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Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background/aims: Robotic cholecystectomy has emerged as an established technique for the treatment of gallbladder disease. We report our experience and surgical results of RC for patients with gallbladder polyps or minimal symptomatic gallstones, and with inflamed gallbladder diseases including acute cholecystitis, empyematous cholecystitis, and gangrenous cholecystitis., Methodology: 925 patients with gallbladder disease were selected to undergo RC at our institution. All procedures were performed using the da Vinci system. No technical difficulty in RC was experienced. Use these advantages, we performed cholecystectomy by placing the trocars transversally on the bikini line('Panty line', 'Bikini line')., Results: From June 2010 to May 2014, 925 gallbladder disease patients underwent RC on the bikini line. Excluding the effects of BMI produced no correlation between operating time and white blood cell count (r = 0.062, p = 0.058). Surgical complications occurred in nine of the 925 patients (0.1%), including cystic duct leakage (n = 4), bleeding (n = 3), common bile duct injury (n = 1), and bladder injury (n = 1). Conversion to open cholecystectomy occurred in one patient due to common bile duct injury (0.01%)., Conclusion: RC is technically an easy to learn, safe method of patients with gallbladder disease, regardless of BMI. In addition, RC can be a treatment for patients with acute inflammation in gallbladder disease.

Background/aims: To discuss the clinical significance of combined application of laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) for one-stage treatment of cholelithiasis complicated with common bile duct stones., Methodology: To retrospectively analyze 40 cases with cholelithiasis complicated with common bile duct stones treated with LC plus intraoperative ERCP between May 2005 and September 2012 and to evaluate the clinical efficacy in the treatment of cholelithiasis complicated with common bile duct stones., Results: Among 40 cases, 36 successfully underwent LC plus intraoperative ERCP and 4 were transferred to open surgery. Eighteen patients with preoperative abnormal liver function showed declined indexes post-operatively. Compared with LC, more patients had abdominal distention and vomiting. Seven patients presented with transient increase in the levels of serum amylase with no incidence of acute pancreatitis. One had hematochezia and recovered after conservative treatment with no incidence of bile leakage and perforation and other severe complications., Conclusions: LC combined with intraoperative ERCP is safe and efficacious in the primary treatment of cholelithiasis complicated with common bile duct stones to avoid open surgery and double surgeries.

Background: Untreated, progressive familial intrahepatic cholestasis (PFIC) results in fibrosis, cirrhosis, and liver failure. It has been shown that partial external biliary diversion (PEBD) may prevent from liver transplantation in patients without cirrhosis. The aim of this study is to present a new laparoscopic technique using a button instead of a bowel conduit for PEBD., Patients and Methods: Two boys with PFIC (patient 1, 17 months; patient 2, 12 years) underwent laparoscopic button cholecystostomy using a 3-trocar technique by insertion of a 14 French MIC KEY button (Kimberly-Clark Worldwide, Inc, Draper, Utah, United States) at the gallbladder fundus secured with two absorbable purse-string sutures. Beside the suitability of the procedure, end points included course of serum bile acids, total bilirubin, liver enzymes, and pruritus at a follow-up of 6 months., Results: No complications related to the operation occurred. Relieve of pruritus was achieved in both the children, due to adequate bile drainage during a follow-up period of 6 months. In patient 2, a 10-mm gallstone was removed simultaneously. In patient 1, serum bile acids decreased from 12.3 to 6.6 µmol/L and in patient 2, serum bile acids decreased from 106.3 to 2.9 µmol/L. Total bilirubin, aspartate amino transferase, alanine amino transferase, and gamma-glutamyltransferase are kept in normal ranges during follow-up. Patient's and parent's acceptance with the button was excellent., Conclusion: Laparoscopic button cholecystostomy is a simple, safe, and sufficient technique for PEBD in patients with PFIC. It achieves an adequate bile flow with consecutive relief of pruritus and avoids an enteric anastomosis., (Georg Thieme Verlag KG Stuttgart · New York.)

Laparoendoscopic rendezvous ERCP and laparoscopic cholecystectomy (LC+ERCP/LERV) is considered an optimal approach for concomitant gallstone and common bile duct stone, but this procedure could be failed due to some technical challenges. We describe a modified technique which was adopted in 32 consecutive cases and yielded good results. A Dormia basket is inserted through cystic duct to enter duodenum and grasp the guide wire which is introduced with sphincterotome through endoscope. After pulling the basket catheter and guide wire into bile duct, the selective bile duct cannulation could be achieved by advancing sphinterotome over guide wire. An atraumatic clamp is also used to temporarily occlude proximal jejunum preventing diffuse bowel distention by air insufflation. The procedure was successfully performed in 31 cases(96.8%) , the mean operative time and endoscopic time were 82.6±19.6 min and 26.5±5.99min, respectively. This modified technique is safe, feasible and associated with short operative time.

Background/aims: Gallbladder stones are still a common pathology worldwide, and the number of patients diagnosed without any symptoms is increasing due to the use of ultrasound and imaging tools such as CT and MRI. The aim of this study was to identify gastroduodenal pathologies in patients with diagnosed asymptomatic gallbladder stones, since some cases of epigastric pain may have led to unnecessary cholecystectomies., Methodology: Gastroscopic investigations were performed in 33 patients diagnosed with asymptomatic gallbladder stones during a gallstone screening program in Chiang Mai, Thailand, and followed-up with yearly ultrasound examinations. The mean age of the patients was 56.6 years, and mean follow-up time was 2.3 years., Results: Our results showed that inflammatory-based gastroduodenal lesions in this group were common (15/33 patients, 45.4%). Lesions included gastric ulcers (1 patient, 3%), duodenal ulcers (5 patients, 15.1%), and gastroduodenal ulcers (2 patients, 6.1%). Almost all of the ulcers were in the healing or scarring stage. Inflammatory-based mucosal changes were also detected in these patients as follows: erosive gastritis (6 patients, 18.2%) and hemorrhagic gastritis (1 patient, 3%)., Conclusions: Inflammatory-based gastroduodenal pathologies such as peptic ulcers and gastritis are common in patients with asymptomatic gallstones. If such patients become symptomatic, meticulous examinations are needed to avoid unnecessary cholecystectomies and resulting complications such as postcholecystectomy syndrome. The theory that gastroduodenal lesions occur after gallbladder removal needs to be re-evaluated given that lesions can be detected before surgery and even before the occurrence of symptoms.

Background/aims: This study is an analysis of the large series of laparoscopic cholecystectomies and compare our results with those reported in the literature concerning complications., Methodology: From December 1993 to September 2010, 10,317 patients with gallstone disease underwent laparoscopic cholecystectomy. Previously operated patients were also included in the study. We analyzed the successfulness of the results, intraoperative and postoperative complications, conversions in open cholecystectomy, mortality and reoperation rate., Results: We registered 23.28% complications. Intraoperative complications were bleeding in 9.84%, gallbladder perforation in 8.63%, stone loss in 1.37%, common bile duct injury in 0.24% and injury of intraabdominal organs in 0.07% of cases. Postoperative complications were bleeding in 1.12%, wound infection in 0.59%, bile leakage in 0.5%, incisional umbilical hernias in 0.37%, subhepatal collection in 0.33%, residual gallstones in choledocus in 0.09%, urine retention in 0.08% and biliary peritonitis in 0.01% of patients. Conversion to open cholecystectomy was necessary in 2.13%. Reoperation was performed in 0.27%. The mortality rate was 0.019%., Conclusions: Our results on large number of patients are similar to other series in the newer literature but the rate of complications should be decreased. The incidence of complications decreases with growing laparoscopic experience.

Background/aims: Predicting technical difficulties in laparoscopic cholecystectomy (LC) in a small regional hospital increases efficacy, cost-benefit and safety of the procedure. The aim of the study was to assess whether it is possible to accurately predict a difficult LC (DLC) in a small regional hospital based only on the routine available clinical work-up parameters (patient history, ultrasound examination and blood chemistry) and their combinations., Methodology: A prospective, cohort, of 369 consecutive patients operated by the same surgeon was analyzed. Conversion rate was 10 (2.7%). DLC was registered in 55 (14.90%). Various data mining techniques were applied and assessed., Results: Seven significant predictors of DLC were identified: i) shrunken (fibrotic) gallbladder (GB); ii) ultrasound (US) GB wall thickness >4 mm; iii) >5 attacks of pain lasting >5 hours; iv) WBC >10x109 g/L; v) pericholecystic fluid; vi) urine amylase >380 IU/L, and vii) BMI >30kg/m2. Bayesian network was selected as the best classifier with accuracy of 94.57, specificity 0.98, sensitivity 0.77, AUC 0.96 and F-measure 0.81., Conclusion: It is possible to predict a DLC with high accuracy using data mining techniques, based on routine preoperative clinical parameters and their combinations. Use of sophisticated diagnostic equipment is not necessary.

Background/aims: The objective of this study was to define the clinical, biochemical and ultrasonographic criteria correlating with a likelihood of a positive preoperative endoscopic ultrasound (EUS) in patients presenting with acute gallstone-related pancreatobiliary disease., Methodology: All patients who underwent EUS prior to elective laparoscopic cholecystectomy were analyzed at the Gastroenterology Unit, Kaplan Medical Center, following acute admission with cholecystitis, cholelithiasis, cholangitis, acute pancreatitis and obstructive jaundice., Results: One hundred and seventy four patients met the inclusion criteria. EUS showed choledocholithiasis in 37 (21.3%) with 35/37 undergoing a preoperative ERCP (24/35 cases - 64.9% positive yield). Twenty seven of the positive EUS studies (73%) were performed during the acute illness, with 50 of the 137 negative studies (36.4%) performed during the acute phase of the illness (p=0.0001). On multivariate analysis, a positive EUS was more commonly found during the acute phase of the illness [OR: 3.445; 95% CI: 1.48-8.008, p=0.004] or if there was transient jaundice [OR: 1.167; 95% CI: 1.002-1.36, p=0.047]., Conclusions: The timing of the examination influences the detection rate of CBD stones by EUS prior to surgery although it may be appropriate to more selectively use EUS in those patients with hyperbilirubinaemia and/or where the CBD is dilated.

Background: Today clinical pathways are established as a basis for the operational and organisational structure of surgical, interventional and conservative treatments in many hospitals., Question: In our study we have evaluated the establishment and systematic applicability of IT-based clinical pathways in the department of general surgery in comparison with existing clinical pathways. Does the systematic application of IT-based clinical pathways improve the quality of medical treatment?, Methods: In our department of general surgery we evaluated and compared the treatment by laparoscopic surgery before and after establishment of IT-based clinical pathways. The preoperative duration of stay, the duration of treatment and the patients' pain perception were compared. Since July 2009 we used in our department of general surgery an IT-based clinical pathway for laparoscopic cholecystectomy and hernia repair. From January 2006 until October 2009 we compared the treatment by these procedures with and without the use of IT-based clinical pathways., Results: From January 2006 until October 2009 743 patients underwent surgery and treatment following the conventional clinical pathway and 51 patients following the new, IT-based clinical pathway. In the group of patients who received a laparoscopic hernia repair we found a reduction of the preoperative duration of stay., Conclusion: IT-based clinical pathways are applicable for routine use in general surgery departments. For certain surgical procedures they are an eligible management device. IT-based clinical pathways lead to an improved operational structure of medical treatment and moreover to a complete and continuous documentation through the electronic file. Especially for departments which are using the electronic file, the use of IT-based clinical pathways can be recommended., (© Georg Thieme Verlag KG Stuttgart ˙ New York.)

Background: A preoperative diagnostic imaging procedure is essential for therapy in cholecystolithiasis. According to the S3-Guidelines of the German Society for General and Visceral Surgery only an ultrasound scan is needed before a cholecystectomy. But an anatomic variant of the bile ducts or choledocholithiasis is poorly shown by an ultrasound. Because of this, we performed a magnetic resonance cholangiopancreatography (MRCP) routinely. This study was designed to show if the MRCP changed the treatment plan or changed the operation method. Furthermore, the sensitivity and specificity concerning abnormalities of the cystic duct, accessory bile ducts and choledocholithiasis should be determined., Patients and Methods: During the time between January 1st 2005 and September 30th 2009 541 patients were included in this retrospective study., Results: Among the 541 cases 98 pathologies were found. These included 51 choledocholithiasis, 20 accessory bile ducts and 13 abnormal cystic ducts. In 29 of the 51 cases of choledocholithiasis a therapeutic splitting was performed only because of the MRCP. In 22 cases the diagnosis was also possible because of the basic diagnostic procedures like ultrasound, laboratory tests and clinical appearance. So the diagnostic aimprovement due to the MRCP is 5.3 %. Four of the 20 accessory bile ducts and 6 of the abnormal cystic ducts were found during the subsequent operation. The sensitivity concerning the anatomic variants is very low (38.5 % concerning the accessory bile ducts and 50 % for the abnormal cystic ducts). But the sensitivity in detecting a choledocholithiasis is very high (94.7 %). There was no evidence in our study that MRCP prevented any complications. The operation method was not changed in any case because of the MRCP result., Conclusion: A routinely performed preoperative MRCP cannot be recommended., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: The aims of this study were to assess the feasibility and safety of emergency ERCP and pancreatic duct (PD) stenting in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy proved difficult, and to compare the clinical outcome of those patients having emergency ERCP without pancreatic stent., Methodology: One hundred and ninety-one consecutive patients with ABP were included in this study. Patients were randomly assigned to either the stent group (n=78) or the no-stent group (n=113). In the stent group, 3-5Fr,5-7cm-long pancreatic stent insertion was initially applied and removed endoscopically 1-2 weeks post-ER-CP. All patients were hospitalized for medical therapy and were followed-up., Results: Mean age, initial symptom-to-ERCP times, Glasgow severity scores and peak amylase and CRP levels at initial presentation were not significantly different in the stent group vs. the no-stent group, and the selective biliary cannulation was achieved in 80% of the stent group and in 94% of the no-stent group (p=0.15). More importantly, the complication rate was significantly lower in the stent group (7.7% vs. 31.9%). There was no difference in mortality between the two groups statistically(1.3% vs. 3.5%)., Conclusions: Pancreatic duct stent-ing is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP, show better outcomes as compared to no-stent group. It is recommended to reduce the incidence of the complication in the emergency ERCP of ABP but difficult sphincterotomy. However, further prospective trials are needed.

Background/aims: The timing for the management of gallstones pancreatitis remains a contentious issue. Various scholars have their own achievement in in regards to this issue., Methodology: We reviewed our hospital charts from Jan 2007 to December 2010 and made a comparative study about early and delayed LC for mild to moderate gallstone pancreatitis in 80 patients., Results: Successful management was obtained in all patients. Out of 80 patients, 54 had underwent for early LC within 48 hours and 26 delayed LC (6-8 weeks)., Conclusions: Our study reveals that early cholecystectomy has nice outcomes in terms of shorter hospital stay and expenses. Proper consultation should be taken from radiological colleague if CBD dilations are >6 mm and contraction of gallbladder appears on imaging modalities. Comorbid conditions, past history of cholecystitis cannot be avoided for proper surgical outcomes. Postoperative complications can be deterred by early LC for mild gallstone pancreatitis. However, large volume studies are essential from different places to answer the debated topic of which management protocol is justifiable for the management of mild to moderate gall stone pancreatitis.

Background/aims: The aim of this prospective trial was to observe the results of the two types of techniques., Methodology: Single port laparoscopic cholecystectomy (SPLC) (56 cases) indication was polyp disease and mild cholecystitis with gall bladder stone (no right upper quadrant tenderness in physical examination, no gall bladder wall thickening in image study). Three ports laparoscopic cholecystectomy (TPLC) (46 cases) was applied to previous laparoscopic surgery indication. There were slight differences in indication as there are still limitations in applying single port laparoscopic cholecystectomy in all patients., Results: The two groups were similar with respect to demographic characteristics. There were no significant differences in operation time, bile leakage during operation, postoperative hospital stay, pain score. Additional port(s) use in single port laparoscopic cholecystectomy were 13 cases, the reasons were difficult dissection of Calot's triangle (7 cases), incomplete ligation by Hem-o-lok clip (3 cases), cystic artery bleeding (3 cases), difficult visual due to obesity (1 case)., Conclusions: Single port laparoscopic cholecystectomy is still in its initial stages. Although many controversies remain regarding stability and possibility, it is believed that development and exchange of new instruments and techniques will form an important part of future minimal invasive surgery.

Background/aims: The progression of endoscopy and devices as well as newly developed treatment methods have enabled endoscopic lithotomy. In this study, we examined to what degree is it possible to endoscopically treat patients who are diagnosed as having common bile duct stones., Methodology: Lithotomy was conducted using a backward side-viewing endoscope for patients without surgical history of upper gastrointestinal tract and patients with stomach reconstructed with Billroth-I method, using an ordinary endoscope for patients with stomach reconstructed with Billroth-II method (Bil-II) and using a double balloon endoscope for patients with difficulty in reaching the papilla or patients of Roux-en-Y anastomosis (R-Y). As for treatment methods, we selected endoscopic sphincterotomy as the first choice for papilla treatment and selected endoscopic papillary balloon dilation for patients with bleeding tendency or patients of Bil-II or R-Y. For patients with multiple stones or giant stones, lithotripsy was selected depending on judgment of the endoscopist., Results: Endoscopic complete lithotomy was successful in 97.7% (168/172). An accidental disease was observed in 2.9% (5/172). In one patient with the perforated gastrointestinal tract, a surgery was performed but others were mild., Conclusions: Common bile duct stones can be endoscopically treated safely with high rate.

Background: Symptomatic gallstones and inflammatory diseases of the gastroduodenum are common causes of upper abdominal pain. PATIENTS / MATERIAL AND METHODS: We evaluated the data of 766  patients who underwent pre-operative oesophagogastroduodenoscopy before elective surgical treatment of cholelithiasis between January  1, 2003 and March 31, 2008., Results: Pathological findings of an inflammatory nature were seen in 43.1 % (330 / 766), 25.2 % (197 / 766) of the patients had a chronic gastritis, 14.9 % (114 / 766) an acute gastritis and 3 % (54 / 766) a gastroduodenal ulcer. Non-specific upper abdominal pain was not significantly related to an inflammatory gastroduodenal dis-ease (p = 0.0755). Independent of the history (p = 0.1065), the therapy concept had to be -changed in favour of a primary non-surgical therapy in 16.3 % (125 / 766) of the examined patients due to relevant gastroscopic findings., Conclusions: The case history is not sufficient for identifying gastroduodenal disease requiring treatment in patients with symptomatic gall-stones. Therefore, contrary to the current leading concepts, preoperative oesophagogastroduodenoscopy should be discussed as a matter of -routine in patients undergoing elective cholecystectomy in order to treat pathological gastroduodenal findings., (© Georg Thieme Verlag Stuttgart ˙ New York.)

Background/aims: Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones. The goal of this study was to investigate the effect of cholecystectomy on alkaline reflux, histopathological changes in the gastric mucosa and H. pylori colonization., Methodology: Eighty five patients who had undergone laparoscopic cholecystectomy were included in this trial (20 males; 65 females; 44.97 ± 11.22 years). All the patients had an upper gastrointestinal endoscopy before and 6 months after the surgery and biopsies in the antrum and corpus were taken to investigate the mucosal changes and assay for the presence of H. pylori., Results: At 6 months post-surgery, the presence of bile in the fasting gastric fluid and an increase in the endoscopic gastritis findings were detected. While none of the patients had chemical gastritis prior to surgery, 7 patients were diagnosed with this condition after surgery. Intestinal metaplasia was detected in 6 patients prior to surgery and 20 patients after surgery. H. pylori was observed in 64 patients before surgery and 52 patients after surgery., Conclusions: An increase in duodenogastric reflux, alkaline reflux gastritis and intestinal metaplasia, and a reduction in H. pylori colonization were observed to occur post-cholecystectomy.

Bile duct injury (BDI) occurring during cholecystectomy has been proposed as the most serious and important cause of morbidity after this procedure. A literature review was performed about the mechanical and preventable factors of bile duct injury listed on Medline databases. Although most injuries occur within the surgeon's first 100 laparoscopic cholecystectomies, it has been suggested that most general surgeons may encounter bile duct injuries. Several techniques have been proposed to avoid this injury. Sound knowledge of anatomy regarding the hepatobiliary system, good surgical skills, awareness of this problem, and referral to higher centres if injury ensues, seem to be the appropriate course of action towards prevention.

In the present era laparoscopic cholecystectomy (LC) has become the gold standard treatment of choice for gallstone disease. This technique has made a new revolution in minimal invasive surgery, but also the spectrum of complications has changed. In this paper we shared our personal experience of LC in 400 hundred cases from January 2007 to December 2010, its complications and prevention. According to our experience the complications were liver bed injury (n=32, 8%), spilled gall stones (n=29, 7.25%), port site infection (n=11, 2.75%), vascular injury (n=18, 4.5%), conversion to open surgery (n=16, 4%), biliary leak (n=10, 2.5%), bowel injury (n=3, 0.75%), CBD stricture (n=4, 1%) and umbilical port hernia (n=2, 0.5%). Before the procedure, patient consent and awareness to all possible complications which may occur intra-operatively is very important. A good surgical team and experience in this procedure seems to prevent hazardous complications.

Background/aims: To assess the safety and effectiveness of simple laparoscopic cholecystectomy in the elderly patients and to compare it with that in younger patients., Methodology: All patients underwent laparoscopic cholecystectomy in a four year period in a university hospital were retrospectively studied. They were divided in two groups according to the age: group A (65 years and above) and group B (below 65 years). Information about the diagnosis, operation time, intraoperative complications, conversion to open cholecystectomy, length of hospital stay, morbidity and mortality were collected., Results: A total of 1539 patients underwent laparoscopic cholecystectomy during the study period, 234 (15.2%) patients in group A and 1305 (84.8%) patients in group B. Group A experienced higher rates of conversion to laparotomy (9% vs. 2.1%, p<0.005), longer operative time (105.5 vs. 89.7 minutes, p<0.005), longer hospital stay (6.2 vs. 2.1 days, p<0.005) and more morbidity (13.7% vs. 5.1%, p<0.005). The overall mortality was 0.3% with no significant statistical difference between both groups., Conclusions: Laparoscopic cholecystectomy is feasible in the elderly patients with low mortality and morbidity. However, it is associated with higher conversion rate, longer operation time, longer hospital stay and higher morbidity compared with younger patients.

Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.

Background/aims: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by stone extraction is a well-established and standard procedure for common bile duct (CBD) stones. An altered anatomy may be related to inaccessible papilla. Percutaneous transhepatic approach, surgery or alternative endoscopy is considered for inaccessible papilla. Percutaneous transhepatic wire-guided retrieval balloon may not be stiff enough for pushing CBD stones in some situations, such as multiple stones or impacted stones. A percutaneous transhepatic cholangiodrainage (PTCD) assisted retrieval balloon technique for increasing the power for pushing CBD stones was designed in this study., Methodology: A PTCD tube was placed in a situation of inaccessible CBD initially. Percutaneous transhepatic approach with wire-guided balloon dilatation of the papilla assisted with a dilatation balloon. After balloon dilatation of papilla, we performed PTCD assisted retrieval balloon under wired-guided for pushing CBD stones into intestine., Results: We report on two patients with inaccessible papilla treated with papillary dilation followed by PTCD tube assisted pushing common bile duct stones., Conclusion: We recommend that papillary dilatation followed by PTCD tube assisted retrieval balloon push in patients with endoscopic inaccessible common bile duct stones, particularly in multiple stones or impacted stone.

A 32 year old female patient underwent laparoscopic cholecystectomy and in the post-operative phase was investigated after developing obstructive jaundice. ERCP revealed a stenosis at the junction of the cystic and common hepatic ducts and this was seen to be directly adjacent to the clips which had been used to ligate the cystic duct. The stricture was easily dilated with a balloon and all her symptoms improved and her liver function tests returned to normal. Eight years later she represented with a mid-common bile duct calculus. An ERCP was performed but the stone could not be dislodged or retrieved and when removed subsequently at open exploration it was found to have precipitated around two metal clips, which had migrated into the lumen of the common bile duct. We propose that the risk of this rare, yet previously reported complication, could be reduced by heeding the longstanding recommendation that only absorbable material be used in biliary surgery, and particularly when there is a short cystic duct.

The laparoscopic paradigm to place different ports according to ergonomic principles is presently challenged by laparoendoscopic single site surgery (LESS). Its objective is to perform a complex task with several instruments using only one access. However, this approach introduces distinct ergonomic problems and requires innovative technical solutions to allow for more complex surgical tasks. In paediatric surgery, this development has just begun. A 16-year-old girl presented with a symptomatic cholecystolithiasis. A multi-channel TriPort (Advanced Surgical Concepts) was introduced through a 20 mm umbilical incision for LESS cholecystectomy. Retraction of the gallbladder was facilitated by a straight grasper, which was inserted transabdominally. For exposition and triangulation a pre-bend dissector (5 mm, Olympus) was employed. Thus, the cystic duct and artery could be exposed, clipped (5mm) and divided. Finally, the gallbladder was dissected from its bed and extracted into a specimen bag. Operating time was 90 minutes and no intra- or postoperative complications occurred. In conclusion, a multi-channel port and angulated instruments during LESS cholecystectomy provided ergonomics close to conventional laparoscopic surgery. For smaller children though, this technology will have to be adapted to their geometry. Finally, even though LESS seems attractive, the present euphoria should not turn into scientific acceptance, until more experience is available and valid data have proven a benefit for patients of any age.

Background/aim: The life-span of humans increased and the prevalence of gallstones has also increased with age. The aim of this study is to examine the associations between age and clinical outcomes in the patients undergoing elective laparoscopic cholecystectomy (LC)., Methodology: A total of 627 patients receiving LC were categorized into three different age groups. Group I was defined as less than 65 years of age (n = 510), group II as 65 to 79 (n = 100) and group III as more than 80 (n = 17). Clinical characteristics of these patients and surgical outcomes were analyzed., Results: Rates of conversion and major complications were similar among three age groups. Group III had a significantly longer length of perioperative hospital stay compared to groups I or II. However, rates of minor complication appeared to be higher as age progressed (group I: 0.6%; group II: 6.0%; group III: 17.6%). In multivariable-adjusted modeling, groups II and III respectively, had a 7.1-fold (95% CI: 1.3-38.1, p = 0.023) and 34.1 (95% CI: 3.8-310.8, p = 0.002) higher risk of having minor complications than group I patients., Conclusion: LC is a safe and accepted procedure in aged patients with uncomplicated gallbladder stones disease, but it may be associated with increased postoperative morbidity.

Background and Methods: The aim of this study was the evaluation of the management of cholecysto- and choledocholithiasis and outcome of -laparoscopic as well as open cholecystectomy (CHE) and common bile duct (CBD) exploration in Bavaria, Germany. A written questionnaire -in-cluding 201 structured items was sent to all 180 hospitals and departments performing gen-eral or abdominal surgery in Bavaria., Results: The response rate was 60 %. A total of 16 615 operations for gallstone disease including 16 051 cholecystectomies and 453 CBD explo-ra-tions with or without cholecystectomy were -reported. 88 % of all cholcystectomies started -laparoscopically, the conversion rate was 5.6 %. The Veres needle (69 %), 4 trocar techniques and electrosurgical hook knife were reported as standard procedures. A retrieval bag was used by 53 % of all surgeons. The overall complication rate for cholecystectomy was 5.46 % including 0.15 % -major bile duct injuries. Relaparoscopy was performed in 0.35 %, relaparotomy in 0.44 % and postoperative treatment by ERC in 1.45 %. The overall hospital mortality rate was 0.13 %. When choledocholithiasis was suspected, a two-stage management ("therapeutic splitting") with preoperative ERC was preferred (99 %). The conversion rate of simultaneous laparoscopic CHE+CBD exploration was 43 %., Conclusion: These results allow an estimation of the frequency and overall risks in surgical therapy for gallstones. At present, new techniques like combined laparoscopic and endoscopic proce-dures, microinstruments or N.O.T.E.S do not play a significant role in Germany.

Background: The objective of this retrospective study is to evaluate the use oflaparoscopic cholecystectomy in the treatment of acute cholecystitis in elderly patients, and to identify risk factors for mortality., Methodology: In this study we have included patients with acute cholecystitis aged 75 years and older. Patients were diagnosed after anatomical and pathological examination of an operative sample. We retrospectively examined 100 patients who underwent cholecystectomy between June 1991 and February 2007. Seventy-nine patients (79%) underwent laparoscopic cholecystectomy, 12 patients (12%) needed a conversion, and 15 patients (15%) were considered unfit to undergo a laparoscopic approach, due to their hemodynamic condition or for other reasons., Results: American Society of Anesthesiologists Scores (ASA), inflammatory syndrome, length of postoperative stay, number of days in the Intensive Care Unit, local complications, and mortality rate are all significantly higher in the 'laparotomy and conversion'. There was not a significant difference in age or general complications between groups. The mortality risk factors include a high level of CRP, biliary peritonitis, emergency, and the necessity of laparotomy., Conclusion: Acute cholecystitis is a severe pathology in the elderly associated with a high rate of morbidity and mortality. Due to the mortality risk factors associated with acute cholecystitis, we recommend elective laparoscopic cholecystectomy for aged patients with symptomatic cholelithiasis, due to its low morbidity and mortality rates.

Background/aims: This study aims to evaluate the outcomes of percutaneous cholecystostomy for acute calculous cholecystitis in patients with high surgical risk and determine whether subsequent cholecystectomy is beneficial and necessary. Percutaneous cholecystostomy has been shown to be a safe treatment option for patients suffering from acute cholecystitis but at high risk for emergency surgery. Controversies still exist on the approach of the cholecystostomy and the subsequent management of these patients., Methodology: From January 1996 to March 2004, percutaneous cholecystostomy was performed on 65 patients that suffered from acute calculous cholecystostomy but were considered high risk for emergency surgery (American Society of Anesthesiologists grade III or IV). Their clinical outcomes were described and risk factors for in-hospital mortality and recurrence of cholecystitis were identified by univariate and multivariate analysis., Results: Percutaneous cholecystostomy was successfully performed in all patients (100%). The clinical response rate was 91%. The in-hospital mortality was 12.3%. Shock on admission was found to be a single independent risk factor for in-hospital death (p=0.006; odd ratio = 16.5; 95% CI = 2.2-123.1). Twenty-four patients underwent subsequent cholecystectomy whereas 33 did not. The 1-year and 3-year recurrence of acute cholecystitis were 35% and 46% respectively in patients who did not have subsequent cholecystectomy. Stone size > or = 1cm was independently associated with higher recurrence of acute cholecystitis (p=0.01; hazard ratio = 6.3, 95% CI 1.6-25.5). However, there was no difference in 1-year and 3-year overall survival between patients with or without cholecystectomy (82% Vs 81% and 59% Vs 63%, p=0.79)., Conclusions: Percutaneous cholecystostomy is a safe and promising treatment for acute calculous cholecystitis in patients who are at high risk for emergency surgery. Cholecystectomy after the resolution of cholecystitis and optimization of associated medical illnesses is always advisable in order to prevent recurrent cholecystitis. However, the limited survival of these patients because of their old age and medical co-morbidities should be taken into consideration.

Background/aims: The objective of the present study was to measure gastric emptying time of solids and semisolids in dyspeptic individuals with cholecystolithiasis before and 6 months after cholecystectomy in order to determine whether cholecystectomy interferes with gastric emptying., Methodology: A prospective, self-pairing study was conducted on 29 patients selected according to appropriate inclusion and exclusion criteria. Gastric emptying time of solids and semisolids was determined before and six months after laparoscopic cholecystectomy by the 13C-octanoic acid and 13C-acetate breath tests, respectively. The samples were analyzed by infrared spectrometry. The gastric retention time (lag phase) and gastric emptying half-time of solid and semisolid were determined and the results obtained before and after surgery were compared in the same patient. In addition, the effects of surgery on dyspeptic symptoms were assessed., Results: No significant differences (p>0.05) in gastric retention time and gastric emptying half-time of solid and semisolid test meals were observed before and after cholecystectomy. Dyspeptic symptoms (pain, upper abdominal gases, early satiety, nausea and vomiting) improved after surgery., Conclusions: Laparoscopic cholecystectomy does not interfere with the gastric emptying time of solids or semisolids in dyspeptic individuals with cholecystolithiasis.

Background/aims: Endoscopic sphincterotomy (EST) is a prerequisite for invasive procedures in the biliary tract or the pancreas. Access to the desired duct system may be facilitated by a precut in the papilla but this has also been described as a risk factor of the procedure. The present study is focused on the clinical situation and anatomical conditions which may increase the need for a precut procedure., Methodology: During a 2-year period, (2001-2002), 562 patients underwent EST. The precut was performed with a papillotome knife when cannulation failed using standard techniques., Results: EST was successful in 545 (97.0%) of the patients, and in 522 (92.8%) in the first session. 173 patients (30.8%) were subjected to precutting. Precutting was used less frequently in patients with biliary stone disease, in 39 of 183, than in those without (P < 0.01). In the presence of a tumor, precut technique was warranted more often, in 62 of 143, as compared to benign disease, 111 of 419 (P < 0.01). Changed anatomical conditions at the papilla increased precut use, in 79 of 143 (P < 0.001), as well as duodenal stenosis, 15 of 22 (P < 0.001). The complication rates were equal, 13.3% using precut and 12.4% in standard EST. The 30-day mortality was higher in the precut group: 8 (4.6%) as compared to 5 (1.3%) using standard EST (P < 0.05) but it was mainly caused by advanced malignancies or severe underlying acute pancreatitis., Conclusions: The need for precut technique seems to be related to the diagnosis and was decreased in the presence of bile duct stones, while it was increased in malignancies. The precut procedure was used more frequently when the anatomical conditions at the papilla were abnormal and in duodenal stenosis.

Acute cholecystitis and acute cholangitis are the most frequent surgical infections of the biliary tree. Early laparoscopic cholecystectomy is the treatment of choice in acute cholecystitis. Laparoscopic operation results in a shorter length of stay and less morbidity. Conversion rate is low in early laparoscopic cholecystectomy. Endoscopic or transhepatic decompression of the bile ducts is the treatment of choice in severe acute cholangitis. While the removal of stones is the causal therapy in choledocholithiasis, further diagnosis and consecutive therapy has to follow after decompression of bile duct stenosis.

Background: The necessity of carrying out pre- or intra-operative imaging of the biliary tree to rule out a possible anatomical abnormality or the presence of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC) is debated. We prospectively assessed the risk of developing symptoms related to bile duct injury or CBD stones after LC in children not receiving peri-operative cholangiography., Materials and Methods: All patients

Background/aims: Reports on the late postoperative complications in patients with pancreaticobiliary maljunction (PBM) are limited., Methodology: Eighteen PBM patients with biliary dilatation and 12 without biliary dilatation were surgically treated at our institute. These 30 PBM patients were retrospectively reviewed, with particular attention to late postoperative complications., Results: Nineteen patients without biliary malignancies underwent resection of the extrahepatic bile duct (BD) and hepaticojejunostomy. Two patients without biliary dilatation or malignancy underwent cholecystectomy alone. Nine patients with malignancies underwent hepatectomy with extrahepatic BD resection in 7 patients, pancreatoduodenectomy (PD) in 1, and PD + hepatectomy in 1. The median follow-up duration was 110 months. All patients without malignancies are presently alive in good healthy condition and have not developed any malignancy postoperatively. Late postoperative complications were seen in 6 (20%). Four patients with biliary dilatation were surgically or endoscopically treated for intrahepatic lithiasis 3, 12, 42 and 54 months after initial operation. One of them had a pancreatic protein plug 216 months after surgery, and was treated with papilloplasty after open laparotomy. In one patient without biliary dilatation, pancreatic protein plug and intrahepatic lithiasis were found 60 and 72 months after surgery, respectively, and both were treated endoscopically., Conclusions: Intrahepatic lithiasis and pancreatic protein plug are frequent late postoperative complications. The intrapancreatic residual choledochus or dilated pancreatic duct seems to be related to pancreatic protein plug. However, intrahepatic lithiasis may occur regardless of the pattern of the biliary tract dilatation. Careful, long-term follow-up is important in patients with PBM.

Introduction: Iatrogenic injuries of the bile duct and hepatic artery represent a continuous problem after laparoscopic cholecystectomy. In this observational study we report about our experiences applying the "critical view of safety", defined as unambiguous identification of the cystic duct and artery by creation of an infundibular window, in order to minimise bile duct lesions and conversion rate., Methods: Between July 2002 and November 2004 100 consecutive laparoscopicly started cholecystectomies were prospectively investigated. The central surgical step of dissection aimed at reaching the "critical view of safety" and its photo printing before cutting the cystic duct and artery, otherwise a conversion was carried out without exception. Primary endpoints of the study were the conversion rate, secondary endpoints the incidence of intra- and postoperative complications, operation time and histological results., Results: 53 of the 100 primary laparoscopic operated patients showed the signs of an acute cholecystitis, 44 patients offered partially multiple abdominal operations in their history. In 19 patients we performed a "therapeutic splitting". Only in 3 patients it was not possible to apply the "critical view of safety" resulting in a conversion to open cholecystectomy. The mean operation time was 81 minutes and the postoperative hospital stay ranged to 5.4 (1-18) days. Postoperatively an insufficiency of cystic duct, a navel infection, an abdominal wall haematoma, an urinary tract infection and a pneumonia occurred in one patient each., Discussion: Pivotal factors leading to bile duct injury after laparoscopic cholecystectomy are systematic mistakes in the surgical technique, an insufficient surgical training and human failure of the surgeon. The introduction of the "critical view of safety" represents an objective, understandable and compulsory criterion for minimising the risk of iatrogenic injuries of the bile duct and decision on conversion to open cholecystectomy.

Background/aims: The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome., Methodology: Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance., Results: Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones., Conclusions: A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.

Background/aims: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy., Methodology: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates., Results: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance., Conclusions: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.

A time-honored praxis is to insert a T-tube after open choledochotomy. Well-known complications of T-tube removal include bile leakage, peritonitis, sepsis and postoperative biliary stenosis. A retained T-tube fragment after surgical common bile duct exploration is an uncommon complication of T-tube removal. We report the first case of retained bile duct stones with a whole T-tube jammed into the biliary tree. A 31-year-old female with gallstone disease was operated on. The operation was started by laparoscopy but converted to open laparotomy because of perforation of the gallbladder. T-tube was inserted but several stones remained in the bile duct. Afterwards routine T-tube removal was impossible: the T-tube had become trapped in the common bile duct. This combination of complications was successfully treated by ERCP.

Background/aims: The aim of this study was to determine useful predictive factors of common bile duct stones (CBDs) as diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent laparoscopic cholecystectomy (LC) for gallstones., Methodology: A total of 510 patients underwent ERCP prior to LC. Also reviewed in each were clinical data, laboratory data, and ultrasonographic findings. Data were evaluated by uni- and multivariate analysis to determine which of the useful predictive factors thus far reported might be in the concurrence of CBDs., Results: Univariate analysis identified jaundice, pancreatitis, ALT, total bilirubin, alkaline phosphatase, amylase, and CBD dilatation at ultrasonography as predictors. Multivariate analysis subsequently identified alkaline phosphatase (p<0.0001), total bilirubin (p=0.0008), amylase (p=0.0009), and CBD dilatation at ultrasonography (p=0.0012) as independent predictive factors of CBDs. The estimates for the detection of CBDs, when the indication of ERCP is determined on the basis of the four predictive factors, were found to be as follows: sensitivity 97.6%, positive predictive value 78.6%, and positive accuracy 95.3%., Conclusions: It is advisable to ascertain by preoperative ERCP whether there might be any CBDs in patients about to undergo an LC for treatment of cholelithiasis insofar as the patient has one or more of these factors. It is concluded that an LC may be performed by omitting the prior ERCP, conversely, on patients devoid of all of these factors.

Although an aberrant hepatic duct entering the cystic duct is not especially rare, the main right hepatic duct entering the cystic duct is extremely rare. A 69-year-old woman developed severe intermittent right upper quadrant pain and high fever. A diagnosis of acute calculus cholecystitis was made by radiographic examinations. Magnetic resonance cholangiopancreatography demonstrated dilatation of the right hepatic duct, but could not identify the junction of the right hepatic duct and the cystic duct. Endoscopic retrograde cholangiopancreatography established that the right hepatic duct joined the cystic duct and that cholecystolithiasis was present. As the right hepatic duct entering the cystic duct can lead to ductal injury, this anomaly should be kept in mind when performing laparoscopic cholecystectomy. Pre- and intraoperative cholangiography contribute to the avoidance of iatrogenic bile duct injury. When the right hepatic duct drains into the cystic duct, the gallbladder should be removed distal to the junction of the hepatic and cystic ducts.

Background/aims: Extensive circumstantial evidence indicates that patients with a predicted severe attack of acute biliary pancreatitis (ABP) should undergo an endoscopic retrograde cholangiography with papillotomy (ERC/PT). However, in clinical practice this procedure is not always performed. This study was conducted to compare outcome in patients with and without ERC/PT., Methodology: Thirty-five of 80 patients admitted with ABP had a predicted severe attack (three or more Ranson criteria). Only in 24 of these 35 patients was an ERC/PT performed., Results: In the ERC/PT group, significantly less pancreatic necrosis (8 vs. 64%, p<0.001) occurred, hospital stay was shorter (median 22 +/- 5 vs. 51 +/- 19 days, P=0.08) and mortality was lower (8 vs. 36%, P=0.01). Twenty-three patients (66%) underwent cholecystectomy after a median period of 10 weeks (range 0-26 weeks) after discharge. During the waiting period, in the ERC/PT group, two patients developed acute cholecystitis whereas recurrent ABP and common bile duct stones occurred in one patient each., Conclusions: In patients with a predicted severe attack of ABP, performing ERC/PT is associated with less morbidity and lower mortality.