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PubMed2005

MR cholangiopancreatography versus endoscopic sonography in suspected common bile duct lithiasis: a prospective, comparative study.

OBJECTIVE: Our purpose was to compare the accuracy of MR cholangiopancreatography and endoscopic sonography for the diagnosis of common bile duct stones in patients with a mild to moderate clinical suspicion of common bile duct stones. SUBJECTS AND METHODS: Forty-seven patients were prospectively enrolled. Inclusion criteria included acute pancreatitis, subclinical jaundice, and clinical features of common bile duct stone migration. Radial endoscopic sonography and MR cholangiopancreatography with the single-shot fast spin-echo technique were performed a maximum of 48 hr apart. The gold-standard diagnosis was obtained with ERCP (n = 20) or intraoperative cholangiography (n = 14) if the results of endoscopic sonography or MR cholangiopancreatography were abnormal or if a cholecystectomy was performed, or by clinical and biochemical follow-up (n = 11) if the results of endoscopic sonography and MR cholangiopancreatography were normal. RESULTS: The final diagnosis was common bile duct stones in 16 patients, malignant obstructions in four, and another biliary disease in two (lithiasis migration aspect with papillary edema); 23 patients had no biliary disease. The sensitivity and specificity of MR cholangiopancreatography were, respectively, 90.5% and 87.5% for etiologic diagnosis and 87.5% and 96.6% for the detection of common bile duct stones. The corresponding values for endoscopic sonography were 86.4% and 91.3% for etiologic diagnosis and 93.8% and 96.6% for visualization of choledocholithiasis. Accuracy did not significantly differ between the techniques. CONCLUSION: In cases of mild to moderate suspicion of choledocholithiasis, the accuracies of endoscopic sonography and MR cholangiopancreatography are similar. Because MR cholangiopancreatography is noninvasive, it may be preferred for this indication.

Adult↗
PubMed2004

A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography.

OBJECTIVES: To compare the clinical and cost-effectiveness of magnetic resonance cholangiopancreatography (MRCP) with diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for the investigation of biliary obstruction. DATA SOURCES: Electronic bibliographic databases, the reference lists of relevant articles and various health services research-related resources. REVIEW METHODS: The data sources were searched and selected studies were assessed using quality criteria. In total, 28 prospective diagnostic studies were identified reporting several suspected conditions plus one of patient satisfaction. Analyses were then performed to establish sensitivities, specificities, likelihood ratios and confidence intervals. The relative cost-effectiveness of adopting MRCP scanning in the investigation of the biliary tree was undertaken using a probabilistic economic model. RESULTS: The median sensitivity for choledocholithiasis (13 studies) was 93% and the median specificity 94%. The median likelihood ratio for a positive value was 15.75 and for a negative value 0.08. Reported sensitivities for malignancy were somewhat lower, ranging from 81 to 86%, and specificities ranged from 92 to 100%. There was some evidence that MRCP is an accurate diagnostic test in comparison to ERCP, although the quality of studies was moderate. Claustrophobia prevented at least some patients from having MRCP in ten of the 28 studies. The other 18 studies did not mention claustrophobia. The probability of avoiding unnecessary diagnostic ERCP is estimated at 30%. These patients could avoid the unnecessary risk of complications and death associated with diagnostic ERCP, and substantial cost saving would be gained. The overall expected cost saving associated with MRCP is GBP149; the overall expected gain in quality-adjusted life-year is estimated at 0.011. CONCLUSIONS: There is some evidence that MRCP is an accurate investigation compared with diagnostic ERCP, although the values for malignancy compared with choledocholithiasis were somewhat lower. The quality of studies was moderate. The limited evidence on patient satisfaction showed that patients preferred MRCP to diagnostic ERCP. The estimated clinical and economic impacts of diagnostic MRCP versus diagnostic ERCP are very favourable. The baseline estimate is that MRCP may both reduce cost and result in improved quality of life outcomes compared with diagnostic ERCP. Further research is suggested to compare MRCP and diagnostic ERCP with final diagnosis and also with the full range of target conditions; to examine patient satisfaction and ways of reducing problems with claustrophobia; to look at protocols to help identify who could most benefit from MRCP or ERCP; to assess the relative need and urgency of patient access to magnetic resonance imaging services, and also to determine how demand would affect availability and potential cost savings.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMedDate not supplied

Magnetic resonance cholangiopancreatography in patients with upper abdominal pain: a prospective study.

BACKGROUND/AIMS: To determine the role of magnetic resonance cholangiopancreatogram with conventional abdominal magnetic resonance examination in patients presenting clinically with upper abdominal pain and abnormal liver function tests and to compare the findings with endoscopic retrograde cholangiopancreatogram results. METHODOLOGY: Magnetic resonance cholangiopancreatogram and endoscopic retrograde cholangiopancreatogram were done in 77 patients. Conventional magnetic resonance examination of the liver and upper abdomen was done first followed by magnetic resonance cholangiopancreatogram using a half fourrier single shot turbo spin echo sequence. Conventional endoscopic retrograde cholangiopancreatogram was done by direct intraductal injection of radiographic contrast material through a duodenoscope under fluoroscopy control. RESULTS: Endoscopic retrograde cholangiopancreatogram failed in 7 patients (9%) and Magnetic resonance cholangiopancreatogram images were inadequate in 3 patients (4%). The findings of adequate magnetic resonance exams in 74 patients were: choledocholithiasis in 24 patients (32%), bile duct stricture in 19 patients (26%), normal biliary ducts in 29 patients (39%) and dilated biliary ducts with no definite cause in 2 patients (3%). The findings of successful endoscopic retrograde cholangiopancreatograms in 67 patients after exclusion of inadequate magnetic resonance cholangiopancreatograms were: choledocholithiasis in 25 patients (37%), bile duct stricture in 18 patients (27%), normal biliary ducts in 21 patients (31%) and dilated biliary ducts with no evident cause in 2 patients (3%) and hemobilia in 1 patient (2%). CONCLUSIONS: Magnetic resonance cholangiopancreatogram is a non-invasive technique, its accuracy is increased if it is combined with conventional abdominal magnetic resonance exam and it can replace the endoscopic retrograde cholangiopancreatogram.

Abdominal Pain↗
PubMedDate not supplied

[Laparoscopic choledochoscopy].

AIM: Of this study was to evaluate the treatment of common bile duct stones (CBDS) by laparoscopic choledochoscopy. MATERIAL AND METHOD: Between 1997-2002, 9 patients (with age between 42-75 years) were treated laparoscopic for CBDS: 8 cases with choledocholithiasis; 1 case with pancreatic neoplasm. Laparoscopic choledochoscopy was performed in 7 cases (84.4%). We used the choledochoscope Pentax of 5 mm diameter and with work canal. RESULTS: We performed the CBD exploration with: transcystic approach-1 case; choledochotomy-6 cases. The CBD diameter was between 1.2-1.5 cm. The bile duct stones diameter were between 0.5-1.5 cm. We performed with successfully the laparoscopic choledochoscopy exploration and extraction of CBD stones to all patients. External biliary drainage (transcystic duct and with Kehr-tube) were done systematically. The major complication (choleperitoneum) occurred in 2 cases (28.5%). The occurrence of residual ductal stones was 0. CONCLUSION: The laparoscopic treatment of choledocholithiasis is feasible, safe and efficient.

Adult↗
PubMedDate not supplied

[Characteristics of the endoscopic retrograde cholangiopancreatography in a national referral center].

PURPOSE: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a method being used for approximately 30 years, in the diagnosis and treatment of a number of hepatobiliary and pancreatic disorders. This study has been undertaken to analyze ERCP characteristics in a national referential center. MATERIALS AND METHODS: This is a retrospective descriptive study of a transverse section of 1702 patients subjected to ERCP in the Digestive Endoscopy Center of Gastroenterology Service of the Arzobispo Loayza Hospital between 2000 and 2003. RESULTS: A total of 239 ERCPs were carried out in 2000; 553 in 2001; 375 in 2002 and 655 in 2003. Seventy five percent (75%) of the patients were female. Prior to ERCP, 70% echographically presented biliary tract dilation; 44% as the only finding and 26% presented biliary tract dilation associated with other findings, giving a total of 70%. One percent (1%) was emergency ERCP. Forty two point six percent (42.6%) of the ERCPs performed were exclusively for diagnostic purposes, while 54.6% ended up being therapeutic. Once the procedure was completed, the most frequent definite diagnosis was choledocholithiasis (903/1702; 53.06%). Ninety two percent (92%) of the CPREs underwent first level difficulty; 98% passed without complications. In 55% of the cases, sphincterotomy was performed. In 54% of the cases a complete technical success was encountered and clinical success in 84% of the cases. CONCLUSIONS: The referral center of the study was characterized by an oscillating frequency of ERCPs which were frequently and, in a majority, conditioned by choledocholithiasis. Predominantly, the processes were at level one difficulty and in a majority a complete technical success was attained.

Adolescent↗
PubMedDate not supplied

Laparoscopic cholecystectomy and management of biliary tract stones in a freestanding ambulatory surgery center.

OBJECTIVE: We conducted a retrospective 4-year study of patients undergoing laparoscopic cholecystectomy at a freestanding ambulatory surgery center. Data on rates of hospital admission, conversion to open surgery, bile duct injury, postoperative bile leakage, and incidence of choledocholithiasis were analyzed. The success rate for dynamic fluoroscopic intraoperative cholangiography was computed, and outpatient laparoscopic common bile duct exploration and anesthetic management were reviewed. METHODS: Patient charts from the ambulatory surgery center, office, and hospital were reviewed over a 4-year period commencing in October 1999. All cases were performed by 1 of 3 surgeons who are experienced with outpatient laparoscopic cholecystectomy and practice routine dynamic fluoroscopic intraoperative cholangiography. RESULTS: A total of 338 laparoscopic cholecystectomies were performed. Dynamic fluoroscopic intraoperative cholangiography was successfully performed in 89% (n = 302). No instances of bile duct injury or conversions to open surgery were reported. A 0.89% (n = 3) incidence of postoperative bile leak occurred. Six patients were admitted for inpatient care for a rate of 1.78%. Choledocholithiasis occurred in 2.0% and was managed successfully in the ambulatory setting. CONCLUSION: Laparoscopic cholecystectomy can be adapted to the freestanding ambulatory surgery environment with very high standards of care and very low complication rates.

Adult↗
PubMedDate not supplied

Why does laparoscopic common bile duct exploration fail?

Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis carries an overall ductal clearance rate of between 85% and 95%. We present our single institute experience with LCBDE. Between July 1999 and July 2003, 60 patients (42 females, 18 males; median age, 59.5 years) with proven choledocholithiasis underwent LCBDE for common bile duct (CBD) clearance. The method failed to clear the CBD in six patients, resulting in a 90% overall success rate. Conversion to a conventional open approach (n = 1), hand-assisted LCBDE (n = 1), T-tube placement followed by multiple postoperative endoscopic retrograde cholangiopancreatography (ERCP; n = 2), and endobiliary stent placement followed by single successful postoperative ERCP in each case (n = 2) were chosen as treatment options when the laparoscopic method failed to clear the CBD. LCBDE is a feasible and safe method of managing CBD stones. Impacted stones at the lower end of the CBD or in the ampulla of Vater represent the most likely factors leading to failure of LCBDE. Laparoscopic endobiliary stent placement followed by postoperative ERCP represents the most attractive alternative in these difficult cases of impacted stones.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMedDate not supplied

["Rendez-vous" procedure. Mini-invasive treatment of biliary stones].

Mini invasive approach, laparoscopic and endoscopic, represents these days a therapeutically standard in treatment of concomitant biliary stones: gallbladder and extrahepatic bile ducts. Had been suggested different procedures known as "rendez-vous" procedures. When choledocholithiasis is diagnosed or supposed, using biochemical and echographic criteria, we decided to make an ERCP just before laparoscopic cholecystectomy under the same anesthesia. Using ERCP we could confirm the choledocholithiasis. The endoscopic sphincterotomy was followed by extraction of the stones using the Dormia basket catheter. The laparoscopic cholecystectomy that followed was technically made in the same way that any laparoscopic procedure is made, according to the gallbladder lesion, the ERCP making no influence to the surgical act.

Adult↗
PubMed1998

Laparoscopic common bile duct exploration: practical application.

OBJECTIVE: To evaluate the effectiveness of laparoscopic common bile duct exploration in unselected patients. DESIGN: Consecutive sample. SETTING: Tertiary care general hospital. PATIENTS: Three hundred and two patients with symptomatic cholelithiasis presenting to a single surgeon during a 5-year period. INTERVENTIONS: Laparoscopic cholecystectomy, cholangiography, and common bile duct exploration. MAIN OUTCOME MEASURES: Successful laparoscopic cholecystectomy and common bile duct exploration. RESULTS: Three hundred and two consecutive patients underwent cholecystectomy for symptomatic cholelithiasis; 280 of the procedures were successfully completed laparoscopically. Cholangiography was attempted in 269 patients, was successful in 239, and revealed evidence of choledocholithiasis in 25. Preoperative ultrasonography and liver function tests predicted the presence of common bile duct stones in 24% and 32% of patients, respectively. Seven of the patients with choledocholithiasis presented with biliary colic, 7 with biliary colic and jaundice, 8 with acute cholecystitis (3 with gallbladder perforation), 1 with acute cholecystitis and jaundice, and 2 with gallstone pancreatitis. Four of 5 patients underwent successful transcystic exploration with a biliary Fogarty catheter, 12 of 16 patients underwent successful transcystic choledochoscopy and stone basket extraction, and all 4 attempts at choledochotomy and choledochoscopic stone basket extraction were successful, for a total success rate of 80% with laparoscopic common bile duct exploration. One of the failures was converted to an open procedure, and 4 of the failures had successful postoperative endoscopic retrograde cholangiopancreatography and extraction of stones. CONCLUSIONS: Laparoscopic cholecystectomy and common bile duct exploration is a highly successful procedure for the management of common duct stones in an unselected group of patients. Choledochotomy with choledochoscopy is the preferred method of common bile duct exploration.

Cholangiography↗
PubMed1983

Acute cholecystitis and common-duct calculi.

The detection of common-duct stones is important in the treatment of patients with acute cholecystitis. The records of 256 patients with histopathologically confirmed acute cholecystitis were reviewed retrospectively. Associated choledocholithiasis was found in 32 (12.5%). Preoperative serum bilirubin and alkaline phosphatase levels were inconsistent predictors of common-duct calculi. Gray-scale ultrasonography is useful in the diagnosis of acute cholecystitis, but its role in the detection of common-duct calculi is uncertain. Dilated bile ducts were found in only three of eight icteric patients examined with ultrasonography. Intraoperative cholangiograms were obtained in 24 of 32 patients with choledocholithiasis, and common-duct stones were successfully demonstrated in 23 of these. Intraoperative cholangiography is a reliable method of detecting common-duct calculi and should be routinely used in the surgical treatment of acute cholecystitis.

Adolescent↗
PubMed1991

Cystic duct cholangiography during laparoscopic cholecystectomy.

At present, there is no consensus regarding the routine use of intraoperative cholangiography during cholecystectomy. We describe a reliable technique for performing cystic duct cholangiography during laparoscopic cholecystectomy. Using this technique, we were able to cannulate the cystic duct in 97% of patients, completely visualize the biliary tree and duodenum in 93% of patients, and identify unsuspected choledocholithiasis in 3% of patients. Treatment options for the management of choledocholithiasis demonstrated by cholangiograms during laparoscopic cholecystectomy include conversion to an open cholecystectomy and common duct exploration, or endoscopic sphincterotomy and common duct stone extraction following laparoscopic cholecystectomy.

Adult↗
PubMed1996

Risk of recurrent biliary tract disease after cholecystectomy in patients with duodenal diverticula.

OBJECTIVE: To determine if the presence of duodenal diverticula predisposes to the development of common bile duct stones. DESIGN: Cohort study; median follow-up, 10.0 years (25th and 75th percentiles, 5.2 and 16.1 years, respectively). SETTING: Tertiary care center. PATIENTS: One hundred fifty-seven patients with radiologically diagnosed duodenal diverticula who had undergone cholecystectomy from 1950 through 1987 and were asymptomatic at the initiation of follow-up. MAIN OUTCOME MEASURES: All patients were followed up for evidence of recurrent biliary tract disease to the following end points: (1) evidence of choledocholithiasis demonstrated by radiologic surgical, or biochemical means and (2) clinical or biochemical evidence of biliary pancreatitis. RESULTS: Of the 157 patients in the study cohort, 13 patients were categorized as having had recurrent biliary tract disease. Using the Kaplan-Meier survivorship method, the cumulative probabilities of recurrent biliary tract disease in patients with radiologically diagnosed duodenal diverticula were 3.6% at 5 years (95% confidence interval, 0.5-6.9), 5.5% at 10 years (95% confidence interval, 1.5-9.4), and 10.2% at 15 years (95% confidence interval, 3.8-16.7). Age, common bile duct exploration and choledochotomy, and the presence of common bile duct dilatation were not found to be significantly associated with recurrence based on a univariate analysis of risk factors by means of the log-rank statistic. CONCLUSIONS: For patients with radiologically diagnosed, second-portion duodenal diverticula, the risk of developing recurrent bile duct stones after cholecystectomy is lower than has been suggested in previous studies. In the absence of concurrent choledocholithiasis, sphincterotomy or biliary bypass at the time of cholecystectomy seems unwarranted.

Adult↗
PubMed1997

Biliary stent replacement cytology.

Using fluoroscopic guidance, polyethylene biliary stents are replaced endoscopically or percutaneously when bile duct stenosis recurs. To improve the sensitivity of conventional biliary cytology, we examined cells recovered from removed stents. Biliary stents removed endoscopically from each of 11 patients were rinsed with saline; next, the rinse was centrifuged and the sediment smeared and Papanicolaou stained. Three patients with choledocholithiasis had biliary stent replacement cytology (BSRC) to exclude a neoplastic etiology. Eight patients with clinicoradiologic evidence of hepatobiliary or pancreatic carcinoma had BSRCs performed for pathologic documentation of carcinoma. BSRC from six of eight patients with clinicoradiologically malignant biliary strictures contained malignant cells, predominantly in loose clusters, but also singly (sensitivity 75%, specificity 100%; positive predictive value 75%, negative predicative value 60%). Reparative epithelial atypia was also present in all cases. BSRC from two patients with clinicoradiological evidence of carcinoma of the biliary region and from three with choledocholithiasis contained only bile pigment, leukocytes, and benign epithelial cells. The sampling of cells which have accumulated on, or in biliary stents, improves the sensitivity of biliary cytology. This is most applicable when 1) a patient is inoperable, 2) tissue biopsy is neither feasible nor diagnostic, 3) prior brush, suction, percutaneous, or endoscopic needle aspiration cytology is inconclusive, and 4) permanent metal stent is needed.

Bile Ducts↗
PubMed2001

Frequent molecular identification of Campylobacter but not Helicobacter genus in bile and biliary epithelium in hepatolithiasis.

Bacterial infection of the biliary tree and bile stasis may be causally related to hepatolithiasis, but which bacterial species are involved and their roles in the pathogenesis of hepatolithiasis have not been ascertained. Recently, the Helicobacter genus was detected in human bile and biliary mucosal samples by molecular techniques, and its association with several biliary diseases has been suggested. The Campylobacter genus, which is closely related to the Helicobacter genus, has also recently been identified as causative of human gastrointestinal diseases. This study attempted to elucidate whether Helicobacter and/or Campylobacter bacteria are present in bile samples and biliary mucosal specimens from hepatolithiasis patients and whether they are involved in the pathogenesis of hepatolithiasis. The 16S rRNA gene of the Helicobacter and of the Campylobacter genus was examined by polymerase chain reaction in DNA samples extracted from bile and/or microdissected biliary epithelium from 69 patients with hepatolithiasis and control patients with choledocholithiasis, cholecystolithiasis, and normal gall bladders. The Helicobacter genus was detected in 1 of 8 (13%) biliary epithelial samples in hepatolithiasis and 1 of 10 (10%) bile samples in choledocholithiasis. The Campylobacter genus was detected in 3 of 14 (21%) bile samples and 5 of 8 (63%) epithelial samples in hepatolithiasis, and in 2 of 15 (13%) bile samples and 1 of 8 (13%) epithelial samples in cholecystolithiasis. The detection rate for Campylobacter in biliary epithelium of hepatolithiasis was significantly higher than in the bile or biliary epithelium of control groups (p<0.05). By a phylogenetic analysis based on nucleotide sequences, the Campylobacter genuses detected in hepatolithiasis were clustered with C. rectus or C. showae. The frequent detection of the Campylobacter 16S rRNA gene in bile, and especially in biliary epithelium of hepatolithiasis, suggests a pathogenetic relationship with Campylobacter infection.

Aged↗
PubMed1980

Exploration of the common bile duct--the relevance of the clinical picture and the importance of peroperative cholangiography.

A series of 500 cholecystectomies performed over a 7-year period was reviewed retrospectively. The reliability of preoperative clinical features such as jaundice and pancreatitis was assessed in determining the presence of choledocholithiasis, and was found to be of limited value. Investigations such as intravenous cholangiography and liver function tests were found also to be inaccurate in the detection of common duct stones as was the appearance of the duct at operation. The usefulness of the peroperative cholangiogram in the detection of common duct stones that would otherwise have been overlooked is emphasized. Common duct stones would have remained undetected in 25 per cent of patients with choledocholithiasis. Despite the use of routine peroperative cholangiography common duct stones were overlooked in 11.25 per cent of patients who underwent exploration.

Adult↗
PubMed1984

Transduodenal sphincteroplasty: an analysis of 118 consecutive cases.

The results of 118 consecutive common bile duct explorations via transduodenal sphincteroplasty are presented and analysed. The operations were performed for suspected choledocholithiasis by one surgeon over a 10-year period. Choledocholithiasis was proved in 22 per cent of the cholecystectomies carried out during this period and tended to present significantly earlier in females, 14.5 per cent presenting before 35 years of age. One hundred and four survivors were traced and 93.5 per cent had achieved a good result at a mean 5-year follow-up.

Adult↗
PubMed1984

Choledochoscopy: are stones missed? A controlled study.

Although the choledochoscope has been available for several years, its use had not achieved universal acceptance. Enthusiasts claim that the incidence of retained stones in the common bile duct would be reduced by using the instrument, but no controlled study by the same team has been reported. Patients undergoing biliary surgery by one surgical team in Southampton were operated upon in one of three hospitals. The choledochoscope was available for use at only one hospital, but the other two were otherwise fully equipped, and no selection of patients was made for any particular hospital. Over a period of 7 years, 707 patients underwent elective or emergency cholecystectomy. Routine choledochography was performed and stones were found or suspected in the bile ducts in 103 (14.6 per cent). The choledochoscope was used in 54 of the bile duct explorations and in 10 patients residual calculi following routine exploration were identified by the instrument. Postoperative T-tube choledochography was performed in 35 patients following choledochoscopy, 31 with choledocholithiasis at operation, and no unsuspected retained stones were demonstrated. In the 49 patients undergoing duct exploration by the same team without the choledochoscope, 32 were found to have choledocholithiasis. Thirty-six postoperative choledochograms were performed and six patients were found to have retained stones. There were no additional complications attributed to the use of the instrument. We conclude that the use of the choledochoscope should reduce the incidence of retained bile duct stones.

Cholecystectomy↗
PubMed1994

Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study.

In patients with symptomatic gallstones the management of choledocholithiasis has been controversial since the introduction of laparoscopic cholecystectomy. A prospective study was made of 300 consecutive patients with symptomatic gallstones managed by laparoscopic cholecystectomy and preoperative endoscopic retrograde cholangiography (ERC) over 2 years. Fourteen patients were excluded either because urgent surgery was required or because they were unfit for laparoscopic cholecystectomy. ERC was performed on 96 patients (34 per cent) who were at risk of choledocholithiasis. The presence of bile duct calculi was confirmed in 59 patients (21 per cent of the total, 61 per cent of those undergoing ERC); stones were removed endoscopically in 53 cases (90 per cent of attempts). The remaining six patients underwent open cholecystectomy and bile duct exploration. Laparoscopic cholecystectomy was attempted in 280 patients (98 per cent); it was necessary to convert to open operation in only three (1 per cent). There were no deaths, no retained stones and no bile duct injuries, and only three patients (1 per cent) developed a significant postoperative complication. Symptomatic gallstones can be managed by preoperative ERC and laparoscopic cholecystectomy with minimal morbidity and mortality.

Adolescent↗