Gallbladder emptying and gallstone formation: a prospective study on gallstone recurrence

BACKGROUND & AIMS: Gallbladder emptying is reduced in many patients with cholesterol gallstones. To clarify the role of impaired gallbladder motility in recurrent gallstone disease, the effect of gallbladder emptying on the formation of recurrent stones was studied prospectively. METHODS: In 54 consecutive patients with single radiolucent gallbladder stones, postprandial gallbladder emptying was assessed sonographically before lithotripsy and 1.8 +/- 0.1 years (mean +/- SE) after gallstone disappearance. Patients were followed up for gallstone recurrence for 0.6-4.1 years (median, 2.6 years). RESULTS: After gallstone disappearance, gallbladder fasting volume (33.7 +/- 3.4 vs. 27.8 +/- 3.0 mL; P = 0.007) and residual volume (12.6 +/- 1.9 vs. 9.7 +/- 1.3 mL; P = 0.010) decreased, whereas the ejection fraction remained unchanged. However, gallbladder volume did not differ whether initial or recurrent stones were present. Gallbladder emptying was more impaired in patients with than patients without later recurrence (47% +/- 5% vs. 63% +/- 2%; P = 0.001). Cox analysis showed that gallbladder emptying was an independent determinant of the risk of gallstone recurrence (P = 0.002). Within 3 years, recurrent stones formed in 53% (actuarial analysis) of patients with an ejection fraction of < 60% but in only 13% of patients with an ejection fraction of > or = 60%. CONCLUSIONS: Gallbladder emptying is an important factor in the formation of recurrent gallstones.     

Gallstone dissolution with chenodeoxycholic acid. A clinical study

Out of 95 patients with radiolucent gallstones who enrolled in a clinical study with chenodeoxycholic acid (CDC) for gallstone dissolution 75 patients with cholecystolithiasis completed 12 months of treatment. As a side effect 31% of patients reported intermittent diarrhea which did not cause cessation of therapy or missing of work. The incidence of biliary colic was markedly decreased during treatment in comparison to the rate in the year before. From more than 20 laboratory values checked before start and every 3 months during therapy only aminotransferases increased up to 3 fold in 20% of patients. gamma-GT elevated in 31% of patients before treatment improved in half of these patients during therapy. Gallstone dissolution defined as 30% or more diminution of the gallstone area on comparable x-rays occurred in 40% of patients. Analysis of factors showed that gallstones above 2 cm in diameter did not dissolve. When the dose of CDC was retrospectively related to body weight a success rate of 68% was found in the group taking more than 13 mg CDC/kg/day. The lithogenic index determined at 6 and 12 months had significantly decreased after 6 months in patients with success. This study demonstrates that medical dissolution of gallstones with chenodeoxycholic acid should be performed in patients with radiolucent stones of less than 2 cm in diameter and with a dose above 13 mg CDC/kg body weight/day. Under these conditions the success rate is above 60% accompanied by minimal side effects.     

Study of the contractility of the gallbladder by ceruletide infusion cholescintigraphy after litholysis

Twenty-six randomly selected patients 2-6 years (mean: 3.5) after rapid percutaneous catheteric litholysis at the Radiological Department were investigated by quantitative Ceruletide cholescintigraphy in this pilot study. The average EF of the patients with recurrent gallstones (Group II) was lower (55 +/- 23%) than that of the patients without stones (69 +/- 23%) (Group I). The authors conclude that this scintigraphic method could help not only to select the best method to make patient stonefree but has an important role in forecasting the prognosis of gallstone recovery after litholytic therapy.     

Does drug-induced litholysis still have a place in treatment of gallstones?

In past years, laparoscopic cholecystectomy has largely taken the place of conservative therapy. However, analysis of our data shows, that conventional litholytic therapy of cholesterol stones using bile acids: a) achieves a success rate of over 80%, as long as the patients are well selected prior to therapy (stones < 1 cm diameter, stone size < one fourth of gallbladder contraction of more than 50% as compared when fasting, isodensity of stones in CT) b) has a mortality rate of 0% c) has high patient compliance, because typical episodes of biliary colics and general dyspeptic complaints due to stones are reduced. Therefore, combination bile acid therapy for lysis of selected cholesterol gallbladder stones is still justified today. Particularly young women with small, suspended concrements or patients with recurrent cholesterol stones benefit by this treatment. Extracorporeal lithotripsy can be justified today only in combination with bile acid therapy. However, the number of treatable persons with gall stones is quite small (< 20% of all patients with stones), duration of therapy is three years and the recurrence rate 2-5 years after successful lysis is 25-50% (solitary stones recur less often than multiple ones). Considering a prevalence of 20% of persons with gall stones in the European Economic Community, there are 12 million patients potentially eligible for litholysis.     

Solitary versus multiple gallstones: the importance of total biliary protein concentration and other factors

BACKGROUND: Nucleating and antinucleating factors play an important role in the pathogenesis of cholesterol crystal nucleation. PATIENTS AND METHODS: In 88 gallstone patients (59 female, 29 male) bile was examined for total biliary protein and glycoprotein concentration, nucleation time and cholesterol saturation index. Gallstone density was measured by in vivo computed tomography. RESULTS: Total biliary protein concentration was positively correlated with the number of gallstones (r = 0.84, p < 0.01) and higher in radiologically detectable isodense gallstones as compared to non-isodense stones (p < 0.01). A negative correlation between total biliary protein concentration, glycoprotein concentration and nucleation time was observed (r = -0.45, p < 0.01 and r = -0.49, p < 0.05). Nucleation time was significantly shorter in the case of multiple versus solitary stones (2.6 +/- 1.3 versus 8.5 +/- 3.0 days, p < 0.01). Cholesterol saturation index and biliary cholesterol concentration were similar in both cases, however a negative correlation between cholesterol saturation index and stone density (r = -0.79, p < 0.01) was found. No correlation was found between cholesterol saturation index and nucleation time (r = -0.04, p > 0.1), independent of gallstone number. None of the examined parameters was related to sex, age, weight or gallbladder function. CONCLUSIONS: Multiple gallbladder stones seem to be associated with shorter nucleation time and higher biliary concentrations of total protein and glycoprotein than solitary stones.     

Cholelithiasis in Taiwan. Gallstone characteristics, surgical incidence, bile lipid composition, and role of beta-glucuronidase

The nature and occurrence of gallstones in Taiwan and their etiologic factors might not be the same as in Western countries and warranted a systematic investigation. Gallbladder biles and gallstones were obtained at surgery from 100 and 74 patients, respectively. Common duct bile and stones were either drained through an indwelling common duct T-tube or aspirated through a nasobiliary catheter in 108 patients. Gallstones were analyzed for bilirubin, cholesterol, bile acid, calcium, and residue, and biles for bile acid, cholesterol, phospholipid, bilirubin, and beta-glucuronidase. There were four major kinds of gallstones in Taiwan: cholesterol/mixed stones, high-residue black formed pigment stones, low-residue brown formed pigment stones, and muddy pigment stones. The surgical incidence of all types of stones increased steadily during the past four decades. During the past 15 years the relative frequencies for mixed, formed pigment, and muddy pigment stones had been roughly 40, 40, and 20%, respectively, with a further increase in the mixed stones and a decrease in the muddy pigment stones in recent years. Improvement of nutritional status and living standards might contribute to such changes. Cholesterol content in the common duct and gallbladder biles was higher in the mixed stone group than in other groups. Bacterial beta-glucuronidase activity was detected in 53% of patients with muddy pigment stones. Endogenous beta-glucuronidase activity and concentration were also highest in this group, intermediate in the formed pigment and mixed stone group, and lowest in the control. We concluded that hypercholesterobilia was responsible for increasing incidence of mixed stones during the past two decades, while both bacterial and human beta-glucuronidase might contribute to pigment cholelithiasis.     

Sebaceous carcinoma of the submandibular gland with high-grade malignancy: report of a case

Inhibitors of 3-hydroxy,3-methylglutaryl coenzyme A (HMG-CoA) reductase have been reported to decrease the cholesterol saturation index (CSI) in duodenal bile in humans and to prevent formation of cholesterol gallstones in animal studies. We performed a prospective study to evaluate the role of HMG-CoA reductase inhibitors as gallstone-dissolving agents. Fifty patients with radiolucent gallstones in a gallbladder opacifying at drip infusion cholecystography were treated with either 10 mg/day simvastatin plus 600 mg/day ursodeoxycholic acid (group 1, n=26) or 600 mg/day ursodeoxycholic acid alone (group 2, n=24) for 12 months. The ratio of solitary to multiple gallstone cases was 21:29. Plasma lipid levels were assessed and ultrasonographic examination of the gallbladder was performed at baseline and at 3-month intervals during treatment. Duodenal bile sampling was performed in five patients in each group at baseline and after 12 months of treatment. Plasma cholesterol decreased significantly in group 1 but not in group 2. In solitary gallstone cases, no significant difference in dissolution rates was observed between groups 1 (3 of 9, 33%) and 2 (4 of 12, 33%). In contrast, the dissolution rate in multiple gallstone cases was significantly higher in group 1 (12 of 17, 71%) than in group 2 (3 of 12, 25%) (p < 0.01). Bile cholesterol saturation index was significantly decreased (p < 0.01) but did not significantly differ between the two groups. These results suggest that combination therapy with simvastatin and ursodeoxycholic acid is more effective for cholesterol gallstone dissolution than ursodeoxycholic acid monotherapy in patients with multiple gallstones.     

Long-term stone recurrence rate after extracorporeal shock wave lithotripsy

PURPOSE: We followed patients who were stone-free after extracorporeal shock wave lithotripsy (ESWL) to investigate the factors that contributed to recurrent calculi. MATERIALS AND METHODS: For longer than 5 years 903 patients without residual fragments 3 months after ESWL were enrolled in this study. Plain abdominal films and/or excretory urograms were evaluated every 6 months for recurrent stones on the side of ESWL. Patients who presented with colic pain or other complaints and who were suspected of having recurrent stones were also examined. Stone recurrence rates were calculated with the Kaplan-Meier method. We assessed the influence of patient age; size, location, composition and configuration of the original stones, and pyuria after ESWL on stone recurrence. RESULTS: Mean followup was 25 months and stones recurred in 183 of 903 renal units (20.3%). Kaplan-Meier recurrence rates were 6.7, 28.0 and 41.8% after 1, 3 and 5 years, respectively. There was a significant correlation between stone recurrence and multiple stones on one hand, and pyuria after ESWL on the other hand. Stones recurred most frequently in the lower calix. Recurrent stones were passed without intervention in 33 cases, while ESWL was repeated in 53. CONCLUSIONS: These data demonstrate the importance of long-term followup and the search for an effective prophylactic therapy to prevent recurrence.     

Similar fragmentation and dissolution after extracorporeal shock wave lithotripsy in eutrophic and overweight patients with gallstones

The aim of this study was to assess the relative importance of overweight and adjuvant treatment with bile acids to obtain fragment dissolution and clearance after biliary extracorporeal shock wave lithotripsy (BESWL), in eutrophic and overweight patients with gallbladder stones. During a 3-year period 103 patients were treated with BESWL. Patients were strictly selected in terms of the number and type of stones. Of the total of 103 patients, 53 were women and 50 men. Mean age was 50.8 +/- 14.3 (range 17 to 86) years. Body mass index was calculated for each patient. All patients underwent BESWL with an electromagnetic device. Medical therapy for stone dissolution included the combination of chenodeoxycholic acid plus ursodeoxycholic acid (50% + 50%), at a total dose of 10-15 mg/day. Of the 103 patients, 45 were eutrophic and 58 were considered overweight. Age was similar in both groups. Number of lithotripsy sessions in eutrophic patients was 1.96 +/- 1.07 and 1.88 +/- 0.84 in overweight patients, but no statistical differences were found. Complete clearance of calculi was observed in more than 50% of the cases after 6 months, and reached 98% after 22 months of therapy in both groups. Total clearance of calculi was similar in patients with single and multiple stones. In conclusion, our results suggest that the time required to obtain complete gallstone clearance after BESWL is similar in eutrophic and overweight patients with gallbladder stones, and also that adjuvant therapy with bile acids plays an important role in gallstone fragment dissolution in these patients.     

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

BACKGROUND: Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients. AIMS: To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence. METHODS: One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient. RESULTS: During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy. CONCLUSION: Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.     

Gallstone formation and gallbladder bile composition after colectomy in dogs

A high prevalence of gallstones has been described in patients following colectomy. The aim of this study was to examine whether lithogenicity is attributed to colectomy. In the present study, changes in gallbladder bile composition and the mechanism of gallstone formation after colectomy were examined in dogs. Ten mongrel dogs underwent restorative proctocolectomy. Seven dogs which received sham operations served as controls. Over a 12-week postoperative period, samples of gallbladder bile, formed gallstones and serum were collected and analyzed. In 7 of the 10 (70%) colectomized dogs, gallstones were found in the gallbladder, while the control dogs had no stones. Macroscopically the gallstones were similar to black pigment stones observed in humans. Chemical analysis and Fourier transform-infrared spectroscopy examination revealed that the stones were composed mainly of sodium bilirubinate and proteins, with minor amounts of calcium salts and cholesterol. Significant increases in biliary pH and concentrations of ionized calcium and unconjugated bilirubin were observed in the gallbladder bile of the colectomy group compared with that of the control group. The total bile acid and total bilirubin concentrations were significantly decreased in the colectomy group. Cholesterol crystal nucleation did not occur. The inhibitory effect of gallbladder bile on calcium carbonate precipitation in an in vitro assay system was preserved even after colectomy. In conclusion, proctocolectomy increases the concentration of unconjugated bilirubin in gallbladder bile and induces pigment gallstones which are composed mainly of sodium bilirubinate and proteins since calcium ions and cholesterol are stabilized in dogs.     

Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy

BACKGROUND: Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable. METHODS: Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC), followed by spincterotomy, despite the absence of common bile duct stones. RESULTS: All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria. During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent predelivery cholecystectomy. CONCLUSIONS: In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for gallstone pancreatitis during pregnancy. Further investigation is warranted.     

Surgical treatment of the paroxysmal tachycardia in Wolff-Parkinson-White syndrome

22 patients with radiolucid stones and functioning gallbladder were grouped to establish ursodeoxycholic acid efficacy (i.e. gallstones dissolution) and innocuousness for gallbladder lithiasis. Methodological aspects were detailed, the dose determined (8 and 10 mg/k/d.) and the patients evaluated after a six months' treatment. 11 patients received "day-time" doses and the other 11 "overnight" dose. Only 7 subjects turned out to be evaluated for the study of biliary lipids, to the other 15 the development of their gallstones was followed up. Successful gallstone dissolution was achieved in 8 patients (53,3%), 2 reduced size and number. 5 out of these 8 patients received "day-time" doses and the other 3 "overnight" doses. From an attendance point of view, we do not consider biliary lipids study (bile cholesterol saturation rate) to be necessary.     

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones

BACKGROUND: On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones. METHODS: When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission. RESULTS: Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4-54) or 22 days if open surgery was used. CONCLUSIONS: In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfering with LC.     

Gallstone prevalence and biliary lipid composition in inflammatory bowel disease

Biliary cholesterol saturation has been correlated with disease variables that might effect bile acid loss in ileitis patients with (N = 9) or without (N = 8) intestinal resection having a defined prevalence of gallstones. In addition, cholesterol saturation was determined in ulcerative colitis patients (N = 7) and gallstone patients (N = 18) as well as in 5 normal controls. Biliary cholesterol saturation in ileitis patients both with and without resection was similar to that in gallstone patients yet the prevalence of gallstones was only 12%. Cholesterol saturation did not correlate with ileal resection nor the extent, duration, or activity of ileitis. Biliary cholesterol saturation was not different in ulcerative colitis patients from that in normal subjects. It is concluded that cholesterol saturation of bile alone does not account for the high prevalence of cholesterol gallstones that has been reported in ileitis patients.     

Effects of octreotide on biliary lipid composition and occurrence of cholesterol crystals in patients with acromegaly. A prospective study

Treatment with the somatostatin analog octreotide is associated with increased gallstone formation. The mechanism of formation of these stones is unclear. The purpose of this study was to examine the effect of a three-month treatment with octreotide on biliary lipid composition and the occurrence of cholesterol crystals in patients with acromegaly. Thirteen patients with active acromegaly, aged 24-76 years, received octreotide (100 micrograms three times daily) for three months. Fasting gallbladder bile was obtained during upper gastrointestinal endoscopy after ceruletide stimulation. Bile was studied before and at the end of the treatment period (N = 7), only before (N = 4), or only at the end of treatment (N = 2). Before treatment, all bile samples but one were supersaturated with cholesterol. However, none contained cholesterol crystals on microscopic examination. At the end of the treatment period, all but two samples were supersaturated with cholesterol. Three of nine samples contained cholesterol crystals, a proportion significantly higher than before treatment. The relative proportions of bile acids, cholesterol, and phospholipids, and the mean cholesterol saturation index were not different before and during treatment. Follow-up ultrasonography showed the occurrence of gallstones in four patients, including the three patients who had cholesterol crystals. We conclude that: (1) fasting gallbladder bile of patients with acromegaly is frequently supersaturated with cholesterol; (2) treatment with octreotide does not increase cholesterol saturation index, but may induce the occurrence of cholesterol crystals. The data are consistent with the view that gallstones induced by octreotide are cholesterol stones and suggest that the drug may impair gallbladder motility and/or decrease cholesterol nucleation time.     

Control of the mutagenicity of arylamines by protein kinases and phosphatases: II. Lack of response of rat liver N-acetyl transferases to phosphorylation modulators

OBJECTIVES: Endoscopic sphincterotomy has become a generally accepted method for extracting common bile duct stones in high risk or cholecystectomized patients. However, stone extraction is impossible by the usual methods in 5 to 10% of cases. The purpose of this study was to evaluate the effect of a recently developed solvent system in patients with large bile duct stones. METHODS: Forty four patients (15 men and 29 women, median age of years) underwent contact dissolution after unsuccessful Dormia extraction. Solvents were administered via a nasobiliary catheter in 41 patients following papillotomy and through a T-tube in 3 patients. Solvent mixtures (26 mM ethylene diamine tetraacetic acid, 40 mM sodium deoxycholate and 30% dimethyl sulfoxide in an alkaline aqueous solution; and a 70/30 dimethyl sulfoxide/methyl tert-butyl ether mixture) were infused continuously and alternatively for 2 hours. RESULTS: Bile duct stones disappeared in 13-24 hours of infusion in 11 patients. In 29 patients, a clear reduction in stone volume occurred, allowing complete endoscopic extraction of the fragments. In 4 patients, the size of the stone did not change. Only mild and transient side-effects including abdominal pain (68%), nausea (72%), vomiting (52%), diarrhea and sleepiness (50%) were observed. CONCLUSION: Direct dissolution therapy could be an effective method for the non-surgical management of large bile duct stones in selected patients when intra- or extracorporeal lithotripsy is unsuccessful.     

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.     

Gallstone pancreatitis: pathophysiology

The stools of 45 patients with proven gallstones pancreatitis were screened for gallstones. An equal number of peripheral with gallstones but without pancreatitis served as the control group. Gallstones were found in the stools of 38 of the 45 patients (84 percent) with gallstone pancreatitis and in only five (11 percent) patients of the control group. The patients with gallstone pancreatitis experienced a relief of symptoms and a decrease in the levels of serum amylase and bilirubin prior to rectal passage of the stones. Operative cholangiography revealed reflux of contrast material into the pancreatic duct of 67 percent of the patients with gallstone pancreatitis and in only 18 percent of the controls. Of the 38 patients that passed stones, 30 cholangiograms (79 percent) demonstrated a functioning common channel. it would appear that a functioning common channel is necessary for reflux and in addition favors stone passage. This study suggests that the pathophysiology of gallstone pancreatitis relates to the temporary impaction of migrating stones at the ampulla of Vater.     

Urgent ERCP and early elective laparoscopic cholecystectomy in biliary pancreatitis

BACKGROUND: For many years the best algorithm of treatment for complicated gallstone disease has been intensively discussed. Gallstone pancreatitis with cholangitis still belongs to the most often identified causes of death of necrotizing pancreatitis. The reduction of complication and lethality rates was mainly achieved by urgent ERCP and sequential cholecystectomy. In a prospective study we have combined endoscopic therapy with laparoscopic cholecystectomy (LC) and are discussing the results. PATIENTS AND METHODS: Between May 1991 and December 1996 146 patients with biliary pancreatitis were subjected to ERCP after laboratory tests and ultrasound screening of the biliary system. If there were no contraindications and the gallbladder was still in situ, LC was attempted during the initial admission. RESULTS: Of the 70 patients with attempted LC 26 had common bile duct calculi, 23 had an impacted papillary stone and 10 had signs of a stone passage. 59 patients underwent LC successfully, a conversion to open surgery was necessary in 11 patients. The morbidity rate amounted to 7%, lethality to 0%. DISCUSSION: Since a more liberal indication for ERCP in the management of acute pancreatitis was introduced the number of biliary related cases of acute pancreatitis is increasing. In response to early endoscopic bile duct clearance the rates of morbidity and mortality can be significantly reduced. Early LC is the ideal complementary treatment option to absolutely prevent recurrencies.