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It is well known that Crohn's disease can involve the duodenum, but isolated secondary complications such as pancreatitis or common bile duct obstruction have only rarely been reported, and never in the same patient. Herein, we describe a patient with duodenal Crohn's disease and both pancreatitis and calculous common bile obstruction. This unusual constellation of findings was managed with percutaneous techniques in which transhepatic catheterization of the bile duct permitted balloon dilatation of the ampulla of Vater, as well as a duodenal stricture. These maneuvers resulted in passage of the biliary stone and relief of the patient's symptoms. The management of this patient may serve as a guide possibly to delay or even prevent surgical intervention in similar cases of benign enteric strictures.

Complications of the initial 200 cases of laparoscopic cholecystectomy (LC) at the Cathay General Hospital within a period of 11 months were reviewed from video documents of the operations and clinical records. The major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%), three retained CBD stones (1.5%), one subphrenic fluid accumulation (0.5%), one liver abscess (0.5%) and one cystic duct stump bile leakage (0.5%). All major complications were cholecystectomy-related, and only one of the seven occurred in cases of acute cholecystitis. Age and sex were not related to its occurrence. The rate of minor complications ranged from 0.5% to 10%; they were: shoulder and back pain (10%), gall bladder perforation (10%), retained stones in the abdominal cavity (5%), transient nausea and diarrhea (5%), extension of umbilical port to a mini-laparotomy (3.5%), prolonged operation time > three hours (2%), subcutaneous emphysema (1.5%), wound infection (1.5%) and prolonged ileus (0.5%). The minor complications occurred largely in patients with acute cholecystitis. The complications occurred mostly during the early period of our study, indicating a learning period phenomenon. These could have been avoided if we had had a thorough knowledge of the potential complications and had strictly followed the principles of laparoscopic surgery. We conclude that LC is safe and the complication rate is not higher than that for open cholecystectomy. Most of the complications are preventable if LC is performed by qualified biliary surgeons following strict precautions.

Cholelithiasis is a common clinical situation. In most individuals it takes an inconspicuous clinical course. In symptomatic patients the complications have to be considered: acute cholecystitis, cholangitis, choledocholithiasis, pancreatitis, ileus by large stones and--in a subgroup of patients--carcinoma of the biliary system. Therapy is warranted in symptomatic patients in order to prevent complications. The decision for use of surgical versus non surgical interventions is decided on a individual basis. In general laparoscopic cholecystectomy is the procedure of choice nowadays. A prophylactic cholecystectomy is as a rule not indicated in asymptomatic patients.

The morbidity of reoperation for retained biliary stones is not significant. Many techniques have been developed to avoid reoperation. This study analyzes T-tube tract choledochoscopy and lithotripsy using a 504-nm pulsed dye laser for treatment of retained stones. A flexible choledochoscope is passed into the biliary tract and laser energy is delivered under endoscopic visualization after passing a 320-microns laser fiber through the instrument channel. Eight patients were treated in nine sessions. The mean number of pulses was 1512.33, delivered at 3 to 5 Hz with an energy of 100 to 120 mJ. In all patients, the biliary tract was cleared. A single patient's treatment was complicated by transient bacteremia. Mean follow-up was 10 months. Choledochoscopic laser lithotripsy is a safe, effective technique that may also play a major role in laparoscopic common duct surgery.

Juxtapapillary diverticula are often associated with biliary lithiasis. The aim of this study was to compare the prevalence of juxtapapillary diverticula in choledocholithiasis and in cholecystolithiasis without common bile duct stones. The results of 520 consecutive retrograde cholangiographies were retrospectively analysed. The prevalence of juxtapapillary diverticula was higher in patients with biliary lithiasis than in patients without: 26.0% vs 10.5% (p less than 0.001). However, juxtapapillary diverticula were more frequently encountered in patients with choledocholithiasis than in those with gallbladder lithiasis or previous cholecystectomy and a stone-free common bile duct: 40.0% vs 10.2% (p less than 0.001). There was no significant difference between the patients with cholecystolithiasis alone and those without biliary lithiasis. Among the patients with previous cholecystectomy or with gallbladder lithiasis, common bile duct stones were more frequently found in patients with juxtapapillary diverticula than in those without: 80.3% vs 40.6% (p less than 0.001). These data suggest that juxtapapillary diverticula are associated only with choledocholithiasis and not with gallbladder lithiasis.

Nine of 35 patients with sickle hemoglobinopathies and cholelithiasis were found to have concomitant common bile duct (CBD) stones. We describe the diagnosis and management of these patients with CBD stones. Historical information, physical examination, and routine laboratory tests were unable to identify accurately the patients with CBD stones. Similarly, ultrasonography of the hepatobiliary system was an insensitive method for detecting CBD stones, as only 3 of 8 patients were correctly identified. In contrast, both an intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography were sensitive procedures for detection of CBD stones. We conclude that CBD stones are relatively common in patients with sickle cell disease and cholelithiasis, and clinicians should have a high index of suspicion for their presence.

Extended transduodenal sphincteroplasty has been suggested as an alternative to choledochoduodenostomy for the surgical management of bile duct stones associated with a periampullary diverticulum but its value has not previously been investigated. Over a 3 year period, nine patients underwent extended transduodenal sphincteroplasty for common bile duct calculi associated with a periampullary diverticulum with no operative or post-operative mortality and minimal morbidity. Follow-up ranging from 20 to 60 months has shown remission of pain in all but one patient, who has had a normal endoscopic cholangiogram and no further episodes of jaundice or cholangitis. Extended transduodenal sphincteroplasty is a safe and effective alternative to choledochoduodenostomy for the surgical management of choledocholithiasis associated with a periampullary diverticulum.

Extracorporeal membrane oxygenation (ECMO) can be lifesaving support for neonates with fulminant respiratory failure. In the 121 patients that we have placed on ECMO since 1983, bleeding, infection, and intracranial hemorrhage have constituted most of the major complications. We have also encountered two cases of biliary calculi in post-ECMO infants. The hemolysis, total parenteral nutrition, diuretics, and prolonged fasting associated with ECMO may predispose neonates to early calculous disease of the biliary tract and may require surgical intervention. Evaluation of abdominal pain or jaundice in infants and children who have been supported with ECMO should include examination of the biliary tree. Cholecystectomy should be seriously considered for infants with cholelithiasis.

Side-to-side choledochoduodenostomy is a safe and effective surgical technique to improve biliary drainage in selected patients. The segment of common bile duct between the anastomosis and the ampulla of Vater may act as a stagnant reservoir or sump. When debris, stones, or infected bile accumulates in the sump, usually because of malfunction of the ampulla of Vater, recurrent abdominal pain or symptoms of cholangitis, pancreatitis, or biliary obstruction may develop. This uncommon (0.14-1.30%) complication is known as the sump syndrome. On imaging studies, diagnostic findings are debris or stone(s) in the common bile duct. Suggestive findings are dilated bile or pancreatic ducts, and changes due to pancreatitis, cholangitis, or liver abscess. Patients with this syndrome frequently have multiple imaging studies before the condition is recognized. The purpose of this essay is to illustrate the imaging findings of this syndrome.

To evaluate the efficacy of a selective approach to biliary pancreatitis, we reviewed the outcomes in 276 consecutive patients undergoing operations for this diagnosis during a 7-year period. Initial conservative therapy resulted in elective operations in 63% and urgent operations in 37%. Only 10 patients (3.6%) required primary pancreatic operations, 50% of them as emergencies. The proportion of common duct surgical explorations fell from 70% of those operated immediately after hospital admission to 20% by the third hospital day. Overall mortality was 1.8% but was increased to 30% in patients having an initial pancreatic operation. We conclude that a selective approach to biliary pancreatitis allows the operation to be performed electively in most patients and is associated with a low mortality and an acceptable length of stay. Most common duct stones pass spontaneously permitting cholecystectomy alone.

A clinic-morphological classification worked out by the author is made on the basis of the experience acquired during the surgical treatment of 680 patients with various forms of cholelithiasis and its complicated forms. The article discusses the peculiarities of surgical tactics depending on the mechanism of cholelith formation. The author makes a conclusion that cholecystectomy is an obligatory condition of treatment together with the drainage, reparative and recovery operations.

Analysis of 460 patients suffering from the postcholecystectomy syndrome (PCS) revealed an abnormality in the major duodenal papilla (MDP) in 32.4% of them. The development of PCS in this group of patients was caused by coexistence of several pathological processes, which was established in 71% of patients with diseases of the MDP. The most frequently encountered conditions were papillitis (59.1%), cicatricial stenosis (56.3%), and stones (14.7%). Papillitis plays a double cause-effect role in PCS: as a primary chronic disease it may lead to cicatricial stenosis of the MDP, and, on the other hand, it may be a consequence of choledocholithiasis, cholangitis, and other diseases. Endoscopic papillosphincterotomy is the most effective method for the treatment of PCS caused by MDP diseases; it makes it possible to reduce significantly the number of repeated abdominal operations.

The authors provide the long-term results of cholecysto-digestive + anastomoses in 59 patients operated on for nontumorous diseases. The gallbladder anastomosed with the upper parts of the alimentary tract preserved reservoir and concentration functions, ability for visualization during cholecystocholangiography. The discrete pulse mechanism of bile secretion via the bile diverting anastomoses and their antireflux function eliminated the risk of chronic pancreatitis and terminal cholangitis. The recovery of deranged liver functions and excretory functions of the pancreas were traced during the postoperative period within 2 to 21 years.

In benign stenosis of the major duodenal papilla, choledocholithiasis and their combination, the performance of endoscopic papillotomy permitted in 89.4% of the 113 patients to avoid the repeated operative intervention. Complications developed in 5.3% of patients, the postoperative lethality was 0.8%.

The many developments in nonoperative methods for the treatment of gallstone disease underscore the importance of understanding the pathogenesis of these stones. Elucidation of the factors responsible for nucleation of crystals and the mechanism by which it occurs would appear to be the challenge if we are to define the cascade of events that results in gallstone formation.

Data of 205 patients with recurrent (48) and residual (157) choledocholithiases are presented. In most observations postoperative cholelithiasis proceeded by the type of chronic intermittent obturation of bile ducts. Highly effective method of diagnosing recurrent and residual calculi is thought to be the endoscopic retrograde pancreatocholangiography, best results of the treatment being obtained after the endoscopic papillosphincterotomy which should be used as the operation of choice.

Foreign bodies are very rare in the common bile duct. We report an unusual case of transient obstructive jaundice, due to a choledochal stone formed around an ingested woody fiber. Review of the literature.

110 transduodenal interventions were performed on patients with acute cholecystitis complicated by choledocholithiasis and stenosis of the major duodenal papilla in 1981-85. Mechanical jaundice was diagnosed in 51 of them. Most of the patients were operated upon in the "cold" period. Papillosphincteroplasty was performed on 73 patients, papillosphincterotomy--on 17, transduodenal ++supra-papillary choledochoduodenoanastomosis--on 20 patients. A special probe was used during operation for the detection and dissection of the major duodenal papilla. Lethality after operation was 2.7%.

Periampullary duodenal diverticula are known to be associated with an increased incidence of common bile duct stones. The nature of the association with gallstones remains uncertain. We have examined the incidence of periampullary diverticula and stones after cholecystectomy to determine whether the stones originate primarily in the common duct or migrate from the gallbladder under the influence of abnormal biliary motility. Six hundred and forty-one patients undergoing ERCP were studied. Ninety-five patients had diverticula (14.8%). Diverticula occurred more commonly in jaundiced patients, 47/95, (48.4%) than in patients with normal bilirubin 185/546 (33.8%) (p less than 0.01). Common duct stones were associated with the presence of a diverticulum in 41/95 patients (43%), compared with only 98/546 without a diverticulum (18%) (p less than 0.001). There was no difference in the incidence of common duct stones in association with a diverticulum between those who had had a cholecystectomy 20/41, and those with intact gallbladders, 21/54 (N.S.). Thus the absence of a gallbladder did not alter the high incidence of common duct stones. We conclude that the stones in the common duct are most likely to be primary stones which have formed as a result of periampullary dysfunction.

The diagnostic value of intraoperative cholangiography (IV) is shown on the basis of analysis of data in the literature and material of two surgical clinics. Statistically significant criteria of the risk of cholangiolithiasis in patients with calculous cholecystitis are identified, which are indications for IC. It is shown that in substantiated rejection of IC the possibility of a diagnostic error is minimal. In tentative diagnosis of cholangiolithiasis in the case, and, consequently, in the choice of the required diagnostic manipulations and methods one should proceed from the principle of reasonable adequacy in a specific case.

The 'sump syndrome' is an uncommon, late complication of a side-to-side choledochoenterostomy. Five patients with this syndrome were encountered over a 5-year period. Pain or cholangitis was the clinical presentation in four patients, whereas one patient presented with secondary septic arthritis and a hepatic abscess. Liver function tests were mildly abnormal in each patient. All patients had a stomal size of less than 1 cm as assessed by forward- or side-viewing endoscopy. Endoscopic retrograde cholangiography revealed either stones or debris in the distal common bile ducts of all patients. Four patients had a surgical clearance of their duct with concurrent closure of the choledochoduodenostomy in three patients and the creation of a Rouxen-Y end-to-side choledochojejunostomy in the fourth patient. The other patient had an endoscopic sphincterotomy performed. After 1-4 years of follow-up, four patients have had a total resolution of symptoms. The other patient with follow-up for 4 years has had one episode of cholangitis which resolved rapidly with antibiotic treatment. The pathogenesis and clinical spectrum of the sump syndrome are reviewed and current management strategies are discussed.

The Sump syndrome is an infrequent complication of a choledochoenterostomy (choledochoduodenostomy or choledochojejunostomy) performed for recurrent stone disease: a sump or pit develops at the retroduodenal section of the choledochus between the enterostomy and papilla where stones, lithogenic bile and gastrointestinal contents accumulate. This may lead to abdominal pain, pancreatitis and cholestasis and/or cholangitis when sludge obstructs the enterostomy. Surgical treatment has been replaced by endoscopic papillotomy. The major interest of this experience was that regarding migration of the stones to intestine, the spontaneous resolution could be documented in two patients; in other two cases, because of contraindications in one case and for refusing therapy in another, the stones still remain at the retroduodenal choledochus. In a follow up of two to eight years there is a favorable evolution without any surgical or endoscopic treatment of the papilla.

We report a case of a pigmented gallstone which formed around a surgical staple in the bile duct. The stone was removed and retrieved endoscopically. A brief review of bile duct foreign bodies and gallstones is presented.

The contribution of major gastrointestinal hormones to bile secretion was studied in 35 male Wistar rats with biliary, duodenal, and vena cava cannulae. Intravenous infusion of secretin, pancreozymin, and glucagon increased bile flow but only secretin affected bile lipid output. OP-CCK exerted the weakest choleretic effect. None of the hormones significantly changed the lithogenic index. Thus, gastrointestinal hormones could play an important role in the regulation of bile flow and bile lipid secretion in rats.

A gross and microscopic study has been made of the changes associated with aging in the distal common bile duct of normal humans. Grossly a progressive narrowing develops with aging at the level of the preampullary portion of the common bile duct. On the contrary, the pancreatic portion of the common bile duct has a tendency to dilatation with aging. Histologically the thickening and sclerosis of the wall in the preampullary portion represent the changes increasing in degree with aging, consisting of: 1) submucosal glandular proliferation and fibrosis, and 2) intermuscular glandular proliferation and fibrosis. On the other hand, the diffuse sclerosis in the pancreatic portion gradually occurs with aging, consisting of: 1) proliferation and fragmentation of elastic fibers, and 2) increase in collagen fibers. Factors influencing the development of these changes associated with age are discussed. The author presumes that decrease in response to an upward tendency of the intraductal pressure resulting from diffuse sclerosis in the wall of the common bile duct, in addition to a progressive narrowing of the preampullary portion, may be responsible for dilatation of the common bile duct, moreover, bile stasis and infection on the biliary tract. It is suggested therefore that these alterations with aging process in the terminal bile duct may be a responsible agent in the formation of common duct stones.

The authors report a series of 10 infants aged from 20 days to 11 months, presenting with CBD lithiasis, explored and cured by radiological procedure. US showed BD dilatation in 9 cases, sludge in the GB in 5 and in the CBD in 2. Histological findings of cholangitis were present in 4 infants. PTC was performed by GB puncture in 6 and BD puncture in 4. There was evidence of a filling defect in CBD but no anatomical anomaly. Blackish concretions were removed through a side-holes catheter or pushed in the duodenum by washing with saline. An external drainage was left a few days to allow control cholangiogram. Three infants underwent subsequent surgery but no residual lithiasis was found. No recurrence has occurred with a follow-up ranging from 10 months to 7 years. Mechanisms of this entity are discussed.

A series of 1,358 cholelithic patients operated on at 32 affiliated hospitals during the last year and 492 patients operated on at authors' hospital during the last 21 years were reviewed with special reference to the cases of recurrent common duct stones. Of the former series 15 patients and of the latter series 12 patients respectively were reoperated on for recurrent, but not for residual, common duct stones, and all of them had in the markedly dilated common duct bilirubin stones showing characteristics of stasis stone-primary in common duct. Two representative cases are presented briefly. Congenital hypotonia of the common duct and inflammatory choledochitis are condemned and bilioenterostomy is recommended for preventing stone recurrences.

The prevalence of cholelithiasis was estimated in 434 cirrhotic patients and 1582 non cirrhotic patients necropsied at Hôpital Beaujon from 1976 to 1984. The overall prevalence of cholelithiasis was significantly higher in cirrhotic than in non cirrhotic patients, 26.3 p. 100 and 20.3 p. 100, respectively. The prevalence of cholelithiasis was higher in cirrhotic than in non cirrhotic patients, whether male or female and at any age, except in women over 60 years and in men over 80 years; in these groups, the prevalence of cholelithiasis in non cirrhotic patients was especially high and therefore did not significantly differ from that in cirrhotic patients. The cause of cirrhosis did not significantly influence the prevalence of cholelithiasis; however, although the number of studied patients was small, the prevalence of cholelithiasis seemed to be particularly high in primary biliary cirrhosis. The prevalence of cholecystectomy was lower in cirrhotic than in non cirrhotic patients, which suggests that cholelithiasis might be less often symptomatic and/or less often complicated in the former than in the latter.