肝门部胆管癌（HC）是一种少见的疾病，通常在60岁左右发病，预后较差；在美国，每年约有3 000例患者被诊断为该病，但仅有不到一半的人可以行手术治疗；有多种因素与HC的发病有关，最常见的有原发性硬化性胆管炎（PSC），胆石症以及寄生虫肝病。患者通常表现为腹痛、瘙痒、体质量减轻和黄疸。CT、MRI及超声可以用来发现胆道病损；逆行性胰胆管造影术（ERCP）及经皮肝胆管造影术（PTC）在评估肿块位置、长度的同时还可以行治疗性的胆汁引流。MRCP在辨别肿瘤延伸范围时同PTC及ERCP有相同的准确性，并且并发症较前两者少。HC的治疗方式主要为手术切除、放射治疗、化疗及光动力学治疗。残余肝脏胆汁引流有助于降低胆红素水平，进而促进残肝的生长；标准的治疗包括切缘为阴性切除（R0），范围为肝外胆管切除、肝切除及周围的淋巴结清扫术；局部的切除术是不适当的；淋巴结侵犯的程度、肿瘤的级别以及切缘的性质是重要的预后指标；如果无法行肿瘤切除，那么在经反复选择后的患者中实施肝移植术也是种可行的方式；尽管数据有限，化疗对于不可切除的患者来说仍有一定的作用；经手术切除的HC患者5年生存率约为10%~40%，然而即使为R0切除，复发率也高达50%~70%。由于这种疾病的复杂性，多种学科的综合治疗是较为理想的治疗方式。

Objective: To determine the risk factors for tumor recurrence and metastasis in patients with intrahepatic cholangiocarcinoma (IHCC) after radical resection. Methods: The clinicopathologic data of 125 IHCC patients undergoing radical resection between January 2002 and May 2008 were collected and reviewed. The postoperative tumor-free survival rate and unfavorable factors affecting postoperative tumor-free survival were analyzed and meanwhile, the relations of CA19-9 level with clinicopathologic actors were also analyzed. Results: The follow-up rate was 81% for the entire group of patients until May 2013 with a median follow-up of 30 months, and 109 patients developed recurrence or metastasis. The cumulative 1-, 3- and 5-year tumor-free survival rate for the entire group was 61.6%, 27.2% and 12.8%, respectively. Multivariate analysis showed that lymph node metastasis (RR=3.990, 95% CI=2.383-6.679, P<0.001), tumor size larger than 5 cm (RR=1.78, 95% CI=1.190-2.663, P=0.005), CA19-9 level over 200 U/mL (RR=1.734, 95% CI=1.138-2.642, P=0.01) and multiple lesions (RR=1.77, 95% CI=1.114-2.812, P=0.016) were independent risk factors for tumor recurrence and metastasis after radical resection. The CA19-9 level was significantly related to the lymph node metastasis rate (OR=3.208, 95% CI=1.276-8.067, P=0.013), and CA19-9 level yielded an area under the curve (AUC) of 0.696 for prediction of lymph node metastasis, with a sensitivity of 75% and specificity of 63%. Conclusion: Lymph node metastasis, tumor size larger than 5 cm, CA19-9 level over 200 U/mL, and multiple lesions are independent unfavorable factors for recurrence and metastasis in IHCC patients after radical resection, and high preoperative CA19-9 level is closely related to lymph node metastasis.

Objective: To compare the clinical effects of three different procedures for palliative biliary drainage in malignant obstructive jaundice. Methods: The clinical data of 37 patients with malignant obstructive jaundice requiring palliative biliary drainage admitted from January 2007 to January 2012 were retrospectively analyzed. Of the patients, 14 cases underwent Roux-en-Y hepaticojejunostomy (conventional internal drainage group), 12 cases underwent modified loop-type biliary-enteric anastomosis (modified internal drainage group) and 11 cases underwent extracorporeal bile shunt (external drainage group). The jaundice reduction effects, intra- and postoperative parameters and survival status among the 3 groups were compared. Results: The postoperative total bilirubin level was significantly decreased in all the 3 groups compared with their preoperative levels, and the jaundice reduction effects of the 3 procedures were similar (P>0.05). The operative time, intraoperative blood loss, time to gastrointestinal function recovery and length of postoperative hospital stay in both modified internal drainage group and external drainage group were significantly reduced compared with conventional internal drainage group, and in external drainage group, the hospitalization cost was significantly lower than that in both conventional internal drainage group and modified internal drainage group and furthermore, the operative time and intraoperative blood loss were even less than those in modified internal drainage group (all P<0.05). Reflux cholangitis occurred in 2 cases (14.2%) in conventional internal drainage group in control group, but in none of the cases in either modified internal drainage group or external drainage group. There was no statistical difference in median postoperative survival among the 3 groups (P>0.05). Conclusion: Modified loop-type biliary-enteric anastomosis has demonstrable efficacy in treatment of malignant obstructive jaundice with quick recovery of organ functions, and can be considered as the first option for palliative biliary drainage. The extracorporeal bile shunt is a simple, minimally invasive procedure with less cost, so it is worthy to be applied in primary-level hospitals.

Objective: To investigate the clinical efficacy of laparoscopic anatomic left hemihepatectomy plus choledochoscopic lithotomy in treatment of left intrahepatic bile duct stones with extrahepatic bile duct stones. Methods: The clinical data of 12 patients with concomitant left intra- and extrahepatic bile duct stones admitted from March 2010 to September 2013 were retrospectively analyzed. All patients were definitely diagnosed having extensive stones in the left hepatic lobe and concomitant common bile duct stones, and all patients underwent laparoscopic anatomic left hemihepatectomy combined with choledochoscopic choledocholithotomy. Results: All operations were successfully completed without any open conversion. The operative time was (182.6±36.3) min, intraoperative blood loss was (213.5±65.5) mL, time to postoperative flatus was (38.5±8.2) h, and length of postoperative hospital stay was (10.3±3.1) d. Bleeding from the cut liver surface and bile leakage occurred in one case each after operation, which were all resolved by conservative treatment. Over a follow-up of 3 months to 3 years with an average of 23 months, no residual stones or new stone formation were found. Conclusion: Laparoscopic anatomic left hemihepatectomy plus choledochoscopic lithotomy is an effective and safe procedure for patients with extensive stones in the left hepatic lobe and concomitant common bile duct stones.

Objective: To evaluate the clinical efficacy of modified ultrasound-guided percutaneous transhepatic catheterization plus cholangioscopic lithotomy in treatment of hepatolithiasis complicated with acute obstructive cholangitis. Methods: The clinical data of 10 patients with hepatolithiasis and acute obstructive cholangitis undergoing ultrasound-directed percutaneous transhepatic catheterization and cholangioscopic lithotomy from June 2013 to June 2013 were retrospectively analyzed. Results: In the 10 patients, ultrasound-guided puncture and catheterization was successfully performed; the pain was relieved 2-3 h after tube placement, while temperature returned to normal level and symptoms of pain and chills disappeared 24-48 h after tube placement. Tube retention time ranged from 40 d to 2 months with an average of 50 d. The 10 patients successfully underwent cholangioscopic stone removal and dilation of bile duct stricture via sinus tract after 6- to 8-week tube placement, and the stone-free rate was 100%. Dark red-colored bloody bile was continuously drained from the drainage tube in one patient 10 min after the puncture and catheterization, which was controlled by intraluminal injection of reptilase and catheter occlusion. No serious complications such as bile leakage or surrounding organ injury occurred in any of the 10 patients. Conclusion: Modified ultrasound-guided percutaneous transhepatic catheterization plus cholangioscopic lithotomy is reliable and effective method for hepatolithiasis with acute obstructive cholangitis, and is recommended to be used.

Objective: To investigate the rational selection of surgical approaches for hepatolithiasis with different classifications. Methods: The clinical data of 667 hepatolithiasis patients undergoing surgical treatment from January 2005 to December 2012 were retrospectively analyzed. Patients underwent a single procedure or combined procedures of bile duct exploration (BDE), hepatectomy (HT), and hepaticojejunstomy (HJS). After classification by the classification method, the stone clearance rate, incidence of postoperative complications and excellent follow-up rate were compared among different surgical approaches for the same type of hepatolithiasis. Results: In the 129 type I patients, the stone clearance rate and excellent follow-up rate after HT and BDE+HT were better than those after other procedures (all P<0.05), while no difference was found in incidence of postoperative complication among the procedures (P>0.05). In the 72 type IIa patients, stone clearance rate and excellent follow-up rate after BDE+HT were better than those after other procedures, while BDE+HJS showed the lowest incidence of postoperative complications (all P<0.05). In the 98 type IIb patients, the stone clearance rate and excellent follow-up rate were the highest after BDE+HT, while HT had the highest incidence of postoperative complications (all P<0.05). In the 25 type IIc patients, no difference in any of the parameters was noted among the procedures (all P>0.05). In the 251 type Ea patients, both stone clearance rate and excellent follow-up rate after BDE+HT were better than those after other procedures, while the incidence of postoperative complications after BDE was lower than that after other procedures (all P<0.05). In the 55 type Eb patients and the 37 type Ec patients, the stone clearance rate and excellent follow-up rate after BDE+HT+HJS were better than those after other procedures (all P<0.05), while no difference in postoperative complications was observed among the procedures (all P>0.05). Conclusion: Based on the rational selection of surgical approaches according to the classification of hepatolithiasis, and with appropriate adjuvant treatments, the tailored and individualized therapy is helpful to improve stone clearance rate and reduce postoperative complications.

Objective: To analyze the risk factors for surgical site infection after surgical treatment of hepatolithiasis, and provide effective preventive measures to reduce this problem. Methods: The clinical data of 117 hepatolithiasis patients undergoing surgical treatment from July 2005 to December 2012 were retrospectively analyzed. The patients were firstly divided, according to whether they received the special perioperative management for prevention of postoperative surgical site infection, into special treatment group and conventional treatment group, and the incidence of postoperative surgical site infection along with other clinical parameters were compared between the two groups; next, the patients were divided, according to whether they had surgical site infection, into infection group and non-infection group, and the risk factors for postoperative surgical site infection were analyzed. Results: Compared with conventional treatment group, the incidence of postoperative surgical site infection was significantly decreased (14.6% vs. 36.8%), time to drainage tube removal and length of time of antibiotic administration and postoperative stay were significantly shortened, and hospitalization cost was significantly reduced in special treatment group (all P<0.05). The univariate analysis showed that postoperative surgical site infection was associated with age, concomitant diabetes, preoperative cholangitis, previous history of biliary surgery, positive bile culture, intraoperative preventive measures, operative time and drainage tube retention time (all P<0.05); further multivariate analysis identified that concomitant diabetes, previous history of biliary surgery and long drainage tube retention time were risk factors, while implementation of intraoperative preventative measures was protective factor for postoperative surgical site infection. Conclusion: Concomitant diabetes, previous history of biliary surgery and long drainage tube retention time are independent risk factors for postoperative surgical site infection, while implementation of intraoperative preventive measures can reduce incidence of surgical site infection and is beneficial to fast recovery of the patients.

Objective: To evaluate the efficacy of gallbladder-preserving treatment via B-ultrasound-guided gallbladder puncture and dual-channel tube placement plus choledochoscopic lithotomy in treatment of acute calculous cholecystitis in high-risk elderly patients. Methods: The clinical data of 35 patients over 80 years of age with acute calculous cholecystitis admitted from January 2012 to December 2013 were retrospectively analyzed. Results: All the 35 patients underwent B-ultrasound-guided gallbladder puncture and dual-channel tube placement for lavage and decompression of the gallbladder and continued drainage, followed by choledochoscopic lithotomy via sinus tract with gallbladder preservation 6 to 8 weeks later. Ultrasound-guided gallbladder puncture and tube placement were successfully performed in all patients in one session, and bleeding occurred in one case after gallbladder puncture, which was controlled by hemostasis treatment. One case was converted to cholecystectomy due to incomplete sinus tract formation of the tube, and gallbladder-preserving cholecystolithotomy was successfully conducted in all the remaining 34 cases (34/35). Follow-up ranged for 4 to 24 months and stone recurrence was observed in one case (1/34). Conclusion: Dual-channel tube placement plus choledochoscopic gallbladder-preserving cholecystolithotomy for high-risk elderly patients with acute calculous cholecystitis is a simple treatment method with reliable efficacy, so its use is recommended.

Objective: To reevaluate the efficacy of laparoscopic common bile duct exploration and conventional open surgery in treatment of common bile duct stones. Methods: The clinical data of 92 patients with common bile duct stones undergoing surgical treatment between January 2012 and January 2014 were collected. Of the patients, 34 cases underwent laparoscopic common bile duct exploration (laparoscopic group), and the other 58 cases received conventional open surgery (open surgery group). The clinical parameters between the two groups of patients were compared after adjustment of confounding variables by propensity score matching (PSM). Results: Thirty pairs of patients were successfully matched by PSM method, and the two matched groups had similar baseline characteristics. There was no statistical difference in operative time between the two groups (P=0.190); the intraoperative blood loss, time to gastrointestinal function recovery and length of hospital stay in laparoscopic group were significantly reduced compared with open surgery group (all P<0.05); the incidence of postoperative complications of the two groups showed no statistical difference (P>0.05). Conclusion: Laparoscopic common bile duct exploration comparing with open surgery for common bile duct stones has the advantages of less intraoperative blood loss, quick postoperative recovery and short length of hospital stay, which is in agreement with previous studies.

Objective: To explore the therapeutic efficacy of percutaneous transhepatic one-stage lithotomy with a rigid choledochoscope in treatment of intrahepatic stones. Methods: Sixty-five patients with hepatolithiasis underwent direct puncture of hepatic duct under B-ultrasound guidance to establish a percutaneous tract, and then lithotomy with a rigid choledochoscope for extraction of the intrahepatic stones was performed after the tract diameter was expanded to 16 to 18 F. Results: Sixty patients were rendered stone free in one session of tract dilation; the procedure was abandoned in 2 cases because the angle between the right hepatic duct and the common bile duct was less than 90°; three cases underwent interventional embolization for post-procedure hemobilia; biliary stricture was seen in 39 cases, which was treated simultaneously according to the patients’ conditions. All patients were followed-up for 26 months, and recurrence rate of intrahepatic stones was 7.7% (5/65). Conclusion: Percutaneous transhepatic one-stage lithotomy with a rigid choledochoscope in treatment of hepatolithiasis is safe and effective, and it may reduce the stone recurrence because of synchronous stone removal and treatment of biliary stricture, so it is a preferable procedure that can avoid the use of the traditional method of operative treatment.

Objective: To investigate the relations of pre-miR-146a gene expression and its rs2910164 allelic polymorphism with cholangiocarcinoma. Methods: In 70 specimens of cholangiocarcinoma tissues from bile duct cancer patients (cholangiocarcinoma group) and 39 specimens of bile duct tissues from cases with non-neoplastic bile duct diseases (control group), the single nucleotide polymorphism of rs2910164 in pre-miR-146a sequence and pre-miR-146a expression was determined by direct DNA sequencing and the quantitative PCR method, respectively. The relations of different pre-miR-146a genotypes with its expression, and clinicopathological profiles and prognosis of cholangiocarcinoma were analyzed. Results: The genotype distribution in cholangiocarcinoma group was significantly different from that in control group, which in the former showed that the ratio of GG and GC genotypes was significantly higher than that of CC genotype, and the frequency of G allele was significantly higher than that of C allele (both P<0.05). In control group, the pre-miR-146a expression level in cases with GG and GC genotypes was lower than that in cases with CC genotype, but the difference did not reach a statistical significance (P>0.05), while the pre-miR-146a expression level in cholangiocarcinoma tissues was significantly lower than that in the bile duct tissues from control group (P<0.05). Multiple logistic regression analysis showed that GG and GC genotypes were possibly the risk factors for bile duct cancer (P=0.052), and the further factor-stratified analysis showed that GG and GC genotypes were associated with the clinical stage and lymph node metastasis of the patients (both P<0.05). Survival analysis for the cholangiocarcinoma patients demonstrated that the survival rate in cases with GG and GC genotypes was lower than that in cases with CC genotype, but the difference had no statistical significance (P=0.178). Conclusion: The increased frequency of G allele at rs2910164 in pre-miR-146a sequence may be responsible for pre-miR-146a gene under-expression and the risk factor for the occurrence and development of bile duct cancer.

Objective: To investigate the effect of metformin on cell proliferation, apoptosis and cell cycle in human cholangiocarcinoma cells and the mechanism. Methods: Human cholangiocarcinoma RBE cells were exposed to metformin, Compound C (AMPK inhibitor) or metformin plus Compound C respectively, using the untreated RBE cells as blank control. The cell proliferation was determined by MTT assay, apoptosis and cell cycle were measured by flow cytometry, and the expressions of proteins associated with AMPK/mTOR signaling pathway were detected by Western blot analysis, respectively. Results: In RBE cells treated with metformin compared with blank control, the survival rate was decreased, apoptosis rate was increased, the ratio of G0/G1 cells was increased while ratio of S cells was decreased, and the phosphorylated AMPK (p-AMPK) level was increased while the phosphorylated mTOR (p-mTOR) was decreased, and all differences had statistical significance (all P<0.05). The above effects exerted by metformin were all abolished by the combination treatment of Compound C, and the differences in all tested indexes had no statistical significance compared with blank control group (all P>0.05). All the indexes in RBE cells treated with Compound C alone had no statistical significance compared with blank control group (all P<0.05). Conclusion: Metformin can inhibit cell growth and promote apoptosis and cell cycle arrest in human cholangiocarcinoma RBE cells, and the mechanism may be associated with its activating AMPK and thereby suppressing mTOR downstream effector molecules.

Objective: To investigate the protective effect of sinomenine against renal damage caused by obstructive jaundice (OJ) in rats and the mechanism. Methods: Twenty-four rats were equally randomized into sham operation group, model group and sinomenine treatment group, and rats in the latter two groups underwent ligation and division of the common bile duct to create OJ model. From the first day after operation, rats in sinomenine treatment group were given sinomenine (80 mg/kg) by daily gavage, while those rats in sham operation group and model group received normal saline of the same volume administered in the same manner instead. On the 8th day after operation, all rats in each group were sacrificed to obtain the blood samples for measurement of the serum urea nitrogen (SUN) and serum creatinine (Scr) levels, and to harvest the renal tissues for pathological examination, and determination of renal malondialdehyde (MDA) and myeloperoxidase (MPO) concentration, and total antioxidant capacity (T-AOC) as well as the protein and mRNA expression of transforming growth factor-β1 (TGF-β1). Results: Except for the sham operation group, all rats in the other two groups exhibited the OJ manifestations and evident pathological changes of renal injury which in sinomenine treatment group were milder than those in model group. Compared with sham operation group, in the other two groups, the SUN and Scr levels were significantly increased, the renal MDA and MPO levels and TGF-β1 protein and mRNA expression levels were significantly increased, while the T-AOC was significantly decreased (all P<0.05), whereas the changing amplitudes in all above parameters in sinomenine treatment group were significantly less than those in model group (all P<0.05). Conclusion: Sinomenine has protective effect against renal injury in OJ rats, and the mechanism may be associated with its antioxidation effects and inhibition of TGF-β1 expression.

Objective: To investigate the PROX-1 and Ki-67 expressions in cholangiocarcinoma tissues and their significance. Methods: The PROX-1 and Ki-67 expressions in cancer tissues form 46 patients with hilar cholangiocarcinoma (29 cases with lymph node metastases, and 17 cases without lymph node metastasis) and bile duct tissues from 23 cases with benign biliary disease were determined by immunohistochemical staining. The relations of PROX-1 and Ki-67 expressions with lymph node metastasis and other clinicopathologic factors of cholangiocarcinoma were analyzed. Results: Positive expression rates of PROX-1 and Ki-67 were both increased in an ascending order in bile duct tissue of benign biliary disease, cholangiocarcinoma tissue without lymph node metastasis and cholangiocarcinoma tissue with lymph node metastases, and all differences had statistical significance (all P<0.05). The positive expression rates of PROX-1 and Ki-67 were both associated with the degree of differentiation of the tumor (both P<0.05), and were not related with sex and age of the patients (all P>0.05). There was a positive correlation between PROX-1 and Ki-67 expression in cholangiocarcinoma tissue (r=0.831, P<0.05). Conclusion: PROX-1 and Ki-67 over-expressions are closely related to the malignant biological behavior of cholangiocarcinoma, and furthermore, there is relevance between their expression levels.

Objective: To investigate the action of the chemotactic factor fractalkine and its receptor CX3CR1 in the pathogenesis of hepatopulmonary syndrome (HPS) in rats. Methods: Forty rats undergoing common bile duct ligation were equally randomized into model group and therapeutic group, and 5 rats subjected to isolation of the common bile duct only were served as sham operation group. Rats in therapeutic group received intraperitoneal injection with CX3CR1-neutralizing polyclonal antibody on postoperative day (POD) 15 to 28, while rats in model group and sham operation group were given normal saline of the same volume instead. On POD 29, rats were sacrificed, their liver function and arterial blood gas were determined, and the pathological changes, accumulation of pulmonary intravascular macrophages (PIM), microvessel density (MVD) and CX3CR1 expression in the lung tissues of rats were examined. Results: Compared with sham operation group, rats in model group showed significantly increased serum levels of alanine transaminase (ALT), alkaline phosphatase (ALP) and total bilirubin (TRIL), decreased arterial partial pressure of oxygen (PaO2), increased alveolar-arterial oxygen gradient (A-aDO2), clear pathological changes, and increased levels of PIM (CD86 expression), MVD (CD34 expression) and CX3CR1 expression in the lung tissues (all P<0.05); rats in therapeutic group showed liver function impairments as well, which however were milder than those in model group (all P<0.05), while there were no significant pathological changes in the lung tissues, and no obvious changes in arterial blood gas indexes and lung PIM, MVD and CX3CR1 expression (all P>0.05). Conclusion: Increased fractalkine/CX3CR1 expression and binding is an important signaling pathway for pulmonary macrophage aggregation and microvascular proliferation in HPS, and blockage of this pathway may inhibit the occurrence and development of HPS.

Objective: To analyze the clinical features of biliary ileus (BI) and current status of its diagnosis and treatment. Methods: The clinical data of 18 BI patients treated during January 1995 and December 2014 in Xiangya Hospital were reviewed, and the records of 284 BI patients from 22 Chinese articles published during the last 20 years were also collected. The clinical features of BI and current status of its diagnosis and treatment were extracted and analyzed. Results: Of the 302 patients, 86 cases (28.2%) were male and 216 cases (71.8%) were female; ages ranged from 36 to 89 with an average age of 63.4; preoperative diagnosis was 24.2% (73/302); 294 cases (97.4%) underwent enterotomy with stone extraction and 8 cases (2.6%) were subjected to intestinal resection and anastomosis; the stone lodged in the duodenum in 27 cases (8.9%), in the jejunum in 71 cases (23.5%), in the distal ileum in 201 (66.6%) and in the colon in 3 cases (1.0%); primary cholecystectomy was performed in 94 cases (31.1%) and choledocholithotomy was performed in 4 cases (1.3%); the incidence of postoperative complications was 27.2% (82/302) and mortality was 0.7% (2/302). Conclusion: BI frequently occurs in elderly women, its accurate preoperative diagnosis is unusual and incidence of postoperative complications is high.

Objective: To evaluate the application value of fast-track surgery (FTS) concept in minimally invasive gallbladder-preserving operation. Methods: Sixty patients with gallstone or polypoid lesions of the gallbladder undergoing minimally invasive gallbladder-preserving operation from January 2010 to December 2013 were randomly designated to observational group and control group, with 30 cases in each group. Patients in observational group received FTS perioperative care, while those in control group were given the traditional perioperative management. The length of postoperative hospital stay, duration of postoperative transfusion, hospitalization expenses, alteration in postoperative C-reactive protein (CRP) levels and incidence of postoperative complications as well as the time and degree of gallbladder function improvement were compared between the two groups of patients. Results: In observational group compared with control group, the length of postoperative hospital stay, duration of postoperative intravenous fluid infusion and hospitalization cost were reduced, the increasing degree of postoperative CRP level was lessened with a shortened duration, the time to gallbladder function recovery was decreased and the degree of gallbladder function recovery was increased. All differences had statistical significance (all P<0.05). There was no statistical difference in incidence of postoperative complications between the two groups (P>0.05). Conclusion: In minimally invasive gallbladder-preserving therapy, using FTS conception with enhanced preoperative management and reduced stress responses to medical procedures can help accelerate gallbladder function recovery, shorten the length of hospital stay, and thereby facilitate the recovery of patients.

Owing to the lack of specific symptoms, the diagnosis of gallbladder carcinoma is often delayed, resulting in very poor prognosis. Increasing the incidence of early diagnosis of gallbladder carcinoma is critical for improving the prognosis of this disease, therefore the research of its biomarkers has become very important. The authors address the research progress in this field with the emphasis on serological biomarkers and molecular biomarkers of gallbladder carcinoma.

Concomitant extra- and intrahepatic bile duct stones are common conditions in general surgery, and their treatment methods include not only the traditional surgery but a variety of minimally invasive methods such as endoscopic, laparoscopic and choledochoscopic technique. However, any use of a single treatment method has its limitations and also cannot achieve the highest efficacy. The authors, based on literature review and extraction of recent relevant documents, address the current status and progress in minimally invasive treatment of concomitant extra- and intrahepatic bile duct stones.