Objective　To explore a new way of treating refractory residual gallstones by endoscopy. Methods　Choledochfiberscope(CHF) combined with air pressure ballistic lithoclast(APBL) under ureterscopy were used on 28 cases of large or impacted residual gallstones. Results　All refractory stones were crushed and extracted completely in 1-3 times, including sufficient once in 16, twice in 10 and thrice in 2. No severe complications were occurred in this series. Conclusions　This procedure is a safe, effective, simplicity, less complication and no heat injury methods. It is proved to be a new way of treating refractory residual gallstones, especially for large or impacted lithiasis. It is worthy for clinical application widely in the future.

Objective　To study the value of intraoperative cholangiography(IOCG) in cholecystectomy for gallbladder stone. Methods　The IOCG data of 694 cases in the Affiliated Hospital, Yanan University Medical School were retrospectively analysed. Results　Among 694 cases with IOCG, 65 had positve findings. Bile duct stone occurred in 44 patients, residnal stone in cyst duct in 7, bile duct injury in 2, and Mirizzi syndrom in 3. Among the 44 cases with bile duct stone, the age of 4.3% cases was 22～50 years old, 10.3% older than 50 years. The incidence of bile duct stone occurring after 50 years old increased with age. The accurate rate of IOCG was 98% in this series. Conclusions　IOCG can not only find residual stone, but also find bile duct abnormality and bile duct injury in time, if correct imagic technique is applied.

Objective　To study the diagnosis and treatment of perforated congenital choledochal cyst(PTCC). Methods　The clinical data of 10 children with PTCC were retrospectively analysed.Results　6 males, 4 females, average age 4.5 years old. The cyst perforted time within 12 hours was in 4 cases, 12～72 hours in 3, and more than 72 hours in 3. Of these cases, 2 had infection and the others had no obvious discomfort before perforation. Of 7 cases undergoing cyst excision and biliary reconstruction, 5 cases were recovered without complications; 2 occurred anastomostic leakaged(1 case had infection before perforation and the other with perforcted time more than 72 hours). 3 cases subjected to external drainage at first, and cyst excision and biliary reconstruction were performed on three months later. Conclusions　If PTCC is treated earlier, cyst excision and biliary reconstruction can be performed as a primary operation.

Objective　To study the causes and management of the reoperation after cholangiointestiostomy(CIS). Methods　A retrospective analysis was made on the clinical data of 28 cases of reoperation after CIS from June 1995 to June 1999. Results　Among the 28 cases, 26 cases(92%) had CIS anastomotic stenosis. Of the 26 cases, 9 cases accompanied with left hepatobiliary duct stenosis, 3 cases with right hepatobiliary duct stenosis, 5 cases with left and right hepatobiliary ducts stenosis. 9 cases with biliary reflux comfirmed by barium meal radiography, all of the 9 cases were subjected to a choleduodenostomy. Of the 28 patients, 3 underwent reanastomose after excision the primary anstomosis, 8 operated with hilar bile duct reform and left lateral hepatolobectomy, 2 with left hepatic duct jejunostomy and hilar bile duct jejunostomy. 15 cases with intrahepatic bile duct jejunal Roux-en-Y anastomosis, after resolved the intrahepatic bile duct stenosis. Conclusions　The basic cause of reoperation after CIS is anastomotic stenosis, the other causes are as follows: the selected operation is unsuitable, the intrahepatic bile duct stenosis is not resolved, and the stonedoes not clean out completly. When reoperation is performed on these cases, the following principles must be abided by: romoving all the stones, resolving the stenosis, making a clear drainage; and performing hepatic lobectomy, anastomotic sustaining and drainage, and cholefibroscopic management must be done if needed.

Objective　To investigate the way of closed establishment of pneumoperitoneum(CEPP) in patients with peritoneal cvity adhesion in laparoscopy cholecystectomy(LC). Methods　CEPP experiences of 1046 patients in 6600 cases LC in our hospital from September 1991 to September 1999 were retrospectively analysed. The difficulty in establishing pneumoperitoneum was divided into two kinds: real establishment pneumoperitoneal difficulty(REPPD) and false establishment pneumoperitoneal difficulty(FEPPD). REPPD was due to Veress needle penetrating into visceral or extensive adhesion in peritoneal cavity resulting in CO2 flowing into difficulty. FEPPD was due to Veress needle pentrating in the fat out of peritoneum, in round hepatic ligament or in greater omentum. The formal situation needed to open laparotomy as a change, and the latter situation could establish pneumoperitoneum successfully by regulating the Veress needle penetrating direction or depth in the second penetration. Results　Of the 1046 patients, 1028 cases had been establishedpneumoperitoneum successfully though CEPP; 6 cases of REPPD and 18 of FEPPD were required opening laparotomy as a change. The successful rate of CEPP was 98.3%. Conclusions　CEPP is a safe and feasible method in patients with peritoneal adhesion in LC. It is the main reason for CEPP failure regarding REPPED as FEPPD made by the deficiency in LC experience and loss confidence in laparoscopist.

Objective　To study the experience in prevention and treatment of iatrogenic bile duct trauma(IBDT). Methods　A retrospective study was made on the clinical data of 118 patients with iatrogenic bile　 duct trauma admitted to the Hunan Provincial People's Hospital from March 1990 to September 2000. Results　50.8%　(60/118) of patients with IBDT resulted from the wrong identification of the anatomy of the Calot' Triangle during cholecystectomy. The clinical diagnosis of IBDT depended on the clinical findings, diagnostic abdominocentesis and image examination. The diagnostic rate of ultrasonography for IBDT was 93.2%(110/118). According to the injury site of bile duct, IBDT could be divided into 6 types, the most common type of　 IBDT was resection of partical hepatic duct and part common bile duct(type Ⅲ) which occurred in 83.9%　(99/118) of the patients. The cure rate of IBCT was 100%(118/118) in this series due to the choice of operation according to the trauma type. Conclusions　The key of prevention to IBDT lies in abiding by the princible of “identifying-cut-recognazing” during cholecystectomy. The choice for surgical operative procedure should agree with the trauma type.

Objective　To investigate the risk factors of gallbladder stone changing to gallbladder carcinoma. Methods　The clinical data of 200 patients with gallbladder stone undergoing operation were retrospective analysed. Results　(1) In the 200 resected gallbladder specimens, gallbladder mucosa hyperplasia was found in 144 specimens(72%), atypical hyperplasia(AHP) in 38(19%), infiltrative cancer in 7(3.5%). All the paracancer mucosa had midder or severe AHP. The incidence of atypical hyperplasia and canceration had increased with patients' age and the history lenth of cyst stone. (2) The content of DNA, the porpotion of euplpoid cells, the AgNOR content in tissues as follows: hyperplasia

Objective　To investigate the systemic stress responses of laparoscopic cholecystectomy(LC). Methods　Seventy patients with cholecystolithiasis were randomly divided into two groups: LC and open cholecystectomy(OC). Peripheral blood samples were obtained during the preoperative day and 1, 3, 5, 7 day after operation. Serum cytokines levels (TNF-α, IL-1β and IL-6) and C-reactive protein(CRP) were measured. Results　Changes of TNF-α and IL-1β before or after surgery in both groups showed no significant difference(P>0.05). Serum concentrations of IL-6 and CRP after surgery in both groups were significantly higher than those before surgery(P<0.05); but there were no significant difference between the two groups(P>0.05). Conclusions　The systemic stress responses of LC have no significant difference comparing with OC.

Objective　To study the significance of alteration of concentration of endothelins(ET) and calcitonin gene related protein(CGRP) in bile in patients with acute choiangitis of severe type(ACST). Methods　The concentration of ET and CGRP were detected by radioimmunoassay in 55 cases of ACST at openation time, and 7th, 14th day after operation. Results　Compared with the control group, the concentration of ET in bile in patients with ACST was significantly higher at operation time(P<0.01～0.001). The concentration of ET in bile also showed significant difference at operation time between the 2 groups with different ACST severity(P<0.05). The concentration of ET in bile gradually reduced after operations. Compared with the control group, the concentration of CGRP in bile was signficantly lower at operation time(P<0.01). CGRP in bile gradually rose after operation. Conclusions　The ET in bile has some effect on the ACST pathologic alterations. The content of ET in bile is related to the severity of ACST. The disturbance of the balance between bile ET and CGRP may contribute to the pathologic process of liver and bile duct injury in ACST.

Objective　To investigate the correlation between the expression of Cyclin D1,Rb and clinicopathologic parameter in bile duct carcinoma(BDC), and evaluate the potential prognostic value. Methods The expression of Cyclin D1, Rb in BDC was detected by immunochemical staining(S-P method). Results　Of 42 samples, 22 cases exhibited Cyclin D1 positive expression(52.38%), correlated with histological grade(P=0.044), hepatic invasion(P=0.0046), clinic stage(P=0.0001) and survival time(P=0.0011). The Rb positive rate was 57.14%(24/42), while the expression was related to histologic grade(P=0.0052), clinic stage(P=0.0042), and lymphatic metastasis(P=0.0068). Conclusions　Ccylin D1 and Rb are correlated with some clinicopathologic parameter of BDC, and Cyclin D1 is a valuable prognostic marker of BDC.