The purpose of this study was to review our experience with laparoscopic common bile duct (CBD) exploration by the transcystic approach and choledochotomy. We selected the transcystic approach for patients whose CBD stones were less than five in number and smaller than 9 mm in diameter, and whose CBD was less than 15 mm in diameter on cholangiograms. Among 217 patients with CBD stones treated laparoscopically, the transcystic approach was performed successfully in 91 of 104 patients in whom it was attempted (87.5%). The other 126 patients underwent laparoscopic choledochotomy, followed by ductal closure with transcystic drainage in 59, T-tube drainage in 46, primary ductal closure in 19, and choledochoduodenostomy in 1. Choledochotomy was converted to open surgery in only 1 patient. The transcystic approach was associated with shorter hospital stay and less morbidity than choledochotomy. However, choledochotomy also had an acceptably low rate of complications. Bile leaks occurred more frequently in those with primary ductal closure than in those with transcystic drainage or T-tube drainage. Residual stones were found in 2 patients with the transcystic approach and in 10 with choledochotomy. The residual stones were removed through the T-tube tract by choledochoscopy in 7 of these 10 patients. From these results we conclude that laparoscopic management of CBD stones is feasible for almost all patients with CBD stones. It is considered to be safe and effective and has the advantage of being a single-stage procedure.

Eighty patients with portal hypertension due to various hepatic diseases were subjected to the oral ammonia tolerance test (OATT). Blood samples were collected before and at 30-min intervals after the administration of ammonium chloride (50 mg/kg). The ammonia levels, and the OATT curve patterns and ~NH3-N values were determined and it was investigated whether there are correlations between these values and various other parameters of hepatic function. The results of OATT correlated with the plasma disappearance rate of indocyanine green and the molar ratio of branched chain amino acids to aromatic amino acids. Our findings suggest that the OATT may reflect the degree of hepatic parenchymal disorders rather than the hepatic circulatory abnormalities and that they may represent a valuable aid in the differential diagnosis of hepatic diseases and in determining the operative indication.---oral ammonia tolerance test; ammonia metabolism; portal hypertension; hepatic failure Ammonia is thought to be an important factor in the manifestation of hepatic failure, and has been investigated in patients with hepatic disorders, especially hepatoencepalopathy in portasystemic shunt (McDermott 1957;Conn 1969). The increased ammonia level in the blood of patients with hepatic diseases is thought to be ascriable to the sum of ammonia derived via two routes, decrease in ammonia metabolism and the inability of ammonia to enter the metabolic cycle due to the existence of an intra-and/or extrahepatic shunt. It is difficult to determine which of these routes represents the major contributor to the increased ammonia level in the blood of the patients with hepatic disease.In this report, the results of the oral ammonia tolerance test (OATT) in patients with portal hypertension are described. PATIENTS AND METHODSEighty patients with portal hypertension were treated in our department, of these cases 58 had liver cirrhosis, 17 idiopathic portal hypertension with hepatic fibrosis and 5 extrahepatic portal obstruction. Four gastric cancer patients without hepatic abnormalities served as the controls. Before inception of this study, voluntary informed consent was obtained from all participating patients.

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