All patients underwent base line and specific investigations especially ultrasound of abdomen as diagnostic modality and for assessment of com- plicated gallstonedisease. Inclusion criteria were all patients diagnosed as cases of complicated gallstonedisease on the basis of history, clinical examination and investigations. Complicated gall- stone disease included cases of acute cholecysti- tis with phlegm, chronic cholecystitis with muco- cele, empyema and perforation with perichole- cystic abscess. Exclusion criteria included unfit patients for general anesthesia, pregnancy, patients with carcinoma of gall bladder, patients with acute pancreatitis and patients with obstructive jaundice. Follow up of all these patients was done at 6 month and one year to assess any complication and inquiry about resumption to work. The data was analyzed on SPSS software.
Three components of metabolic syndrome were present in 27% of cases. All 5 components were present in 2% of cases. None of the components were associated in 31% of patients with gallstonedisease. Only one patient had bile duct injury during operation which was diagnosed in the first postoperative day. Severe adhesions were noted intaoperatively around the gall bladder and Calot’s triangle. Patient later developed cutaneous biliary fistula and went into septic shock. She was managed aggressively and bile duct injury managed conservatively. Later SLE (Systemic Lupus Erethematosus) was diagnosed and revised treatment started. Patient improved and was discharged after 2 months. Nine out of 100 (9%) developed mild or less severe post operative wound infection out of which 8% had metabolic syndrome. This is discussed later in this section. Other complications were 3 patients developed post operative pyrexia which was treated with paracetamol and one patient developed cutaneous biliary fistula which was mentioned earlier. Majority of the patients had multiple stones(65%). Solitary stone were present among 20% and stones were double among 15%. Most common type of stone in our study was mixed type comprising 53%. It is followed by cholesterol stones and pigment stones which constitute 36% and 11% respectively.
Totally, 273,385 adults aged ≥20 were hospitalized for all gallstone diseases and related complications during 1997–2005, but only 208,516 fulfilled the inclusion crite- ria of severe gallstonedisease. Among them, 170,781 were identified with incident hospital admissions. After exclud- ing patients with primary and metastatic cancer of the liver, pancreas, and bile duct (n = 5377); malignant neo- plasm of other sites (n = 7826); hematological malig- nancy (n = 441); human immunodeficient virus infection/acquired immunodeficiency syndrome (n = 9); and unavailable or incorrect gender or age information in the database (n = 800), 155,322 incident cases (71,187 [45.8%] men and 84,135 [54.2%] women) were included in our study. Concomitant diagnoses included diabetes in ~11% of cases, chronic liver disease in 3%, hyperlipi- demia in 1%, alcoholism in 0.2%, and hemolytic disease in 0.3%. The mean annual population of Taiwan aged 20 years or older during 1997–2005 was 15,863,966. Table 2 summarizes the average rates of hospital admissions for severe gallstonedisease, gallstone-related complications, and gallstone-related procedures for men and women in the overall population and each age group.
Cholesterol gallstonedisease is initiated in a liver which produces abnormal bile with excess cholesterol relative to bile salts and phospholipid. To define the responsible secretory mechanism(s), the rate of biliary lipid secretion was measured by a duodenal marker perfusion technique, while the bile salt pool was simultaneously estimated by isotope dilution. Two groups of control patients expected to have normal biliary lipid composition--14 subjects without hepatobiliary disease and 6 patients with pigment
Study subjects were recruited from the contingent of indi- viduals invited to undergo routine colonoscopy according to the recommendations of German Health Organisation and for cancer prevention. Individuals, who agreed the participation in the study, were personally interviewed and seen by the physicians regarding their health condi- tions. Subjects included in this study had a) normal serum lipid values and no history of taking lipid-lowering drugs or drugs interfering with bile acid uptake, b) no known medical conditions affecting lipid metabolism, c) normal liver function and no signs of haemolysis or other condi- tions associated with pigment stones, d) no intestinal sur- gery and e) no impaired nutritional status. None of the gallstone carriers or controls had symptomatic gallstonedisease, abnormal liver function, elevated serum lipids or inflammation in the ileum. Biopsies and blood samples were collected from a total of 168 individuals in the Robert Bosch Hospital in Stuttgart. Blood samples (3–5 mL) were used for cholesterol and phytosterol measurements as well as for genotyping investigations. Up to eight ileal biopsy specimens were taken from each participant (for this inves- tigation two separate samples, each about 8–10 mg, were used). 134 subjects were healthy controls and 34 indivi- duals had gallstones. The presence or absence of gallstones was confirmed by ultrasound. Serum triglycerides and cholesterol levels were analysed by standard clinical tests.
Gallstone ileus accounts for approximately 1% to 4% of all cases of mechanical bowel obstruction. However, in the population over the age of 65 it is the cause of 25% of non-strangulated small bowel obstructions. Diagnosis is often delayed and mortality is high, ranging at 15% to 18%, which may also reflect the age and comorbidity of affected patients . Gallstones usually enter the bowel through a biliary enteric fistula, which complicates 2% to 3% of cases of cholecystolithiasis with associated epi- sodes of cholecystitis . Due to the sedimentation of intestinal content, gallstones increase in diameter as they pass the bowel. The majority of obstructing gall- stones are located in the terminal ileum (50% to 75%), followed by the proximal ileum and jejunum (20% to 40%). Gallstones impacted in the duodenum account for less than 10% . A gastric outlet obstruction secondary to an impacted gallstone in the duodenum or pylorus is called Bouveret syndrome. It was first described in 1896 by the French internist Leon Bouveret, and up to 1999 only 175 cases had been described in the medical litera- ture . Our case is a rare description of Bouveret syn- drome developing four months after successful treatment of symptomatic gallstonedisease and after a four-month period with no symptoms.
Gastro-intestinal surgery has undergone a revolution in the recent years by the introduction of laparoscopic techniques. The concept of “keyhole surgery” created an immediate disparity between the potential of the new technique and training of surgeons to perform it. Now modern surgical methods are aimed at giving cure along with minimal invasive techniques with patient in mind, safety never being compromised. Cholelithiasis, which continues to be one of the most common digestive disorders encountered, was traditionally being dealt by conventional or open cholecystectomy. With the introduction of laparoscopic cholecystectomy, the surgical community witnessed a revolution in basic ideology and the importance of minimal access surgery.
OPERATIVE BILIARY ENDOSCOPY (CHOLEDOCHOSCOPY) At operation, a flexible fibreoptic endoscope can be passed down the cystic duct into the common bile duct enabling stone identification and removal under direct vision. The technique can be combined with an X ray image intensifier to ensure complete clearance of the biliary tree. After exploration of the bile duct, a tube can be left in the cystic duct remnant or in the common bile duct (a T tube) and drainage of the biliary tree established. After 7 to 10 days a track will be established. This track can be used for the passage of a choledochoscope to remove residual stone in awake patients. This technique is invaluable in the management of difficult stone disease and prevents the excessive prolongation of an operative exploration of the common bile duct.
A ten-year follow up in the GREPCO study revealed opposite findings. The study demonstrates a high incidence of gallstonedisease in women belonging to a rural free-living population in Italy and suggests body mass index and parity as possible true risk factors. Moreover, it confirms that a remarkable proportion of asymptomatic patients become symptomatic and eventually undergo cholecystectomy.  More recent follow-up studies also reveal that silent gallstones are not that innocent. Similarly a population-based Swedish study revealed that intervention is required in 10% of patients in 5 years. 
Gallstones represent a serious burden for Western health- care systems: 10–20% of Europeans and Americans carry gallbladder stones [1,2]. The prevalence of gallstone dis- ease is rising, possibly as a result of longer life expectancy and altered nutritional habits. Many gallstones are silent, but symptoms and complications ensue in around 25– 50% of cases, necessitating surgical removal of the gall- bladder, usually by laparoscopic cholecystectomy [2,3]. Each year, more than 170,000 cholecystectomies are per- formed in Germany . Cholelithiasis incurs annual medical expenses in excess of $6 billion in the US and is currently the second most expensive digestive disease, exceeded only by reflux disease . The clinical manage- ment of gallstonedisease is almost exclusively based on cholecystectomy and endoscopic or medical treatment of complications. Cholecystectomy, although an established procedure, still carries a small but existent complication rate, especially when performed in an acute setting. Mor- tality rates following cholecystectomy range from less than 0.1% in clinical studies to 0.7% (as documented for all cholecystectomies performed in Germany in 2004) . In the US, about 3,000 deaths (0.12% of all deaths) per year are attributed to complications of cholelithiasis and gallbladder disease .
Background: Gallstonedisease is a significant health problem world over (in both developing and developed nations). The incidence of gallstonedisease increases after age of 40years and it becomes 4-10 times more common in old age. As many as 16% and 29% of women above the age of 40-49 years and 50-59 years, respectively, had gall stones. Laparoscopic cholecystectomy introduced in 1985 has become the procedure of choice for surgical removal of the gallbladder. The aim is to compare laparoscopic cholecystectomy and open cholecystectomy in patients of cholelithiasis by measuring parameters such as use of post-operative analgesia, operative time, post-operative hospital stays, morbidity, mortality and patient satisfaction.
was increasingly gaining recognition in peadiatic practice due to significant documented increase in non-heamo- lytic cases over the last two decades. The observed gallstones prevalence, clinical presentation, pathological fea- tures of gallstones, and analysed metabolic causes of gallstones in children are different from those stones found in adults. Gallstones are most commonly an incidental finding in children. The prevalence of chliothiasis in symptomatic patients was found to be 26.95% higher than the prevalence of gallstones in children in other parts of world, and the mean age of presentation was 9.3 years ranging from 6 - 14 years. Male to female ratio was 3:2 and male predominance was found in all age groups contrary to female predominance in adults. Most common presenting symptom reported was right upper quadrant pain (89.4%) and second most common presentation was nausea and vomiting (60.5%), similar to presentation of symptomatic gall stones in adults. Among 38 patients, 4 (10.5%) patients had positive family history of gall stones in first degree relatives. 25 (65.7%) patients had no underlying risk factor for gall stones contrary to presumption that gall stones in children are mostly to some heamotological disorder or other predisposing factors. Chronic cholecystitis was found in 81% of patients with gallstones and composition of gallstones retrieved was different from those of adult gallstones with calcium carbonate gallstones relatively common in children but composition of black and brown stones were almost sim- ilar to adult stones. The above results demonstrated that gallstones and gallstone related complications in pea- diatic populations was different from the adult gallstonedisease and there was an increase in prevalence of gall- stones in children with no under lying risk factor for gallstones.
cholesterol gallstonedisease are sedentary life styl, obesity, aging, feminity, diet rich in saturated fats, simple sugars and other dietar y factors like consumption of rapeseed oil, cotton seed oil, butter, beans, tomatoes and tea . Although, it is generally a greed that gallstone composition mainly depends upon dietary habits of the patients, there is still littlie agreement about the risk of specific dietar y components for specific type of gallstone 27 . Gender
In a study done by Johanna L, Gediminas K (2007), the prevalence of subclinical hypothyroidism was 11.4% in gallstones and none of the patients was clinically h ypothyroid . The results of thyroid profile in our study were comparable to other studies. In our study the number of cases with low FT4 were 27 against none in controls. All controls had normal FT4 levels. P value of the observation is .014103 which is significant (p<. 05). This suggested that low FT4 is involved in the pathogenesis of gallstones. In our study, the number of case with low FT3 were 25 against no controls. All controls had normal FT3 hormone level. P value is 0.0194 which is significant. This indicated that low thyroid hormone level is involved in the pathogenesis of gallstonedisease .
Cholesterol crystallization is the initial step in the com- plex process of gallstone formation and its subsequent complications such as gallstone pancreatitis [1,4,18,19]. Micorcrystals refers to cholesterol monohydrate, calcium bilirubinate, or calcium carbonate [14,15,20]. In most reports, bile aspiration from the duodenum or from the bile duct yields microcrystals in 50% to 73% of patients with idiopathic pancreatitis . A variety of methods for obtaining bile for assessment of nucleation time and microcrystals have been described; nasoduodenal aspira- tion, nasobiliary aspiration, endoscopic extraction, percu- taneous gallbladder puncture and aspiration during operation [22-24]. Duodenal bile is not ideal for determi- nation of nucleation time, due to contamination by pan- creatic enzymes. Nasobiliary aspiration of bile may be superior, but collection of bile via a nasobiliary tube after cholecystokinin injection, may carry a risk of pancreatitis [21,22]. Endoscopic cannulation, visualization of the extra-hepatic biliary system and bile aspiration has its own risks of pancreatitis [23,24]. In our study, we chose trans-laparoscopic bile aspiration as our method for obtaining bile samples at the time of laparoscopic chole- cystectomy. Also, direct cannulation of the bile duct would avoid the sampling bias of aspirating stagnant bile in the gallbladder as in nasoduodenal or nasobiliary tech- niques. Ideally bile should have been obtained from healthy individuals, to serve as controls, but this was not possible. True idiopathic pancreatitis is due to microcrys- talisation of hepatic bile. This may be different from the established gallstone pancreatitis, where, pancreatitis is thought to result from passage of a gallstone through the common bile duct, causing a degree of ductal obstruc- tion. Gallstonedisease, gallstone pancreatitis and idio- pathic pancreatitis do not appear isolated clinical entities. Rather, they appear to be manifestations of an altering spectrum of “nucleation time” of lithogenic bile. Idio- pathic pancreatitis, which is associated with abnormal bile nucleation time, should be termed, “microcrystal pancreatitis”.
The incidence of biliary stones does not increase in ESRD patients. Patients with ESRD have been regarded as being for surgery because of platelet dysfunction, activated fibrinolysis and impaired healing. In our study, there was significant more complications, higher conversion rates and longer hospital stay in ESRD group. Fortunately, these complications were easily handled without any serious morbidity or mortality. However, certain co-mor- bidities like hepatitis C virus (HCV) infection may change this opinion. In this group of patients, there are no additional risk factors when compared to the general population. It is an important cause of chronic liver disease and predispose to gallbladder stone among ESRD patients. Estimates of the prevalence of HCV antibodies in patients on hemodialysis (HD) in developed countries range from 7% to 40% and are higher in the developing countries of the world . Hepatitis B, the other chronic viral infection of liver is seen in the ESRD patients. The prevalence of serum hepatitis B surface antigen (HBsAg) sero-positivity in HD patients is 0% - 10% in the developed countries, and 2% - 20% in the developing countries .
In general, based on the results of this study research and comparing them with other studies, it is concluded that there the presence of gallstone in patients with coronary artery stenosis compared to that in patients without coronary artery stenosis is not significantly different. It is finally, recommended that further studies with a larger sample size to be carried out to confirm the results of this study. Finally, as stated above, prevention is crucial in cardiovascular disease in order to reduce the burden of the disease. For prevention, the risk factors associated with it should be considered which gallbladder diseases are very important in this regard. In addition, taking preventive actions is very important.
Gallstone formation in the gallbladder, bile duct, and liver is a common digestive disease, occurring in 10 – 20% of the population in Western countries, and approximately 25% of these patients eventually require surgical removal due to severe symptoms [1, 2]. Traditionally, gallstones have been divided by gross inspection into 4 categories: choles- terol stones, black pigment (calcium bilirubinate) stones, brown color stones, and mixed stones that consist of both cholesterol and calcium bilirubinate [2 – 4]. However, this classification method is largely dependent upon the exter- nal shape and color of gallstones and does not accurately reflect the cases wherein the internal morphology of gall- stones is different from the external one.
It is a prospective observational study done at SCBMCH, Cuttack a tertiary care hospital. Any patient for primary laparoscopic cholecystectomy who got converted to open cholecystectomy is included in this study .The total no. of patient in this study is 50 patients. The exclusion criteria are patient primarily operated with open method, patient not fit for lap. Cholecystectomy, done as a part of other surgery, age< 18, any patient not consenting for participation. Institutional ethics committee clearance was taken. Patient’s informed consent was taken. A scoring system is formulated for prediction of conversion from laparoscopic to open cholecystectomy taking different criteria into consideration.
Cholecystectomy, gold standard treatment for gallstone- related diseases, is practiced in a high percentage of patients with this condition. Such procedure, considered by many harmless, was, in our study, associated with a significant risk of developing biliary gastritis after 6 months during the postoperative period. This occurrence was found in our series in 58% of patients who under- went cholecystectomy (Fig. 1). However, the presence of symptoms in post-operative timing does not reflect the histological findings in these same patients: while, in fact, a positive histological BRI was found in 58% of patients after cholecystectomy, clinical symptoms were found in 41.9% of them .In addition these symptoms could also be related to the persistence of H. pylori infection.