0
January 1996, Vol 131, No. 1 >
ARTICLE | January 1996

Selection Criteria for Preoperative Endoscopic Retrograde Cholangiopancreatography in the Laparoscopic Era FREE

Gavin S. M. Robertson, MD, FRCS; Carol Jagger, MSc, PhD, MFPHM; Paul R. V. Johnson, MB, ChB, FRCS; Barry J. Rathbone, MD, MRCP; Anthony C. B. Wicks, MD, MRCP; David M. Lloyd, MD, FRCS; Peter S. Veitch, MB, BS, FRCS
Arch Surg. 1996;131(1):89-94. doi:10.1001/archsurg.1996.01430130091019
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Comments

Background:  Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography.

Objective:  To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP).

Design:  Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy.

Setting:  Two ERCP units in adjacent teaching hospitals.

Patients:  Three hundred seventeen patients with gallstones and in situ gallbladders.

Intervention:  Common bile duct imaging at ERCP.

Main Outcome Measures:  Abnormalities justifying ERCP.

Results:  Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests (P<.001), jaundice (P<=.001 ), a dilated CBD on ultrasound (P<.001), or CBD stones on ultrasound (P<.001), On the other hand, patients with normal ducts were significantly more likely to have been referred with pancreatitis (P=.003) or elevated results of individual liver function tests (P<.001). A logistic regression model using age, presence of jaundice at ERCP, levels of alkaline phosphatase and albumin, and ultrasonography showing dilated ducts or visible CBD stones was found to have a specificity of 75% and a sensitivity of 89%. Past pancreatitis or elevated results of individual liver function tests were not predictive factors.

Conclusion:  The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.(Arch Surg. 1996;131:89-94)

REFERENCES

1 +
Neuhaus H, Feussner H, Ungeheuer A, Hoffmann W, Siewert JR, Classen M.  Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy . Endoscopy . 1992;;24:745-749.
2 +
Perissat J, Huibregtse K, Keane FBV, Russell RCG, Neoptolemos JP.  Management of bile duct stones in the era of laparoscopic cholecystectomy . Br J Surg . 1994;;81:799-810.
3 +
Fletcher DR.  Changes in the practice of biliary surgery and ERCP during the introduction of laparoscopic cholecystectomy to Australia: their possible significance . Aust N Z J Surg . 1994;;64:75-80.
4 +
Boulay J, Schellenberg R, Brady PG.  Role of ERCP and therapeutic biliary endoscopy in association with laparoscopic cholecystectomy . Am J Gastroenterol . 1992;;87:837-842.
5 +
Brodish RJ, Fink AS.  ERCP, cholangiography, and laparoscopic cholecystectomy: The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) opinion survey . Surg Endosc . 1993;;7:3-8.
6 +
Graham SM, Flowers JL, Scott TR, et al.  Laparoscopic cholecystectomy and common bile duct stones: the utility of planned perioperative endoscopic retrograde cholangiography and sphincterotomy: experience with 63 patients . Ann Surg . 1993;;218:61-67.
7 +
Hawasli A, Lloyd L, Pozios V, Veneri R.  The role of endoscopic retrograde cholangio-pancreaticrogram in laparoscopic cholecystectomy . Am Surg . 1993;; 59:285-289.
8 +
Mo LR, Yau MP, Hwang MH, Lin RC, Kuo JY, Tsai CC.  The role of ERCP and therapeutic biliary endoscopy in laparoscpic cholecystectomy . J Laparoendosc Surg . 1993;;3:19-22.
9 +
Roy A, McAlister V, Passi RB.  Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis with laparoscopic cholecystectomy . Can J Surg . 1993;;36:81-84.
10 +
Vitale GC, Larson GM, Wieman TJ, Cheadle WG, Miller FB.  The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy . Surg Endosc . 1993;:7:9-11.
11 +
Voyles CR, Sanders DL, Hogan R.  Common bile duct evaluation in the era of laparoscopic cholecystectomy . Ann Surg . 1994;;219:744-752.
12 +
Widdison AL, Longstaff AJ, Armstrong CP.  Combined laparoscopic and endoscopic treatment of bile duct stones: a prospective study . Br J Surg . 1994;; 81:595-597.
13 +
Corder AP, Scott SD, Johnson CD.  Place of routine operative cholangiography at cholecystectomy . Br J Surg . 1992;;79:945-947.
14 +
Tate JJT, Lau WY, Li AKC.  Laparoscopic cholecystectomy for biliary pancreatitis . Br J Surg . 1994;;81:720-722.
15 +
Barkin AN, Barkun JS, Fried GM, et al.  Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy . Ann Surg . 1994;;220:32-39.
16 +
Taylor TV, Armstrong CP, Rimmer S, Lucas SB, Jeacock J, Gunn AA.  Prediction of choledocholithiasis using a pocket microcomputer . Br J Surg . 1988;: 75:138-140.
17 +
Del Santo P, Kazarian KK, Rogers JF, Bevins PA, Hall JR.  Prediction of operative cholangiography in patients undergoing elective cholecystectomy with routine liver function chemistries . Surgery . 1985;;98:7-11.
18 +
Thornton JR, Lobo AJ, Lintott DJ, Axon ATR.  Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain . Gut . 1992;:33:1559-1561.
19 +
Lacaine F, Corlette MB, Bismuth H.  Preoperative evaluation of the risk of common bile duct stones . Arch Surg . 1980;;115:1114-1116.
20 +
Hauer-Jensen M, Karesen R, Nygaard K, et al.  Predictive ability of choledocholithiasis indicators: a prosepctive evaluation . Ann Surg . 1985;:202:64-68.
21 +
Wilson TG, Hall JC, Watts JMcK.  Is operative cholangiography always necessary? Br J Surg . 1986;;73:637-640.
22 +
Mroz CT, Wilson-Relyea J.  Predicting the need for intraoperative cholangiography after cholecystectomy . Surg Gynecol Obstet . 1988;;167:347-349.
23 +
Mansberger JA, Davis JB, Scarborough C, Bowden TA.  Selective intraoperative cholangiography: a case for its use on an anatomic basis . Am Surg . 1988;; 54:31-33.
24 +
Taylor TV, Torrance B, Rimmer S, Hillier V, Lucas SB.  Operative cholangiography: is there a statistical alternative? Am J Surg . 1983;;145:640-643.
25 +
Faris I, Thomson JPS, Grundy DJ, Le Quesne LP.  Operative cholangiography: a reappraisal based on a review of 400 cholangiograms . Br J Surg . 1975;:62: 966-972.
26 +
Shively EH, Wieman TJ, Adams AL, Romines RB, Garrison RN.  Operative cholangiography . Am J Surg . 1990;;159:380-384.
27 +
Hauer-Jensen M, Karesen R, Nygaard K, Solheim K, Amlie EJB, Rosseland AR.  Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis . Surgery . 1993;;113:318-323.
28 +
Leslie D.  The width of the common bile duct . Surg Gynecol Obstet . 1968;;126: 761-764.
29 +
Reiss R, Deutsch AA, Nudelman I, Kott I.  Statistical value of various clinical parameters in predicting the presence of choledochal stones . Surg Gynecol Obstet . 1984;;159:273-276.
30 +
Saltzstein EC, Peacock JB, Thomas MD.  Preoperative bilirubin, alkaline phosphatase and amylase levels as the predictors of common duct stones . Surg Gynecol Obstet . 1982;;154:381-384.
31 +
Pernthaler H, Sandbichler P, Schmid TH, Margreiter R.  Operative cholangiography in elective cholecystectomy . Br J Surg . 1990;;77:399-400.
32 +
Yip AWC, Ng WS, Chow WC, Choi TK, Lam KH.  Plea for selective operative cholangiography . J R Coll Surg Edinb . 1991;;36:21-24.
33 +
Clair DG, Carr-Locke DL, Becker JM, Brooks DC.  Routine cholangiography is not warranted during laparoscopic cholecystectomy . Arch Surg . 1993;;128:551-554.
34 +
Grace PA, Qureshi A, Burke P, et al.  Selective cholangiography in laparoscopic cholecystectomy . Br J Surg . 1993;;80:244-246.
35 +
Galloway SW, Blazeby JM, Tulloh B, Poskitt KR.  Selective cholangiography before laparoscopic cholecystectomy . Br J Surg . 1993;;80( (suppl) ):S6.
36 +
Watkin DS, Haworth JM, Leaper DJ, Thompson MH.  Assessment of the common bile duct before cholecystectomy using ultrasound and biochemical measurements: validation based on follow-up . Ann R Coll Surg Engl . 1994;;76:317-319.
37 +
Tobin MV, Mendelson RM, Lamb GH, Gilmore IT.  Ultrasound diagnosis of bile duct calculi . BMJ . 1986;;293:16-17.
38 +
Berci G.  Preoperative ERCP and intraoperative cholangiography in the age of laparoscopic cholecystectomy . Surg Endosc . 1993;;7:2.
39 +
Cotton PB.  Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy . Am J Surg . 1993;:165:474-478.
40 +
Kozarek RA.  Laparoscopic cholecystectomy: what to do with the common duct . Gastrointest Endosc . 1993;;39:99-101.
41 +
O'Rourke NA, Askew AR, Cowen AE, Roberts R, Fielding GA.  The role of ERCP and endoscopic sphincterotomy in the era of laparoscopic cholecystectomy . Aust N Z J Surg . 1993;;63:3-7.
42 +
Wilson TG, Jeans PL, Anthony A, Cox MR, Toouli J.  Laparoscopic cholecystectomy and management of choledocholithiasis . Aust N Z J Surg . 1993;;63:443-450.
43 +
Scott-Coombes D, Thompson JN.  Bile duct stones and laparoscopic cholecystectomy . BMJ . 1991;;303:1281-1282.
44 +
Cetta F.  Common duct stones in the era of laparoscopic cholecystectomy: changing treatments and new pathologic entities . J Laparoendosc Surg . 1994;;4:41-44.
45 +
Armstrong CP.  Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study . Br J Surg . 1994;;81:1699-1700.
46 +
Benjamin IS.  Second opinions in laparoscopic cholecystectomy . Lancet . 1994;; 344:542-543.
47 +
Altman DG, Gore SM, Gardner MJ, Pocock SJ.  Statistical guidelines for contributors to medical journals . BMJ . 1983;;286:1489-1493.
48 +
Acosta JM, Ledesma CL.  Gallstone migration as a cause of acute pancreatitis . N Engl J Med . 1974;;290:484-487.
49 +
Kelly TR.  Gallstone pancreatitis: pathophysiology . Surgery . 1976;;80:488-492.
50 +
Stone HH, Fabian TC, Dunlop WE.  Gallstone pancreatitis: biliary tract pathology in relation to time of operation . Ann Surg . 1981;;194:305-312.
51 +
Safrany L, Cotton PB.  A preliminary report: urgent duodenoscopic sphincterotomy for acute gallstone pancreatitis . Surgery . 1981;;89:424-428.
52 +
Neoptolemos JP, London N, Slater ND, Carr-Locke DL, Fossard DP, Moossa AR.  A prospective study of ERCP and endoscopic sphincterotomy in the diagnosis and treatment of gallstone acute pancreatitis: a safe and rational approach to management . Arch Surg . 1986;;121:697-702.
53 +
Rhodes M, Armstrong CP, Longstaff A, Cawthorn S.  Laparoscopic cholecystectomy with endoscopic retrograde cholangiopancreatography for acute gallstone pancreatitis . Br J Surg . 1993;:80:247.
54 +
Carr-Locke DL.  Role of endoscopy in gallstone pancreatitis . Am J Surg . 1993;; 165:519-521.
55 +
Hashmonal M, Arisson R, Schramek A.  Indications for exploration of the bile ducts . Int Surg . 1980;;65:239-245.
56 +
Kurzweil SM, Shapiro MJ, Andrus CH, Wittgen CM, Herrmann VM, Kaminski DL.  Hyperbilirubinemia without common bile duct abnormalities and hyperamylasemia without pancreatitis in patients with gallbladder disease . Arch Surg . 1994;;129:829-833.
57 +
Younes RN, Vydelingum NA, Derooij P, et al.  Metabolic alterations in obstructive jaundice: effect of duration of jaundice and bile duct decompression . HPB Surg . 1991;;5:35-48.
58 +
Galloway SW, Blazeby J, Tulloh B, Poskitt KR.  Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study . Br J Surg . 1994;;81:1699.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Neuhaus H, Feussner H, Ungeheuer A, Hoffmann W, Siewert JR, Classen M.  Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy . Endoscopy . 1992;;24:745-749.
2 +
Perissat J, Huibregtse K, Keane FBV, Russell RCG, Neoptolemos JP.  Management of bile duct stones in the era of laparoscopic cholecystectomy . Br J Surg . 1994;;81:799-810.
3 +
Fletcher DR.  Changes in the practice of biliary surgery and ERCP during the introduction of laparoscopic cholecystectomy to Australia: their possible significance . Aust N Z J Surg . 1994;;64:75-80.
4 +
Boulay J, Schellenberg R, Brady PG.  Role of ERCP and therapeutic biliary endoscopy in association with laparoscopic cholecystectomy . Am J Gastroenterol . 1992;;87:837-842.
5 +
Brodish RJ, Fink AS.  ERCP, cholangiography, and laparoscopic cholecystectomy: The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) opinion survey . Surg Endosc . 1993;;7:3-8.
6 +
Graham SM, Flowers JL, Scott TR, et al.  Laparoscopic cholecystectomy and common bile duct stones: the utility of planned perioperative endoscopic retrograde cholangiography and sphincterotomy: experience with 63 patients . Ann Surg . 1993;;218:61-67.
7 +
Hawasli A, Lloyd L, Pozios V, Veneri R.  The role of endoscopic retrograde cholangio-pancreaticrogram in laparoscopic cholecystectomy . Am Surg . 1993;; 59:285-289.
8 +
Mo LR, Yau MP, Hwang MH, Lin RC, Kuo JY, Tsai CC.  The role of ERCP and therapeutic biliary endoscopy in laparoscpic cholecystectomy . J Laparoendosc Surg . 1993;;3:19-22.
9 +
Roy A, McAlister V, Passi RB.  Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis with laparoscopic cholecystectomy . Can J Surg . 1993;;36:81-84.
10 +
Vitale GC, Larson GM, Wieman TJ, Cheadle WG, Miller FB.  The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy . Surg Endosc . 1993;:7:9-11.
11 +
Voyles CR, Sanders DL, Hogan R.  Common bile duct evaluation in the era of laparoscopic cholecystectomy . Ann Surg . 1994;;219:744-752.
12 +
Widdison AL, Longstaff AJ, Armstrong CP.  Combined laparoscopic and endoscopic treatment of bile duct stones: a prospective study . Br J Surg . 1994;; 81:595-597.
13 +
Corder AP, Scott SD, Johnson CD.  Place of routine operative cholangiography at cholecystectomy . Br J Surg . 1992;;79:945-947.
14 +
Tate JJT, Lau WY, Li AKC.  Laparoscopic cholecystectomy for biliary pancreatitis . Br J Surg . 1994;;81:720-722.
15 +
Barkin AN, Barkun JS, Fried GM, et al.  Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy . Ann Surg . 1994;;220:32-39.
16 +
Taylor TV, Armstrong CP, Rimmer S, Lucas SB, Jeacock J, Gunn AA.  Prediction of choledocholithiasis using a pocket microcomputer . Br J Surg . 1988;: 75:138-140.
17 +
Del Santo P, Kazarian KK, Rogers JF, Bevins PA, Hall JR.  Prediction of operative cholangiography in patients undergoing elective cholecystectomy with routine liver function chemistries . Surgery . 1985;;98:7-11.
18 +
Thornton JR, Lobo AJ, Lintott DJ, Axon ATR.  Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain . Gut . 1992;:33:1559-1561.
19 +
Lacaine F, Corlette MB, Bismuth H.  Preoperative evaluation of the risk of common bile duct stones . Arch Surg . 1980;;115:1114-1116.
20 +
Hauer-Jensen M, Karesen R, Nygaard K, et al.  Predictive ability of choledocholithiasis indicators: a prosepctive evaluation . Ann Surg . 1985;:202:64-68.
21 +
Wilson TG, Hall JC, Watts JMcK.  Is operative cholangiography always necessary? Br J Surg . 1986;;73:637-640.
22 +
Mroz CT, Wilson-Relyea J.  Predicting the need for intraoperative cholangiography after cholecystectomy . Surg Gynecol Obstet . 1988;;167:347-349.
23 +
Mansberger JA, Davis JB, Scarborough C, Bowden TA.  Selective intraoperative cholangiography: a case for its use on an anatomic basis . Am Surg . 1988;; 54:31-33.
24 +
Taylor TV, Torrance B, Rimmer S, Hillier V, Lucas SB.  Operative cholangiography: is there a statistical alternative? Am J Surg . 1983;;145:640-643.
25 +
Faris I, Thomson JPS, Grundy DJ, Le Quesne LP.  Operative cholangiography: a reappraisal based on a review of 400 cholangiograms . Br J Surg . 1975;:62: 966-972.
26 +
Shively EH, Wieman TJ, Adams AL, Romines RB, Garrison RN.  Operative cholangiography . Am J Surg . 1990;;159:380-384.
27 +
Hauer-Jensen M, Karesen R, Nygaard K, Solheim K, Amlie EJB, Rosseland AR.  Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis . Surgery . 1993;;113:318-323.
28 +
Leslie D.  The width of the common bile duct . Surg Gynecol Obstet . 1968;;126: 761-764.
29 +
Reiss R, Deutsch AA, Nudelman I, Kott I.  Statistical value of various clinical parameters in predicting the presence of choledochal stones . Surg Gynecol Obstet . 1984;;159:273-276.
30 +
Saltzstein EC, Peacock JB, Thomas MD.  Preoperative bilirubin, alkaline phosphatase and amylase levels as the predictors of common duct stones . Surg Gynecol Obstet . 1982;;154:381-384.
31 +
Pernthaler H, Sandbichler P, Schmid TH, Margreiter R.  Operative cholangiography in elective cholecystectomy . Br J Surg . 1990;;77:399-400.
32 +
Yip AWC, Ng WS, Chow WC, Choi TK, Lam KH.  Plea for selective operative cholangiography . J R Coll Surg Edinb . 1991;;36:21-24.
33 +
Clair DG, Carr-Locke DL, Becker JM, Brooks DC.  Routine cholangiography is not warranted during laparoscopic cholecystectomy . Arch Surg . 1993;;128:551-554.
34 +
Grace PA, Qureshi A, Burke P, et al.  Selective cholangiography in laparoscopic cholecystectomy . Br J Surg . 1993;;80:244-246.
35 +
Galloway SW, Blazeby JM, Tulloh B, Poskitt KR.  Selective cholangiography before laparoscopic cholecystectomy . Br J Surg . 1993;;80( (suppl) ):S6.
36 +
Watkin DS, Haworth JM, Leaper DJ, Thompson MH.  Assessment of the common bile duct before cholecystectomy using ultrasound and biochemical measurements: validation based on follow-up . Ann R Coll Surg Engl . 1994;;76:317-319.
37 +
Tobin MV, Mendelson RM, Lamb GH, Gilmore IT.  Ultrasound diagnosis of bile duct calculi . BMJ . 1986;;293:16-17.
38 +
Berci G.  Preoperative ERCP and intraoperative cholangiography in the age of laparoscopic cholecystectomy . Surg Endosc . 1993;;7:2.
39 +
Cotton PB.  Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy . Am J Surg . 1993;:165:474-478.
40 +
Kozarek RA.  Laparoscopic cholecystectomy: what to do with the common duct . Gastrointest Endosc . 1993;;39:99-101.
41 +
O'Rourke NA, Askew AR, Cowen AE, Roberts R, Fielding GA.  The role of ERCP and endoscopic sphincterotomy in the era of laparoscopic cholecystectomy . Aust N Z J Surg . 1993;;63:3-7.
42 +
Wilson TG, Jeans PL, Anthony A, Cox MR, Toouli J.  Laparoscopic cholecystectomy and management of choledocholithiasis . Aust N Z J Surg . 1993;;63:443-450.
43 +
Scott-Coombes D, Thompson JN.  Bile duct stones and laparoscopic cholecystectomy . BMJ . 1991;;303:1281-1282.
44 +
Cetta F.  Common duct stones in the era of laparoscopic cholecystectomy: changing treatments and new pathologic entities . J Laparoendosc Surg . 1994;;4:41-44.
45 +
Armstrong CP.  Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study . Br J Surg . 1994;;81:1699-1700.
46 +
Benjamin IS.  Second opinions in laparoscopic cholecystectomy . Lancet . 1994;; 344:542-543.
47 +
Altman DG, Gore SM, Gardner MJ, Pocock SJ.  Statistical guidelines for contributors to medical journals . BMJ . 1983;;286:1489-1493.
48 +
Acosta JM, Ledesma CL.  Gallstone migration as a cause of acute pancreatitis . N Engl J Med . 1974;;290:484-487.
49 +
Kelly TR.  Gallstone pancreatitis: pathophysiology . Surgery . 1976;;80:488-492.
50 +
Stone HH, Fabian TC, Dunlop WE.  Gallstone pancreatitis: biliary tract pathology in relation to time of operation . Ann Surg . 1981;;194:305-312.
51 +
Safrany L, Cotton PB.  A preliminary report: urgent duodenoscopic sphincterotomy for acute gallstone pancreatitis . Surgery . 1981;;89:424-428.
52 +
Neoptolemos JP, London N, Slater ND, Carr-Locke DL, Fossard DP, Moossa AR.  A prospective study of ERCP and endoscopic sphincterotomy in the diagnosis and treatment of gallstone acute pancreatitis: a safe and rational approach to management . Arch Surg . 1986;;121:697-702.
53 +
Rhodes M, Armstrong CP, Longstaff A, Cawthorn S.  Laparoscopic cholecystectomy with endoscopic retrograde cholangiopancreatography for acute gallstone pancreatitis . Br J Surg . 1993;:80:247.
54 +
Carr-Locke DL.  Role of endoscopy in gallstone pancreatitis . Am J Surg . 1993;; 165:519-521.
55 +
Hashmonal M, Arisson R, Schramek A.  Indications for exploration of the bile ducts . Int Surg . 1980;;65:239-245.
56 +
Kurzweil SM, Shapiro MJ, Andrus CH, Wittgen CM, Herrmann VM, Kaminski DL.  Hyperbilirubinemia without common bile duct abnormalities and hyperamylasemia without pancreatitis in patients with gallbladder disease . Arch Surg . 1994;;129:829-833.
57 +
Younes RN, Vydelingum NA, Derooij P, et al.  Metabolic alterations in obstructive jaundice: effect of duration of jaundice and bile duct decompression . HPB Surg . 1991;;5:35-48.
58 +
Galloway SW, Blazeby J, Tulloh B, Poskitt KR.  Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study . Br J Surg . 1994;;81:1699.

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