Correlative super-resolution microscopy with deep UV reactivation

Correlative super-resolution microscopy has the potential to accurately visualize and validate new biological structures past the diffraction limit. However, combining different super-resolution modalities, such as deterministic stimulated emission depletion (STED) and stochastic single-molecule localization microscopy (SMLM), is a challenging endeavour. For correlative STED and SMLM, the following poses a significant challenge: (1) the photobleaching of the fluorophores in STED; (2) the subsequent reactivation of the fluorophores for SMLM and (3) finding the right fluorochrome and imaging buffer for both imaging modalities. Here, we highlight how the deep ultraviolet (DBUE) wavelengths of the Mercury (Hg) arc lamp can help recover STED bleaching and allow for the reactivation of single molecules for SMLM imaging. We also show that Alexa Fluor 594 and the commercially available Prolong Diamond to be excellent fluorophores and imaging media for correlative STED and SMLM.

Super-resolution microscopy: a brief history and new avenues

Super-resolution microscopy (SRM) is a fast-developing field that encompasses fluorescence imaging techniques with the capability to resolve objects below the classical diffraction limit of optical resolution. Acknowledged with the Nobel prize in 2014, numerous SRM methods have meanwhile evolved and are being widely applied in biomedical research, all with specific strengths and shortcomings. While some techniques are capable of nanometre-scale molecular resolution, others are geared towards volumetric three-dimensional multi-colour or fast live-cell imaging. In this editorial review, we pick on the latest trends in the field. We start with a brief historical overview of both conceptual and commercial developments. Next, we highlight important parameters for imaging successfully with a particular super-resolution modality. Finally, we discuss the importance of reproducibility and quality control and the significance of open-source tools in microscopy. This article is part of the Theo Murphy meeting issue 'Super-resolution structured illumination microscopy (part 2)'.

At the molecular resolution with MINFLUX?

MINFLUX is purported as the next revolutionary fluorescence microscopy technique claiming a spatial resolution in the range of 1-3 nm in fixed and living cells. Though the claim of molecular resolution is attractive, I am concerned whether true 1 nm resolution has been attained. Here, I compare the performance with other super-resolution methods focusing particularly on spatial resolution claims, subjective filtering of localizations, detection versus labelling efficiency and the possible limitations when imaging biological samples containing densely labelled structures. I hope the analysis and evaluation parameters presented here are not only useful for future research directions for single-molecule techniques but also microscope users, developers and core facility managers when deciding on an investment for the next 'state-of-the-art' instrument. This article is part of the Theo Murphy meeting issue 'Super-resolution structured illumination microscopy (part 2)'.

Super-resolution structured illumination microscopy: past, present and future

Structured illumination microscopy (SIM) has emerged as an essential technique for three-dimensional (3D) and live-cell super-resolution imaging. However, to date, there has not been a dedicated workshop or journal issue covering the various aspects of SIM, from bespoke hardware and software development and the use of commercial instruments to biological applications. This special issue aims to recap recent developments as well as outline future trends. In addition to SIM, we cover related topics such as complementary super-resolution microscopy techniques, computational imaging, visualization and image processing methods. This article is part of the Theo Murphy meeting issue 'Super-resolution structured illumination microscopy (part 1)'.

Laser-free super-resolution microscopy

We report that high-density single-molecule super-resolution microscopy can be achieved with a conventional epifluorescence microscope set-up and a mercury arc lamp. The configuration termed as laser-free super-resolution microscopy (LFSM) is an extension of single-molecule localization microscopy (SMLM) techniques and allows single molecules to be switched on and off (a phenomenon termed as 'blinking'), detected and localized. The use of a short burst of deep blue excitation (350-380 nm) can be further used to reactivate the blinking, once the blinking process has slowed or stopped. A resolution of 90 nm is achieved on test specimens (mouse and amphibian meiotic chromosomes). Finally, we demonstrate that stimulated emission depletion and LFSM can be performed on the same biological sample using a simple commercial mounting medium. It is hoped that this type of correlative imaging will provide a basis for a further enhanced resolution. This article is part of the Theo Murphy meeting issue 'Super-resolution structured illumination microscopy (part 1)'.

Astrocyte layers in the mammalian cerebral cortex revealed by a single-cell in situ transcriptomic map

Although the cerebral cortex is organized into six excitatory neuronal layers, it is unclear whether glial cells show distinct layering. In the present study, we developed a high-content pipeline, the large-area spatial transcriptomic (LaST) map, which can quantify single-cell gene expression in situ. Screening 46 candidate genes for astrocyte diversity across the mouse cortex, we identified superficial, mid and deep astrocyte identities in gradient layer patterns that were distinct from those of neurons. Astrocyte layer features, established in the early postnatal cortex, mostly persisted in adult mouse and human cortex. Single-cell RNA sequencing and spatial reconstruction analysis further confirmed the presence of astrocyte layers in the adult cortex. Satb2 and Reeler mutations that shifted neuronal post-mitotic development were sufficient to alter glial layering, indicating an instructive role for neuronal cues. Finally, astrocyte layer patterns diverged between mouse cortical regions. These findings indicate that excitatory neurons and astrocytes are organized into distinct lineage-associated laminae.

Serial perioperative cell-free DNA levels in donors and recipients undergoing living donor liver transplantation

BACKGROUND

Effect of anaesthesia and surgery on cell-free DNA (cfDNA) is not known. Given that surgical stress augments inflammation and injury, we hypothesized that levels of cfDNA will fluctuate during perioperative period. Therefore, in this study serial perioperative cfDNA concentration was measured in donors and recipients undergoing living donor liver transplantation (LDLT).

METHODS

Baseline, post-induction, intraoperative and post-operative plasma cfDNA levels were evaluated in 21 donors and recipients each, by Sytox green method. In addition, qPCR was performed in a subset of samples.

RESULTS

Baseline cfDNA levels were higher in recipients (37.62 ng/ml) than in donors (25.49 ng/ml). A decrease in cfDNA was observed following anaesthesia induction in both recipients (11.90 ng/ml) and donors (10.75 ng/ml). When the kinetics of the cfDNA was monitored further, an increase was noted intraoperatively in donors (46.18 ng/ml) and recipients (anhepatic phase: 56.25 ng/ml, reperfusion phase: 54.36 ng/ml). cfDNA levels remained high post-operatively. One recipient who developed post-operative sepsis had the highest cfDNA level (94.72 ng/ml).

CONCLUSION

Plasma cfDNA levels are high in recipients indicative of liver injury. Lower cfDNA levels following induction may be attributed to the subduing effect of anaesthetic agents on cell death. High cfDNA levels seen in intra- and post-operative phases reflect cellular trauma and inflammation. This similar pattern of fluctuation of cfDNA level in donors and recipients is suggestive of its possible utility as a surgical stress marker. In addition, comparable cfDNA levels in anhepatic and reperfusion phase reflect less ischemia reperfusion injury during LDLT.

Histone Code and Higher-Order Chromatin Folding: A Hypothesis

Histone modifications alone or in combination are thought to modulate chromatin structure and function; a concept termed histone code. By combining evidence from several studies, we investigated if the histone code can play a role in higher-order folding of chromatin. Firstly using genomic data, we analyzed associations between histone modifications at the nucleosome level. We could dissect the composition of individual nucleosomes into five predicted clusters of histone modifications. Secondly, by assembling the raw reads of histone modifications at various length scales, we noticed that the histone mark relationships that exist at nucleosome level tend to be maintained at the higher orders of chromatin folding. Recently, a high-resolution imaging study showed that histone marks belonging to three of the five predicted clusters show structurally distinct and anti-correlated chromatin domains at the level of chromosomes. This made us think that the histone code can have a significant impact in the overall compaction of DNA: at the level of nucleosomes, at the level of genes, and finally at the level of chromosomes. As a result, in this article, we put forward a theory where the histone code drives not only the functionality but also the higher-order folding and compaction of chromatin.

Quantitative super-resolution localization microscopy of DNA in situ using Vybrant® DyeCycle™ Violet fluorescent probe

Single Molecule Localization Microscopy (SMLM) is a recently emerged optical imaging method that was shown to achieve a resolution in the order of tens of nanometers in intact cells. Novel high resolution imaging methods might be crucial for understanding of how the chromatin, a complex of DNA and proteins, is arranged in the eukaryotic cell nucleus. Such an approach utilizing switching of a fluorescent, DNA-binding dye Vybrant® DyeCycle™ Violet has been previously demonstrated by us (Żurek-Biesiada et al., 2015) [1]. Here we provide quantitative information on the influence of the chemical environment on the behavior of the dye, discuss the variability in the DNA-associated signal density, and demonstrate direct proof of enhanced structural resolution. Furthermore, we compare different visualization approaches. Finally, we describe various opportunities of multicolor DNA/SMLM imaging in eukaryotic cell nuclei.

A transient ischemic environment induces reversible compaction of chromatin

Background

Cells detect and adapt to hypoxic and nutritional stress through immediate transcriptional, translational and metabolic responses. The environmental effects of ischemia on chromatin nanostructure were investigated using single molecule localization microscopy of DNA binding dyes and of acetylated histones, by the sensitivity of chromatin to digestion with DNAseI, and by fluorescence recovery after photobleaching (FRAP) of core and linker histones.

Results

Short-term oxygen and nutrient deprivation of the cardiomyocyte cell line HL-1 induces a previously undescribed chromatin architecture, consisting of large, chromatin-sparse voids interspersed between DNA-dense hollow helicoid structures 40–700 nm in dimension. The chromatin compaction is reversible, and upon restitution of normoxia and nutrients, chromatin transiently adopts a more open structure than in untreated cells. The compacted state of chromatin reduces transcription, while the open chromatin structure induced upon recovery provokes a transitory increase in transcription. Digestion of chromatin with DNAseI confirms that oxygen and nutrient deprivation induces compaction of chromatin. Chromatin compaction is associated with depletion of ATP and redistribution of the polyamine pool into the nucleus. FRAP demonstrates that core histones are not displaced from compacted chromatin; however, the mobility of linker histone H1 is considerably reduced, to an extent that far exceeds the difference in histone H1 mobility between heterochromatin and euchromatin.

Conclusions

These studies exemplify the dynamic capacity of chromatin architecture to physically respond to environmental conditions, directly link cellular energy status to chromatin compaction and provide insight into the effect ischemia has on the nuclear architecture of cells.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-015-0802-2) contains supplementary material, which is available to authorized users.

Single molecule localization microscopy of the distribution of chromatin using Hoechst and DAPI fluorescent probes

Several approaches have been described to fluorescently label and image DNA and chromatin in situ on the single-molecule level. These superresolution microscopy techniques are based on detecting optically isolated, fluorescently tagged anti-histone antibodies, fluorescently labeled DNA precursor analogs, or fluorescent dyes bound to DNA. Presently they suffer from various drawbacks such as low labeling efficiency or interference with DNA structure. In this report, we demonstrate that DNA minor groove binding dyes, such as Hoechst 33258, Hoechst 33342, and DAPI, can be effectively employed in single molecule localization microscopy (SMLM) with high optical and structural resolution. Upon illumination with low intensity 405 nm light, a small subpopulation of these molecules stochastically undergoes photoconversion from the original blue-emitting form to a green-emitting form. Using a 491 nm laser excitation, fluorescence of these green-emitting, optically isolated molecules was registered until "bleached". This procedure facilitated substantially the optical isolation and localization of large numbers of individual dye molecules bound to DNA in situ, in nuclei of fixed mammalian cells, or in mitotic chromosomes, and enabled the reconstruction of high-quality DNA density maps. We anticipate that this approach will provide new insights into DNA replication, DNA repair, gene transcription, and other nuclear processes.

Phytoplankton species diversity indices in Anjanapura reservoir, Western Ghat region, India

A qualitative study on species composition and diversity of phytoplankton flora was carried out in the Anjanapura reservoir. Water samples were collected monthly at four sites from November 2005 to October 2007 for plankton analysis. A total of 152 phytoplankton species belonging to 59 genera were recorded. The species belonging to genera Crucigenia, Pediastrum, Scenedesmus, Tetraedron, Cyclotella, Gyrosigma, Melosira, Navicula, Fragillaria, pinnularia, Synedra, Closterium, Cosmarium, Euastrum, Staurastrum, Gleocapsa, Merismopedia, Microcystis, Oscillatoria, Euglena and Phacus were found dominant. Phytoplankton density was recorded in the range of 222-1467 Org l(-1) for chlorococcales, 267-1467 Org I (-1) for diatoms, 44-889 Org l(-1) for desmids, 44-889 Org l(-1) for blue-greens and 22-1667 Org l(-1) for euglenoids. Seasonal density Shannon-Weiner diversity index (1.60-1.88) indicate that reservoir exhibited rich phytoplankton and Nygaard tropic status indices for myxophycean (1.0-1.50), chlorophycean (1.62-2.16), diatoms (0.10-0.14), euglenophycean (0.18-0.19) and compound quotient(3.25-4.66) showed that reservoir was moderately polluted. From the observed data, it could be concluded that the presence of more diverse group of phytoplankton indicate the productivity of the reservoir.

Ileal ganglioneuromatosis with adenocarcinoma in a patient with multiple neurofibromatosis

Von Recklinghausen's disease or type 1 neurofibromatosis is an autosomal dominant disease characterized by mucocutaneous neurofibromas, café-au-lait spots and involves many organs including gastrointestinal tract. Gastrointestinal involvement in neurofibromatosis is uncommon and is seen 25% patients and nearly 5% of them are only symptomatic (Shekitka and Sobin, Am J Surg Pathol 18:250-257, 1994; Tomita et al., Int J Colorectal Dis 21: 89-91, 2006).

Hypolipidemic Effect of Celastrus paniculatus in Experimentally Induced Hypercholesterolemic Wistar Rats

The objective of the present study was to evaluate hypolipidemic effect of methanolic extract of Celastrus paniculatus in experimentally induced hypercholesterolemic rats. Hypercholesterolemia was induced by feeding the animals with high fat diet. Oral administration of methanolic seed extract (50%) of Celastrus paniculatus at the optimized dose of 65 mg/kg body weight, substantially reduced the plasma total cholesterol, triglycerides and LDL cholesterol in comparison with induced hypercholesterolemic animal group and the results were comparable with the standard hypocholesterolemic drug and almost similar to the control group. Atherogenic index and liver weight of treated animals also showed significant decrease compared to the hypercholesterolemic animals. It substantially increased the HDL cholesterol level as compared to control group. A significant increase in the activities of lipoprotein lipase and plasma LCAT enhanced hepatic bile acid synthesis and thereby, increased degradation of cholesterol to neutral sterols. Furthermore, the activities of HMG-CoA reductase, glucose 6-phosphate dehydrogenase and malate dehydrogenase were significantly reduced. Histological studies showed less cholesterol deposits in the aorta of animals fed with seed extract of C. paniculatus compared to the induced hypercholesterolemic animals not given C. paniculatus supplement.

Corneal changes in type II diabetes mellitus in Malaysia

AIM

To compare corneal endothelial structure and central corneal thickness (CCT) between type II diabetics and non-diabetic control patients. To look for correlations between diabetic status and corneal findings.

METHODS

Hospital-based, observational study. 200 eyes (from 100 type II diabetic patients and 100 controls) were included. Specular microscopy and pachymetry were used to measure endothelial cell density, size, coefficient of variation in cell area, hexagonality as well as corneal thickness. Independent t-tests were used to compare variables between diabetics and controls. Pearson correlation tests were used to evaluate correlations between corneal findings and diabetic status such as duration of diabetes, haemoglobin A1c (HbA1c) level and severity of diabetic retinopathy.

RESULTS

Endothelial cell density in the diabetic group (2541.6±516.4 cells/mm(2)) was significantly lower than that in the control group (2660.1±515.5 cells/mm(2), P<0.05). The average size of endothelial cells, standard deviation (SD) of cell size and coefficient of variation (CV) of cell area were all significantly higher in diabetics. Hexagonality was significantly lower in diabetics (41.1%±19.6%) compared to non-diabetics (45.2%±20.6%). CCT was higher in diabetics but not significant (P>0.05). Duration of diabetes, HbA1c level and severity of diabetic retinopathy were not significantly correlated with corneal endothelial findings.

CONCLUSION

Type II diabetes causes a significant alteration in the state of the cornea including reduction in endothelial cell density and increased pleomorphism and polymegathism. Central corneal thickness is unaffected.

Plant metabolites: an alternative and sustainable approach towards post harvest pest management in pulses

Grain legumes are an important source of proteins in vegetarian diet besides their role in biological nitrogen fixation. They are prone to heavy pest infestation both on and off the field. Pest associated losses are an important contributing factor towards declining per capita availability of grain legumes. Synthetic chemical pesticides have played an important role in crop preservation, however their incessant use has posed several environmental and human health concerns. Methyl bromide and phosphine are commonly used for the post harvest preservation of grain legumes. However, the former has to be phased out by 2015 as per the Montreal protocol whereas the latter is showing development of resistance to it by the insects. In the light of this, alternative, safer and sustainable strategies are needed for crop protection. Plants can serve as a rich source of bioactive chemicals for this purpose. Both primary as well as secondary metabolites can be evaluated against the target pests. The paper reviews the status of research in the area of use of plant metabolites in post harvest pest management of grain legumes.

Socioeconomic background in relation to stage at diagnosis, treatment and survival in women with breast cancer

In a large population-based series of invasive breast cancer patients, we investigated socioeconomic background (SEB) in relation to (a) stage at diagnosis; (b) treatment pattern; and (c) 5-year survival. Women diagnosed during 1998–2000 and resident in the Northern and Yorkshire regions of England were identified from the cancer registry database (N=12 768). Logistic regression and Cox proportional hazards analyses were used to estimate associations between SEB (defined using the Townsend Index for area of residence) and tumour stage, treatment pattern, and survival. Living in a more deprived area was associated with increased likelihood of being diagnosed with stage III or IV disease (age-adjusted odds ratio (OR) 1.13; 95% confidence interval (CI) 1.08–1.18 per quartile increase in Townsend score), and, after adjustment for age and stage, reduced odds of having surgery (OR 0.85; 95% CI 0.80–0.91), and receiving radiotherapy (OR 0.91; 95% CI 0.88–0.94). Amongst patients receiving surgery, those living in more deprived areas had decreased odds of having breast conserving surgery (age plus stage-adjusted OR 0.92; 95% CI 0.89–0.95). Living in a more deprived area was also associated with increased mortality (age- plus stage-adjusted hazard ratio 1.08; 95% CI 1.05–1.11). These effects may operate through several pathways, such as later presentation leading to advanced disease.

Bilateral corneal perforation in a sexually active adult male with gonococcal conjunctivitis

A 41 year-old Malay man had been treated by general practitioners for bilateral red eyes with profuse discharge of three weeks' duration with no improvement. He then presented to an ophthalmologist who noted profuse purulent discharge, bilateral corneal perforation, lid swelling and chemosis. Culture of the ocular discharge grew Neisseria gonorrhoeae. Treatment with systemic and topical antibiotics prevented microperforations in the right eye from progressing to overt perforation and was able to control disease in the left eye.

Prevalence of blindness and cataract surgery in Gandaki Zone, Nepal

BACKGROUND/AIM

Himalaya Eye Hospital (HEH), established in 1993, is rendering eye care services in the Gandaki and Dhaulagiri zones. The hospital has extensive community outreach activities along with services for outpatients, emergencies, and subspecialties such as vitreoretinal, paediatric, and low vision. The operation theatre is well equipped to match the surgical needs including phaco surgery for cataract. The hospital has performed more than 14 000 cataract surgeries and 250 000 treatment services during this period. The aim of this study was to estimate the prevalence of blindness, visual impairment, and cataract surgical coverage among the older adult population of three districts of Gandaki Zone, where 80% of the hospital's service recipients reside.

METHODS

People aged 45 years and older were enrolled in the study using a stratified cluster design. Subjects in 25 randomly selected clusters from the listed 806 were recruited through door to door visits. Each recruited subject had visual acuity (VA) and clinical examination conducted by an ophthalmologist. The survey was preceded by pre-pilot and pilot studies to refine the operational method. To assess quality assurance the interobserver variation in VA measurement was also carried out in five different clusters.

RESULTS

Out of 5863 selected subjects 85.3% were examined. Blindness defined as presenting VA <6/60 in both eyes was found in 2.6% (95% confidence interval (CI): 2.2 to 3.9), whereas 16.8% individuals examined had vision <6/19 in one or both eyes. Cataract was the principal cause of blindness in 60.5%, and refractive error was the dominant cause of vision impairment (<6/19) 83.3%. Cataract surgical coverage was 59.5% among the cataract blind and associated with younger age, literacy, and male sex.

CONCLUSION

The finding suggests a positive impact of the HEH programme on the prevalence of blindness and cataract surgical services in the survey area. Strategies to further improve access and utilisation of facilities and increase cataract surgical coverage need to be developed.

Postoperative seizures after extratemporal resections and hemispherectomy in pediatric epilepsy

Objectives: To estimate frequency and risk factors for acute postoperative seizures (APOS) within the first week after extratemporal cortical resection (ETR) and hemispherectomy (HS) in children and to assess the predictive value of APOS on long-term seizure outcome in this group.

Methods: The authors conducted a retrospective analysis of children (<18 years), who underwent ETR or HS for intractable epilepsy between 1995 and 2002. APOS features and seizure outcome after ETR or HS were obtained at 6, 12, and 24 months. Univariate logistic regression was used for risk factors of APOS and life table analysis and log rank tests for seizure outcome at 0 to 6, 6 to 12, and 12 to 24 months.

Results: Of 132 patients, 34 (26%) had APOS. APOS were more frequent after ETR (26/71) than HS (8/61) (p < 0.01). APOS, irrespective of their timing, number, semiology, or other perioperative complications, were an independent predictor of poor postoperative seizure outcome at 2 years (p < 0.001). The estimated odds of postoperative Engel class I outcome in the APOS vs non-APOS categories was 0.27 (73% less likely) for 0- to 6-month, 0.22 (78% less likely) for 6- to 12-month, and 0.13 (87% less likely) for the 12- to 24-month intervals.

Conclusions: Acute postoperative seizures (APOS) occur in 26% children, and the risk is higher after extratemporal cortical resection than hemispherectomy. APOS predict a poor postoperative seizure outcome at 6, 12, and 24 months. This study is useful for counseling families after epilepsy surgery. It also suggests that APOS may not be discounted as “benign” in research studies that evaluate seizure outcomes after epilepsy surgery.

Changes in astigmatism in children with congenital nystagmus

BACKGROUND

Astigmatism is commonly reported in children with and without nystagmus. In children less than 4 years of age the astigmatism changes from against the rule (ATR) to with the rule (WTR) astigmatism in children without nystagmus. However, little is known about children with congenital nystagmus. We compared astigmatism in children with congenital nystagmus below 4 years and above 4 years of age.

MATERIAL AND METHODS

Three hundred and fifty-six eyes in 178 children who satisfied the study criteria were included. The children were divided into those below 4 years of age (n of eyes = 192) and those above (n of eyes = 164). Cycloplegic refraction (with manual retinoscopy) carried out at presentation and at the last follow-up were recorded and compared. Cycloplegia was achieved using cyclopentolate eye drops. Outcome of eyes with no astigmatism at initial presentation was compared with the final refraction in both the age groups. The visual acuity at the first presentation was compared with the visual acuity at the last presentation.

RESULTS

Average follow-up duration was 3.36+/-1.59 years. On presentation, 176 (49.44%) eyes did not have any astigmatism. We found that 26 (25.2%) out of the 103 children below 4 years of age who did not have any astigmatism on presentation developed WTR astigmatism after a mean follow-up of 3.5+/-1.5 years. (p= 0.042). In children >or=4 years of age only 7 (9.6%) children out of 73 developed WTR after a mean follow-up of 3.4+/-1.4 years. The visual acuity change was not found to be significant in the two groups. The majority (90.3%) improved or had same visual acuity in group A and 88.9% improved or had the same visual acuity in group B at the last follow-up (p= 0.77).

DISCUSSION

Our incidence of WTR astigmatism in children with congenital nystagmus is similar to those previously reported series. Our data suggest that there is a significant chance that children under 4 years with congenital nystagmus may develop WTR astigmatism compared with children above 4 years of age.

CONCLUSION

With the rule (WTR) astigmatism is common in children with nystagmus. Children under 4 years of age presenting with no astigmatism may acquire WTR astigmatism as they grow. The amount of astigmatism increases with age in children with nystagmus. Visual acuity, however, remains stable as the age advances.

Multidisciplinary approach in the long-term management of intrahepatic stones: Indian experience

BACKGROUND

Intrahepatic stones, though common in East Asia, are uncommon in India. There is paucity of data from India regarding the treatment and long-term outcome of patients with intrahepatic stones.

METHODS

We retrospectively analyzed medical records of 35 patients with intrahepatic stones who had been treated surgically. Endoscopic biliary drainage had been used in patients who presented with acute cholangitis. Intraoperative stone clearance was confirmed by choledochoscopy and intraoperative cholangiography. Outcome of surgery, frequency and subsequent management of recurrent intrahepatic stones, and factors associated with stone recurrence and cholangitis were analyzed.

RESULTS

Twenty-one (60%) patients had bilobar disease. Eight patients underwent hepatectomy and 16 hepatico-jejunostomy with access loop; 12 of these were jejuno-duodenal anastomoses. Postoperative morbidity was observed in 10 patients (29%). Recurrence of stones occurred in 12 patients (34%) and cholangitis in 9 patients (26%). Presence of bilobar disease and associated biliary strictures were associated with recurrent cholangitis (p< 0.05). Two patients (6%) required re-operation for recurrent cholangitis. Complete removal of recurrent stones using conventional endoscope was possible through jejuno-duodenostomy in all 5 cases who had this type of access loop construction.

CONCLUSION

Surgical treatment for intrahepatic stones depends on the site of involvement. Construction of a jejuno-duodenal access loop in patients with bilobar disease and intrahepatic strictures is helpful in facilitating postoperative stone clearance. A multidisciplinary approach is beneficial especially when the disease is bilobar and recurrent in type.