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The charges of severe problems similar to pancreatitis (all <4%) and perforation (all <0. The alternative between these methods or surgical procedure depends largely on availability and native expertise. The electrohydraulic probe consists of two coaxially isolated electrodes at the tip of a versatile catheter, which is capable of delivering electric sparks in short, speedy pulses leading to sudden enlargement of the encompassing liquid setting and generating stress waves that result in stone fragmentation (Picus, 1990). Continuous saline irrigation is used with the bipolar electrode positioned at the floor of the stone to present a media for shock-wave power transmission, to flush away debris, and to keep enough visualization (DiSario et al, 2007). The authors used a mother-daughter cholangioscope and achieved fragmentation in 96% of the patients, with an eventual stone clearance fee of 90%. Complications included cholangitis (14%), pancreatitis (1%), and hemobilia (1%) that was efficiently treated with epinephrine. There was only one complication of cholangitis, handled conservatively with antibiotics. During holmium laser therapy, steady ductal irrigation with normal saline is required to provide a medium for the switch of vitality and to assist clear stone fragments (Lee et al, 2012). Despite the fragmentation of stones, normal strategies similar to balloon sweep or mechanical lithotripsy may still be required to fully clear the duct of all debris. The holmium laser has a excessive absorption coefficient in water and due to this fact has a greater security margin and has greater than a hundred instances the vitality absorption than the neodymium laser (Maydeo et al, 2011). A potential research in 2011 examined 60 sufferers with choledocholithiasis who both failed remedy with standard methods or have been referred for management of potentially troublesome stone elimination (Maydeo et al, 2011). Complications included fever in three patients (although these patients were already admitted with cholangitis), postprocedure ache requiring hospital admission in 4 patients, and a biliary stricture in 1 affected person who developed a stricture proximal to the stone, which was efficiently handled with dilation utilizing a 10-Fr biliary stent for 3 months. In contrast to intracorporeal strategies, direct contact with the stone is unnecessary. Most facilities localize stones with fluoroscopic focusing during distinction perfusion of the bile duct through an endoscopically positioned nasobiliary catheter or percutaneous drain (Gordon et al, 1991; White et al, 1998). Minor problems are frequent and embody biliary ache, hemobilia, transient liver operate test elevations, and cutaneous petechiae. Furthermore, issues with tube placement, such as unintended dislodgment, have led to the alternative therapy of short-term biliary endoprosthesis placement (Kiil et al, 1989; Rustgi & Schapiro, 1991). Of eighty four patients deliberately handled with everlasting plastic stents for endoscopically irretrievable stones and followed for a mean of 3 years, forty nine (58%) developed biliary complications, and 9 died on account of complications. Most of the patients had an extended, symptom-free interval, nonetheless, before problems developed, supporting stenting solely as a shortterm remedy (Bergman et al, 1995; Maxton et al, 1995). However, the silicone covering on the stent has allowed for delayed stent removing and thus has subsequently been efficiently used in an off-label trend for benign biliary diseases, corresponding to benign biliary strictures and complex bile duct stones (Deviere et al, 2014; Tarantino et al, 2012). It has been postulated that the friction between the stones and the stent reduces the stone measurement, and radial dilating force of the stent across the papilla further assists within the clearance of choledocholithiasis (Garcia-Cano et al, 2013; Katsinelos et al, 2003). A retrospective review studied 36 sufferers with complex biliary stones who had incomplete ductal clearance despite the usage of advanced extraction methods (Cerefice et al, 2011). All patients had successful procedures by way of biliary drainage, and the stents had been left in place for a median of 200 days. Gallstones and Gallbladder Chapter 36C Stones in the bile duct: endoscopic and percutaneous approaches 617 6 months without any complications related to stent placement. The preliminary outcomes with these agents had been disappointing because of incomplete stone dissolution and complications. Serious opposed occasions resulting in discontinuation of treatment occurred in 5% of patients, together with hemorrhage from duodenal ulceration, acute pancreatitis, jaundice, pulmonary edema, acidosis, anaphylaxis, septicemia, and leukopenia, but no deaths were reported. The use of natural solvents, such because the aliphatic ether methyl tert-butyl ether (Allen et al, 1985), additionally has been disappointing, with full stone dissolution achieved in solely 30% to 45% and an unacceptable complication price related to systemic absorption from spillover of solvent into the duodenum and intrahepatic bile ducts (Brandon et al, 1988; Diaz et al, 1992; Kaye et al, 1990; Murray et al, 1988; Neoptolemos et al, 1990). Complication charges should be interpreted with warning as a outcome of definitions of hemorrhage, acute pancreatitis, cholangitis, and perforation often differ, although many studies use consensus definitions (Cotton et al, 1991). The combined protecting impact of pancreatic stents and rectal nonsteroidal antiinflammatory drugs is the subject of ongoing research. A new, extremely potent protease inhibitor, nafamostat mesylate, has shown important efficacy in early trials; however, bigger medical research are needed (Park et al, 2011). Postsphincterotomy bleeding is often acknowledged instantly after the sphincterotomy, but some patients might have delayed bleeding. Controlled sphincterotomy method with using blended current, while avoiding the "zipper" reduce, is a recommended methodology to prevent bleeding. In sufferers with delayed bleeding, symptoms are much like any routine higher gastrointestinal bleed, together with hemodynamic modifications and melena. Mild cholestasis may be evident due occlusion of the biliary orifice with blood clots. Most experts now would count on to extract stones in at least 90% of successful sphincterotomies. Failure to extract or pass stones could additionally be as a end result of the size or number of stones throughout the duct or unfavorable duct diameter, often in its retropancreatic phase. Interpretation of success charges necessitates care as a end result of centers with higher expertise are extra probably to be referred troublesome circumstances that may be failures from attempts elsewhere, biasing outcomes. Patient groups additionally vary considerably from unit to unit and nation to country, reflecting different referral patterns, choice of sufferers, and attitudes towards endoscopic therapy. In rare instances of main arterial hemorrhage, endoscopic view of the papillary area is obscured by blood, precluding any additional endoscopic therapies. In these sufferers, angiography with superselective embolization of the active bleeding website has been proven to be highly efficient (Maleux et al, 2014). Duodenal perforation is comparatively rare and is either a small retroperitoneal perforation related to the sphincterotomy or a big duodenal perforation from the shaft of the scope. Most of these long-term problems are amenable to further endoscopic therapy. Ductal exploration could additionally be accomplished through the cystic duct or directly via a choledochotomy. Bile duct clearance charges common 90%, with a median fee of conversion to open operation of 4% (Tranter & Thompson, 2002). The outcomes of these trials have been strikingly similar, demonstrating similar ductal clearance rates for each teams (75% to 95%) with comparable charges of complications and mortality. In studies that examined hospital parameters, the single-stage surgical method provided decrease length of stay and cut back hospital costs. Length of stay and related hospital prices can be lowered with improved coordination between the surgeon and the endoscopist. Although the singlestage method appears a minimum of equivalent to the two-stage method, implementation of this strategy is restricted to facilities A. Gallstones and Gallbladder Chapter 36C Stones in the bile duct: endoscopic and percutaneous approaches 619 with significant expertise in laparoscopic bile duct exploration.

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Recent research present that this fluke can promote the expression of focal and cell-cell adhesion proteins in cholangiocarcinoma cells and secretion of matrix metalloproteinases, resulting in the proliferation and invasion of this most cancers (Won et al, 2014). Hepatocellular carcinoma also has been associated with clonorchiasis, together with hepatitis B virus and alcohol consumption as cofactors (Tan et al, 2008). Moreover, gallbladder tubulovillous adenoma has been reported with Clonorchis infection (Cheng et al, 2013). Human clonorchiasis and opisthorchiasis are primarily recognized by the detection of eggs in feces. The Kato-Katz method is accepted as one of the best for fecal examination, though sometimes the eggs may not be detected because of biliary obstruction or intermittent egg excretion, just like that encountered with fascioliasis. Thus a quantity of Kato-Katz thick smears may increase the detection fee of Clonorchis eggs (Qian et al, 2013). Early detection of those liver fluke infections is essential to forestall the appearance of cholangiocarcinoma in the untreated people. Ruangsittichai and colleagues (2006) reported high sensitivity and specificity utilizing a recombinant eggshell protein, with potential for the serodiagnosis of human opisthorchiasis. Treatment Praziquantel, a by-product of pyrazino isoquinoline, is the drug of alternative for O. For clonorchiasis, the beneficial dose of praziquantel is 25 mg/kg thrice at 5 hour intervals in 1 day (total dose, seventy five mg/kg), with a remedy fee of 83% to 85% (Rim, 2005). Occasionally, coinfection with Fasciola and Clonorchis has been reported in areas where each parasites are endemic, and therapy ought to embody each praziquantel and triclabendazole (Kim et al, 2014). Other surgical problems reported are ileal volvulus, perforations, intussusception, and impacted a number of worm boluses (Ramareddy et al, 2012). In addition, eight confirmed partial obstruction of the biliary tract, and eight discovered ruptured cysts; F hepatica (n. Endoscopic sphincterotomy was performed, after which the choledochus was examined rigorously using a balloon catheter and basket process. The treatment for Ascaris within the biliary tract is elimination of the adult parasite through the endoscope, followed up by a single oral dose of albendazole (400 mg). Hepatic hydatid cyst (larval cystic stage of adult parasite tapeworm Echinococcus granulosus) rupture into the biliary tree happens in 5% to 25% of sufferers and constitutes the most common complication of hepatic echinococcal cysts (see Chapter 74). However, oral albendazole (400 mg) twice every day can be began before the procedure. The remedy of alternative for hepatic echinococcosis normally includes antihelmintic remedy and surgical resection or percutaneous aspiration. Regardless of administration, antihelmintic drugs ought to all the time be began earlier than endoscopic or surgical remedy to inactivate intracystic materials and decrease allergic problems or postoperative recurrence. Ait Ali A, et al: Hepatobiliary distomatosis: a mistaken explanation for cholangitis, Gastroenterol Clin Biol 26:541, 2002. Almendras-Jaramillo M, et al: Hepatic fascioliasis in children: unusual clinical manifestations, Arq Gastroenterol 34:241�247, 1997. Apt W, et al: Treatment of human chronic fascioliasis with triclabendazole: drug efficacy and serologic response, Am J Trop Med Hyg fifty two:532�535, 1995. Aroonroch R, et al: Hepatic fascioliasis because of Fasciola hepatica: a twocase report, J Med Assoc Thai 89:1770�1774, 2006. Ashrafi K, et al: Plant-borne human contamination by fascioliasis, Am J Trop Med Hyg seventy five:295�302, 2006. Bjorland J, et al: An outbreak of acute fascioliasis amongst Aymara Indians in the Bolivian Altiplano, Clin Infect Dis 21:1228�1233, 1995. Black J, et al: Human fascioliasis in South Africa, S Afr Med J 103:658� 659, 2013. Blancas G, et al: Fasciolosis humana y compromiso gastrointestinal: estudio de 277 pacientes en el Hospital Nacional Cayetano Heredia, 1970-2002, Rev Gastroenterol Peru 24:143�157, 2004. Bonniaud P, et al: Ultrasound side of fascioliasis of the biliary tract, J Radiol 65:589�591, 1984. Bulbuloglu E, et al: Diagnosis of Fasciola hepatica circumstances in an working room, Trop Doct 37:50�52, 2007. Chemale G, et al: Proteomic evaluation of glutathione transferases from the liver fluke parasite, Fasciola hepatica, Proteomics 6:6263�6273, 2006. Cheng Y, et al: Gallbladder tubulovillous adenoma in a patient with liver fluke infection, J Gastrointestin Liver Dis 22:374, 2013. Choi D, et al: Cholangiocarcinoma and Clonorchis sinensis infection: a case-control examine in Korea, J Hepatol forty four:1066�1073, 2006. Cosme A, et al: Fasciola hepatica examine of a series of 37 sufferers, Gastroenterol Hepatol 24:375�380, 2001. Cosme A, et al: Sonographic findings of hepatic lesions in human fascioliasis, J Clin Ultrasound 31:358�363, 2003. Cruz-Lopez O, et al: Fasciolosis hepatica diagnosticada en fase de estado, Rev Gastroenterol Mex 71:59�62, 2006. Dalimi A, Jabarvand M: Fasciola hepatica within the human eye, Trans R Soc Trop Med Hyg 99:798�800, 2005. Das K, et al: Non-resolving liver abscess with Echinococcus crossreactivity in a non-endemic area, Indian J Gastroenterol 26:92�93, 2007. Diaz Fernandez R, et al: Obstructive jaundice, Fasciola hepatica: a new case report, Rev Cubana Med Trop fifty seven:151�153, 2005. Dobrucali A, et al: Fasciola hepatica infestation as a really rare explanation for extrahepatic cholestasis, World J Gastroenterol 10:3076�3077, 2004. Favennec L, et al: Double-blind, randomized, placebo-controlled examine of nitazoxanide within the remedy of fascioliasis in adults and youngsters from northern Peru, Aliment Pharmacol Ther 17:265�270, 2003. Furst T, et al: Global burden of human food-borne trematodiasis: a systemic review and meta-analysis, Lancet Infect Dis 12:210�221, 2012. Gabrielli S, et al: Parasitological and molecular observations on a little family outbreak of human fasciolosis recognized in Italy, Scientific World Journal 2014:417159, 2014. Gil-Gil F, et al: Hepatobiliary fascioliasis with out eosinophilia, Rev Clin Esp 206:464, 2006. Giron�s N, et al: Immune suppression in superior persistent fascioliasis: an experimental research in a rat model, J Infect Dis 195:1504�1512, 2007. Gonzalo-Orden M, et al: Diagnostic imaging in sheep hepatic fascioliasis: ultrasound, computer tomography and magnetic resonance findings, Parasitol Res 90:359�364, 2003. Heredia D, et al: Gallbladder fascioliasis in a affected person with liver cirrhosis, Med Clin (Barc) 82:768�770, 1984. Inoue K, et al: A case of human fasciolosis: discrepancy between egg measurement and genotype of Fasciola sp, Parasitol Res a hundred:665�667, 2007. Kaewpitoon N, et al: Opisthorchiasis in Thailand: evaluate and current standing, World J Gastroenterol 14:2297�2302, 2008. Katz N, et al: A easy device for quantitative stool thick-smear technique in schistosomiasis mansoni, Rev do Inst Med Trop S�o Paulo 14:397�402, 1972. Kaya S, et al: Seroprevalence of fasciolosis and the distinction of fasciolosis between rural area and city center in Isparta, Turkey, Saudi Med J 27:1152�1156, 2006. Keiser J, Utzinger J: Emerging foodborne trematodiasis, Emerg Infect Dis 11:1507�1514, 2005.

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These complications embrace hepatic ischemia, infarction, hepatic failure, gallbladder ischemia, bile leak, and abscess formation. Angiography could be extraordinarily helpful in the analysis and treatment of these patients. In 25 of 43 sufferers present process angiography to diagnose and deal with postpancreatectomy hemorrhage, a bleeding website was positioned and embolized with an 80% success price in controlling the hemorrhage (Yekebas et al, 2007). The comparatively low price of positive angiograms may be defined by the high incidence of venous bleeding encountered in the postpancreatectomy affected person. Regional portal hypertension develops in many of these sufferers as a outcome of splenic or superior mesenteric venous compression or occlusion secondary both to the underlying pathology or a surgical complication. If the underlying etiology is compression of the splenic vein, percutaneous transhepatic stenting of the splenic vein may be doubtlessly useful. However, delineation of pathology in smaller branches, corresponding to with vasculitis, or refined pathologic adjustments may require the elevated morphologic element afforded by catheter angiography. In that circumstance, the influx have to be corrected both by surgical or endovascular interventions. Another potential area of concern is pancreaticoduodenectomy, particularly in jaundiced sufferers. Treatment of Visceral Arterial Aneurysms Visceral artery aneurysms are uncommon entities that involve the celiac, splenic, superior mesenteric, or inferior mesenteric arteries and their branches (see Chapter 124). True aneurysms contain all three vessel walls and are normally atherosclerotic or developmental in origin and differ from those encountered in pancreatic inflammatory illness, that are sometimes pseudoaneurysms. Depending on the scale and location of the aneurysm, mortality from rupture ranges from 25% to 100% (Cordova & Sumpio, 2013). The splenic artery is the commonest affected artery, adopted by the hepatic artery. Splenic artery aneurysms in girls of childbearing age are of particular concern due to their propensity to rupture during childbirth. Most splenic aneurysms are saccular and positioned within the mid to distal section of the artery (Nosher et al, 2006). Endovascular treatment of splenic artery aneurysms is decided by the tortuosity and placement of the aneurysm. Stent placement is used for extra proximal disease and distal illness in a tortuous vessel is usually treated with coil embolization (Hemp & Sabri, 2015). Traditionally, surgical resection or ligation of the visceral aneurysms was the gold commonplace of therapy; nevertheless, endovascular treatments have largely replaced open resection. Large studies have reported technical success charges starting from 89% to 98% (Hemp & Sabri, 2015; Sachdev et al, 2006; Tulsyan et al, 2007). Endovascular therapies are associated with shorter hospital keep, compared with surgical restore: 3. The hepatic artery supplies the bile duct, and the bile duct has been rendered devoid of collateral arterial supply during donor hepatectomy. Arterial insufficiency sometimes results in biliary strictures and to probably diffuse biliary ductal infarction. Hepatic artery thrombosis might lead to irretrievable allograft injury and should necessitate retransplantation. When a hepatic arterial stenosis is identified earlier than superior biliary damage, endovascular remedy with both balloon angioplasty and/or stent placement is warranted. The most typical vasculitis with hepatic involvement is polyarteritis nodosa, which can not lead to symptoms despite involvement of the visceral arteries, though pancreatitis, cholecystitis, and hepatic dysfunction could additionally be observed. Arterial abnormalities in the liver have also been recognized in sufferers with systemic lupus erythematosus and Wegener granulomatosis. Diagnosis of Other Visceral Vascular Disease Segmental Arterial Mediolysis A rare vascular dysfunction, segmental arterial mediolysis, may require catheter angiography for definitive prognosis. This dysfunction is characterised pathologically by noninflammatory destruction of clean muscle cytoplasm, resulting in arterial dissection and aneurysm formation. Clinically, these lesions are prone to both occlusion by dissection in addition to rupture, leading to catastrophic stomach hemorrhage. Treatment with coil embolization within noncritical arterial beds has been reported (Davran et al, 2010). The hepatic arterial malformations that shunt blood into the hepatic venous system may be initially noted on a cross-sectional imaging research, but the findings may be nonspecific. Although this disorder has been treated with transcatheter techniques, embolotherapy has presently fallen out of vogue because of the danger of precipitating hepatic failure. This abnormality has been associated with human immunodeficiency virus infection as well as with using certain medicine, including immunosuppressives, antimetabolites, and oral contraceptives. Although often benign, it has been associated with spontaneous massive hemorrhage and subsequently may be encountered angiographically in the course of the investigation of hepatic bleeding (Choi et al, 2009). Localization of Functional Pancreatic Neuroendocrine Tumors (See Chapter 65) Calcium stimulation arteriography was developed and described in 1991 (Doppman et al, 1991). When 1 mL of 10% calcium gluconate is injected into an artery supplying the pancreas, tumor cells degranulate and release insulin into the portal venous circulation. In the article by Guettier and colleagues (2009), calcium stimulation arteriography was probably the most delicate method for localizing surgically proven insulinomas, with an accuracy of 84%, a false-negative fee of 11%, and a false-positive rate of 4%. Percutaneous transhepatic sampling of the splenic, superior mesenteric, and portal venous system can be performed to diagnose occult neuroendocrine tumors of the pancreas. This could also be carried out along side calcium stimulation as described earlier, or it might be performed without stimulation due to the upper concentration of the hormone when obtained instantly or adjoining to the venous tributary. Insulinomas Greater than 90% of insulinomas are single, benign tumors for which surgical resection is curative. These tumors are the most typical tumors originating from the islets of Langerhans (see Chapter 65). Fifty p.c of gastrinomas happen within the pancreas, with the duodenum being the most common extrapancreatic location. When an occult gastrinoma is encountered, angiography has been used for localization. The ideas are equivalent to the localization of insulinomas; nonetheless, secretin has been used in addition to calcium gluconate as the stimulating agent. Angiographically, gastrinomas are less hypervascular and harder to detect compared to insulinomas. Moreover, the 50% extrapancreatic location makes detection tougher, often requiring superselective catheterization to consider the duodenum. Cross-sectional imaging can accurately depict the connection of a mass in the pancreas to both the splenic and superior mesenteric veins. It also has the advantage of simultaneous opacification of all the venous buildings. These situations embody planning of percutaneous venous intervention in situations the place occlusions are suspected or often to plan a surgical portosystemic shunt. When detailed visualization of the venous anatomy is required, a higher dose of distinction media can be used for the arterial injection, increasing the clarity of venous opacification.

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Meanwhile, with placement of self-expandable metallic stents in areas of strictures, 2-year patency rates have been estimated to be approximately 40% (Siriwardana et al, 2005). These outcomes are controversial, including some recommendations that these stents not be used for dilation. Therefore full clearance of intrahepatic calculi is obligatory if adverse results are to be prevented. Endoscopic therapeutic intervention in patients with Rouxen-Y anastomosis and hepaticojejunostomy is typically difficult. Surgical Treatment In the 1970s, the primary surgical remedy was cholecystectomy with stone elimination and insertion of a T-tube to permit removing of remnant stones by postoperative cholangioscopy (Choi et al, 1982; Sato et al 1980; Yamakawa et al, 1980). Currently, the frequency of use of cholecystectomy with stone removal and insertion of a T-tube has remarkably decreased (1985-1988, 50. Choledochojejunostomy or transduodenal papilloplasty was additionally performed in Nineteen Seventies; however, these are hardly ever performed currently. Intrahepatic stones restricted to the left lobe, accounting for about half of cases, characterize a good indication for liver resection alone from the views of remedy and therapy time (Shah et al, 2012). The incidence of residual stones after hepatectomy is often lower than after endoscopic lithotripsy (see Table 39. Jan and colleagues (1996) reported considerably superior outcomes with hepatectomy versus nonsurgical remedy (stone recurrence: 9. In addition, peripheral stone impaction and ductal angulation are the reason for issue. Postoperative choledocholithotomy through the fistula formed by T-tube placement within the widespread bile duct. Management of bilateral hepatolithiasis is more sophisticated than the administration of unilateral hapatolithiasis. Indeed, Chen and colleagues (1997) reported the speed of complete stone clearance was 84% at 1 yr after operation, regardless of 60% of the patients having remnant stones immediately after the operation. In addition, combining hepatectomy and hepaticojejunostomy with anchoring of the jejunal A. A, A case of secondary hepatolithiasis after excision of congenital choledochal cysts. Some filling defects (arrows) within the left hepatic duct were demonstrated on magnetic resonance cholangiopancreatography. B, Three-dimensional computed tomography shows marked atrophy of the left hemiliver with diminished portal move. D, Resected specimen shows marked atrophy and impacted stones in the left hemiliver. If stones recur several years after complete stone clearance, this jejunal limb can be utilized as an access route to the biliary system underneath local anesthesia. Some think about this a helpful process for prevention of bacterial reflux into the liver (Herman et al, 2005). However, complementary hepaticojejunostomy itself could cause cholangitis (Kusano et al, 2001). Herman and colleagues (2010) confirmed that each one patients submitting to liver resection solely showed good outcomes, whereas 7 of 17 patients (41. In an try and clarify the downside of bilioenteric anastomosis, they in contrast solely sufferers with unilateral illness, with and without hepaticojejunostomy; there was a big distinction between the teams, displaying the negative effects of the bilioenteric anastomosis on patient consequence. Bilateral partial resection of the liver could provide good longterm results even within the sufferers with bilateral intrahepatic stones and stenosis (Yang et al, 2010). The incidence of stone recurrence after bilateral and unilateral hepatectomy for bilateral intrahepatic stones was 11. However, it should be noted that there have been three hospital deaths among 54 sufferers within the bilateral resection group, which had been associated to postoperative liver failure. Even in patients with bilateral stones, stone recurrence rates are low and comparable to that of unilateral stones if the extent of liver resection is the identical as stone-affected segments (Li et al, 2012). The security of hepatectomy has improved, however the postoperative complication rates, including wound an infection, hemobilia, and biliary fistula, are nonetheless 15. Li and colleagues (2012) reported that left lobectomy or hepatectomy within 1 month of the final episode of cholangitis is a danger factor for postoperative bile leakage. With current advances in laparoscopic techniques, laparoscopic liver resection is more and more being performed for hepatolithiasis (Cai et al, 2007). Magnetic resonance picture demonstrating dilated proper posterior intrahepatic duct containing a number of stones. B, Three-dimensional computed tomography reveals a number of biliary stenosis and dilation in the left lateral part. C, Bilateral hepatectomy, left lateral sectionectomy, and posterior sectionectomy, with T-tube insertion was carried out. The orifice was then moreover resected and sutured to cut back the scale of remnant dilated posterior duct to be as small as attainable. F, Postoeprative cholangioscopy reveals a remnant stone that subsequently eliminated using basket forceps. Gallstones and Gallbladder Chapter 39 Intrahepatic stones 655 remains to be limited, operative mortality and residual stone rates are similar to open hepatectomy (Lai et al, 2010). On the opposite hand, elevated postoperative problems have been reported (Zhou et al, 2013), and thus no consensus yet exists relating to its scientific usefulness. Because of its sophisticated pathologic features similar to repeated cholangitis and multiple operations, diffusely distributed hepatolithiasis is untreatable by hepatectomy, cholangiojejunostomy, and choledochoscopy, and subsequently often leads to portal hypertension and liver failure. The major elements that predict the long-term end result of intrahepatic stones are concomitant cholangiocarcinoma, cholangitis, liver abscess, and biliary cirrhosis because of repeated cholangitis. Recurrence charges, relying on the sort of remedy and presence or absence of bile duct strictures, range from 0% to 50. Patients with recurrence may have repeated/chronic cholangitis and develop biliary cirrhosis over a interval of 10 to 20 years. These patients require careful long-term follow-up as a result of most cancers is understood to develop after 10 to 20 years. The overall 10-year survival price in hepatolithiasis is about 80% to 90% (Jan et al, 1996; Uenishi et al, 2009). A drawing of mixing hepaticojejunostomy with anchoring of Roux-en-Y jejunal limb to the abdominal wall for the purpose of postoperative stone extraction (upper). A cholangiogram after lithotomy reveals no remnant stones in the dilated left hepatic duct (arrowheads) (lower). Al-Sukhni W, et al: Recurrent pyogenic cholangitis with hepatolithiasis� the position of surgical remedy in North America, J Gastrointest Surg 12:496�503, 2008. Best R: the incidence of liver stones related to cholelithisis and its clinical significance, Surg Gynecol Obstet 78:425�428, 1944. Bettschart V, et al: Cholangiocarcinoma arising after biliary-enteric drainage procedures for benign illness, Gut 51:128�129, 2002.

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Complete clearance of stones is typically inconceivable because of the presence of an enormous number of stones, or as a end result of many extra stones are discovered solely on postoperative cholangiogram. Postoperative choledochoscopy is required through the T-tube tract, or a cutaneous stoma is required. With quite a few periods of choledochoscopy aided by electrohydraulic lithotripsy, full stone clearance can be achieved in 90% of sufferers (Table forty four. With the assist of the "mother-baby" endoscope system, the complete stone elimination fee is roughly 64%. Access to the biliary tract by using the gastroscope through choledochoduodenostomy or interposition duodenojejunostomy has been considered (Cunha et al, 2002; Ramesh et al, 2003). Although these strategies have the advantage of no cutaneous stoma or percutaneous tube, both have the disadvantage of poor entry to the small intrahepatic ducts by the gastroscope. Hepatic Resection Partial hepatectomy is indicated for destroyed liver segments, multiple cholangitic liver abscesses, and concomitant cholangiocarcinoma (Cheung & Kwok, 2005; Co et al. After hepatectomy, the proper and customary ducts are explored for elimination of intraductal stones. Right sided hepatectomy was once seldom performed, thought-about too dangerous and undesirable for a nonmalignant condition. If the inflow and outflow vascular dissection is tough because of previous operation or infection, it may be sensible to proceed to parenchymal transection immediately and to achieve vascular control inside the liver parenchyma. Furthermore, mobilization of the right facet of the liver may end up in bacteremia; therefore the anterior approach is most popular (Liu et al, 2003). Adhesion of the left lateral segment to the adjoining viscera on account of repeated an infection and rupture of liver abscess might predispose to injury to the vagus nerve, diaphragm, and phrenic veins and to a better incidence of postoperative septic problems (Fan et al, 1993a). The location of the stoma has to be planned fastidiously earlier than the operation to keep away from scarred areas. Choledochoscopic extraction of stones is mostly effective, but occasional large stones could show tough and may defy fragmentation by electrohydraulic lithotripsy. An acceptable selection of antibiotic and wound protection during the operation might lower the incidence of wound infections. With advances in the laparoscopic surgery technique, left lateral segmentectomy and even left hepatectomy might be carried out in select patients with an atrophic segment by using a hand-assisted gadget (Chen et al, 2004; Tang & Li, 2003) (see Chapter 105). These sufferers skilled less ache and had a shorter hospital stay, though the operation was longer and more challenging (Tang et al, 2005). Intrahepatic duct strictures have been treated by selfexpanding metallic stents with a reported patency rate of roughly 60% (Jeng et al, 1999; Tsukamoto et al, 2004; Yoon et al, 1997). However, using such stents for benign biliary stricture continues to be controversial. Liver Transplantation Bilateral and extensive presence of intrahepatic stones far out into the peripheral ducts may not be amenable to resection and endoscopic treatment. Meticulous surgical procedure to Treatment for Intrahepatic Duct Strictures Strictures positioned in the extrahepatic bile duct may be treated or circumvented by hepaticojejunostomy performed proximal to the stricture. Intrahepatic duct strictures associated with liver atrophy or numerous cholangitic abscesses are best treated by partial hepatectomy. If vital thickness of the liver parenchyma remains to be present, the stricture is finest treated by instrumental dilation (Cheng et al, 2000). After adequate dilation and elimination of stones, nevertheless, such strictures could recur, and the stoma of the hepaticocutaneous jejunostomy, if present, must be reopened for repeat C. Biliary Infection and Infestation Chapter 44 Recurrent pyogenic cholangitis 741 numerous kinds of imaging and on the expertise of the group, particularly in choledochoscopy. The greatest outcomes are achieved after good imaging research, selection of the suitable process for the individual case, and vigilant postoperative choledochoscopy before removal of the T-tube or closure of the cutaneous stoma. Our series indicate that the rising use of aggressive treatment-such as partial hepatectomy, hepaticocutaneous jejunostomy, and diligent postoperative choledochoscopy-can result in a 100 percent stone clearance rate and 3% stone recurrence price after a median follow-up period of 26 months, with a mortality rate of solely 1% (see Table 44. With respect to the location of the illness, patients with simple disease patterns may be anticipated to do well in the long term with drainage procedures, whereas patients with difficult illness patterns are expected to have a 30% recurrence of symptoms (Chijiiwa et al, 1995; Jan et al, 1996). Along with recurrence of stones and strictures, progressive liver injury leads to portal hypertension, liver failure, and cholangiocarcinoma. Approximately 10% to 20% of sufferers could finally die of the disease, and the incidence of issues is related to the failure to eradicate stones completely at remedy (Jan et al, 1996). This hemorrhage, together with the underlying sepsis, leads to a much larger threat than in different sufferers present process liver transplantation. If liver transplantation is carried out before multiple biliary procedures, the end result appears to be acceptable (Chen et al, 2008; Strong et al, 2002). Mobilization of the native liver also can induce bacteremia and further improve the risk of hemodynamic instability. Although it will not be potential to prevent recurrence of stones and strictures in all sufferers, the development of a permanent percutaneous access to the biliary tract can facilitate the general management and cut back the magnitude of subsequent procedures. For easier cases, full removal of the stones and dilation or bypass of all strictures mixed with vigilant follow-up can forestall disease recurrence. In the case of establishment of secondary biliary cirrhosis and liver failure, an early choice on liver transplantation should be made earlier than the surgical danger has turn into excessively high. Chen P, et al: Laparoscopic left hemihepatectomy for hepatolithiasis, Surg Endosc 18:717�718, 2004. Czerniak A, et al: Liver atrophy complicating benign bile duct strictures: surgical and interventional radiologic appearances, Am J Surg 152:294�300, 1986. Guglielmi A, et al: Hepatolithiasis-associated cholangiocarcinoma: outcomes from a multi-institutional nationwide database on a case series of 23 patients, Eur J Surg Oncol 40(5):567�575, 2014. Hwang S, et al: Intrahepatic biliary exploration via the left hepatic duct orifice during left hepatectomy in patients with left-sided hepatolithiasis, Langenbecks Arch Surg 393:383�389, 2008. Kitagawa Y, et al: Intrahepatic segmental bile duct patterns in hepatolithiasis: a comparative cholangiographic examine between Taiwan and Japan, J Hepatobiliary Pancreat Surg 10:377�381, 2003. Kubo S, et al: Case of hepatolithiasis recognized by magnetic resonance cholangiography, Osaka City Med J forty one:25�30, 1995. Mage S, Morel S: Surgical expertise with cholangiohepatitis (Hong Kong disease) in Canton Chinese, Ann Surg 162:187�190, 1965. Mahadeva S, et al: Endoscopic intervention for hepatolithiasis associated with sharp angulation of proper intrahepatic ducts, Gastrointest Endosc fifty eight:279�282, 2003. In Okuda K, editor: Postgraduate course, Hong Kong, 1982, International Association for the Study of the Liver/Asian Pacific Association for the Study of the Liver. Nakayama F, et al: Hepatolithiasis in Japan: present status, Am J Surg 139:216�220, 1980. Nakanuma Y, et al: Pathologic options of hepatolithiasis in Japan, Hum Pathol 19:1181�1186, 1988. Nakanuma Y, et al: Multistep carcinogenesis of perihilar cholangiocarcinoma arising within the intrahepatic massive bile ducts, World J Hepatol 1:35�42, 2009. Ohta G, et al: Pathology of hepatolithiasis: cholangitis and cholangiocarcinoma, Prog Clin Biol Res 152:91�113, 1984.

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Pancreas Biopsy Despite the best efforts of clinicians and advances in imaging, most patients with pancreatic most cancers still initially present with unresectable illness (see Chapter 59). An anterior method to the pancreas may be difficult because of interposed colon, spleen, or mesenteric vessels, which we would like not to traverse. Retroperitoneal and Pelvic Biopsy A Most retroperitoneal and pelvic biopsies are performed to decide the reason for lymphadenopathy. When the affected person has a recognized malignancy with the proclivity to unfold via retroperitoneal lymphatics, needle biopsy is indicated, and that is generally easily and simply carried out. When lymphoma is a consideration, biopsy specimens must be obtained either for flow cytometry and/or surgical pathology (cores), relying on local practice and experience. Occasionally, a biopsy is carried out to diagnose a soft tissue mass suspected to be a sarcoma. For major prognosis of sarcoma, histologic material is beneficial for classifying the sarcoma, and core biopsy should be performed. If recurrence is the problem, the diagnosis often could be established on the idea of cytology alone. In ladies with pelvic plenty that could be adnexal, needle biopsy should be carried out only after the diagnosis of ovarian cancer has been excluded or after an oncologic gynecologist has been consulted. The biopsy process itself might lead to peritoneal contamination, relegating the affected person to intraperitoneal chemotherapy, when an easier treatment regimen may need been attainable. The size, location, and nature of the target lesion, in addition to operator expertise, and obtainable equipment decide which modality is used. The measurement of the needle used and sort of specimen acquired vary depending on the clinical indication. Diagnostic charges for needle biopsy of malignant lung lesions have been reported as greater than 90% (Swischuk et al, 1998). Lung biopsy could additionally be useful to present materials within the setting of metastatic illness, major malignancy, and/or infection. Not way back, all instances of non�small-cell lung cancers were handled in an analogous fashion. However, recent studies have shown that histologic subtype and certain molecular alterations influence the response to various chemotherapies and targeted brokers (Moreira et al, 2012; Travis et al, 2010). For instance, bevacizumab, a humanized monoclonal antibody focused at endothelial growth factor, is contraindicated in patients with squamous cell lung carcinoma due to elevated danger of pulmonary hemorrhage (Johnson et al, 2004). Bone biopsies are typically performed utilizing bigger needles (11 to 15 gauge) than these used for organ or delicate tissue. Purely lytic lesions are the exception, as a result of small-caliber needles will usually suffice to doc metastases and are in a place to penetrate bone within the setting of cortical destruction. Risks of biopsy embrace bleeding, pneumothorax, infection, bile leak, and needle-tract seeding of tumor. To reduce the risk of bleeding, we advocate that every one patients ought to have acceptable laboratory work earlier than biopsy, together with a whole blood count and coagulation profile. Biopsy in thrombocytopenic patients may be carried out with platelet protection, although the choice to proceed with biopsy must be considered rigorously. It is advisable to have patients cease antiplatelet drugs, if potential, to reduce the chance of bleeding; nonetheless, the chance of stopping antiplatelet remedy should be weighed against the danger of bleeding from the biopsy; sometimes, the balance favors performing the biopsy while the patient remains on his or her common medication(s). The risk of significant bleeding after liver biopsy is less than 1% (Piccinino et al, 1986). In many cases, the bleeding is selflimited, and conservative management comprising observation and hydration will suffice. Some authors advocate putting absorbable gelatin sponge (Gelfoam) pledgets in the biopsy tract via the needle after core biopsy, however this has not been shown definitively to decrease the danger of main bleeding (Hatfield, 2008). Pain out of proportion to imaging findings after liver biopsy may be because of bile peritonitis (Ruben & Chopra, 1987). Care must be taken to minimize needle passes via the gallbladder, cystic duct, or dilated bile ducts. If the gallbladder is inadvertently punctured, it must be aspirated as fully as potential before eradicating the needle. Bile leaks resulting in discernible collections are uncommon after liver biopsy in the absence of downstream biliary obstruction. Adrenal lots and lesions in the dome of the liver sometimes require an approach for biopsy that crosses the lung base, placing sufferers at risk for pneumothorax. The two commonest issues after lung biopsy embrace hemoptysis and pneumothorax (Covey et al, 2004). Hemoptysis happens in roughly 10% of sufferers who bear lung biopsy and is normally self-limited, however it might be frightening to the patient. Pneumothorax occurs in 20% to larger than 40% of patients after biopsy and requires placement of a chest tube in approximately 6% to 12% of circumstances. The risk of pneumothorax is usually related more to affected person than technical elements, though depth of the target lesion, variety of pleural surfaces transgressed, and patient positioning (prone positioning decreases the chance of pneumothorax) have been proven to affect the likelihood. Elderly patients and sufferers with underlying persistent obstructive pulmonary illness are more vulnerable to pneumothorax requiring therapy (Covey et al, 2004; Hiraki et al, 2010; Takeshita et al, 2015). A symptomatic or enlarging pneumothorax is treated with a small-bore chest tube (generally 8 to 12 Fr) and sometimes necessitates hospital admission. A number of methods have been described in an attempt to decrease the incidence of pneumothorax requiring chest tube placement after percutaneous lung biopsy. These embrace autologous blood patch injection into the needle observe (Herman & Weisbrod, 1990), embolization of the needle monitor using gelatin sponge slurry (Tran et al, 2014), quickly putting a affected person in a "puncture-side-down" place following removing of the biopsy guiding needle (Kim et al, 2015), and use of business monitor plugs, among others. Hemorrhagic pericardial tamponade is a rare, probably lifethreatening complication after mediastinal biopsy (Kucharczyk et al, 1982). Although hypoxemia may be a feature, this complication may be distinguished from iatrogenic pneumothorax clinically by the development of hypotension with narrowing of the heartbeat pressure and diminished amplitude of the electrocardiogram complicated on the monitor. The prognosis could be confirmed instantly by scanning the center and pericardium, and it could be handled by immediately placing a drainage catheter into the pericardial space. The interval between biopsy and look of a tract metastasis is 6 to 24 months (Kosugi et al, 2004; Schotman et al, 1999). Although the incidence is relatively small, the potential for rendering a affected person ultimately incurable because of tract or peritoneal seeding ought to be thought of within the risk/benefit evaluation for each patient. Increasingly, needle biopsy is important to provide materials for genetic analysis. If nonspecific findings are evident on cytology, including inflammatory or reactive changes, fibrous tissue, or normal website tissue, or, if atypical cells are present, another biopsy ought to be carried out, or the lesion ought to be closely adopted up, depending on the pretest likelihood of disease. The position of biopsy in affected person management is evolving in tandem with the event of associated fields, including useful and molecular imaging. Until biopsies are now not necessary, every effort ought to be made to maintain morbidity low and diagnostic charges excessive. Al-Leswas D, et al: Biopsy of strong liver tumors: opposed consequences, Hepatobiliary Pancreat Dis Int 7(3):325�327, 2008. Behrens G, Ferral H: Transjugular liver biopsy, Semin Intervent Radiol 29(2):111�117, 2012. Boldrini L, et al: Mutational analysis in cytolological specimens of advanced lung adenocarcinoma: a sensitive method for molecular prognosis, J Thorac Oncol 2(12):1086�1090, 2007. Bruix J, Sherman M: Management of hepatocellular carcinoma: an replace, Hepatology 53(3):1020�1022, 2011.

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Full-thickness, single interrupted 4-0 or 5-0 absorbable sutures approximate the inferior fringe of the duct to the superior fringe of jejunum. Following placement, the posterior row of sutures is tied with knots on the inside. Placement of a sponge circumferentially across the anastomosis allows an intraoperative check to affirm absence of a giant bile leak. To perform this anastomosis, the anterior surface of the duct is uncovered and opened longitudinally for a distance of two. The biliary-enteric anastomosis can then be completed in an identical manner as described for side-to-side hepaticojejunostomy (see earlier). A single interrupted anterior (or right) row of sutures permits publicity for placement of the posterior (or left) row, approximating duct to jejunum, followed by completion of the anterior row (Winslow et al, 2009). After mobilization of hepatic flexure of the colon, a beneficiant Kocher maneuver is carried out to enable adequate mobility of the duodenum to enable building of a tensionfree anastomosis. This produces incisions which are perpendicular to each other (unlike the parallel configuration used during hepaticojejunostomy). As with the hepaticojejunostomy, the duodenotomy is generally shorter in size than the ductotomy. The anastomosis is then constructed in a manner that anastomoses the bile duct transversely to the longitudinally-oriented duodenotomy. Full-thickness sutures are made to approximate the ductal mucosa to duodenal mucosa. A fourth nook suture can then be positioned between the proximal finish of the ductotomy and the midpoint of the anterior duodenal wall. As earlier than, use of a single row of sutures minimizes the chance of anastomotic narrowing. Advantages of a surgical approach versus nonoperative decompressive modalities are long-term patency and sturdiness without the uncommon need for repeat stent placement or revisions. Choledochojejunostomy could be performed as an end-to-side or side-to-side anastomosis. The duct is opened at the level of the planned anastomosis, and the endobiliary stent, if present, is removed. It is essential to identify wholesome, well-vascularized duct proximal to the extent of injury or pathology to keep away from ischemic stricture. Similarly, care should be taken to avoid extreme circumferential dissection of the duct, as this will compromise its blood supply. A 50- to 70-cm Roux-en-Y limb of jejunum is passed retrocolic and to the best of the middle colic vessels and positioned to reside adjacent to the proximal bile duct in a tension-free method. The posterior wall of the duct is sutured to the jejunum with a running 3-0 or 4-0 absorbable suture. A jejunotomy is common along the duct, and single interrupted 3-0 or 4-0 absorbable sutures are used to approximate the jejunal mucosa to the duct mucosa with the knots tied on the inside of the lumen. Due to the small lumen, the anastomosis is Cholecystoduodenostomy and Cholecystojejunostomy Loss widespread approaches to biliary bypass are cholecystoduodenostomy or cholecystojejunostomy. The cholecystoenteric bypass is relatively straightforward to construct, however long-term patency charges are suboptimal compared with maneuvers that immediately decompress the extrahepatic biliary ducts. A second row would do nothing however lower the choledochoduodenostomy orifice size and ought to be prevented. Digital strain on the duodenum or the frequent duct should give no evidence of leakage. The anastamosis may be drained or not, based on preference (the leak fee is 1%). The presence of a closed-suctiondrain(Jackson-Pratttype)obviatestheneedfora subsequent percutaneous drainage catheter if this uncommon complicationoccurs. Ifitentersatthe stage of the tumor (dashed line), the process is contraindicated. Cholecystoenterostomy may be appropriate in conditions the place major tumoral obstruction obscures entry to the porta hepatis; nonetheless, the obstruction must not prolong to the extent of the cystic duct insertion. The presence of cholelithiasis is one other consideration, as vital stone burden throughout the gallbladder makes this operative technique much less enticing. Operatively, the gallbladder and cystic duct are evaluated to guarantee their suitability for biliary decompression; particularly, a patent cystic duct is required for this system to present effective drainage. To assemble a cholecystoduodenostomy, a Kocher maneuver is used to present enough duodenal mobility for a tension-free anastomosis. The gallbladder fundus is secured to the antimesenteric border of duodenum or jejunum with interrupted 3-0 absorbable sutures. A cholecystotomy is carried out and the gallbladder evacuated of stones and bile; a bile specimen can be sent for evaluation. Continuity with the frequent hepatic duct is confirmed, and a corresponding enterotomy mirroring the cholecystotomy is fashioned. Other analyses have additionally confirmed the security and longevity of biliary decompression, with low charges of fistula and stricture formation necessitating subsequent operative intervention (Chapman et al, 1995; Jarnagin et al, 1998; Murr et al, 1999; Tocchi et al, 1996). In sufferers present process bypass for benign illness, consideration should be given to extended scientific monitoring, as there appears to be each a risk of delayed stricture and an elevated threat of cholangiocarcinoma. In a evaluation of 1003 sufferers undergoing biliary decompression, cholangiocarcinoma developed in 5. Costi R, et al: Diagnosis and administration of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy, World J Gastroenterol 20:13382�13401, 2014. Suc B, et al: Surgery vs endoscopy as main treatment in symptomatic patients with suspected widespread bile duct stones, Arch Surg 133:702�708, 1998. Tocchi A, et al: Late growth of bile duct most cancers in sufferers who had biliary-enteric drainage for benign illness: a follow-up study of greater than a thousand sufferers, Ann Surg 234:210�214, 2001. The Greek physician Trallianus described calculi within radicles of a human liver (Glenn & Grafe, 1966). During the sixteenth century, Vesalius and Fallopius described gallstones in the gallbladders of dissected human bodies (Schwartz, 1981). Fernelius is among the first authors who took note of them when examining stool samples (Coe, 1757). Attempts to treat gallstones began in the eighteenth century, based on in vitro experiments by Percival dissolving gallstones by using water impregnated with mounted air (Percival, 1775). In 1788 in his book "Considerations on Bilious Diseases: and Some Particular Affections of the Liver and the Gallbladder, "Andree beneficial a light infusion of ginger, orange peel, and heat water on an empty stomach for these suffering with symptomatic gallstones. The first try at surgical treatment of gallstones is ascribed to John Stough Boobs, considered the daddy of gallbladder surgical procedure, who efficiently performed a cholecystotomy and extraction of gallstones in 1867 (Ellis, 2009). In 1878, James Marion Sims performed the first planned cholecystostomy for biliary drainage as a treatment choice for cholecystitis (Fowler, 1900). He performed the primary successful cholecystectomy, setting the trail for therapeutic surgical intervention for symptomatic cholelithiasis (Halpert, 1932). One century later, in 1985, Eric Muhe carried out the primary laparoscopic cholecystectomy by using a custom-made laparoscope known as the "galloscope," a hemoclip and a pistol-grip scissors. This represented one vital advance in surgery that opened the trendy period in the surgical remedy of gallstones (Walker, 2001).

References

• Wesson JA, Johnson RJ, Mazzali M, et al: Osteopontin is a critical inhibitor of calcium oxalate crystal formation and retention in renal tubules, J Am Soc Nephrol 14:139n147, 2003.
• Sanyanusin P, Schimmenti LA, McNoe TA, et al: Mutation of the gene in a family with optic nerve colobomas, renal anomalies and vesicoureteral reflux, Nat Genet 13(1):129, 1996.
• Herschorn S, Barkin J, Castro-Diaz D, et al: A phase III, randomized, doubleblind, parallel-group, placebo-controlled, multicentre study to assess the efficacy and safety of the ?3 adrenoceptor agonist, mirabegron, in patients with symptoms of overactive bladder, Urology 82(2):313n320, 2013.
• Vaarala MH, Tammela TL, Perttila I, et al: Sacral neuromodulation in urological indications: the Finnish experience, Scand J Urol Nephrol 45(1):46n51, 2011.