Search

Oriental cholangiohepatitis is a condition occurring in the Asian population, characterised by recurrent bacterial cholangitis and presence of calculi within the intrahepatic bile ducts, biliary strictures and an increased risk for cholangiocarcinoma. It is an uncommon disease in the West that may not always be considered. The therapeutic approach is multidisciplinary and highly individual, and includes antibiotic therapy, endoscopic and percutaneous biliary drainage with stone removal and dilation of strictures, and in selected cases surgical resection of affected liver segments. We report our experience with five relatively young adult patients largely originating from China, who presented with pyogenic cholangitis and were considered to suffer from oriental cholangiohepatitis. To our knowledge this is the first report of this condition in the Netherlands. Physicians treating patients with pyogenic cholangitis should be aware of this disease and consider the diagnosis in all Asian immigrants with biliary tract disease.

Background: Crigler-Najjar syndrome (CN) is a very rare genetic disorder characterized by an inability to conjugate bilirubin. Contrary to CN type I, patients with CN II exhibit residual capacity to conjugate bilirubin and may present a normal life expectancy., Case Presentation: We report an unusual late diagnosis of CN type II in an 80-year-old female admitted with severe acute cholangitis. While the patient present typical clinical and radiologic signs of bile duct obstruction and cholangitis, her blood analysis showed severe unconjugated hyperbilirubinemia. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis and allowed therapeutic intervention. The anatomopathologic examination of her gallbladder following cholecystectomy showed signs of chronic cholecystitis., Conclusion: The risk of gallstone disease may be increased in patients with CN syndrome. While unusual, we alert to this curious and potential life-threatening presentation.

Background: Bile duct injuries (BDI) have been reported to occur more frequently during laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). Several studies have demonstrated various potential predisposing factors for BDI. However, there is a controversy as to whether gallbladder inflammation is a significant predictor for BDI. Therefore, out primary aim was to investigate the relationship between inflammation and BDI at LC, and secondarily to present the management and clinical outcome of BDI., Methods: We recorded all consecutive LC performed between 1993 and 2005 in our institution by nine staff surgeons. BDI were classified according to Strasberg's classification. Simple and multivariate logistic regression analysis was performed to evaluate the association between inflammation and BDI occurrence during LC., Results: There were 2,184 patients. Among those, 344 had inflammation (16%). The conversion rate was 5% and was higher among male, elder patients, and those with inflammation. The BDI incidence was 0.69% (0.14% for major and 0.55% for minor injuries) and it was significantly higher in those with inflammation compared to those without inflammation (p = 0.01). In particular, the risk for BDI was almost 3.5 times higher in those with inflammation (OR = 3.61, 95% CI 1.27-10.21). Inflammation remained an independent risk factor for BDI even after adjustment for potential confounders. Among patients sustaining injury, one died and two have recurrent cholangitis. No association was observed between clinical outcome and management of BDI, time of diagnosis, sex, and inflammation., Conclusion: We revealed that inflammation is an independent predictor of BDI occurrence during LC. Therefore, it would be advisable for surgeons to not hesitate to convert a LC to an OC in the presence of inflammation.

Objective: To evaluate the optimal timing of hepatectomy for intrahepatic lithiasis complicated with acute cholangitis., Methods: One hundred and twenty-six patients with hepatolithiasis who had a history of acute cholangitis and underwent hepatectomy were reviewed retrospectively. According to the period between the surgery and last attack of acute cholangitis, 126 patients were divided into 3 groups: > 3 months (group A, n = 73), 1 approximately 3 months (group B, n = 28), < 1 month (group C, n = 25). The operation time, blood loss, hospital stay, postoperative complications and stone residual rate were compared among the groups., Results: The intraoperative blood loss of C group was (644.0 +/- 625.7) ml, which was significantly higher than those of A and B group [(409.2 +/- 250.7) ml and (423.2 +/- 237.1) ml, respectively]. The numbers of patients who needed transfusion and the amount of blood transfusion in group C were also higher than those of group A and B. The incidence rate of complications, residual stone in group C were all markedly higher than those of group A and B. The period of hospital stay in group C was much longer than that in group A and B., Conclusions: The optimal timing of hepatectomy for hepatolithiasis complicated with acute cholangitis is at least one month after subsidence of cholangitis.

The most distinctive and typical complications of cholelithiasis are cholangitis and hepatitis. The article presents an analysis of peculiarities of immune homeostasis in 41 patients with cholelithiasis complicated by hepatitis and cholangitis before and after surgical treatment and with the use of antihomotoxicologic and homeopathic medications.

853 Patients with acute calculous cholecystitis were operated during 2004 in the Center of surgery of liver, bile ways and pancreas. Preoperative preparation of 62 patients with cholecystitis complicated with hepatitis and cholangitis, included intravenous administration of 5 antihomotoxycological medications simultaneously with routine pharmacological drugs. It resulted in lessening a hospital stay treatment by 2.3 days; also by 34.2% postoperative paresis of intestinum, by 52.3% duration of postoperative wound healing, by 54.7% such postoperative problems as dyspeptic symptoms, dyscomphort in right hypohondrium, suffering because of fullness and distortion in epigastrium after food intake and others. The time of preoperative preparation in the group of the operated patients was less by 0.91 days and consists 6.8 hours.

Background: Peripapillary choledochoduodenal fistula (PCDF) is occasionally detected during endoscopic retrograde cholangiopancreatography. Cholelithiasis and biliary bougienage are two suspected causes of PCDF., Methods: The medical records for 841 patients who underwent endoscopic retrograde cholangiopancreatography between 1993 and 2002 were reviewed for evaluation of PCDF., Results: A total of 327 patients had common bile duct stones, and 16 of these had a PCDF at the papilla of Vater. None of the 16 patients had a history of pancreatitis, duodenal ulcer, or had undergone endoscopic retrograde cholangiopancreatography previously. Seven of the 16 had not undergone biliary surgery., Conclusions: This study indicates that PCDF is a relatively common complication of common bile duct stones and cholangitis. According to the present results, PCDF is more frequently associated with common bile duct stones than with biliary surgery and bougienage.

Background: Currently, cholecystectomy is recommended for patients with gallstone-induced pancreatitis. ERCP with endoscopic sphincterotomy (ES) within 24 to 48 hours is also suggested for the treatment of acute gallstone pancreatitis. The aim of this study was to determine outcome after cholecystectomy versus ES alone in patients with gallstone pancreatitis., Methods: One hundred seventeen patients with gallstone pancreatitis were included in this prospective observational study. Inclusion criteria were typical abdominal pain; serum amylase level 3 times or greater than normal; and gallbladder stones and a dilated bile duct, with or without stones, by US, CT, or ERCP., Results: Eighty-three patients (Group A) underwent cholecystectomy after initial evaluation including ERCP in 43 (53%) and ERCP with ES in 38 (47%). The remaining 34 (Group B) underwent successful ERCP with ES alone. Mean follow-up was 33 months for Group A and 34 months for Group B. Recurrent gallstone pancreatitis was noted in 2 patients (2.4%) in Group A (bile duct stone in 2, sludge and papillary stenosis in 1), and in 1 patient (2.9%) in Group B. Ten patients in Group B had follow-up US of the gallbladder that showed disappearance of stones in 3. During follow-up, there was no significant difference in the rates of biliary complications (Group A, 3.6% vs. Group B, 11.6%; p = 0.19) or serious complications (pancreatitis, cholecystitis, cholangitis) (Group A, 3.6% vs. Group B, 5.8%). Also, there was no significant difference in procedure-related complications., Conclusions: Recurrence of pancreatitis after ERCP with ES alone for gallstone pancreatitis is rare. In patients who have undergone ES alone, cholecystectomy should be considered only if there are overt manifestations of gallbladder disease (e.g., biliary pain, cholecystitis, cystic duct obstruction) and not for prevention of recurrent gallstone pancreatitis. Because treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy, these patients may require close surveillance.

Aim: This paper describes the procedure of detection of Helicobacter pylori (H. pylori) in bile specimens in patients suffering from benign diseases of biliary ducts (lithiasis with/without nonspecific cholangitis)., Methods: The group of 72 patients entering the study consisted of 32 male and 40 female (45% and 55%, respectively). Bile was obtained during ERCP in 68 patients, and during cholecystectomy in 4 patients. A fast urease test (FUT) to determine the existence of H. pylori in gastric mucosa was carried out for all the patients during the endoscopic examination. The existence of genetic material of H. pylori was determined by detection of ureA gene by the method of nested PCR. The results of this reaction were shown by electrophoresis on 10g.L(-1) agarose gel in a band of 256bp., Results: The majority of the patients included in our study had biliary lithiasis without signs of cholangitis (48 patients, 67%), whereas other patients were complicated by cholangitis (17 patients, 24%). Seven patients (9%) had normal ERCP, forming thus the control group. In the group of patients with lithiasis 26 patients (54.2%) had positive PCR of H. pylori in bile and among the patients with associated cholangitis positive PCR was detected in 9 patients (52.9%). Among the seven patients with normal ERCP only one (14%) had positive PCR of H. pylori. A high percentage of H. pylori infection of gastric mucosa was observed (57 patients, 79%). It was also observed that its slightly higher positivity was in the patients with distinct bile pathology: 81% FUT positive patients in the group with choledocholithiasis alone and 76% in the group with choledocholithiasis associated with cholangitis. Seventy-one percent of the patients with regular findings had positive FUT., Conclusion: The prevalence of H. pylori infection both in bile and in gastric mucosa in patients with benign diseases of biliary ducts does not show a statistically significant difference in relation to the prevalence of the same with the patients with normal ERCP. The existence of H. pylori infection possibly does not play a role in pathogenesis of benign biliary diseases.

Results of complex examination and treatment of 138 patients with postcholecystectomic cholangiolithiasis were analyzed. Residual cholangiolithiasis was diagnosed in 104 (75.4%), recurrent--in 34 (24.6%) patients. Differential-diagnostic symptoms of residual and recurrent cholangiolithiasis are specifiEd. Diagnostic and curative algorithm was developed, criteria of choice of curative (instrumental or surgical) methods were clarified. Mini-invasive surgeries (endoscopic papillosphincterotomy, suprapapillar choledochoduodenostomy, dissection of stenosed choledochoduodenoanastomosis, percutaneous transhepatic cholangiostomy, lithoextraction through external bile fistual, mechanical and laser lithotripsy, nasobiliar drainage) from different diapeutic approaches were performed in 137 (99.3%) patients. Diapeutic instrumental procedures were effective and final in 91.9% cases (in residual cholangiolithiasis--94.2%, in recurrent--82.4% cases). Lethality was 0.7%.

Minimally invasive technologies were used in treatment of 89 patients with cholelithiasis complicated by mechanical jaundice and purulent cholangitis. Advantages of the two-stage operative treatment of such patients were shown. The first stage is decompression of the bile duct, the second stage is a radical operation either by laparoscopic or minilaparotomic methods. It allows to avoid extensive and traumatic operations and secures better immediate and long-term results of treatment.

The medical approach to treatment of cholangiohepatitis and cholelithiasis in 9 horses is described. Seven horses were treated successfully and returned to normal use, with a minimum follow-up period of 12 months. Long-term antimicrobial therapy was believed to be critical in those cases that survived, with a median treatment duration of 51 days (range 17-124 days). Treatment failure was associated with severe periportal and bridging hepatic fibrosis from biopsy material obtained at admission in 2 horses, one of whom also presented with hyperammonaemic hepatic encephalopathy. Transabdominal ultrasound was used diagnostically in each case to obtain hepatic biopsy material for histopathology and bacterial culture, to evaluate hepatic size and echogenicity and to identify and monitor the dissolution of hepatoliths. Histologically, all horses had evidence of suppurative cholangiohepatitis with varying degrees of periportal and bridging fibrosis. Discrete hyperechoic calculi were identified in 4 cases, but all horses had ultrasonographic evidence of biliary obstruction with numerous dilated bile ducts. Aerobic and anaerobic cultures of liver biopsy material were negative from 7 horses, but 2 different species of Escherichia coli were obtained from one horse, and Bacteroides vulgatus and Escherichia coli were isolated from another. In all 7 horses that survived, clinical recovery was seen before normalisation of biochemical indices of hepatobiliary function including gammaglutamyl transaminopeptidase (GGT), alkaline phosphatase (AP), bile acids and serum bilirubin. Serum GGT levels were monitored extensively as a marker of hepatobiliary disease and actually increased during the initial period of clinical improvement in horses that recovered. Supportive medical therapy with i.v. fluids was also a critical part of the therapy of several cases in this report, both acutely and in the management of chronic cases that deteriorated clinically during treatment. Previous therapeutic failures may well be related to treatment periods of inadequate duration, and the authors recommend that antimicrobial therapy should be continued until GGT values are normal.

Routine laparoscopic cholangiography and sonography have been recommended for identification of unsuspected bile duct stones in laparoscopic cholecystectomy. The increased prevalence of retained stones seems, however, to confirm that cholangiography has been used rather selectively. The aim of this study was to investigate the kind and extent of a possible correlation between inflammatory changes in the bile duct mucosa and the hepatoduodenal ligament in patients with and without unsuspected bile duct stones. Sixty-eight patients, without symptoms or signs of bile duct stones in their case histories, laboratory findings, and preoperative sonography results, underwent laparoscopic cholecystectomy for symptomatic gallstone disease and diagnostic transcystic cholangiography and cholangioscopy. The initial step at laparoscopy revealed edema of the periductal loose tissue, vascular dilation, and petechiae on the external surface of the distal portion of the extrahepatic bile duct in 47 of 68 patients. Cholangioscopy revealed inflammatory changes in the mucosa of the distal and sphincteric portions of the extrahepatic bile duct in 45 of 47 patients, and unsuspected ductal stones were identified in 41 of these 45 patients. Neither the external surface of the bile duct nor its mucosa exhibited any signs of inflammation in the 21 remaining patients (controls), all of whom showed stone-free bile ducts. Inflammatory changes in the bile duct mucosa, occurring along with unsuspected mobile ductal stones in this study, were reflected on the external surface of the bile duct with a specificity of 87%. The changes in the external surface of the bile duct can be recognized at the initial inspection in laparoscopic cholecystectomy, as in this study, and indicate that more accurate diagnostic procedures to identify unsuspected ductal stones should be used.

Intrahepatic calculi is characterized by an intractable course and frequent recurrences, requiring multiple operative interventions. Chronic proliferative cholangitis, an active and long-standing inflammation of the stone-containing bile ducts with the hyperplasia of epithelia and the proliferation of the duct-associated mucus glands, may underlie the complex nature of the disease. In terms of the pathophysiology, interest has been focused on the role of secretory low-molecular-weight phospholipases A2 (sPLA2s) as inflammatory mediators or factors modulating cell functions via their specific sPLA2-receptor, and also on the production and secretion of altered mucin molecules from the inflamed bile ducts. In search of factors involving chronic proliferative cholangitis, the sPLA2 isoforms in the bile such as the pancreatic-type sPLA2 (group IB sPLA2) and the arthritic-type sPLA2 (group IIA sPLA2), were assayed to correlate protein masses of the sPLA2s with alterations in biliary composition. Furthermore, the steady-state messenger RNA (mRNA) levels of the sPLA2s, the membrane-bound sPLA2-receptor, cystic fibrosis transmembrane conductance regulator (CFTR), and mucin core polypeptide (MUC) genes in the bile ducts were assayed by reverse- transcriptase polymerase chain reaction (RT-PCR). Immunoreactive sPLA2-IB and sPLA2-IIA levels were significantly higher in the bile from the stone-containing hepatic ducts (2315 +/- 677 for sPLA2-IB; 281 +/- 42 for sPLA2-IIA ng/dL, mean +/- SEM; n = 20) than in the ductal bile from gallbladder stone patients (609 +/- 92, P <.01; 22 +/- 2, P <.01; n = 24). The increased sPLA2 levels were associated with a concomitant increase in lysophosphatidylcholine, prostaglandin E2 (PGE2), and total mucin concentrations. The affected bile ducts showed an increased mRNA level of sPLA2-IB and sPLA2-IIA compared with the ducts from control subjects, in whom the mRNAs of the sPLA2-receptor and other sPLA2 isoforms, such as groups V and X sPLA2s, were coincidently expressed. Reflecting the increased amounts of total biliary mucins, the affected ducts showed an increase in mRNA levels of CFTR as well as MUC2, MUC3, MUC5AC, MUC5B, and MUC6 compared with the ducts from control subjects. In intrahepatic calculi, an enhanced expression of the sPLA2s and their possible cross-talk via sPLA2-receptor may be of pathophysiological significance for the chronic proliferative cholangitis, in association with the enhanced CFTR expression and the alterations in mucin gene expression in the bile ducts, probably through potentiating arachidonate metabolism with associated biliary alterations favoring growth of preexisting stones and even further progressions.

Stone formation in the biliary system is a rare condition in infants. A few cases of bile stones in the biliary tree have been reported with underlying predisposing factors, such as sepsis and antibiotic usage. This article describes a surgically treated 16-week-old infant with recurrent cholangitis who had a bile stone in the hepatic duct after chlamydia sepsis.

This study was conducted to clarify the pathogenesis of portal vein obstruction (PVO) associated with intrahepatic stones. Five cases with PVO and intrahepatic stones were studied retrospectively. The coincidence rate of PVO in intrahepatic stones was 5.8% (5 of 86 cases), and that of intrahepatic stones in PVO, 45.5% (5 of 11 cases). All cases had one or more symptoms of cholangitis, such as high-grade fever, abdominal pain, and jaundice prior to diagnosis of PVO. The portal vein was occluded at the main trunk in 4 and in the left branch in 1. Intrahepatic stones were found in bilateral hepatic lobes in 3 and in the left lobe in 2. Numerous calcium bilirubinate stones were packed in dilatated intrahepatic bile ducts of an excised specimen of the liver. Microscopically, arterial structures could be seen, but the portal vein ceased to be evident about the involved bile duct. Based on the results of this study, persistent cholangitis and packed gallstones were concluded essential to the development of PVO accompanied by intrahepatic stones.

The successes of supportive management of patients with severe acute pancreatitis in recent years has evolved from our improved understanding of some of the serious consequences of pancreatic necrosis on other organ systems. When gallstone disease is identified as the cause in such patients, there has been an expectation that biliary intervention will lead to a more rapid resolution of the index attack and prevention of future pancreatitis. There is now convincing evidence, in the setting of severe gallstone-associated pancreatitis using prognostic scoring, that not only is emergency or early elective biliary surgery associated with an unacceptable morbidity and mortality but that appropriate endoscopic therapy is safe and highly effective. In populations where concomitant cholangitis is common, emergency biliary endoscopic management provides optimal therapy for all grades of pancreatitis.

Objective: To analyze the efficacy of a combined approach using ERCP plus laparoscopic cholecystectomy in the treatment of gallstones associated to benign common bile duct obstruction., Design: Prospective study., Setting: Tertiary-care medical center., Patients: From a total of 270 laparoscopic cholecystectomies performed between October 1991 and January 1994, a group of 25 patients in whom preoperative ERCP was performed to rule out bile duct obstruction was selected for analysis., Results: Choledocholithiasis was documented in nine patients (36%). In eight of them, stones were retrieved by ERCP. The diagnosis of odditis was established in five patients and a papilotomy was performed. The entire bile duct was normal in 11 cases. All patients in whom the common bile duct was normal, or cleared endoscopically, underwent laparoscopic cholecystectomy uneventfully. There was one complication of papilotomy. Duodenal perforation occurred in one patient who ultimately died., Conclusion: The combined approach using ERCP followed by laparoscopic cholecystectomy seems to be adequate for the treatment of gallstones associated to bile duct obstruction.

Recent studies have indicated that solitary or multiple gallstones may differ with respect to the conditions favoring their formation, such as nucleation time. We examined the clinical, histological and laboratory characteristics of symptomatic gallstone disease in a series of 125 consecutive patients with either solitary (n = 33) or multiple (n = 92) cholesterol gallstones undergoing cholecystectomy. The nature of biliary pain was found to differ in the two groups. Histological diagnoses of acute cholecystitis and gallbladder cancer was more frequent in the patients with multiple stones, and cholesterolosis in those with solitary stones. Furthermore, the stone cholesterol content was higher in the solitary stone group than in the multiple stone group. Morbid complications such as cholangitis and pancreatitis were rare and occurred only in the multiple stone group. The results support the view that gallbladder disease presents histological evidence of biliary complications more often in patients with multiple cholesterol stones than in those with solitary stones.

We have treated 894 gallstone patients for these five years. The average age was 55.47 and 163 cases (18.2%) were more than 70 year-old. One of the important characteristics of the aged gallstone patients that they often had bile duct stones causing acute obstructive cholangitis. The other was that they accompanied another organ disorders. Early biliary drainage was the best way to avoid multiple organ failure under such conditions. Principally, surgical treatment if it's possible, was most reliable for bile duct stones. Thirty-five patients of bile duct stones were treated with our new surgical procedure. That was primary closure technique of the common bile duct following lithotomy under pre- or intra-operative insertion of naso-biliary drainage catheter. Especially in the elderly, this technique was useful to reduce post operative hospital stay by 19 days compared with the ordinary T-tube drainage.

Recently, it has been suspected in animal models that a decrease in portal blood flow plays a role in the formation and progression of hepatolithiasis. To find whether this hypothesis is applicable to humans, we examined histologically the intrahepatic portal venous and arterial systems in normal livers (n = 13), extrahepatic biliary obstruction (n = 18), intrahepatic biliary sludge and microcalculi (n = 18, most of which were associated with biliary obstruction and might represent pathogenesis of an early developmental stage of hepatolithiasis), and fully developed hepatolithiasis composed of calcium bilirubinate stones (n = 30). A scoring method was employed to quantify portal stenosis, portal phlebosclerosis, arterial stenosis, and parenchymal atrophy. We found that these vascular changes were significantly more severe in hepatolithiasis than in biliary sludge and microcalculi, or in extrahepatic biliary obstruction. There were no significant differences in the vascular changes except for arterial stenosis between the latter two. There is a positive correlation between vascular stenosis and parenchymal atrophy. These findings suggest that portal venous stenosis deteriorates during the progression of hepatolithiasis. We could not find direct evidence that portal venous stenosis is an initial lesion followed by the formation of hepatolithiasis. The vascular changes may be caused by an inflammatory extension of cholangitis and may deteriorate, causing parenchymal atrophy during the progression of hepatolithiasis.

Cholelithiasis is considered as a major health problem in Mexico do to its high prevalence. The spectrum of gallstones ranges from sympatomatic to asymptomatic gallbladder stones. The most frequent complications are acute cholecystitis, choledocholithiasis, cholangitis and pancreatitis. The standard method for diagnosis is ultrasonography but for a better evaluation and in order to cover the ultrasonographic faults, the oral cholecystogram is recovering value. Computarized axial tomography, technetium marked radionucleids and ERCP are valuable tools to avoid unnecessary surgical exploratory choledochotomies. The elective treatment for symptomatic cholelithiasis and asymptomatic cholelithiasis with risk factors in cholecystectomy with cholangiography at operating room. In choledocholitiasis the choice is choledochotomy with "T" tube drainage and sphincteroplasty and choledochoduodenal anastomosis evaluated at operating room. Acute cholecystitis is treated with early or emergency cholecystectomy. With the help of litotripsy, interventional radiology and endoscopy extraction, the procedures for treatment of biliary pathology the changing, both surgical and non surgical procedures are complementary.

Western life-style and an older population make gallstones, "silent" or otherwise, a commoner problem than in the past. Whilst symptomatic gallstones should be treated surgically, "silent" gallstones usually remain that way and do not require prophylactic cholecystectomy. However, if common bile duct stones have been demonstrated or only suspected, surgery is the treatment of choice even in the absence of symptoms. Surgical mortality is very low at less than 1% for cholecystectomy and bile duct exploration. These figures apply to a population of whom half are over 70 years of age. Chemical dissolution of cholesterol gallstones is only of use in a small minority of patients, notably those at high surgical risk or who refuse surgery. Endoscopic sphincterotomy is useful as primary treatment in cases of cholangitis and gallstone-associated pancreatitis, and often allows removal of bile duct stones in inoperable patients.

Oriental cholangitis is a poorly understood syndrome consisting of intrahepatic pigment stone formation with chronically recurrent exacerbations and remissions. Endemic to Asia, it is being encountered more frequently in the United States due to increased immigration of asians. Twenty-one patients with oriental cholangitis (9 men and 12 women), 19 to 84 years of age, all of whom immigrated from asian countries, were treated between 1970 and 1983. All had histories of episodic abdominal pain, most with jaundice, chills, and fever. Laboratory results were nonspecific but frequently included leukocytosis and hyperbilirubinemia. All patients were operated on with 15 having cholecystectomy, common duct exploration, and a bilioenteric anastomosis. E. coli was cultured from specimens obtained from the biliary tracts of all patients, and 13 patients had more than one organism. Four patients had a previous history of parasitic infection, and four different patients had parasites identified in the biliary tract intraoperatively. Early recognition and appropriate operation will decrease morbidity and mortality.

Statistical analysis of a group of 1,114 patients operated for biliary lithiasis shows that the gravity of the disease, the nature of the complications that accompany it, the need to approach the common bile ducts (CBD) and age, stand at the origin of postoperative complications. To reduce postoperative morbidity elective surgery should be performed in cases of biliary lithiasis with paucity of symptoms during periods free of an attack and before the patient ages.

This is a case report on a bronchobiliar fistula after frequent recurrences of cholangites following an occlusion of a hepaticojejunostoma. Sufficient drainage and correction of the stenosis as well as balancing of water and electrolyte metabolism were without any therapeutic success. The patient died in consequence of an acute liver dystrophy.

Severe coagulopathy in a male patient with septicemia, renal failure, and obstructive jaundice secondary to cholelithiasis precluded safe endoscopic sphincterotomy. A temporary nasobiliary drain, inserted at endoscopic retrograde cholangiopancreatography, decompressed the biliary tree, allowing eventual safe sphincterotomy and bile duct clearance after correction of coagulopathy and improvement in his clinical condition.

Cholecystostomy was performed on 22 patients with acute cholecystitis after partial (13) or complete (9) removal of gallbladder stones. One patient had complementary common-duct drainage. Early mortality occurred in two patients. Three patients with associated cholangitis but intraoperative reflux of cysticduct bile were all treated by cholecystostomy alone and survived. For the poor-risk patient with cholecystitis, cholecystostomy is effective. When there is associated cholangitis and documented cystic-duct patency, cholecystostomy is also sufficient. When accompanying cholangitis is associated with cystic-duct occlusion, choledochotomy and T tube drainage should be added.

The peripheral lymph of the leg and venous blood from donor volunteers were compared. The lymph was found to issue at a higher rate in the active period of the day (from 9 a. m. to 9 p. m.) than at night (from 9 p. m. to 9 a. m.) and is equal to 0.45 and 0.22 X 10(-3) litre/hour, respectively. Its cell composition was lower than that of the peripheral blood (lymph, 2.04 X 10(7) cell/litre; blood, 509 X 10(7) cell/litre) with erythrocytes and platelets not taken into account. Lymphocytes (over 90 per cent) and monocytes (9 per cent) prevailed; the cell number varied with the time of the day; at daytime it was 5-6 times greater than at night. The immunological parameters of the lymph were characterized by a lower content of B cells, greater proportion of 0 cells, and a close T-cell proportion, the active lymphocytes being prevalent. This T-cell proportion correlated with higher spontaneous and lower PHA-induced proliferative activities. The lymph immunoglobulin level was 10-27 per cent of the serum immunoglobulin level; a relationship was observed between the plasma and lymph levels in different age groups.