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The serum amylase was elevated to 800 units (< 160 units normal) upon admission to the emergency room. Over the next several days the serum amylase decreased into the normal range and the patient's epigastric pain resolved. Normal values were observed for the liver panels obtained both in the emergency room and after admission.

Question 1: This patient should be managed with the following intervention (s):

[] (a) emergency ERCP < 24 hours after admission to the hospital
[] (b) laparoscopic cholecystectomy with IOC during this admission
[] (c) laparoscopic cholecystectomy without IOC during this admission
[] (d) discharge from the hospital with readmission and three to six weeks for laparoscopic cholecystectomy
[] (e) a and c
[] (f) Don't Know

[] (a) an attempt to flush the stones from the common duct
[] (b) trans-cystic common bile the exploration with a choledochoscope and stone baskets
[] (c) laparoscopic choledochotomy for stone removal
[] (d) postoperative ERCP if flushing of the stones fails
[] (e) a and d
[] (f) Don't Know

Question 3: The surgeon is unable to flush the stones from the common bile duct using saline solution under pressure. Acceptable alternative method(s) of management of this patient include:

[] (a) Installation of 10 ml of one percent lidocaine into the common duct and the administration of 1.0 unit of intravenous glucagon with another attempt to flush the stones
[] (b) The placement of a trans-cystic common bile duct catheter for post-operative cholangiography with possible postoperative ERCP/ES
[] (c) Expectant management after completion of the laparoscopic cholecystectomy
[] (d) a and b
[] (e) All of the above
[] (f) Don't Know

A routine intraoperative cholangiogram is performed during laparoscopic cholecystectomy for an obese 26 year old Hispanic female with known multiple small gallstones and a normal preoperative liver panel. The cystic duct is large and several stones are milked out of the cystic duct choledochotomy made for the cholangiogram catheter. The following cholangiogram is obtained.

[] (a) an attempt should be made to flush the stones from the common bile duct
[] (b) the stones may be removed after attempted flushing with a radiographic technique utilizing digital fluoroscopy and stone baskets before laparoscopic cholecystectomy
[] (c) one stage stone removal by trans-cystic duct choledochoscopy for stone removal with stone baskets before completion of the laparoscopic cholecystectomy
[] (d) laparoscopic cholecystectomy followed by postoperative ERCP for stone removal
[] (e) all of the above
[] (f) Don't Know

Question 5: Since no common duct stones can be observed in this frame (or in others not shown in this still presentation):

[] (a) No completion cholangiogram is required
[] (b) Completion cholangiography should be performed selectively
[] (c) Unless unusual circumstances preclude completion cholangiography, then a routine completion cholangiogram should be performed
[] (d) None of the above
[] (e) Don't Know