laparoscopic cholecystectomy (LC) is the length of time it takes, which in turn increases the cost. In this study, we recorded the time spent by the radiographer providing IOC service in the context of optimizing the utilization of the radiographer and IOC time.

Background: Gallbladder perforation during laparoscopic
cholecystectomy (LC) with spillage of bile and gallstones
occurs in a substantial number of patients (up to 40%). Most
surgeons believe that free intraperitoneal stones are not a
justification for conversion to laparotomy even if a large
number of stones are left in situ. There are, however, a
number of reports demonstrating that, on occasion, these
unretrieved gallstones may cause infection or abscess, inflammation,
fibrosis, adhesions, cutaneous sinuses, small
bowel obstruction, or generalized septicemia. The aim of
this study was to determine the outcome of unretrieved gallstones
in the peritoneal cavity after gallbladder perforation
during LC.
Methods: In a 7-year period between 1989 and 1996, prospective
data were maintained on 856 patients who underwent
LCs by a single surgeon (R.J.F.). Of the 856 patients,
165 (16%) had gallbladder perforations resulting in lost
gallstones in the peritoneal cavity. A concerted attempt was
made to remove the lost stones using a variety of extraction
devices. Of these 165 patients, 106 (64%) were available for
follow-up through mail (76%) and by telephone (24%). The
mean age of these patients was 64.9 years (range, 18 to 98
years), and the mean follow-up was 44.8 months (range 4.9
to 92.3 months).
Results: Of the 106 patients with unretrieved gallstones, we
identified four patients with short-term complications and
one patient with a long-term complication. The first patient
with a short-term complication had pyrexia for 10 days
postoperatively. Diagnostic evaluation, which included
computed tomography (CT) scan, failed to reveal any abnormality.
The patient was treated conservatively with a
course of oral antibiotics. In the second patient, cellulitis
developed at a drain site after its removal, which resolved
with oral antibiotics. The third patient acquired an umbilical
wound abscess, which drained spontaneously, requiring no
treatment. A sterile subphrenic collection developed in the
fourth patient 1 month postoperatively, which was treated
with percutaneous drainage under CT guidance. The only
long-term complication was spontaneous erosion of a gallstone
from the back of a patient with a questionable history
of inflammatory bowel disease 8 months postoperatively.
All of the patients made complete recoveries.
Conclusions: In most patients, unretrieved gallstones are of
no consequence, but complications occur occasionally. It is
therefore advisable to retrieve as many gallstones as possible
during LC short of converting to a laparotomy.

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.

BACKGROUND:
The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology.
METHODS:
Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989.
RESULTS:
Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality.
CONCLUSIONS:
LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.

Introduction Bile duct injuries have been substantially increased after the introduction of laparoscopic cholecystectomy (LC). They are accompanied by major morbidity, occasional mortality, lengthening of hospital stay, additional health costs, and deterioration of patients' quality of life and life expectancy. The aim of this study was to present the method of "critical view of safety" (CVS) as safe and feasible for the prevention of bile duct injuries during laparoscopic cholecystectomy. Patients and Methods During a 6-year period from January 2002 till December 2007, 1,046 LCs (369 men and 677 women) were performed mainly for symptomatic gallstone disease. The CVS technique recommends clearing the triangle of Calot of fat and fibrous tissue and taking the gallbladder off the lowest part of its attachment to the gallbladder bed. The "infundibular" technique (identification of cystic duct and gallbladder junction) was used whenever CVS was not possible to perform. Results The CVS was performed in 998 patients (95.4%). Overall, 27 patients needed conversion to the open approach (2.6%). This rate was higher in patients with acute inflammation undergoing early operation (nine of 128, 7%) compared with patients operated later or electively (18 of 914, 1.9%). There was no bile duct injury in the 1,046 cholecystectomies. Postoperatively, five patients had bile leaks which were transient and stopped spontaneously after 2-14 days. Two reoperations were performed because of severe bleeding. Conclusion CVS clarifies the relations of the anatomic structures that should be divided, and therefore, it should be ideally and routinely applied in all LCs because of its highly protective role against bile duct injuries.

Background: Paroxysmal supraventricular tachycardia is a common dysrhythmia that occurs at all ages. Its management is determined by presenting symptoms and previous history of the patient. Patients present with a continuum of symptoms ranging from palpitations to syncope. The incidence of supraventricular tachycardia increases with age. Objectives: To discuss the etiology, precipitating factors, and acute management of supraventricular tachycardia; and to discuss nodal reentry circuits and representative electrocardiographic findings. Case Report: We present the case of an 84-year-old man with gallstone pancreatitis, choledolcholithiasis, and cholecystitis complicated by paroxysmal supraventricular tachycardia. We review this dysrhythmia, emphasizing its significance in elderly patients. Conclusion: Supraventricular tachycardia is a common dysrhythmia that can result in syncope or myocardial infarction. We present a case of an elderly man with new-onset atrioventricular (AV) nodal reentry tachycardia, possibly precipitated by overdrive of his autonomic nervous system due to pain and infection. As the percentage of the elderly in our population is growing rapidly and the incidence of AV nodal reentry tachycardia increases with age, emergency physicians should be familiar with this dysrhythmia-its etiology, precipitating factors, presentations, and treatment. It will present more frequently in the future. Published by Elsevier Inc.

Background: Studies of ERCP-related morbidity seldom include a sufficient patient follow-up. The aim of this study was to characterize and to evaluate the frequency of complications, cardiopulmonary untoward events in particular. Methods: All patients undergoing ERCP during a 2-year period were included in this prospective study. Complications were assessed at the time of ERCP and by postal/telephone contact at 30-days after the procedure. Results: A total of 1177 ERCPs were included in the analysis, of which 56.2% were therapeutic. The 30-day complication rate was 15.9%; the procedure-related mortality rate was 1.0%. Post-ERCP pancreatitis occurred in 3.8% of patients (3 deaths). Hemorrhage or perforation occurred with 0.9% and 1.1%, respectively, of the procedures (3 deaths). One perforation that resulted in the death of the patient occurred after placement of an endoprosthesis. Cholangitis occurred in relation to 5% of the ERCP procedures (3 deaths). Cardiorespiratory complications occurred in 2.3% (2 deaths). Dilated bile duct (p = 0.0001), placement of stent (p = 0.001), and use of more than 40 mg of hyoscine-N-butyl bromide (p < 0.05) were risk factors for complications by multivariate analysis. Risk of pancreatitis was increased with age under 40 years (p = 0.0078), placement of stent (p = 0.031), and a dilated bile duct (p = 0.036).

Introduction: L'objectif étant de comparer, rétrospectivement, les résultats du traitement combiné séquentiel à ceux de la chirurgie ouverte chez des patients pris en charge pour lithiase vésiculaire (LV) et lithiase de la voie biliaire principale (LVBP) durant la même hospitalisation. Méthodes: L'étude a concerné 132 patients pris en charge au CHU Hassan de Fès entre Décembre 2003 et Décembre 2011. Nos patients ont été répartis sur deux groupes thérapeutiques. Le premier correspondant aux malades ayant eu une sphincterotomie endoscopique première suivie d'une cholécystectomie par voie coelioscopique. Le deuxième incluant les malades ayant eu un traitement exclusivement chirurgical. La comparaison des deux groupes a porté sur les résultats en termes de morbi-mortalité, de séjour post opératoire et d'efficacité du traitement. Résultats:

Rokitansky-Aschoff sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall and are usually referred to as adenomyomatosis. The role of this study is to demonstrate that Rokitansky-Aschoff sinuses of the gallbladder are a risk factor for the formation of black pigment gallstones. A total of 179 removed gallbladders, were hystologically examinated. Sixty-four of the 179 consecutive cholecystomized patients had typical adenomyomatosis. Thirty-eight of the 64 patients with adenomyomatosis had black pigment gallstones, alone (n ¼ 22) or in association with single (n ¼ 12) or multiple (n ¼ 4) cholesterol gallstones in the same gallbladder. Twelve of these patients did not have the typical risk factors for black stones (hemolysis, cirrhoses, gastrectomy, etc). Gallstones were examined by infrared spectroscopy and X-ray diffractometry. In addition, in a subset of 14 patients, the gallstones and the gallbladder wall were examined by scanning electron microscopy. At least in the initial phases of formation, Rokitansky-Aschoff sinuses were found close to small intraparietal vessels and sometimes they contained black pigment microstones. After the fourth to fifth decades of life, black gallstones can be found in the Rokitansky-Aschoff sinuses and in the main gallbladder lumen. Black pigment gallstones can form in Rokitansky-Aschoff sinuses of the gallbladder in absence of the typical risk factors for bilirubin suprasaturation of bile.

Background: Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. Methods: From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. Results: A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients.

Author contributions: Șurlin V, Săftoiu A and Dumitrescu D contributed equally to the conception and design of the review, aquisition, analysis and interpretation of data; Șurlin V and Dumitrescu D wrote and drafted the manuscript; Săftoiu A revised it critically and gave final approval of the version to be published.

Background: The routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy remains controversial. Methods: A retrospective review of 950 consecutive laparoscopic cholecystectomies performed during an 8-year period was performed. For the first 2 years, IOC was performed selectively, and thereafter routinely. Results: Attempted in 896 patients, IOC was successful in 734 (82%). Bile duct stones were found in 77 patients (10%), dilated ducts without stones in 47 patients (6%), and anatomic variations in 4 patients (0.5%). There were four (0.4%) minor intraoperative complications related to the IOC, with no consequences for the patients. There were three (0.3%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients. In two of these patients, the structure recognized and catheterized as the cystic duct was revealed by IOC to be the bile duct. Thus IOC prevented extension to a major common bile duct (CBD) injury. Conclusions: Findings show that IOC is a safe technique. Its routine use during laparoscopic cholecystectomy may not prevent bile duct injuries, but it minimizes the extent of the injury so that it can be repaired easily without any consequences for the patient. The prevention of a major bile duct injury makes IOC cost effective.

The occurrence of retained/recurrent calculi after primary CBDE followed by temporary T-tube decompression, have remained at rates varying from 5.4% to 20.9% over the last 10 years in spite of sophisticated pre and intraoperative imaging techniques. It is postulated that a functional obstruction, due to dysmotility of the SO, lies behind most stone-containing ducts. Thus it seems logical to us that a permanent "fenestration" should be the management of most such ducts.

Background/Aims: From quantitative trait locus mapping in inbred mice, we identified the Nr1h4 gene encoding the nuclear bile salt receptor FXR as a candidate gene for the cholesterol gallstone susceptibility locus Lith7. Here, we investigated further an association of the gene encoding FXR and gallstone susceptibility in mice and humans.

Background. Prior Billroth II gastrectomy is an important factor presenting diffi culties in endoscopic retrograde cholangiopancreatography (ERCP) administration. We retrospectively evaluated the usefulness and safety of therapeutic ERCP using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy. Methods. Forty-three patients with bile duct stones after Billroth II gastrectomy who underwent ERCP from January 1998 to February 2008 were enrolled in this study. We used anterior oblique-viewing endoscopes for all procedures. Endoscopic sphincterotomy was performed using a needle knife guided by a biliary stent. A total of 808 patients without gastrectomy who had undergone ERCP for bile duct stones in the same period were reviewed as controls. Results. The success rate of access to the papilla of Vater was 88.4%, and the average time required for such access was 13 min. In cases of successful access, selective cannulation of the bile duct and complete stone removal were achieved in 94.7% and 94.6% of patients, respectively. The incidence of complications was 4.7%. As for the success rate of selective cannulation, complete stone removal ratio, and the incidence of complications, there were no signifi cant differences compared with the control group. Conclusions. Use of an anterior oblique-viewing endoscope enables good success rates in selective cannulation and complete stone removal to be achieved in patients with prior Billroth II gastrectomy. The safety of therapeutic ERCP for removal of bile duct stones in those patients is comparable to that in patients with normal anatomy.

To evaluate the influence of familiality on the prevalence of gallstone disease (GD) in Italy. Families of 79 subjects with gallstones (cases) and of 79 subjects without gallstones (controls) were investigated for the presence of gallstones by ultrasonography. Index cases and index controls were matched for age, sex, and operative unit. Sixty-three and sixty-two husbands and wives of index cases and index controls, respectively, were also studied. Overall, the prevalence of GD was significantly higher (c2=14.52, P&lt;0.001) in the 202 first-degree relatives of subjects with gallstones than that in the 201 first-degree relatives of subjects without gallstones (28.6% vs 12.4%, relative risk (RR) 1.80, 95% confidence interval (CI) 1.29-2.63). In particular, prevalence of GD was significantly higher in mothers, fathers, and sisters of index cases than that in the respective family members of index controls. The highest RR was observed in mothers (RR=2.35, 95%CI 1.38-4.3). Prevalence of ...

a b s t r a c t Introduction: About 7e12% of patients who harbor gallbladder calculi concomitant common bile duct (CBD) calculi are present. The treatment of gallbladder calculi has standardized in the form of laparoscopic cholecystectomy but management of CBD calculi is still evolving. Endoscopic removal of CBD calculi <2 cm in diameter is successful in 90e100% of cases but patients harboring stones >2 cm in diameter high failure rates can be seen. Traditionally, laparoscopically one can achieve success rate comparable to endoscopic surgery but large and impacted calculi may cause failures. If one uses pneumatic lithotripsy during laparoscopic management of CBD calculi one can achieve 100% stone clearance irrespective of size, degree of hardness and impaction. This study evaluates the feasibility of using pneumatic lithotripsy for CBD calculi. To our knowledge this is the 1st reported series of using pneumatic lithotripsy for CBD calculi. Material and methods: From June 2002 to June 2010 96 laparoscopic CBD explorations (LCBDE) were done for CBD calculi. Patients having choledocholithiasis with CBD diameter of >10 mm were taken for LCBDE while in patients with CBD diameter of <10 mm were referred for endoscopic clearance. Additionally ERCP failure cases were also subjected to LCBDE. Rigid nephroscope was used for LCBDE and usually calculi were removed by forceps only. In patients having large, hard &/or impacted calculi pneumatic lithotripsy were used for fragmentation. Results: Out of the 96 patients in 12 (12.5%) cases pneumatic lithotripsy was used for stone fragmentation. Out of these 12 cases 5 (41.6%) were ERCP failure cases. At a mean hospital stay of 2.5 days 100% stone clearance was achieved in all cases with no perioperative complication.