Efficacy and safety of double endoscopy combined with exploration in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis

OBJECTIVE

To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

METHODS

A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023.

RESULTS

Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05).

CONCLUSION

Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.

Persistent and new-onset symptoms after cholecystectomy in patients with uncomplicated symptomatic cholecystolithiasis: A post hoc analysis of 2 prospective clinical trials

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for treating biliary colic in patients with gallstones, but post-cholecystectomy abdominal pain is commonly reported. This study investigates which symptoms are likely to persist and which may develop after a cholecystectomy.

METHODS

Patients from 2 previous prospective trials who underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis were included. Patients completed questionnaires on pain and gastrointestinal symptoms before surgery and at 6 months follow-up. The prevalence of persistent and new-onset abdominal symptoms was evaluated.

RESULTS

A total of 820 patients received cholecystectomy and were included, 75.4% female (n = 616/820) mean age 49.4 years (standard deviation 13.7). At baseline, 74.1% (n = 608/820) of patients met all criteria for biliary colic. Cholecystectomy successfully resolved biliary colic in 94.8% (n = 327/345) of patients, but 36.5% (n = 299/820) of patients reported persistent abdominal pain after 6 months of follow-up. The prevalence of most abdominal symptoms reduced significantly. Symptoms such as flatulence (17.8%, n = 146/820) or restricted eating (14.5%, n = 119/820) persisted most often. New-onset symptoms were frequent bowel movements (9.6%, n = 79/820), bowel urgency (8.5%, n = 70/820), and new-onset diarrhea (8.4%, 69/820).

CONCLUSION

Postcholecystectomy symptoms are mainly flatulence, frequent bowel movements, and restricted eating. Newly reported symptoms are mainly frequent bowel movements, bowel urgency, and diarrhea. The present findings give clinical guidance in informing, managing, and treating patients with symptoms after cholecystectomy.

Meta-analysis of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in patients with cholecystolithiasis and choledocholithiasis

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy plays an important role in the treatment of cholecystolithiasis combined with choledocholithiasis; however, there is no unified standard for the interval of ERCP before laparoscopic cholecystectomy. We conducted a literature search, data extraction and meta-analysis on this topic. Twelve articles with 1142 patients were included, including 567 patients in the E-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed within 72 h after ERCP) and 575 patients in the D-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed 72 h after ERCP). The results showed that: compared with the D-laparoscopic cholecystectomy group, the duration of cholecystectomy was shorter in the E-laparoscopic cholecystectomy group [weighted mean difference (WMD) = -16.18, 95% confidence interval (CI) (-22.27 to -10.08), P  < 0.00001], and the postoperative hospitalization was shorter [WMD = -1.24, 95% CI (-1.98 to -0.50), P  < 0.0001]. There were fewer complications [odds ratio (OR) = 0.25, 95% CI (0.39-0.62), P  < 0.0001], lower conversion rate [OR = 0.39, 95% CI (0.21-0.71), P  = 0.002], lower high sensitivity C-reactive protein at 3 days after surgery [WMD = -8.76, 95% CI (-12.59 to -4.93), P  < 0.00001], and fewer neutrophils in the ampulla of gallbladder specimen [WMD = -4.21, 95% CI (-4.55 to -3.88), P < 0.00001]. Therefore, in the treatment of cholecystolithiasis combined with choledocholithiasis by laparoscopic cholecystectomy within 72 h after ERCP, the degree of inflammation before and after surgery is less, the operation time and hospital stay are shortened, the postoperative complications and the conversion rate are reduced, which is a more appropriate time for surgery.

Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis

BACKGROUND

The need for intraoperative endoscopic nasobiliary drainage during laparoscopic cholecystectomy and laparoscopic common bile duct exploration with primary closure is controversial in the treatment of cholecystolithiasis combined with choledocholithiasis. The aim of this study was to evaluate the safety and efficacy of laparoscopic cholecystectomy + laparoscopic common bile duct exploration + intraoperative endoscopic nasobiliary drainage + primary closure (LC + LCBDE + IO-ENBD + PC). The safety of different intubation methods in IO-ENBD was also evaluated.

METHOD

From January 2018 to January 2022, 168 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent surgical treatment in our institution. Patients were divided into two groups: group A (n = 96) underwent LC + LCBDE + IO-ENBD + PC and group B (n = 72) underwent LC + LCBDE + PC. Patient characteristics, perioperative indicators, complications, stone residual, and recurrence rates were analyzed. Group A was divided into two subgroups. In group A₁, the nasobiliary drainage tube was placed in an anterograde way, and in group A₂, nasobiliary drainage tube was placed in an anterograde-retrograde way. Perioperative indicators and complications were analyzed between subgroups.

RESULTS

No mortality in the two groups. The operation success rates in groups A and B were 97.9% (94/96) and 100% (72/72), respectively. In group A, two patients were converted to T-tube drainage. The stone clearance rates of group A and group B were 100% (96/96) and 98.6% (71/72), respectively. Common bile duct diameter was smaller in group A [10 vs. 12 mm, P < 0.001] in baseline data. In perioperative indicators, group A had a longer operation time [165 vs.135 min, P < 0.001], but group A had a shorter hospitalization time [10 vs.13 days, P = 0.002]. The overall complications were 7.3% (7/96) in group A and 12.5% (9/72) in group B. Postoperative bile leakage was less in group A [0% (0/96) vs. 5.6% (4/72), P = 0.032)]. There were no residual and recurrent stones in group A. And there were one residual stone and one recurrent stone in group B (all 1.4%). The median follow-up time was 12 months in group A and 6 months in group B. During the follow-up period, 2 (2.8%) patients in group B had a mild biliary stricture. At subgroup analysis, group A₁ had shorter operation time [150 vs. 182.5 min, P < 0.001], shorter hospitalization time [9 vs. 10 days, P = 0.002], and fewer patients with postoperative elevated pancreatic enzymes [32.6% (15/46) vs. 68% (34/50), P = 0.001].

CONCLUSION

LC + LCBDE + IO-ENBD + PC is safer and more effective than LC + LCBDE + PC because it reduces hospitalization time and avoids postoperative bile leakage. In the IO-ENBD procedure, the antegrade placement of the nasobiliary drainage tube is more feasible and effective because it reduces the operation time and hospitalization time, and also reduces injury to the duodenal papilla.

Effect of Microscope Combined with Wechat Smart Platform on Clinical Efficacy and Gastrointestinal Function of Patients with Cholecystolithiasis Combined with Common Bile Duct Stones

To explore the clinical efficacy of microscope combined with Wechat smart platform in patients with cholecystolithiasis and choledocholithiasis, this paper proposes the effect of microscope combined with Wechat smart platform intervention after laparoscopic lithotomy and choledocholithotomy on the clinical efficacy and gastrointestinal function of patients with cholecystolithiasis combined with choledocholithiasis. From February 2018 to March 2019, 78 patients with gastric cancer were selected by our clinic and included in the research team. Evaluate the efficacy of endoscopic biliary lithotomy (LBL) + bile duct lithotomy (TBL) + T-tube drainage therapy to provide reliable evidence for improved efficacy and efficacy in order to provide a strong reference for improving the effectiveness and safety of surgical treatment of choledocholithiasis. Safety of surgical treatment of diseases. Gallstone disease. The experiments did not show any significant differences between the two groups during surgery. Diabetes was lower in the control group, and hospital incidence was lower in the control group. There were no significant differences between the two groups for preoperative WHOQOL-100 scores. Two weeks and four weeks after surgery, the man-key-100 score was higher than that of the control group. Endoscopic cholecystectomy + choledocholithotomy + choledochoscopic lithotomy + T-tube fluid have been shown to be effective in promoting rapid intestinal function and improving patient quality of life and are appropriate for therapeutic use.

Laparoscopic Cholecystectomy in Cirrhotic Patients: A Retrospective Study

Introduction: Cirrhosis is a leading cause of morbidity and mortality around the world. Although cirrhotic patients are considered to have a higher risk for surgical procedures than non-cirrhotic ones, there are certain pathologies such as gallstones cholecystitis that cannot be treated otherwise. The focus of this study is to evaluate the main characteristics of the patients with lithiasic cholecystitis and liver cirrhosis and to assess if there is a correlation between them and postoperative morbidity evaluated with Dindo-Clavien classification. Material and Methods: This is a retrospective study. The database from General Surgery Department of Fundeni Clinical Institute was queried between 2014-2018 using as key words "cirrhosis" and "cholecystitis". The initial interrogation reveled 57 cases out of which 3 were excluded since other resections were associated. Results: This study identified that Dindo-Clavien classification positively correlates with the open approach (0.405, p=0.002), emergency surgery (0.599, p=0.000), acute cholecystitis (0.476, p=0.000), high MELD score (0.291, p=0.008) and Child score (0.346, p=0.007) and furthermore with high levels of total bilirubin (0.220, p=0.047), high INR (0.286, p=0.010), the presence of ascites (0.303, p=0.022) and portal hypertension (0.266, p=0.044). It also correlates negatively with the levels of hemoglobin (-0.295, p=0.044). Conclusion: Adequate estimation of perioperative mortality and morbidity is generally limited by the retrospective nature of most studies and the patient's selection criteria. Emergency surgery, acute cholecystitis and the open approach carry the highest risk for unfavorable results of cholecystectomy in cirrhotic patients.

One-step versus two-step procedure for management procedures for management of concurrent gallbladder and common bile duct stones. Outcomes and cost analysis

BACKGROUND

The management of cholelithiasis and choledocholithiasis combined is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. This study aims to demonstrate how, on the basis of the personal experience, the Rendez-vous technique, that combines the two techniques in a single-stage operation is better than the sequential treatment.

METHODS

Between June 2017 to December 2019, 40 consecutive patients with cholelithiasis and choledocholithiasis combined were enrolled for the study: 20 were treated with the sequential treatment and 20 with the Rendez-vous method. The preoperative diagnostic work-up was similar in the two group. The endpoints of the study included incidence of endoscopic and surgical complications, rate of hospitalization and cost analysis.

RESULTS

The study showed no difference in demographic parameters between the two groups, but the success rate of clearance of CBD was significantly smaller for sequential arm, with the need of additional procedures. We found a statistical reduction of postoperative acute pancreatitis, hospital stay and charges in Rendez-vous group, at the expense of a prolonged total operating time.

CONCLUSIONS

The data of the study confirm the superiority of the Rendez-vous technique because it resolves cholelithiasis associated with choledocholithiasis in a single surgical act, with greater acceptance of the patient who avoids a second invasive surgical act, and with a reduction in complications; moreover, it requires shorter hospitalization, resulting in reduced costs. We propose this option in the management of cases where preoperative ERCP-ES has failed.

KEY WORDS

Common bile duct stones, Cholecysto-choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Laparoscopic cholecystectomy, Laparo-endoscopic Rendez-vous.

Gender as a predictive factor in cholecystectomy - is it true or false?

INTRODUCTION

Cholecystolithiasis is one of the most frequent disorders of the human digestive system in a present population. It is common to point out that male gender is one of strong risk factors for complications during cholecystectomy, however the debate about that seems to be still open.

AIM OF THE STUDY

The aim of this study was to compare the values related to the course and treatment effects between gender in patients undergoing cholecystectomy, based on own material.

MATERIALS AND METHODS

The study encompassed 504 patients who were admitted to General Surgery And Polytraumatic Injury Department of University Hospital in Kraków, Poland between 2013 and 2018, with the initial diagnosis of cholecystolithiasis (scheduled cases) and acute cholecystitis (emergency cases). The patients underwent surgical gallbladder removal. In this group there were 326 (64.7%) female and 178 (35.3%) male patients.

RESULTS

Statistically significant differences between both genders were found containing age, type of admission, numeric rating scale of pain during admission, results in American Society of Anesthesiologists physical status classification system, outcomes in Acute Physiology And Chronic Health Evaluation II severity-of-disease classification system, percentage of conversions, mortality, period of time from admission to surgical procedure, mean duration of the procedure, blood tests and histopathological results.

CONCLUSIONS

Subgroups of the cases where determining factor is gender are strongly heterogeneous. Although treatment results were different for both subgroups and these differences were partly statistically significant, it cannot be clearly determined on the basis of a study with such selection of patients, that gender is an independent risk factor for surgical gallbladder removal.

A Female with Right-Sided Thoracic Kidney with Bochdalek Hernia: A Case Report

The thoracic kidney is the rarest form of an ectopic kidney that usually present on the left thoraxand twice more common in males. No case has been reported from Nepal and very few cases arereported worldwide. We report a 24 years-old female with right thoracic kidney with Bochdalekhernia diagnosed incidentally. We have included clinico-radiological and surgical findings of thecase with a review of the literature.

Efficacy and safety of laparoscopic bile duct exploration versus endoscopic sphincterotomy for concomitant gallstones and common bile duct stones: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to compare the efficacy and safety of laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct (CBD) stones exploration (LCBDE) with LC plus endoscopic sphincterotomy (EST) in the treatment of patients with gallstones and CBD stones.

METHODS

The authors searched PubMed, Web of Science, and Embase to identify relevant studies. Risk ratios (RRs) were pooled to compare stone clear, retained stone, conversion to other procedures, and complications. Weighted mean differences (WMDs) were pooled to compare operative time, and length of hospital stay. A fixed-effects model or random-effects model was used to pool the estimates, according to the heterogeneity among the included studies.

RESULTS

A total of 11 randomized controlled trials (RCTs) involving 1663 patients were included in this meta-analysis. The pooled estimate suggested that LC-LCBDE had comparable effects with LC-EST in terms of CBD stone clear rate (RR = 1.02, 95% CI: 0.95, 1.09; P = .583), retained stones rate (RR = 1.27, 95% CI: 0.51, 3.19; P = .607), and length of hospital stay (WMD = -0.96 days, 95% CI: -2.20, 0.28). In addition, LC-LCBDE was associated with significantly higher conversion rate (RR = 1.59, 95% CI: 1.08, 2.35; P = .019) and less operative time (WMD = -11.55 minutes, 95% CI: -16.68, -6.42; P < .001) than LC-EST. The incidence of complications was not significant difference between the 2 surgical approaches (RR = 1.07, 95% CI: 0.86, 1.34; P = .550).

CONCLUSION

Based on the current evidence, both LC-LCBDE and LC-EST were highly effective in detecting and removing CBD stones and were equivalent in complications. However, our results might be biased by the limitations. Large-scale well-designed RCTs are needed to confirm our findings.

Percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach for removing concurrent gallbladder stone and common bile duct stone in a patient with billroth II gastrectomy and acute cholecystitis: A case report

BACKGROUND

A 61-year-old man presented with upper abdominal pain and jaundice. Abdominal computed tomography imaging revealed stones in the gallbladder and the common bile duct, with a thickening of the gallbladder wall and an obvious increase in the volume of the gallbladder. Initial treatment using endoscopic retrograde cholangiopancreatography failed due to the presence of surgically altered gastrointestinal anatomy. Stones in the gallbladder and common bile duct were subsequently removed concurrently via percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach. Liver function recovered rapidly, with total bilirubin and direct bilirubin levels decreasing to normal, with a concomitant improvement in hemoglobin and thrombocyte levels and resolution of the upper abdominal pain and jaundice.

CONCLUSION

Percutaneous transhepatic papilla balloon dilatation, combined with a percutaneous transcystic approach, provided an effective alternative treatment for removing concurrent stones in the common bile duct and gallbladder in a patient with a previous Billroth II gastrectomy and presenting with an acute cholecystitis.

[Bouveret's syndrome - a rare complication in connection with cholecystolithiasis and a variant of gallstone ileus]

Bouveret's syndrome is a very rare complication to cholecystolithiasis resulting in gallstone ileus. It is caused by ectopic gallstones in the duodenum due to a bilioenteric fistula. Symptoms may include vomiting and upper abdominal pains. The condition is associated with high mortality, making it important to recognize. The treatment includes surgical removal of the gallstone. However, the optimal therapeutic approach has still not been found. In this case report a 59-year-old female with Bouveret's syndrome is presented.

From Laparoscopic Cholecystectomy to Liver Transplantation: When the Gallbladder Becomes the Pandora s Box

Bile duct injuries (BDI) tend to be more complex in laparoscopic than in open cholecystectomy procedures, and frequently involve young adults with benign pathologies. The ultimate consequence may be a liver transplantation (LT), making this situation one of the most rare transplant indications. Fatal post-transplant outcome is extreme infrequently reported. Aim of this study is to report on our single-case experience and to review the literature concerning lethal outcome after LT for major BDI following cholecystectomy. A 36-year old obese caucasian woman underwent a laparoscopic cholecystectomy for symptomatic cholecystolithiasis at an outside institution. Intraoperatively, she sustained an E4 BDI in conjunction with total transection of the right hepatic artery. The surgeon converted to an open laparotomy, examined the site, placed two drains, and immediately transferred the patient to our center for further evaluation and treatment. At relaparotomy, a dearterialized right liver as well as 7 bile duct orifices was found; a right hemihepatectomy and a Roux-en-Y drainage of 4 left-sided bile ducts were performed. The postoperative course was complicated by bile leaks requiring re-operation and relapsing episodes of cholangitis and intrahepatic bilomas, requiring re-submissions of the patient and conservative treatment with intravenous antibiotics and percutaneous drainage procedures, respectively. She subsequently developed severe endocarditis leading to cardiac mitral and aortic valves insufficiency (grade III and II, respectively) demanding mechanical replacement of them. The patient developed secondary biliary cirrhosis, was listed to Eurotransplant with a Model for End-Stage Liver Disease score of 39, and underwent LT 19 months after the laparoscopic cholecystectomy. Histology of the explanted liver showed 50% parenchymal necrosis, chronic cholestasis and cirrhosis. On post-transplant day 5, she developed cardiogenic shock associated with pericardial tamponade that despite adequate surgical drainage progressed to multi-organ failure and death 2 days later. The two most frequent complications of hepatobiliary surgery that may ultimately require LT are: 1) lesions of the bile duct leading to recurrent cholangitis, chronic cholestasis, and secondary biliary cirrhosis, and 2) hilar vascular lesions (almost always arterial) associated with fulminant hepatic failure. Up to date there have been very few publications about LT as a treatment option following major BDI. To the best of our knowledge, 4 deaths post-LT after major BDI during laparoscopic cholecystectomy are reported in the literature (1-3) (Table 1). The indications for LT in these 4 cases were fulminant hepatic failure (n=2) (2) and secondary biliary cirrhosis (n=2) (1, 3) and the deaths occurred 6 days, 1 month, 7 and 18 months post-operatively, respectively. Five additional fatal outcomes after LT for secondary biliary cirrhosis after major BDI during open cholecystectomy were reported in the literature (3-5). Four patients died at 7 days, 1 month, 7 and 8 months post-LT, respectively (3-4). The fifth patient died after 2 subsequent transplants for hepatic artery thrombosis unrelated to the initial injury sustained during cholecystectomy (5). This indeed displeasing analysis of the overall 10 cases shows, that despite the very few post-transplant fatal outcomes reported in the literature, this is a real scenario representing one of the most dreaded outcomes of a seemingly simple procedure such as cholecystectomy.

Intrahepatic perforation of the gallbladder causing liver abscesses: case studies and literature review of a rare complication

A spontaneous (non-traumatic) gallbladder perforation with gallstone disease is not common. Concomitant development of a liver abscess is a very rare complication observed in such cases. A few cases of intrahepatic gallbladder perforations with chronic liver abscesses have been described. However, a patient series summarising classical and atypical presentations, relevant imaging studies, and the role of surgical and non-surgical options are lacking. We report a short case series on this rare complication of intrahepatic gallbladder perforations and share our experience of management of this condition.

Bouveret Syndrome - An Exceptional Complication of a Very Frequent Disease

The Bouveret syndrome is an exceptional complication of the gallbladder lithiasis. Hereby it is described the case of a patient with a history of gallstones complicated on the long-term outcome with gastric outlet obstruction, due to a large gallstone of the duodenum, migrated via a cholecysto-duodenal fistula. The clinical, radiological features and the patient management are described.

Single-stage management with combined tri-endoscopic approach for concomitant cholecystolithiasis and choledocholithiasis

OBJECTIVE

The aim of this study was to investigate the value of a single stage with combined tri-endoscopic (duodenoscopy, laparoscopy and choledochoscopy) approach for patients with concomitant cholecystolithiasis and choledocholithiasis.

METHODS

Fifty-three patients with combined gallbladder stones and common bile duct stones from February 2014 to April 2015 were randomized assigned to two groups: 29 patients underwent single-stage surgery with combined duodenoscope, laparoscope and choledochoscope (combined tri-endoscopic group), and 29 patients underwent endoscopic sphincterotomy to remove common bile duct stones followed by laparoscopic cholecystectomy several days later (control group). The success rate of complete stone removal, procedure-related complication, hospital stay and the cost of hospitalization were compared between the two groups.

RESULTS

Altogether, 53 patients (29 patients in combined tri-endoscopic group and 24 patients in control group) successfully underwent the surgery and ERCP procedure. Three patients in the control group developed post-ERCP pancreatitis. One case of bile leaking and one case of residual stone were noted in the combined tri-endoscopic group. There were no significant differences between the two groups with regard to both complete stone removal [96.6 % (28/29) vs. 100 % (24/24)] and procedure-related complication rate [3.4 % (1/29) vs. 12.5 % (3/24)] (p > 0.05). No open surgery was required in either group. There were significant differences between the two groups with regard to hospital stay (6.72 ± 1.3 days vs. 10.91 ± 1.6 days, p < 0.01) and cost of hospitalization (15,724 ± 1613 CNY vs. 19,829 ± 2433 CNY, p < 0.05).

CONCLUSION

The single-stage combined tri-endoscopic approach for concomitant cholecystolithiasis and choledocholithiasis was just as safe and successful as the control group. In addition, it resulted in a shorter hospital stay and less cost.

[A case of multifocal colon carcinoma and cholecystolithiasis in an elderly patient]

An 83-year-old woman was admitted to our hospital because of general fatigue and symptoms of anemia. For 20 years, she had experienced right hypochondrial pain several times a year. Colonoscopic examination revealed a type 2 tumor at the ascending colon. The biopsy specimen was a Group 5 and type 0-IIa polyp at the transverse colon. The endoscopic mucosal resection (EMR) specimen was a well-differentiated adenocarcinoma(Stage pSM [2mm], ly0, v0). An apple core lesion in the cecum was detected by enema. Abdominal computed tomography demonstrated cholecystolithiasis and no metastasis or distant metastases. Therefore, a diagnosis of multifocal colon carcinoma and cholecystolithiasis was made. Expanding right hemicolectomy with cholecystectomy was performed. The patient was discharged without any complications. Subsequently, she underwent adjuvant chemotherapy for 6 months. At present, 1 year after surgery, the patient is still alive and has shown no signs of recurrence.

[Cholecystolithiasis as a cause of local hepatitis]

In an acute inflammation of gallbladder inflammatory process spreads on surrounding tissues, including hepatic tissue, what causes the regional hepatitis occurrence. In some patients, suffering calculous cholecystitis on background of transition of inflammatory process from gallbladder to hepatic tissue likewise a regional hepatitis, hyperbilirubinemia, the skin yellowness are revealed, what simulates choledocholithiasis and obturation jaundice.

Prehepatocholedochal proper hepatic artery. Rare anatomical variant. Surgical considerations. Case report

In classical anatomic variants, the proper hepatic artery (PHA)continues the common hepatic artery (CHA) after the gastroduodenal artery (GDA) detaches itself and divides into the right hepatic artery (RHA) and left hepatic artery (LHA), the proper hepatic artery being located to the left of the hepatocholedochal duct (HCD). This paper presents an abnormal positioning of the PHA placed before the HCD with an increased diameter of about 5-7 mm, which could be confused with the HCD. We present the case of a 57 year-old woman diagnosed with acute lithiasic cholecystitis, associated with hypersplenism and hypertension. The literature mentions manifold anatomical variants of arterial liver vascularization,including PHA. For this reason, this paper presents an overview of similar cases that can be found in medical literature. The aforementioned case is a rare topographic anatomy for the PHA that can easily pass for HCD especially during celioscopy, therefore it is crucial for this to be acknowledged by all surgeons.

[Laparoscopic cholecystectomy in case of acute cholecystitis]

The article describes the results of laparoscopic cholecystectomy in patients with acute cholecystitis. 97 patients including 13 men and 84 women aged from 20 to 74 years were included in the study. There was not the conversion to laparotomy and intraoperative complications in all cases. 83 patients, which amounted to 85.7% of the patients, were discharged on the next day after operation. The last 14 patients had the variation of postoperative hospitalization period from 2 to 4 days. Laparoscopic cholecystectomy is a safe and effective procedure in patients with acute cholecystitis.

One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones: our experience of the last 9 years in a retrospective study

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis

BACKGROUND

The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined.

OBJECTIVES

To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue.

DATA COLLECTION AND ANALYSIS

Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial.

AUTHORS' CONCLUSIONS

Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.

[Combined laparoscopic operations in patients with acute appendicitis and biliary calculous disease]

The experience of surgical treatment was summarized in patients, suffering an acute appendicitis, in whom simultaneously a biliary calculous disease was revealed. The procedure and technical aspects of performance of simultant laparoscoplic operation were depicted, the indications and contraindications for simultant operation conduction were determined, a consequence of the operative stages performance was determined. The main advantages of simultant laparoscopic operations were proved and the results of treatment analyzed.

The relationship between gallbladder status and recurrent biliary complications in patients with choledocholithiasis following endoscopic treatment

BACKGROUND

Endoscopic methods are currently the treatment of choice for patients with common bile duct (CBD) stones, but subsequent management of the intact gallbladder for patients following endoscopic treatment is still controversial. The primary aim of this study was to discover the association between gallbladder status and recurrent biliary complications for patients with CBD stones after endoscopic treatment. Additionally, we also sought to determine risk factors for recurrent biliary complications in these patients.

METHODS

The records of 1625 patients with CBD stones following endoscopic treatment were reviewed. A total of 681 patients were enrolled and subsequently categorized into four groups: Group 1 (n = 201), calculous gallbladder; Group 2 (n = 140), acalculous gallbladder; Group 3 (n = 175), elective cholecystectomy after endoscopic treatment; and Group 4 (n = 165), prior cholecystectomy. The basic demographics and recurrent biliary complications during follow-up among these four groups were analyzed by Chi-square test, ANOVA, Kaplan-Meier analysis, and log-rank test.

RESULTS

During the median follow-up period of 34 months, 133 patients (20%) with recurrent biliary complications were identified. The recurrence rates of Groups 1, 2, 3, and 4 were 29%, 11%, 15%, and 19%, respectively. Kaplan-Meier analysis showed that patients with calculous gallbladder had a significantly higher rate of recurrent biliary complication. In multivariate analysis, patients with a history of cirrhosis, juxta-papillary diverticulum, calculous gallbladder, CBD size ≥ 1.5 cm, and endoscopic management with endoscopic sphincterotomy were at a higher risk for developing biliary complications (p = 0.029, p = 0.039, p < 0.001, p = 0.002, p = 0.021, respectively.)

CONCLUSION

Patients with cholecystolithiasis and CBD stones had a higher incidence of recurrent biliary complications. For some of these patients, elective cholecystectomy following endoscopic treatment may be considered. However, routine elective cholecystectomy in patients with normal gallbladder is not appropriate because of the low recurrence of biliary complications. Whether gallbladder function affects the biliary clearance and biliary complications requires further research.

Evidence-based current surgical practice: calculous gallbladder disease

BACKGROUND

Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

DISCUSSION

Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

Cholecystolithiasis is associated with Clonorchis sinensis infection

BACKGROUND

The objective of this study was to analyze gallbladder stones for direct evidence of a relationship between Clonorchis sinensis infection and gallbladder stones formation.

METHODOLOGY

We investigated one hundred eighty-three gallbladder stones for the presence of Clonorchis sinensis eggs using microscopy, and analyzed their composition using Fourier transform infrared spectroscopy. We confirmed the presence of Clonorchis sinensis eggs in the gallbladder stones using real-time fluorescent PCR and scanning electron microscopy.

PRINCIPAL FINDINGS

Clonorchis sinensis eggs were detected in 122 of 183 gallbladder stones based on morphologic characteristics and results from real-time fluorescent PCR. The proportion of pigment stones, cholesterol stones and mixed gallstones in the egg-positive stones was 79.5% (97/122), 3.3% (4/122) and 17.2% (21/122), respectively, while 29.5% (18/61), 31.1% (19/61) and 39.3% (24/61) in the egg-negative stones. The proportion of pigment stone in the Clonorchis sinensis egg-positive stones was higher than in egg-negative stones (P<0.0001). In the 30 egg-positive stones examined by scanning electron microscopy, dozens or even hundreds of Clonorchis sinensis eggs were visible (×400) showing a distinct morphology. Many eggs were wrapped with surrounding particles, and in some, muskmelon wrinkles was seen on the surface of the eggs. Also visible were pieces of texture shed from some of the eggs. Some eggs were depressed or without operculum while most eggs were adhered to or wrapped with amorphous particles or mucoid matter (×3000).

CONCLUSION

Clonorchis sinensis eggs were detected in the gallbladder stones which suggests an association between Clonorchis sinensis infection and gallbladder stones formation, especially pigment stones.

[Ultrasonography in the diagnosis of cholelithiasis and its complications]

The author presents the results of ultrasound investigation (USI) of 419 patients with cholecystocholedocholithiasis. The diagnostic accuracy of USI methods in patients with calculous cholecystitis was 98.8%. Direct signs of visualization of concrements in the common bile duct (CBD) were found but in 68.5% of patients. On the basis of USI results the common bile stones were found in 287 (68.5%) patients. The concrements omitted in transabdominal USI were diagnosed using endoscopic retrograde cholangiopancreaticography, magnetic resonance cholangio-pancreaticography, endoscopic ultrasonography as well as in operative intervention.

Multidetector computed tomography diagnosis of ileal and antropyloric gallstone ileus

Gallstone-induced ileus is a rare complication of cholelithiasis, and gastric outlet obstruction is even rarer. We describe the multidetector computed tomographic diagnosis of small bowel obstruction resulting from a gallstone impacted in the distal ileum and of gastric outlet obstruction from a gallstone impacted in the pyloric antrum (Bouveret syndrome).

Laparoscopic cholecystectomy in a patient with Steinert myotonic dystrophy. Case report

Myotonic dystrophy (MD) is a serious multi-systemic autosomal dominant disease. The estimated incidence is 1 in every 8000 births, with an estimated prevalence of between 2.1 and 14.3 cases per 100,000 inhabitants. Signs and symptoms vary from a severe form of congenital myopathy, present from birth and often fatal, to a classic form and a delayed form, which generally presents after the age of 50 and in which the only sign is a cataract and life expectancy is completely normal. We describe the clinical case of a 40-year-old woman with Steinert myotonic dystrophy who underwent laparoscopic cholecystectomy (under general anesthesia) for symptomatic gallbladder stones. The conduct of anesthesia in such patients must be carefully considered, as hypothermia, shivering, electrical and mechanical stimulation, and the drugs used can all trigger myotonia.

[Low-flow xenon anesthesia in surgical patients with hypertension]

A comparative study of central hemodynamics in 60 patients with essential hypertension during low flow anesthesia with xenon and nitrous oxide is carried out. The main group consisted of 30 patients, 22 male and 8 female, in the median age of 45.9 +/- 23 years. 22 patients out of those had 2nd stage essential hypertension, while the other 8 had 3rd stage. The control group consisted of 30 patients, 20 male and 10 female, in the median age of 45.1 + 1.3 years. 4 patients had 3rd stage essential hypertension, 26 patients had 2nd stage. The both groups were clinically comparable by the character and severity of the main disease, the carried out surgery (open cholecystectomy) and the qualification of surgeons. Results of the research showed, that low flow monoanesthesia with xenon abruptly eradicated the unfavourable consequences of induction of anesthesia (3-5 mg/kg of sodium thiopental or 2-2.5 mg/kg of propofol) and had a positive effect on the parameters of central hemodynamics of patients with essential hypertension. Xenon anesthesia, compared to nitrous oxide, rapidly stabilized the parameters of blood pressure and heart rate and can be recommended as a method of choice in patients with essential hypertension and compromised myocarium. Nitrous oxide with bolus of regular fentanyl doses doesn't reliable anesthesiological protection during open cholecystectomy and shows signs of toxicity.

[Regulation of blood circulation in the surgical correction of portal hypertension]

56 patients with portal hypertension were examined who underwent decompressive shunt surgery. Cardiorhytmography and integral rheography body were performed in different stages. In the late postoperative period, there were positive changes in the autonomic regulation of functions: reduced tension index and sympathetic influence on heart rhythm, increases the value of other indicators of heart rate variability. Due to an increase in heart rate and peripheral vascular resistance normalizes blood pressure while reducing the values of cardiac output. There is a further normalization of the reactivity of blood circulation: arterial pressure and vascular resistance during the functional test remained at a constant level of magnitude of shock and cardiac index significantly increased and then decreased to the level of the original values, which corresponds to the reaction apparently healthy. Disorders of regulation, state and reactivity of blood flow in portal hypertension, manifested: 1. Reduction of heart rate variability with a significant increase in sympathetic activity of autonomic nervous system. 2. Reduction of cardiac output and vascular resistance, heart rate, changes in physiological determination of hemodynamic parameters: Blood pressure is determined only by the vessel resistance. 3. Reduction of blood pressure in response to breath holding test.

[Biliary pancreatitis]

It is provided the basic information of the etiopathogenesis, diagnosis of biliary pancreatitis, drug treatment of patients with holetsistolitiaz, and the information of biliary pancreatitis's prevention.

Ruptured hepatic subcapsular hematoma following laparoscopic cholecystectomy: report of a case

Laparoscopic cholecystectomy is now a standard procedure for cholecystolithiasis because of its minimally invasive nature compared to the conventional method. However, severe complications that have never been seen for open surgery have also been reported. Here, we report the case of a 28-year-old woman who underwent laparoscopic cholecystectomy and then developed a ruptured subcapsular hematoma. On postoperative day 1, she developed shock, and postoperative bleeding was suspected. During re-operation, a ruptured subcapsular hematoma of the whole right lobe of the liver with active bleeding was found, and hemostasis was achieved. In this case, it was assumed that the rupture of the subcapsular hematoma was due to compression of the liver by the clamp for retrieving the spilled gallstones during the first operation and perioperative administration of nonsteroidal anti-inflammatory drugs.

[Spontaneous bilio-cutaneous fistula in cholecystolithiasis]

Spontaneous cholecystocutanea fistula is very rare disorder. The occurrence is very frequent in women above 60 years old. The symptoms of this disorder are nonspecific. The diagnosis is not made when the symptoms are not search actively. The first type of examination is fistulography. Laparotomic scheduled chelocystectomy is preferred in therapy. Conservative approach is suitable therapy only for polymorbid patients.

[Laparoscopic cholecystectomy in a patient with situs inversus totalis]

OBJECTIVE

To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations.

CASE REPORT

A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis.

CONCLUSIONS

Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

[Laparoscopic cholecystectomy in a patient with situs inversus totalis]

Situs inversus totalis is a rare situation, but possible, witch presents difficulties in diagnosis and treatment of gallstone, due to the location in the mirror of abdominal organs. In this material it presents the case of a woman in age of 64 years with situs inversus totalis and gallstone. There are described the clinical and imaging features, also the laparoscopic surgery with the difficulties encounter by right handed surgeon. The conclusion is that in this patients, laparoscopic cholecystectomy may be performed safely by a surgeon with experience in laparoscopy and classic biliary surgery.

[Treatment of calculous cholecystitis, complicated by obturational jaundice]

Results of surgical treatment of 52 patients for chronic calculous cholecystitis, complicated by cholelithiasis, were studied. In 26 (50%) patients as a first stage of treatment there was applied endoscopic papillosphincterotomy (EPST) and transpapillary endobiliary manipulations and then--laparoscopic cholecystectomy (CHE). In 13 (25%) patients as the first stage of treatment EPST and transpapillary endobiliary manipulations were performed, and as the second one--CHE through laparotomy. In 13 (25%) patients there were performed an open CHE. choledocholithotomy and one of variants of the biliary ducts drainage. In chronic calculous cholecystitis, complicated by cholelithiasis, the optimal treatment consists of complex endoscopic treatment. The combined and standard surgical tactic are indicated when application of endoscopic technologies is impossible.

[Case-control study of risk factors in cholangiocarcinoma]

OBJECTIVE

To investigate the risk factors of intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC).

METHODS

The clinicopathological data of 190 patients with cholangiocarcinomas (61 ICC and 129 ECC) diagnosed and treated in the Peking Union Medical College Hospital between 1998 and 2008 were collected. The clinicopathological data of 380 matched healthy controls were also collected. The information about liver diseases, family history, diabetes, smoking and drinking were recorded and analyzed.

RESULTS

The positive rate of HBsAg(+) and anti-HBc(+), HBsAg(-) and anti-HBc(+) and the incidence of choledocholithiasis or hepatolithiasis in ICC patients were 27.9%, 50.8% and 14.8%, respectively. The incidence of diabetes mellitus, cholecystolithiasis, choledocholithiasis or hepatolithiasis and previous cholecystectomy in ECC patients were 18.6%, 15.5%, 18.6% and 13.2%, respectively. The incidences of all above mentioned factors in the ICC or ECC patients were significantly higher than that in the controls (P < 0.05). Compared with the patients with ECC, the ICC patients had a significantly higher cirrhosis rate (P < 0.05).

CONCLUSION

Our study results show that choledocholithiasis or hepatolithiasis, liver cirrhosis and chronic HBV infection are possible risk factors for intrahepatic cholangiocarcinoma, while choledocholithiasis or hepatolithiasis, diabetes mellitus, cholecystolithiasis, history of cholecystectomy are risk factors for extrahepatic cholangiocarcinoma.

[Nonalcoholic fatty liver disease in 210 patients]

OBJECTIVE

To analyze the clinical characteristics of nonalcoholic fatty liver disease.

METHODS

We compared the weight, waistline, blood pressure, fasting plasma glucose (FPG), triglyceride (TG), total cholesterol (TC), alanine aminotransferase (ALT), uric acid (UA), and complication of cholecystolithiasis of 210 patients with nonalcoholic fatty liver disease who were diagnosed either clinically or by B ultrasound and/or CT (NAFLD group) and 248 normal persons (control group) from January 2008 to June 2009 in Third Xiangya Hospital.

RESULTS

The weight, weight index, waistline, blood pressure, FPG, TG, ALT, and UA in the NAFLD group were higher than those in the control group (P<0.01). Patients with nonalcoholic fatty liver disease had higher incidence of cholecystolithiasis (P<0.01).

CONCLUSION

The occurrence of nonalcoholic fatty liver disease is related to weight, weight index, waistline, blood pressure, FPG, TG, ALT, UA, and cholecystolithiasis.

[Laparoscopic cholecystectomy in situs viscerum inversus totalis: technical note]

The Authors report the case of a patient admitted in Emergency Room for biliary colic. She knew her dextrocardia. ECG and chest X-ray confirmed the dextrocardia. Ultrasonography and CT scan discovered a situs viscerum inversus totalis and cholecystolithiasis responsible of the abdominal colic. Laparoscopic cholecystectomy was performed. The Authors discuss the clinical case and the particular technique used.