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Background/aims: The purpose of the study was to see the effect of age, sex, body mass index, previous cholecystectomy, hepatomegaly and fasting status on the common bile duct diameter., Methodology: A series of 463 patients, 283 females and 180 males, with no hepatobiliary or pancreatic pathology were included in this study, the mean age was 45 +/- 16 years. Their age, sex, weight, height, fasting status and previous cholecystectomy was assessed and recorded by a physician prior to ultrasound examination. All patients were examined by real-time ultrasound to see if there was any pathology in the hepatobiliary and pancreatic area. Those with history of common bile duct exploration, endoscopic sphincterotomy or with previous history of cholecystectomy of less than 6 months and patients with common bile duct pathology were excluded from the study. The midportion of the common bile duct was taken as a fixed measurement for all patients and the size of the liver was also recorded. Analysis of variance as part of SPSS statistical package was used where common bile duct was considered a dependent variable, while sex, fasting status, hepatomegaly and previous cholecystectomy were considered to be independent variables, age and sex were considered as co-variants., Results: The factors found to be significantly affecting the diameter of the common bile duct (P<0.05) were age, previous cholecystectomy and body mass index., Conclusions: If the CBD dilatation can not be explained by age, previous cholecystectomy and BMI, a pathology causing obstruction should be ruled out.

Background/aims: To review our experience and to compare it with similar series published in the literature with emphasis on the safety, the rate of conversion, the mortality and the morbidity of the procedure., Methodology: From January 1994 to February 2003, the files of 1208 cases of laparoscopic cholecystectomy were retrospectively analyzed; the technique of surgery as well as the associated co-morbid conditions, the rate of conversion to open cholecystectomy, and the morbidity and mortality was analyzed and compared to other series. Simple descriptive statistics were used., Results: The average age was 47.2 +/- 15.1 years (4-94), there were 878 (72.7%) females and 330 (27.3%) males. Of this series 20 patients underwent laparoscopic cholecystectomy while pregnant, 576 (48%) of the patients had co-morbid conditions. Conversion to open cholecystectomy was required in 32 (2.6%) cases and 25 (2.1%) patients had complications but no single biliary tract injury was noted. One patient died and his death was not directly related to the procedure. The average hospital stay was 2.8 (0.5-35) days., Conclusions: With patience and meticulous technique laparoscopic cholecystectomy in the third millennium is safer and quicker than open cholecystectomy. Our results compare favorably with those published to date.

Background/aims: Despite advances in diagnostic and therapeutic modalities, the prognosis of gallbladder carcinoma is still poor. The purpose of this study is to look for peculiarities of primary gallbladder carcinoma in Jordan regarding its incidence, clinical and pathological aspects., Methodology: A retrospective study over a period of 19 years comprising 66 patients was reviewed; only patients treated primarily in our hospital were included. There were 40 females and 26 males (ratio of 3:2)., Results: The main presenting symptom was abdominal pain in 54 patients (82%); correct preoperative diagnosis was made in only 20% of cases. Cholecystectomy alone was the most commonly performed operation (32 cases), cholecystectomy in combination with biliary bypass and/or hepatic resection (16 cases), biopsy of the gallbladder was performed in 12 cases and bypass with T-tube drainage in 6 cases. Postoperative morbidity and mortality were encountered in 48% and 18% respectively., Conclusions: The incidence and clinicopathological aspects of gallbladder cancer in Jordan seem to resemble that in the west, albeit with a lower age incidence. Diagnosis remains difficult and the outcome is still poor in the majority of cases.

Background/aims: Because of our previous experience with transjugular intrahepatic portosystemic shunt, we decided to apply the transjugular approach to preoperative portal embolization. The aim of this pilot study was to determine the feasibility and the potential advantages and disadvantages of this new method., Methodology: Under ultrasound guidance the right or left portal branch was punctured from the right, median or left hepatic vein. Then, a catheter was placed near the portal bifurcation and used to perform right portal branch embolization with a mixture of Histoacryl and Lipiodol. Pre- and post-transjugular preoperative portal embolization duplex ultrasound and CT scan were performed to assess portal flow and liver tissue growth. Hospital stay, pain and hepatic enzymes were monitored., Results: Fifteen patients underwent a transjugular preoperative portal embolization without any serious complication. Mean of hospital stay was 3.3 +/- 0.6 days. (2-5 days). Portal embolization was successful in all cases; left portal branch velocity increased from 11.8 +/- 7.5 cm/s before, to 16.5 +/- 3.5 cm/s on day one, and 14.8 +/- 3.3 cm/s on day 28 after transjugular preoperative portal embolization; volume of non-embolized segments increased by 10% within the 4 weeks after transjugular preoperative portal embolization. Right hepatectomy was possible in 12 patients, Conclusions: This method is safe, painless, and can be proposed in cases of impossibility to perform the standard percutaneous transhepatic portal embolization (tumor interposition, impaired hemostasis).

Background/aims: The experience in laparoscopic cholecystectomy is increasing, more difficult cases are performed even by the junior surgeons. This policy has led the investigators to look for methods to identify potentially difficult laparoscopic cholecystectomy., Methodology: A prospective study was performed to find out the factors that determine technical difficulty in laparoscopic cholecystectomy. Two hundred and twenty-seven patients (170 females and 57 males) with symptomatic gallbladder stones were recruited for this study from June 1995 to September 1997. The overall difficulty score as a dependent variable was based on the following operative parameters: duration of surgery, bleeding, dissection of gallbladder wall, adhesions, spillage of bile, spillage of stones and difficulty of gallbladder extraction. Multiple regression analysis was used to assess the significance of the following potential difficulty variables (Independent) in predicting the variation in the overall difficulty score: age, sex, body mass index, gallbladder size, common bile duct diameter, gallbladder wall thickness, liver size and the presence of adhesions., Results: Gallbladder wall thickness, presence of adhesions, liver size and gallbladder size were found to be significant predictors of the variation in overall difficulty score (Adjusted R2 = 0.48)., Conclusions: We believe that the above-mentioned four difficulty factors are important, however, experience of the surgeon plays a major role in reducing difficult laparoscopic cholecystectomy and consequently decreasing it's complications.

Background/aims: Management of common bile duct stones in the era of laparoscopic surgery is still controversial. The purpose of this study is to investigate the safety, feasibility, success rate and short-term results of the selective use of endoscopic retrograde cholangiopancreatography in patients undergoing laparoscopic cholecystectomy., Methodology: A prospective study comprising 300 consecutive patients with either symptomatic or complicated gallbladder stones was performed between January 1994 and November 1996. Depending on clinical, laboratory and ultrasonographic criteria, 73 patients (24.3%) underwent endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy. The procedure was successful in 71 patients (97%) either preoperatively in 62 patients (21%) or postoperatively in 9 patients (3%)., Results: Endoscopic retrograde cholangiopancreatography was positive in 37 cases (52%), endoscopic sphincterotomy and stone extraction was performed in 35 cases and endoscopic sphincterotomy alone was performed in 2 cases for benign papillary stenosis. The overall predictive value for the presence of common bile duct stone was 52%, the predictive value for patients with jaundice, dilated common bile duct together with elevated liver enzymes was 73.3%. Complications of perioperative endoscopic retrograde cholangiopancreatography were encountered in 4 patients (5.5%) with no mortality., Conclusions: We conclude that the combination of perioperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy is a useful approach for the management of choledochocholelithiasis.

Background/aims: Safety of laparoscopic cholecystectomy (LC) during pregnancy is still controversial, we report our experience in the management of 42 pregnant patients suffering from symptomatic gallbladder stones., Methodology: Between June 1993 and July 1998, we performed 1700 LC's. During this period we dealt with 42 pregnant patients who had symptoms of gallbladder stones. Following an initial period of conservative management, only 16 patients underwent LC during pregnancy and 26 patients responded to medical management and were operated upon later on after delivery., Results: Sixteen patients were operated upon successfully during pregnancy, 2 in the 1st trimester, 10 in the 2nd trimester and 4 in the 3rd trimester. No complications occurred and all patients carried on their pregnancies to term and delivered healthy babies., Conclusions: From our experience and from the review of the literature on this subject, LC during pregnancy is safe, however the indications should be restricted to patients with complications or to those suffering from repeated and persistent symptoms not responding to medical management.