Mirizzi syndrome is a complication of long standing cholelithiasis. In this, obstruction of the extrahepatic bile duct by stone/s in the Hartman's pouch or cystic duct (Mirrizi type I) may erode in to the bile duct forming cholecystobiliary fistula (Mirrizi type II). Altered biliary tract anatomy and the associated pathology make cholecystectomy, open or laparoscopic, a formidable undertaking. Awareness of this entity and its preoperative diagnosis is of paramount importance to avoid injury to the bile duct at surgery. Improper surgical procedures may lead to long-term stricture formation. The present article reviews the available literature on various aspect of this syndrome including its pathogenesis, diagnosis and recommended management guidelines.

Fourteen cases of Mirizzi's syndrome are presented here. Clinical presentation was pain (14), jaundice (14), fever (10) and peritonitis (1). A clinical diagnosis of choledocholithiasis was considered in all the patients. Pre‐operative diagnosis of Mirizzi's syndrome was made in five patients on the basis of cholangiogram and the remaining cases were diagnosed at surgery. The stage (type) of Mirizzi's syndrome was based on the extent of erosion of the common bile duct. Four patients had type I, seven type II and three type III lesions. Associated choledocholithiasis was present in five and acute free perforation of the gall‐bladder in one. The operative procedures performed were partial cholecystectomy for type I, partial cholecystectomy, choledochoplasty and T‐tube choledochostomy for type II and bilioenteric anastomosis for type III lesions. Two patients had retained common bile duct stones. Mean follow up was 14 months (range 1–27 months). One patient with secondary biliary cirrhosis continues to have persistently elevated serum alkaline phosphatase levels without any demonstrable biliary obstruction. Diagnostic and operative strategies are discussed and a follow up protocol for such patients is suggested.

Background: Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report two cases of Dieulafoy's lesion of the duodenum and discuss the management of this extremely uncommon entity.

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A-patients in whom the injury was detected during cholecystectomy, group B-patients who presented within 2 weeks of cholecystectomy and group C-patients who presented after 2 weeks of cholecystectomy. Our team acted as rescue surgeons and performed 'on-table' repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/ or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intraabdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into three categories: grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A-six patients, group B-33 patients and group C-20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8 days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3 months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40 months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.Keywords Cholecystect...

Particle Induced X-ray Emission (PIXE) technique has been used to determine the trace elements present in fourteen representative human gallstone samples collected from eastern region (Orissa) and thirteen representative samples collected from southern region (Chennai) of India. PIXE irradiation of the samples has been carried out by using the 3 MV tandem type horizontal pelletron accelerator facility at Institute of Physics, Bhubaneswar with proton beam of energy 3 MeV. In the present investigation, twenty one trace elements like S , Cl , K , Ca , Ti , V , Cr , Mn , Fe , Ni , Cu , Zn , As , Se , Br , Rb , Sr , Y , Zr , Mo and Pb have been estimated in all the three types of gallstones viz. cholesterol stone, mixed stone and pigment stone. While sulphur in cholesterol stones in the eastern region was less than that of the southern region, sulphur was present as a minor element in the pigment stones of both the regions. Less concentration of copper in the gallstones from eastern region is another interesting observation. The lower values of copper in the patients of eastern region may be due to different types of food habits. The concentrations of all the elements in the southern region pigment stones have higher values than that of the eastern region. Moreover, the concentrations of Fe and Mo in cholesterol stone and pigment stone samples in southern region have also higher values than in eastern region. The current PIXE study is of its first kind in this eastern region of India.

Dyspepsia is a common complaint in patients presenting with gallstone disease. Since the stomach appears to be its site of origin, the present study was undertaken to assess gastric emptying in patients with gallstone disease and to find out its correlation with dyspeptic symptoms before and after cholecystectomy. Gastric emptying (t1/2) was prospectively assessed in 43 patients with symptomatic gallstones (29 with and 14 without dyspepsia). These data were compared with that of 20 healthy volunteers (control group). Delayed gastric emptying (> 112 min: mean + 2 s.d. of the control group) was observed in 18 patients (42%; P < 0.002), 10 of whom presented with dyspepsia and eight without (NS). Re‐evaluation in 18 of the 29 patients with dyspepsia, 3 months after cholecystectomy, revealed complete disappearance of symptoms in three, improvement in 11 and no change in four patients. After 6 months, two patients had reverted back to their pre‐operative dyspeptic status; resulting in three patients completely cured, nine partially cured and six without any change in their dyspeptic status at this time. Gastric emptying was delayed in nine of the 18 patients before cholecystectomy. After cholecystectomy, normal emptying was observed in all but one patient (P < 0.005). Dyspeptic symptoms, however, completely disappeared in one patient, improved in five and remained unchanged in three. In the remaining nine patients, gastric emptying was normal both before and after cholecystectomy. Gallstone disease is associated with delayed gastric emptying but this delay was not the cause of dyspepsia in these patients. Cholecystectomy normalizes gastric emptying, a finding that has not been reported previously. However, on the basis of gastric emptying alone, it is not possible to predict the outcome of cholecystectomy.

The case of a large amebic liver abscess with an atypical presentation is reported. High output bile drainage persisted after ultrasound guided percutaneous catheter drainage because of a preexisting communication of the abscess with the right hepatic ductal system. The abscess was managed successfully by surgical evacuation and internal drainage into a defunctioned jejunal loop.

A prospective study was undertaken to evaluate the changes in portal venous pressure in patients with benign biliary obstruction (BBO) but without overt clinical, endoscopic or radiological evidence of portal hypertension. Portal venous pressure was measured at laparotomy in 20 patients (10 each with either benign biliary stricture or choledocholithiasis) before and after biliary decompression. Pressure was found to be on the high side in seven patients (>25 cm of saline in three patients and > 30 cm of saline in four). The mean fall of pressure was 3.4 cm of saline after biliary decompression. No correlation could, however, be found between portal venous pressure and duration of biliary obstruction, serum bilirubin or bile duct pressure. Liver histology showed mild to moderate cholestatic changes but maintained portal architecture in all. Benign biliary obstruction may therefore, lead to elevation of portal pressure, even though the patient may not necessarily have any clinical, endoscopic or radiological manifestations of portal hypertension. The pathogenesis of this ‘latent’ portal hypertension is probably multifactorial. If biliary obstruction is left untreated the development of overt portal hypertension may become a possibility in the future.