[Laparoscopic cholecystectomy in day-surgery analysis of feasibility in 166 consecutive patients]. / La colecistectomia laparoscopica in day-surgery: analisi di fattibilità su 166 pazienti consecutivi.

BACKGROUND: Day-Surgery (DS) is a widely spreading reality, both for clinical advantages to patients and organizational and economic profit to hospitals. In the last years, DS has been proposed for the treatment of a large number of diseases as inguinal and crural hernias, varicose vein, benign anorectal and thyroid pathologies. Recently, also laparoscopic cholecystectomy (LC) has been realised as DS procedure, and the initial results are promising. OBJECTIVES: To determine both the clinical feasibility of LC in DS and the factors that can predict an extension of hospital stay. MATERIALS AND METHODS: The present study is a retrospective analysis of 166 patients who underwent surgery because of symptomatic cholelithiasis in a three-year period; all patients underwent elective LC in ordinary hospital-stay. In order to identifying the patients potentially eligible for LC in DS, we carried on a selection by means of 3 consecutive stages: stage A, selection on the basis of preoperative data, stage B, selection on the basis of intraoperative factors and stage C, selection on the basis of postoperative parameters. RESULTS: Out of 166 patients, only 33 (19,8%) would have been successfully treated in DS. CONCLUSIONS: This study showed that LC in DS can be realised in strictly selected patients, on the basis of rigorous clinical and organizational criteria; furthermore, a continuous training of surgeons and nursing staff, the implementation of tele-medical facilities and the improvement of anesthesiological techniques will allow to the best results.

[The surgical needs of elderly patients in day-surgery]. / I fabbisogni di chirurgia in Day Surgery nell'anziano.

AIM: The possibility of carrying out surgery in day-surgery (DS) conditions is gradually becoming reality in most branches of surgery; in recent years, DS has also found a place in general surgery, with unquestionable advantages for the management of patients, particularly the elderly. The purpose of the present study is to investigate general surgery needs in DS conditions in elderly patients in order to analyse the clinical-administrative feasibility of DS procedure and the level of its acceptability in this group of patients. METHODS: A specially drafted questionnaire was submitted to patients admitted over a period of 18 months to the General Surgery Division of the University of L'Aquila. The details investigated in the questionnaire were: age, sex, educational qualification, working activity (independent or employee), presence in the patient's relational entourage of health workers willing to serve the patient at home, the patient's willingness to undergo the surgery for which he was admitted to the DS. The questionnaires of the over-64s were examined and the percentage of patients willing to undertake DS intervention instead of normal hospitalisation was evaluated; this willingness was then compared with the parameters sex, educational qualification, working activity and presence in the patient's relational entourage of health workers willing to assist the patient at home. RESULTS: 317 questionnaires were compiled. In 78 cases (24.6%) the patient was older than 64; the data for these patients were extrapolated. Willingness to undergo surgery in DS conditions was expressed by 23 patients (29%), whereas 55 patients (71%) stated that they were not available. In relation to sex, willingness to use the DS was 29.7% in the 37 male patients and 29.2% in the 41 females. With reference to the qualification, willingness was expressed by 71.4% of patients with a degree, 26.9% of patients with a high school leaving certificate and 15.7% of patients with a lower qualification. DS-willingness was 28% in the 75 pensioners and 66.6% in the 3 patients who worked for themselves. As regards the presence in the relational entourage of the patient of health workers ready to assist at home, DS-willingness was 23.9% in the 71 patients who did not have anyone in their relational entourage and 85.7% in the 7 patients who had such a health worker in their entourage. CONCLUSIONS: Willingness to undergo DS by elderly patients is mainly influenced by three factors: educational qualification, working activity and possibility to have home assistance from someone in the relational entourage; these parameters can be considered veritable selection criteria for DS in the elderly. The quality improvement in assistance levels and the introduction in the near future of telematic communication system could lead to an extension of DS indications to the elderly.

[Intraoperative cholangiography during laparoscopic cholecystectomy: selective or routine?]. / Colangiografia intraoperatoria in corso di colecistectomia laparoscopica: selettiva o di routine?

Since its presentation by Mirizzi in 1931, the role of intraoperative cholangiography (ICHO) has been controversial and has become an argument even more disputed with the introduction of laparoscopic cholecystectomy (VLC) in 1988. The Authors reviewed their experience to determine the most appropriate use of ICHO during VLC on the basis of a retrospective analysis of cases of selective ICHO. From December 1991 to January 2001, 597 patients, 552 elective procedure and 45 emergency procedure, were reviewed. Of 552 patients 62 presented with at least one diagnostic criterion for symptomatic gallstone disease and were treated by means of ERCP completed with endoscopic sphincterectomy (ES) when a stone of the common bile duct was found, while the remaining 490 patients underwent VLC; a total of 10 ICHO were performed, two of which in the ERCP group and 8 in the VLC group. The 45 patients treated in emergency underwent VLC; in 43 cases ICHO was performed. Of all patients, there were 2 cases of common bile duct injuries (0.33%) and in both cases ICHO was not performed. A cholangiogram added 27 min to the average duration of surgery. On the basis of both the literature and Authors' experience, it can be stated that the routine use of ICHO is not useful to reduce bile duct injuries, while it significantly increases the cost of the surgical procedure due to the increase of average operative time. The use of ICHO seems to be effective to demonstrate clinically unsuspected choledocholitiasis, although, at present, the real clinical advantage deriving from the detection of these stones is not clear. The Authors conclude that further prospective, randomized studies are necessary to assess the precise role of ICHO with regard to VLC.

[Total thyroidectomy in the surgical treatment of thyroid disease a retrospective clinical study]. / La tiroidectomia totale nel trattamento della patologia tiroidea.

BACKGROUND: Thyroid diseases constitute a group of benign and malignant affections, among which the most represented is multinodular goitre. Nowadays, an important question regards routine total thyroidectomy as the treatment of choice for all thyroid diseases. The aim of the present study is to verify if total thyroidectomy can always represent an option for modern surgery of thyroid disease. METHODS: One hundred-thirty-seven patients underwent operations for thyroid disease during an 11-year period. Fifty-three patients underwent total thyroidectomy, 27 affected by a benign pathology and 26 by a malignant one. RESULTS: Both short term and long term results have been analysed. CONCLUSIONS: In conclusion, the authors affirm that a complete resection of the gland is mandatory for the surgeon in the treatment of malignant diseases because the primary aim for oncologic surgery of the thyroid is the reduction of local recurrence and the increase of survival. As far as benign diseases are concerned, some surgeons affirm that morbility of non-total operations is lower than total thyroidectomy; anyway, the authors affirm that the most important factor to prevent morbility after total thyroidectomy is an appropriate surgical technique. In this way, both the identification of parathyroid glands and the identification preparation of recurrent nerve are considered the most valid method to prevent lesions. Another factor in favour of total thyroidectomy is represented by the risk of carcinoma on the residual tissue.

[Non-palpable lesions of the breast: retrospective clinical study]. / Lesioni non palpabili della mammella: studio clinico retrospettivo.

A non-palpable breast lesion (NPBL) is a disease of the mammary gland that cannot be detected during clinical examination but that can be visualized by mammography and/or ultrasonography, either during screening programs or sometimes in asymptomatic women. These small lesions require an adequate diagnostic-therapeutic approach to ensure correct treatment. The aim of the present study was to analyse a series of NPBLs retrospectively in order to define them nosologically and establish an adequate diagnostic-therapeutic work-up for such cases. Ninety-three patients with a total of 99 NPBLs were observed from January 1989 to December 1999. The 99 NPBLs were submitted to ultrasonography and 31 (31.3%) were also submitted to US-guided fine needle aspiration biopsy (FNAB). Later on the diagnostic-therapeutic procedure involved surgical biopsy after radiological centering and, in the case of malignant neoplastic lesions, surgical intervention and adjuvant therapy. Ultrasonography confirmed the presence of NPBL in 45 cases of the 99 detected at mammography (45.4%). Cytological examination of the 31 FNABs yielded the following results: unreliable 19.3%, suspected malignancy 42%, negative for neoplastic cytology 6.5%, positive for carcinoma 32.3%. The histological diagnosis was one of mammary carcinoma in 41 patients (43%). Among the 41 carcinomas there were 8 (19.5%) carcinomas in situ, 24 (58.5%) invasive ductal carcinomas, 8 (19.5%) invasive lobular carcinomas, and 1 (2.5%) medullary carcinoma. In the 32 (80%) patients submitted to lymphadenectomy for 33 invasive carcinomas, 6 patients (18.7%) presented positive lymph nodes (N1). The Authors conclude that NPBLs are an important clinical entity because they may be the expression of a malignant lesion; most NPBLs are diagnosed during screening programs or sometimes in asymptomatic women by means of mammography, which is the only standardised method for their identification. The poor diagnostic capability of non-invasive methods and the potential malignancy of NPBL justify the indication for surgical excisional biopsies; in cases of histological findings of malignancy it is often possible to perform conservative surgery with similar results to radical surgery in terms of survival. When NPBLs turn out to be invasive carcinomas, a concomitant lymphadenectomy is mandatory.

[Multicenter prospective study of informed consent in general surgery]. / Studio prospettico multicentrico sul consenso informato in chirurgia generale.

To understand the level of acceptance, awareness and usefulness of informed consent, a group of 119 patients (59 men and 60 women) from different types of hospitals were given a questionnaire which required only 'YES or NO' answers, both before and after surgery. The questionnaire concerned the patient's knowledge about pathology, operative risks, approval, anxiety caused, understanding of information received and consent given, and also if he would inform a relative in the same condition. From the analysis of the results it was established that: the more information a patient has about his illness and operation risks, the more he will want to have; the less he knows the less he will want to know, and he will also have more faith in the doctors. Some patients would not inform a relative with a similar pathology. To conclude, informed consent, instead of being a right of the patient is progressively becoming more a right of the doctor. It does not have any real effect on the patient's choice but is useful, as it represents a moment of personalised attention from medical personnel, though the patient may not completely understand the information received. There are few advantages in strictly medical terms but informed consent has increased malpractice litigation.

[Efficacy of somatostatin and its analogues in the treatment of acute pancreatitis: clinical retrospective study]. / Efficacia della somatostatina e dei suoi analoghi nella terapia della pancreatite acuta: studio clinico retrospettivo.

Acute pancreatitis is an acute inflammatory disease of the pancreas, with variable involvement of other regional tissues or remote organ systems. Acute pancreatitis is mild in 80% of cases; virtually all patients with this form of disease will survive, because it's associated with minimal organ dysfunction and uneventful recovery; the severe pancreatitis develops in 20% of cases and is associated with higher morbidity and mortality. It's most important to identify the severity of disease at the moment of hospital admission; many scoring systems have been developed to serve as early prognostic signs: Ranson's criteria, Imrie's criteria, Apache II score, Balthazar's TC score. Recently, new drugs have been proposed in the treatment of acute pancreatitis, as, for example, calcitonine, glucagon, systemic antioxidants, antagonists of the receptors of interleukines, antiproteases (aprotinin and gabexate-mesilate) and the inhibitors of pancreatic secretions (somatostatin and its analogues). However, many controversies still exist concerning the real efficacy of these drugs in the treatment of acute pancreatitis, particularly regarding the inhibitors of pancreatic secretions: recently, some studies showed that somatostatin is able to actually reduce the local complication of the disease and the development of severe forms of acute pancreatitis; on the other hand, other studies failed to show real advantages of somatostatin reducing morbidity and mortality for pancreatitis. The aim of present study is a retrospective analysis of patients affected by acute pancreatitis in order to evaluate efficacy of somatostatin and its analogues. All patients subdivided in two groups: group A, patients treated with conventional therapy plus somatostatin and/or octreotide (SS/LS), and group B, patients treated only with conventional therapy. Results seem to show that somatostatin does not positively affect morbidity and mortality in patients with acute pancreatitis. The Authors conclude that, at present; somatostatin cannot be considered surely effective in preventing complications and mortality in acute pancreatitis. Further studies are still necessary to verify the effectiveness of somatostatin and its analogues in the therapy of acute pancreatitis.

[Laparoscopic appendicectomy: an 8-year clinical experience]. / Appendicectomia laparoscopica: esperienza clinica di 8 anni.

BACKGROUND: For more than a century, open appendectomy through a laparotomy has been the golden standard for the surgical removal of the appendix. Nowadays, many surgeons question the utility of laparoscopic surgery to perform appendectomies because it is commonly stated that the appendix can be removed through a small surgical incision carrying a minimal surgical trauma to the patient. Although open appendectomy is really safe, on the other hand it carries a considerable risk of postoperative complications, is associated with postoperative pain and affects patient s normal activity. Laparoscopic appendectomy was first described in 1983 and, in many studies, it is described to be better than open standard technique for the treatment of appendiceal diseases. The aim of the present study is the retrospective analysis of laparoscopic appendectomies performed in a 8-year period. METHODS: The authors report on 129 patients who underwent laparoscopic appendectomy. RESULTS: Conversion rate was 0.7 %, while the laparoscopic procedure was completed in 96 female and 32 male patients. The position of the appendix was behind the cecum in 37 cases, associate diseases were found in 15 cases. Mean operative time was 51 minutes; kind of laparoscopic instrumentation affected the operation time. Histologically there were 71 (55.5 %) focal appendicitis, 22 (17.1 %) suppurative appendicitis, 11 (8.6 %) gangrenous appendicitis, 18 (14.1 %) chronic appendicitis showing signs of previous suppurative episodes and 6 (4.7 %) normal appendix. There were neither in-hospital morbidity nor mortality. Follow-up showed reduced postoperative pain, short hospital stay, fast return to complete social activity. CONCLUSIONS: The authors conclude that laparoscopic technique can be considered a safe and effective procedure for the removal of the appendix as it has the advantage of allowing faster postoperative recovery; moreover the author recommend a wider and routinely use for appendectomy.

[Intestinal infarction. Retrospective clinical study]. / L'infarto intestinale. Studio clinico retrospettivo.

Acute mesenteric ischaemia is the result of inadequate blood flow to all or part of the small intestine and the right half of the colon. Irrespective of the cause of the ischaemic insult, the end results are similar, namely, a spectrum of bowel injury ranging from completely reversible alterations of bowel function to transmural haemorrhagic necrosis of the intestinal wall. Depending on the degree of ischaemia and the length of bowel involved, a wide variety of clinical presentations are observed. Mesenteric infarction is a pathology which is encountered fairly often in elderly patients where the concomitance of other diseases make its prognosis more severe, especially since the diagnosis is usually late. The pessimism expressed more than 70 years ago concerning this disease is still shared by many physicians today. The authors report on their experience with 37 cases of mesenteric infarction. The median age of the patients was 77 years (range: 66-91). The mortality rate was 67.5% (25 deaths) which is in line with the results in the literature. The median hospital stay was 17 days (range: 10-71). The authors emphasise the difficulty of diagnosing and treating this entity, also in view of the fact that, in most centres, it is impossible to perform emergency selective angiography of the superior mesenteric artery. The need for an early specific diagnosis is stressed, because the therapeutic options may vary widely in relation to the different causes of acute intestinal ischaemia.

[An intramural hematoma of the duodenum]. / L'ematoma intramurale del duodeno.

Intramural hematoma of the duodenum is a rare event which is usually associated with trauma. Because of the rarity of this problem, there has been little conformity of opinions as to diagnosis and treatment of this disease. The authors report on a case of intramural hematoma of the duodenum post-traumatically occurred in a young woman. Etiopathogenesis, diagnosis and treatment of hematoma of the duodenum are thoroughly examined in the present study. Plain abdominal radiography, oral barium study, ultrasound examination, CT and RNM are diagnostic tools in this disease. It appears that most patients with intramural hematoma of the duodenum would respond well to conservative management; surgery should be reserved for those cases that remain obstructed over seven days or have evidence of peritonitis. However surgery is mandatory in cases of uncertain diagnosis. The evacuation of hematoma is considered the most effective and safest surgical treatment.

[Adenocarcinoma of the duodenojejunal flexure. A report of 2 clinical cases and a review of the literature]. / L'adenocarcinoma della giunzione duodeno-digiunale. Presentazione di due casi clinici e revisione della letteratura.

The authors report two cases of adenocarcinoma of the duodenojejunal angle and remark the rarity of this pathology, the difficulty of making diagnosis peculiar to neoplasm of the small intestine and the difficulty of treatment peculiar to tumours of the duodenum. According to the literature the diagnosis was determined through X-ray films, after traditional endoscopy was inadequate. Surgical treatment is radical, with extensive exeresis procedures (unless the mesenteric upper vessels are infiltrated) since the prognosis of this tumours is good.

[Mesh repair of inguinal and femoral hernia]. / Chirurgia protesica delle ernie inguinali e crurali.

The authors describe a 6-year experience with mesh repair of inguinal and femoral hernia in a surgical teaching department. Two hundred and ninety-seven hernioplasties were performed in 256 consecutive patients: 237 Trabucco sutureless and 11 Lichtenstein tension-free hernioplasties for inguinal hernia; 21 tension-free hernioplasties for femoral hernia; 20 Wantz GPRVS and 8 Rutkow tension-free hernioplaties for recurrences. Local anaesthesia was used in 59% of cases. Seventy-two patients (28.1%) refused this type of anaesthesia. The hospital stay was two days in all cases. The local postoperative morbidity rate was 8.7% (wound infections: 1.0%; neuralgia: 1.3%; haematomas: 2.0%; seromas: 2.3%; no testicular atrophies). The recurrence rate was 1.9% in the group of patients undergoing surgery from 1994 to 1997 (103 herniorrhaphies; follow-up: 3-6 years) and 0% in the group of patients operated on after 1997 (170 herniorrhaphies; follow-up: 2 years-6 months). The results confirm that the use of a prosthetic mesh (patch and plug) is the treatment of choice for hernia repair. Moreover, this experience in a surgical teaching department shows that these procedures can be safely and effectively performed by all surgeons.

[Therapeutic strategy in symptomatic diverticular disease of the colon]. / La strategia terapeutica nella malattia diverticolare conclamata del colon.

Diverticular disease of the colon has been recorded with increasing frequency and approximately 25-30% of symptomatic patients require surgery for complications. Controversy still surrounds the best operative approach for the management of diverticular disease, particularly when it presents with complications. The three-stage operation has, for the most part, been abandoned because of its unacceptably high morbidity and mortality rates. Today it is generally believed that performing two-stage surgery is a wise decision, namely segmentary resection either without (Hartmann's procedure) or with anastomosis, protected by a covering colostomy. However, the ideal intervention is a one-stage surgical procedure (segmentary resection and primary anastomosis without a covering colostomy), but this can only be performed in selected patients. The aim of this study was to analyse the clinical course and the medical and surgical therapy retrospectively in 79 patients with symptomatic diverticular disease in order to identify the best therapeutic procedure; specifically, the severity of septic complications was evaluated using Hinchey's classification. The authors conclude that most patients with symptomatic diverticular disease require specific medical therapy. If surgical treatment is necessary (complicated diverticular disease), Hartmann's procedure is still a valid surgical option, particularly in the presence of diffuse faecal peritonitis. Colonic resection and primary anastomosis are certainly a satisfactory treatment, because of their low morbidity and mortality rates, but this surgical approach is only feasible in selected patients. Finally, it is a matter for the individual surgeon's experience to select the best surgical procedure in any particular situation, depending on age and general state, local findings and the extent of peritonitis.

[The role of melatonin in the immediate postoperative period in elderly patients]. / Il ruolo della melatonina nell'immediato decorso postoperatorio dei pazienti anziani.

BACKGROUND: Melatonin induces sleep and modulates immune system. Aim of the paper is to show a possible relation between impaired rhythm of melatonin secretion and the onset of postoperative septic complications and insomnia in old patients undergoing surgery. METHODS: Fifty old patients, aged from 60 to 94 years, have been studied; 39.5% of the patients had neoplastic disease. Melatonin serum levels have been evaluated by ELISA technique at 12 p.m., 3 a.m. 8 a.m. immediately before operation. Postoperative clinical findings of insomnia and septic complications have been recorded. RESULTS: The melatonin serum mean values of all the patients were 16.3 pg/ml at 12 p.m., 22.4 pg/ml at 3 a.m. and 7.1 pg/ml at 8 a.m. Neoplastic patients showed the higher values of melatonin (26.696 pg/ml, 33.143 pg/ml, 9.185 pg/ml), long-lived patients (> 90 years) the lower. The melatonin secretion curve of the old patients with postoperative insomnia (19.961 pg/ml, 20.297 pg/ml, 9.378 pg/ml) or postoperative septic complications (20.695 pg/ml, 16.183 pg/ml, 6.036 pg/ml) was significantly different compared with that of other patients. The peak was advanced, lower and decreased slowly in the midnight. CONCLUSIONS: The study seems to show a possible correlation between impaired rhythm of melatonin secretion and postoperative insomnia and postoperative sepsis in old patients undergoing surgery.

[Aortic dissection: role of the general surgeon in diagnostic-therapeutic procedure]. / Dissecazione aortica: ruolo del chirurgo generale nell'iter diagnostico-terapeutico.

Aortic dissection occurs when there is a tear or separation of the aortic intima from the media; flow of blood into the intima-media space allows the tear to develop into a dissecting hematoma. Aortic dissection is a rare condition which represents an acute cardiovascular emergency for which the appropriate therapy is immediate surgical correction. Patients with aortic dissection show a heterogeneous constellation of symptoms; hence, clinical suspicion is often difficult. Only a minority of patients has "classic" symptomatology, the electrocardiogram is often misleading and the chest radiogram is almost always non-specific. In Italy, the usual "hospital routine practice" assigns the key-role in the emergency diagnostic procedure for these patients to the general surgeon. In view of the necessity of immediate cardiac surgery and the overwhelming likelihood of adverse events when surgery is delayed, techniques for diagnosis must be accurate, widely available and easily and quickly used. The present study consists of four case-reports of aortic dissection thoroughly examined and confronted with the literature. Management strategy based on emergency echocardiography is a reliable, feasible and successful technique for evaluating patients with aortic dissection. It allows a rapid accurate diagnosis with a single examination that can also be performed in the emergency room and provides information of sufficient diagnostic value to allow immediate cardiovascular surgery. CT scan and/or MRI are also valid tools for the emergency diagnosis of aortic dissection. However, a major problem still exists: the range of symptoms is sufficiently broad that a high index of "personal suspicion" of aortic dissection is required on the part of the general surgeon when he performs the role of "emergency-team leader".

Biological effects of preoperative radiotherapy on metastatic lymph nodes from rectal cancer.

The quantitative description of the proliferative activity of cancer cells correlates with the aggressiveness of malignant tumors. The aim of this retrospective study was to determine the biological effect of adjuvant therapy on metastatic lymph nodes from rectal cancer and to compare the results between patients treated with surgery alone and patients treated with preoperative radiotherapy. Expression of the proliferating cell nuclear antigen (PCNA) was examined in metastatic lymph node samples of 12 rectal cancer patients receiving and 14 patients not receiving preoperative radiotherapy. PCNA immunostaining was performed by an avidin-biotin complex immunoperoxidase technique. The results of the mean proliferation index (PI) between the two groups were compared. A semiquantitative PCNA grading system was also estimated. In patients receiving preoperative radiotherapy, the PI was 22.8 per cent, and only one patient had high proliferative grade. On the contrary, the PI in nonirradiated patients was 67.6 per cent, and nine patients showed high proliferative grade. Although not sufficient to reach significance in terms of prognosis, the present study confirms the clinical value of radiation therapy, and it supports the suggestion to treat Dukes' C patients with preoperative radiotherapy to decrease the risk of local recurrence.

[The current controversies over video laparoscopic cholecystectomy as the treatment of choice for cholelithiasis]. / Attuali controversie sulla colecistectomia per via videolaparoscopica come trattamento di scelta per la calcolosi della colecisti.

Recently, the widespread use of laparoscopic cholecystectomy allowed to reach several goals such as a minimal invasive approach, a minimal operative trauma, the absence of aesthetic or functional damage of the abdominal wall, and a quick return to full activities. On the other hand, as all innovations, laparoscopic cholecystectomy is matter of debate and a number of controversies have recently appeared in the Scientific Literature. On the basis of their experience and through a critical review of the Literature, the Authors have therefore analyzed possible solutions to such controversies. Particularly, current indications and contraindications of this approach, surgical technique and relative sites of insertion of the trocars, the need to drain or not, the pre- and intra-operative study of the bile duct and the approach in case of bile duct stones pre- or intra-operatively demonstrated, have been evaluated as possible answers. The Authors conclude that indications to laparoscopic cholecystectomy are the same of those for laparotomy, contraindications are represented by coagulopathies, liver cirrhosis and plastic peritonitis. At present it is still impossible to affirm which is the best surgical technique, the best position for the surgeon, and the best site for the insertion of the trocars, while drainage must be used only in those cases in which further manoeuvres on the bile duct are required. At last the Authors underline there is no need for a routine intraoperative cholangiography during laparoscopic cholecystectomy, however such technique must be known by laparoscopic surgeons since it may be mandatory in some selected cases. ERCP, on the contrary, is a valid support to laparoscopic cholecystectomy in the treatment of gallbladder stones associated with bile duct stones.