Differences in Outcome and Comparison of Stress and Immune Status in Patients with Recurrent Common Bile Duct Stones after Biliary Tract Surgery Choosing Three Procedures (ERCP, OCBDE, and LCBDE) for Treatment.

OBJECTIVE: To compare the effect of choosing ERCP, OCBDE, and LCBDE for the treatment of patients with recurrent common bile duct stones after biliary tract surgery. METHOD: 115 patients with recurrent common bile duct stones after biliary surgery in our hospital were retrospectively analyzed and divided into three groups according to the procedure, 36 patients in the ERCP group, 38 patients in the OCBDE group, and 41 patients in the LCBDE group, and compared the efficacy, stress status, and immune status of the three groups. RESULT: The stone removal rates were 91.67%, 97.37%, and 97.56% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). There were statistical differences between the ERCP, OCBDE, and LCBDE groups in terms of operative time, postoperative recovery time of exhaustion, recovery time of defecation, recovery time of feeding, and hospitalization time (P < 0.05). The postoperative complication rates were 8.33%, 10.53%, and 7.32% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). The recurrence rates within 1 year after surgery were 2.78%, 7.89%, and 2.44% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). CONCLUSION: ERCP has short operative time, short hospital stay, and rapid postoperative recovery. LCBDE has mild trauma, and OCBDE has a wide range of application. Each of the three procedures has its own advantages and shortcomings, and the most appropriate procedure should be selected on the basis of comprehensive evaluation.

Gallbladder stone formation in Iraqi patients is associated with bacterial infection and HLA class II-DRB1 antigens.

BACKGROUND: Gallbladder stone is recently increased among the Iraqi society due to many risk factors such as bacterial infection and some HLA class II antigens. AIM(S): This study investigates the types of bacterial infection and HLA-DRB1 antigens' ratio that may be correlated with gallbladder stone formation. Setting and Design: The study included 45 patients and the same number of healthy individuals as a control group. Patients were with multiple gallstones. Gallstone bacterial culture was demonstrated to diagnose viable bacteria. HLA-DRB1 alleles' frequency was investigated using sequence-specific oligonucleotide probes (PCR-SSOP). RESULTS: Irrespective of gallstone type and size, different types of living viable bacteria were isolated from the cores of the studied gallstones in 80% of the studied cases versus 20% of sterile gallstones. Gram-negative bacteria cultures were the dominant (89.3%), including Escherichia coli, Klebsiella spp., Proteus spp., Acinetobacter spp., and Enterobacter spp. Mixed infection of Gram-positive and negative bacteria was noted: Escherichia coli and Enterococus spp. and the others of Escherichia coli and Acitobacter spp., and Klebsiella spp. and Pseudomonas spp. Gram-positive bacteria cultures were also detected at lower rate (10.7%) including Staphylococci spp. The frequency of HLA-DRB1*03:01, HLA-DRB1*4:03, HLA-DRB1*13:22, and HLA-DRB1*15:10 alleles was significantly elevated in patients compared to the healthy control group. CONCLUSION: Results ensured the viability of the bacteria isolated from the core of gallstones and showed positive correlation between gallbladder stone and different bacterial infection. In addition, HLA-DRB1 alleles were significantly high in patients compared to healthy control group suggesting them as risk factors (P < 0.05).

Neutrophil Extracellular Traps Initiate Gallstone Formation.

The presence of gallstones (cholelithiasis) is a highly prevalent and severe disease and one of the leading causes of hospital admissions worldwide. Due to its substantial health impact, we investigated the biological mechanisms that lead to the formation and growth of gallstones. We show that gallstone assembly essentially requires neutrophil extracellular traps (NETs). We found consistent evidence for the presence of NETs in human and murine gallstones and describe an immune-mediated process requiring activation of the innate immune system for the formation and growth of gallstones. Targeting NET formation via inhibition of peptidyl arginine deiminase type 4 or abrogation of reactive oxygen species (ROS) production, as well as damping of neutrophils by metoprolol, effectively inhibit gallstone formation in vivo. Our results show that after the physicochemical process of crystal formation, NETs foster their assembly into larger aggregates and finally gallstones. These insights provide a feasible therapeutic concept to prevent cholelithiasis in patients at risk.

Adaptive Immune Cell Dysregulation and Role in Acute Pancreatitis Disease Progression and Treatment.

Acute pancreatitis (AP) is an inflammation of the pancreas caused by various stimuli including excessive alcohol consumption, gallstone disease and certain viral infections. Managing specifically the severe form of AP is limited due to lack of an understanding of the complex immune events that occur during AP involving immune cells and inflammatory molecules such as cytokines. The relative abundance of various immune cells resulting from the immune dysregulation drives disease progression. In this review, we examine the literature on the adaptive immune cells in AP, the prognostic value of these cells in stratifying patients into appropriate care and treatment strategies based on cell frequency in different AP severities are discussed.

[IMPROVING THE RESULTS OF SURGICAL TREATMENT OF GALLSTONE DISEASE].

THE PURPOSE OF THE STUDY: optimization measures for postoperative management of patients after laparoscopic cholecystectomy. MATERIAL AND METHODS: In the study group included 102 women and 302 men. At the 303 patients (75%) for specific indications ERCP was performed. Age of patients varied from 16 to 80 years and averaged 47.7 ± 12.9 years. It should be noted that at 298 (98.3%) patients ERCP was performed prior to laparoscopic cholecystectomy with diagnostic or therapeutic purposes. To assess the effectiveness of treatment comparison group (control group) consisted of 20 patients with postoperative complications identified after cholecystectomy; patients received basic diet. Main group--25 patients, where in treatment as an additional therapeutic agent administered vegetables "Hepartea". Liver function was assessed by biochemical studies (total protein, urea, ALT and AST). Were determined the quality of life of patients immediately after surgery and at certain stages of rehabilitation after the application of supportive therapy. RESULTS: According to clinical, laboratory and morphological studies acute cholecystitis abscess was observed at 0.25 ± 0.25%; chronic calculous cholecystitis in 75.7 ± 2.13%. Among the total surveyed hospitalized patients in 16 (5.3%) patients ERCP was performed with diagnostic, and in 287 (94.7%) cases--with curative intent. Statistical analysis of data obtained from the structural components of the SF-36 in 30 days after completion of conservative therapy with herbal preparation revealed some nnormalization of protein metabolism, enzyme activity and other indicators of liver function. CONCLUSION: dates on the main group of the patients noted relatively fast dynamics of normalization of stimulating cell-mediated immunity, evidenced by a more pronounced and significant decrease in protein damage and reduction of urea. Chemical analysis of peripheral blood and clinical trials show greater therapeutic effect of herbal drug when used in the early postoperative period after laparoscopic cholecystectomy. Using herbal drug in treatment of complications of laparoscopic cholecystectomy can effectively stop clinical and biochemical manifestations of inflammation, reduce the incidence of postoperative complications and reduce the time of rehabilitation, which has a significant beneficial impact on the quality of life of patients.

[DYNAMIC OF CLINICAL, LABORATORY AND SONOGRAPHIC PARAMETERS AFTER SUCCESSFUL LITHOLITIC THERAPY AT PATIENTS WITH GALLSTONE DISEASE IN ASSOCIATION WITH METABOLIC SYNDROME].

UNLABELLED: The aim of study was to determine the leading clinical, immunological and sonographic pararneters, reflecting the efficiency of Ursodeoxycholic acid (UDCA) at the rate of 10 mg per 1 kg of body weight in the treatment of gallstone disease in patients with metabolic syndrome (MS). MATERIALS AND METHODS: An assessment of clinical, biochemical immunological and sonographic parameters in 54 patients with gallstone disease associated with the metabolic syndrome before and after the six-month treatment UDCA were made. RESULTS: In accordance with our results the significant predictors, reflecting successful litholitic therapy at patients with gallstone disease in association with metabolic syndrome are decrease the serum concentration of gamma-glutamyltranspeptidase (P = 0.003), matrix metalloproteinase-9 (P = 0.001), increase the serum concentration of tissue inhibitor of metalloproteinases-1 (P = 0.02), decrease the left liver lobe thickness (P = 0,003) and the thickness of gallbladder wall (P = 0.0002). CONCLUSION: The results of our study have shown that the therapy with ursodesoxycholic acid of patients with metabolic syndrome leads to decrease of factors of gallstone progression (elevated levels of gamma-glutamyltranspeptidase, matrix metalloproteinase-9 and increased thickness of the left lobe liver and gallbladder wall).

[The cytokine profile in the patients with acute calculous cholecystitis and correction of its disorders].

The results of application of systemic cytokinotherapy and splenopid in patients, operated on for an acute calculous cholecystitis, are presented. While in patients of a control group the conventional basic therapy was conducted, to the patients of the main group the systemic cytokinotherapy and splenopid were conducted preoperatively and postoperatively on background of basic therapy during 3-10 days at average. In both groups preoperatively the reduction of interleukin-2 (IL-2) and gamma-interferon (IFNgamma) content were observed, as well as raising of the blood level of the tumor necrosis factor-alpha (TNF-alpha), IL-6 and IL-10. In the patients of a control group a tendency towards the studied indices normalisation was noted postoperatively, and in the patients of the main group the elimination of the organism cytokine state dysbalance was achieved. While doing comparative analysis of ratio of TNF-alpha/IL-10 and IL-2/IL-10 in the blood serum in the main group there was established, that up to the observation period end the both indices were close to the norm.

Gender-specific association of the interleukin 18 gene with symptomatic gallstone disease.

BACKGROUND AND AIM: Symptomatic gallstone disease (SGSD) induced several inflammatory responses and affected extrahepatic bile ducts. Although the pathology and environmental risk factors of gallstone disease are well documented, immune or inflammatory responses in SGSD development are still inconclusive. Interleukin 18 (IL18) is a pro-inflammatory cytokine that plays an important role in immune, infectious, and inflammatory diseases because of the induction of interferon-γ. In this study, we investigated whether polymorphisms of the IL18 gene were associated with SGSD susceptibility. METHODS: Genomic DNA was isolated from the whole blood samples of 445 patients with SGSD and 1121 gallstone-free controls. The IL18 rs549908T>G, rs5744247C>G, rs187238G>C, rs1946518T>G, and rs360719A>G polymorphisms were genotyped using predeveloped TaqMan allelic discrimination assay. RESULTS: We found IL18 rs5744247G allele conferred protection against SGSD in female patients (odds ratio = 0.75, corrected P-value = 0.015). Haplotype analysis revealed that TGGTA protected females from SGSD development (odds ratio = 0.75, corrected P-value = 0.02). CONCLUSIONS: Based on our findings, IL18 rs5744247C>G polymorphism could be a potential genetic marker to predict SGSD susceptibility in Han Chinese women.

Evaluation of lymphocytes CD4+ and CD8+ and expression of ZAP-70 kinase on CD3+ and CD19+ lymphocytes in obese patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Obesity has become a global epidemic and a leading metabolic disease in the world. Laparoscopic surgeries may influence the function of the immunologic system. The percentages of CD4+ and CD8+ T lymphocyte cells have been described as prognostic factors for patients undergoing abdominal surgeries. This study aimed to evaluate the changes in CD4+ and CD8+ T lymphocyte cells, the ratio of CD4+ to CD8+ cells, and the ZAP-70 kinase expression on T CD3+ and B CD19+ cells in obese and normal-weight individuals undergoing laparoscopic cholecystectomy (LC). METHODS: The study group consisted of 46 asymptomatic patients with gallstones shown by ultrasound examination but without signs of any gallbladder complications. The patients underwent planned LC. Blood samples were obtained at three times, and the percentages of studied cells were measured by flow cytometry. Patients were enrolled to two groups: N group (body mass index [BMI], ≤ 25 kg/m(2)) and O group (BMI, ≥ 30 kg/m(2)). For statistical analysis, the Mann-Whitney U test and the Wilcoxon matched-pairs signed-ranks test were used. All p values lower than 0.05 were considered significant. RESULTS: The percentage of CD4+ T cells did not differ between the N and O groups before or after the surgery. Only in the N group did the percentage of CD4+ lymphocytes increase from 0 to 48 h. A higher percentage of CD8+ lymphocytes was observed in the O group postoperatively than in the N group. Differences of ZAP-70 kinase expression in the O group were observed at 24 and 48 h of the study. Decreased expression of ZAP-70 kinase was shown in the N group at both 0-24 and 24-48 h. In the O group, this tendency was noted at 24-48 h. CONCLUSIONS: Immunologic activation after LC was confirmed in both weight groups. However, higher modulation, more typical for open surgeries, was observed in the obese group.

Biliary innate immunity: function and modulation.

Biliary innate immunity is involved in the pathogenesis of cholangiopathies in patients with primary biliary cirrhosis (PBC) and biliary atresia. Biliary epithelial cells possess an innate immune system consisting of the Toll-like receptor (TLR) family and recognize pathogen-associated molecular patterns (PAMPs). Tolerance to bacterial PAMPs such as lipopolysaccharides is also important to maintain homeostasis in the biliary tree, but tolerance to double-stranded RNA (dsRNA) is not found. In PBC, CD4-positive Th17 cells characterized by the secretion of IL-17 are implicated in the chronic inflammation of bile ducts and the presence of Th17 cells around bile ducts is causally associated with the biliary innate immune responses to PAMPs. Moreover, a negative regulator of intracellular TLR signaling, peroxisome proliferator-activated receptor-gamma (PPARgamma), is involved in the pathogenesis of cholangitis. Immunosuppression using PPARgamma ligands may help to attenuate the bile duct damage in PBC patients. In biliary atresia characterized by a progressive, inflammatory, and sclerosing cholangiopathy, dsRNA viruses are speculated to be an etiological agent and to directly induce enhanced biliary apoptosis via the expression of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). Moreover, the epithelial-mesenchymal transition (EMT) of biliary epithelial cells is also evoked by the biliary innate immune response to dsRNA.

An immunohistochemical study of osteopontin in pigment gallstone formation.

Mucin glycoproteins from the gallbladder epithelium are thought to contribute to the matrix or nucleus of gallstones and other biomineralization systems. The involved acidic glycoproteins have been reported in bile and gallstones. In addition, osteopontin (Opn) is a noncollagenous acidic bone matrix glycoprotein that possesses calcium-binding properties. To investigate the role of Opn in pigment gallstone formation, the involvement of Opn in pigment gallstone formation was studied immunohistochemically in the gallbladder wall and in the stones. Staining for Opn was strongly positive in the epithelium of stone-laden gallbladders and in their stones. The stone-laden gallbladders were infiltrated by macrophages, which intensely stained for Opn. Sections of the pigment stones, under low magnification, showed a lamellar pattern of Opn immunolabeling and showed a reticular pattern under high magnification. Our results indicate that Opn, an acidic glycoprotein from the gallbladder epithelium, seems to be involved in lithiasis. Opn from macrophages and/or the epithelium seems to help form the matrix protein.

Proinflammatory cytokines in alcohol or gallstone induced acute pancreatitis. A prospective study.

OBJECTIVES: If differences of inflammatory pathways in acute pancreatitis exist for various etiologies, selective and specific antiinflammatory and other modulatory treatment regimens might be indicated. Circulating levels of prominent proinflammatory cytokines IL-6, 8, 18, and TNF-alpha were measured in patients having their first attack of either alcohol- or gallstone-induced acute pancreatitis. METHODS: Seventy-five consecutive patients were prospectively included over a 15-month period, sixty of them being either alcohol- or gallstone-induced. All patients were treated according to a standardized algorithm. Blood samples were obtained immediately on admission and, again, at days 1, 2, and 14. RESULTS: A significant effect of the etiology on the levels of IL-8 in the alcohol group as compared to the gallstone group (P=0.003) was found. No etiologic differences were observed for IL-6, IL-18, TNF-alpha, or CRP. Furthermore, no significant differences, either regarding the need for treatment at the intensive care unit or of 30-day mortality, were found. CONCLUSION: The present study confirms previous findings and supports the hypothesis that, except for IL-8, the biochemical profile and clinical outcome is independent of the underlying etiology. Revealing the complex spatial and temporal profile of proinflammatory cytokine expression in acute pancreatitis is necessary and important for the development of a more targeted rational therapy.

Possible relationship between intestinal barrier function and formation of pigment gallstones in hamsters.

BACKGROUND: The presence of bacteria in bile is an important factor in the formation of pigment gallstones. The bile of healthy people is sterile and bacteria in the biliary system come from endogenous infection from the gut. Yet, the route of bacterial translocation into the bile duct is still unclear. Theoretically, two routes exist: one is through the intestinal barrier and the other is by direct reflux from the sphincter of Oddi. This study was undertaken to explore the relationship between the effectiveness of intestinal barrier and the formation of pigment gallstones in hamsters. METHODS: Thirty-two hamsters were divided into an experimental and a control group, with 16 hamsters in each group. A low protein and high cellulose diet was given for 6 weeks to induce the formation of pigment gallstones in the experimental group (PS) and a normal diet was given to the control group (CON). Morphological changes, changes in the levels of serum endotoxin and diamine oxidase, and changes in the numbers of B lymphocytes, plasma cells and secretory immunoglobin A (sIgA) in the intestinal mucosa were assessed after 6 weeks. RESULTS: Four hamsters died during lithogenesis and body weight decreased in the PS group. Pigment gallstones were found in 11 hamsters at the end of the experiment, giving a lithogenesis rate of 91.67%. The serum endotoxin level before and after gallstone formation in the PS group was 0.2960+/-0.1734 U/ml and 8.2964+/-4.6268 U/ml, respectively (P<0.05). The blood diamine oxidase level before and after gallstone formation in the PS group was 2.6333+/-0.8037 U/ml and 3.3642+/-0.9545 U/ml, respectively (P<0.05). The numbers of B lymphocytes, plasma cells and sIgA in the intestinal mucosa in the PS group were 71.56+/-2.89, 68.65+/-2.09 and 27.56+/-1.07, respectively, and were significantly decreased compared with the corresponding values in the CON group (94.25+/-3.69, 93.47+/-3.98 and 42.57+/-1.96, respectively, P<0.05). CONCLUSIONS: A low protein and high cellulose diet can markedly reduce intestinal barrier function and facilitate the formation of pigment gallstones. The decrease of intestinal barrier function may take part in the formation of pigment gallstones.

[The immunological changes and prognosis of cholestatic jaundice in choledocholithiasis]. / Imunologichni promeni i prognoza na kholestatichnata zhultenitsa pri kholedokholitiaza.

Fifty-six patients presenting choledocholithiasis are covered by the study. They are distributed in groups according to total serum bilirubin values, as follows: with total serum bilirubin < 20 mumol/l--17; 20 to 50 mumol/l--13; 50 to 80 mumol/l--9; and > 80 mumol/l--17 cases. Sixty healthy, sex and age matched individuals serve as controls. The immunocompetent cells are determined flow cytometrically with FACS TAR (BECTON DICKINSON). A panel of monoclonal antibodies (Becton Dickinson) is used, including: Leu4 (anti-CD3+)--T-lymphocytes; Leu3a (anti-CD4+)--helper/inducer lymphocytes; Leu2a (anti-CD8+)--suppressor/cytotoxic cells; Leu11a (anti-CD16+)--cells with a natural killer activity; Leu12 (anti-CD19+)--B-lymphocytes. As shown by the obtained results there are no changes in cell-mediated immune response among choledocholithiasis patients with normal values of total serum bilirubin. Parallel to increasing the degree of cholestatic jaundice (ChJ) severity, the absolute values of lymphocytes and their subpopulations decrease. The deficit is most clearcut in patients presenting the highest degree cholestasis, as compared to healthy individuals ((Ly: 1690 +/- 174/2277 +/- 186; CD3+: 956 +/- 119/1793 +/- 67; CD4+: 607 +/- 83/988 +/- 80; CD8+: 239 +/- 52/639 +/- 85; CD16+: 146 +/- 38/367 +/- 55; CD19+: 181 +/- 33/200 +/- 13. In 11 cases with early restored biliary drainage (by the 21st day of ChJ), total serum bilirubin decreases within 10 days after the operation (choledochoduodenoanastomosis), whereas lymphocytes and their subpopulations show an increase in absolute values. Two months after choledochoduodenoanastomosis, the total serum bilirubin and the lymphocyte subpopulations being examined regain their normal values. In two instances with rather late biliary drainage recovery (30 days after ChJ) the total serum bilirubin and lymphocyte subpopulations under study show no tendency whatsoever towards normalization at 10 days postoperatively. The results of the study demonstrate that the poor prognosis among ChJ patients is also related to inhibition of the cell-mediated immune response. The early biliary drainage recovery (at 21 days of ChJ) exerts a more favourable effect on the immune system, and improves the prognosis of the clinical course run by the pathological process.

A case of common bile duct stone with cholangitis presenting an extraordinarily high serum CA19-9 value.

A 63-year-old male complained of right upper abdominal pain and jaundice. Laboratory data on admission showed hyperbilirubinemia, elevation of biliary enzymes and an extraordinarily high value of serum CA19-9 (60,000 U/ml). Diagnostic imaging modalities including abdominal ultrasonogram, abdominal CT and PTC suggested a stone impaction of the common bile duct. Jaundice subsided after PTC-drainage in association with decreasing serum CA19-9 value, which returned to the normal level six weeks later. Spontaneous delivery of the stone via the fistula was confirmed by cholangiography through the drainage tube. Though there are few reports of such a high serum CA19-9 level, the possibility of benign biliary tract disease should be considered in patients showing an extraordinarily high serum CA19-9 value.

[Level of circulating immune complexes in patients with complicated cholelithiasis]. / Uroven tsirkuliruiushchikh immunnykh compleksov u patsientov s oslozhnennoi zhelchnokamennoi bolezníu.

In 165 patients with the different forms of cholelithiasis, a level of the circulating immune complexes (CIC) was measured in the blood serum and bile from the common bile duct at the postoperative period. In associated purulent-resorptive and cholemic intoxication, the CIC level in the blood serum and bile increases. This, in turns, enhances the likelihood of the development of purulent-septic complications at the postoperative period, and requires performance of target immunocorrection.

[The cellular-humoral immune factors of patients with cholelithiasis uncomplicated and complicated by an inflammatory process]. / Prouchvane na kletuchno-khumoralni imunni faktori pri bolni s neuslozhnena i uslozhnena s vuzpalitelen protses zhluchnokamenna bolest.

82 patients-10 p. with uncomplicated cholelithiasis, 8 p. with chronic calculous cholecystitis, 34 p. with choledocholithiasis with stenosing papillo-odditis--and 30 healthy controls were examined, with monoclonal antibodies of the firm "Becton-Dickinson". The following immunocompetent cellular clones and subclones were examined: CD3+, CD16+, CD4+, CD8+, CD19+ CD4/CD8, HLA-DR+, CD3+. The results were read with analyzer for fluorescently marked activated cell clones "FACS-TAR". The serum IgA, IgM, IgG, C3-C4 complement fractions and circulating immune complexes were also examined. The analysis of the results shows that in the complicated cases of cholelithiasis with an inflammatory process in the biliary ducts several humoral and cellular immune factors take part.

[Immunologic reactivity of patients with obstructive jaundice of non-neoplastic etiology]. / Immunoreaktivnos't u bo'lnykh s mekhanicheskoi zheltukhoi neopukholevogo geneza.

Immunity values were studied in patients with obstructive jaundice of cholelithic etiology. The number of immune cells was reduced and the formation of antibodies was deficient in these patients in the preoperative period. The degree of immunodeficiency correlated with the duration of jaundice and the degree of bilirubinemia. The level of autoantigens was also increased. An operation promotes still greater suppression of immunity. The values of immunity were normalized earlier in patients who had received immunomodulation therapy.

Anergy in patients with biliary lithiasis.

A prospective study was carried out in 428 subjects (212 controls and 216 patients) to evaluate the delayed cell-mediated immune response preoperatively in patients with biliary lithiasis. The delayed hypersensitivity response was assessed by a Multitest and subjects were classified as immunocompetent, relatively anergic or anergic. Significant differences were found between control subjects and patients with cholelithiasis compared with those with acute cholecystitis (P less than 0.01), non-icteric choledocholithiasis (P less than 0.01) and choledocholithiasis with jaundice (P less than 0.05). There were also differences between patients with icteric and non-icteric choledocholithiasis (P less than 0.02). Seven possible causative factors for anergy were evaluated: a haemoglobin concentration of less than or equal to 12 g/l and a haematocrit of less than or equal to 35 per cent were related to the appearance of anergy and relative anergy in patients with acute cholecystitis. Bilirubin levels greater than or equal to 34 mumol/l were found in 60 per cent of patients with choledocholithiasis and relative anergy and in 80 per cent of those who were anergic (P less than 0.001). These results show a high incidence of failure of the cell-mediated immune response in patients with acute cholecystitis (71 per cent) and icteric choledocholithiasis (82 per cent). In the latter, jaundice appears to be associated with this failure. A close correlation between relatively anergic and anergic state and the development of postoperative septic complications was found.