الفهرس 
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Abstract
Laparoscopic cholecystectomy has been the gold standard in the treatment of gallstone disease, and most of cholecystectomies are performed this way today. However, it is recognized that 3–33% of patients with symptomatic gallstones might harbor common bile duct (CBD) stones.
The surgical approaches used for cholecystolithiasis with secondary choledocholithiasis include laparotomy, laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). With the advent of minimally invasive surgery and accelerated rehabilitation surgery, minimally invasive surgery procedures such as endoscopic procedures have become the main methods for treating extrahepatic biliary calculi.
Stones can cause obstruction in the common bile duct. The patient can have abdominal pain, fever, jaundice and other manifestations, and choledochal dilatation can be seen by abdominal ultrasound in symptomatic choledocholithiasis, which is easily diagnosed. In contrast, most cases of secondary choledocholithiasis do not have symptoms and are often missed in diagnosis.
On one hand, this may lead to the persistent presence of common bile duct stones and related complications. On the other hand, it may lead to an increased incidence of postoperative residual stones and related life-threatening complications, exacerbating the pain and economic burden for patients after laparoscopic cholecystectomy. Therefore, an important issue has become how to easily and efficiently identify secondary asymptomatic choledocholithiasis in patients with common cholecystolithiasis.
Patients are often suspected of having choledocholithiasis when they present with right upper quadrant pain with elevated liver enzymes in a primarily cholestatic pattern. However, some patients may have floating biliary stones without causing symptoms or clinical manifestations.
Gamma-glutamyl transferase (GGT) is one of the most commonly requested laboratory tests and is a key test used for the laboratory evaluation of liver damage. Serum GGT is mainly derived from the liver and is produced by hepatocyte mitochondria, excreted by the biliary tract, and primarily distributed in the liver cytoplasm and intrahepatic bile duct epithelium.
It also indicated that an abnormal increase in serum GGT plays an important role in predicting cholecystolithiasis combined with secondary asymptomatic choledocholithiasis, and it may be an effective serological index for routine screening. With the exception of obvious jaundice, a raised GGT level has been suggested to be the most sensitive and specific indicator of CBD stones.
The current literature is poor with clinical trials evaluating GGT as a predictor for asymptomatic biliary stones in patients undergoing cholecystectomy. That is why we conducted the current study.
We aimed to evaluate the sensitivity and accuracy of GGT in the diagnosis of silent common bile duct stones in patients diagnosed with gall stones and scheduled for cholecystectomy.
Our results summarized as the following:
• The age of patients included in our study was ranged from 19 years to 60 years with mean (± SD) was 40.37± 11.47 years. Fourteen (46.7%) cases were males and 16 (53.3%) were female with male to female ratio was 0.88: 1. The mean BMI was 27.93± 1.55 Kg/m2 and ranged from 25 Kg/m2 to 31 Kg/m2.
• The mean hemoglobin was 11.27± 1.08 g/dl. The mean WBCs was 8007.30 ±1488.98 ×103/L. In addition, the mean platelets count was 218.33 ±15.60 ×109/L.
• The mean ALT and AST were 64.80 ±12.99 IU/L and 49.00 ±9.49 IU/L respectively. The mean total bilirubin, GGT and ALP were 0.77± 0.17, 295.67± 249.20 and 204.67± 171.85 respectively.
• The mean serum creatinine was 1.01±0.17 mg/dl while the mean serum HbA1c was 5.07±0.51.
• More than half (53.3%) had normal liver and thick gall bladder wall was seen in 53.3% cases. Most cases had multiple gall stones, as they constituted 76.7% of patients. The size of stones were more than 4 mm in 60% cases. common bile duct was dilated in 53.3% cases with mean diameter of 11.87± 1.48 mm. common bile duct stones was found in seven cases (23.3%).
• By MRCP, single stone was detected in three cases while 43.3% cases had multiple stones. Common bile duct had average caliber in 46.7% cases with mean CBD diameter measured by MRCP was 11.87± 1.87 mm. laparoscopic cholesestectomy was done in 46.7% cases while ERCP was done first then ERCP in 53.3% cases. Intraoperative data showed that there was no apparent abnormalities in gall bladder, cystic duct and CBD.
• The mean postoperative hemoglobin was 10.77±0.77 g/dl. The mean WBCs was 7968.10 ±1053.72 ×103/L. In addition, the mean platelets count was 214.20 ±12.23×109/L.
• The mean ALT and AST were 59.47 ±10.96 IU/L and 45.10±9.23 IU/L respectively. The mean total bilirubin, GGT and ALP were 0.65±0.15, 38.73 ±6.48 and 83.97 ±5.82 respectively.
• It was found that there common bile duct stones was significantly higher in cases with high GGT compared to cases with normal GGT (p=0.033).
• It was found that multiple common bile duct stones was significantly higher in cases with high GGT compared to cases with normal GGT (p=<0.001). In addition, the decision of doing ERCP before laparoscopy was significantly higher in cases with high GGT compared to cases with normal GGT (p=<0.001).
• For detecting CBD stones, GGT had sensitivity and specificity of 100% and 71.4%, respectively, when a cut-off value of 71.4 u/l was applied.