A network meta-analysis of primary prophylaxis for invasive fungal infection in haematological patients.

WHAT IS KNOWN AND OBJECTIVE: Antifungal prophylaxis is an option to reduce the incidence of invasive fungal infection (IFI) in haematological patients. To date, no network meta-analysis (NMA) of high-quality evidence (double-blind randomized controlled trials) has been performed on this subject. This systematic review and NMA aimed to evaluate the safety and efficacy of different antifungal agents used for prophylaxis of IFI in patients with haematological disorders. METHODS: A systematic review was performed according to PRISMA and Cochrane recommendations. The search for articles was conducted on PubMed, Scopus and the Web of Science. We searched for double-blind randomized clinical trials comparing antifungal agents for IFI prophylaxis head-to-head vs placebo in patients with any blood cancer. Network meta-analyses were conducted using Addis version 1.16.6. Evaluation of the quality of included RCTs was also performed. RESULTS: Twenty-five trials were included in the qualitative and quantitative analyses. Posaconazole stood out as the best IFI prophylaxis option and for avoiding IFI-related mortality. For the incidence of candidiasis outcome, the azoles were superior to placebo. Voriconazole and posaconazole were, respectively, the first and second best options. For the incidence of aspergillosis outcome, the probability rank suggested that voriconazole followed by liposomal amphotericin B is, possibly, the best choice. The quality of studies was considered good, with a mean Jadad score of 4.0. WHAT IS NEW AND CONCLUSION: The results of our work support prophylaxis with antifungal agents as reducing the risk of IFI in haematological patients. Overall, the second-generation azoles were found to be the best option for preventing IFI in this population.

Performance of Chaetosiphon fragaefolii (Hemiptera: Aphididae) in Different Strawberry Cultivars.

The green aphid Chaetosiphon fragaefolii (Cockerell) (Hemiptera: Aphididae) is one of the most important pests of strawberry production systems worldwide. One of the fundamental points for developing management strategies for this aphid is the understanding of its population growth since this allows predictions about future population peaks and which are the most appropriate hosts for its survival and reproduction. Thus, the goal of this study was to evaluate the biological and population growth parameters of C. fragaefolii in four strawberry cultivars (Albion, Aromas, Camarosa, and San Andreas). The highest survival of the nymph stage was observed in 'San Andreas' (87%) and the lowest in 'Camarosa' (43%). 'Albion' had the highest net reproductive rate (R0 = 6.39) and the mean time for the population to double in number (TD = 5.61), thus presenting the best reproductive parameters for C. fragaefolii. 'Camarosa' and 'Aromas' had the lowest R0 values (2.65 and 2.70, respectively) and the highest TD values (10.89 and 10.34, respectively). We conclude that antibiosis mechanisms are involved in the resistance process of 'Camarosa' to C. fragaefolii. The characterization and the use of resistant cultivars can be an essential strategy to assist aphid management.

Influence of Trichomes in Strawberry Cultivars on the Feeding Behavior of Chaetosiphon fragaefolii (Cockerell) (Hemiptera: Aphididae).

Chaetosiphon fragaefolii (Cockerell) (Hemiptera: Aphididae) is the predominant aphid in strawberry (Fragaria × ananassa Duchesne) production systems in Brazil. This pest species directly damages the plants and is also responsible for spreading viruses. Further, C. fragaefolii often renders strawberry cultivation unviable, because of its high reproductive rate, as well as the large number of individuals generated through parthenogenesis. The present study aimed to (1) evaluate the feeding behavior of C. fragaefolii in four strawberry cultivars (Albion, Aromas, Camarosa, and San Andreas) and (2) identify the resistance factors associated with the number and type of trichomes in the cultivars, and also its effect on the feeding behavior of C. fragaefolii, using the electrical penetration graph (EPG) technique. The results revealed an intrinsic relationship between the number of trichomes on the cultivar and feeding behavior of C. fragaefolii. A higher number of trichomes, both tector and glandular, was observed in Albion compared to that of other cultivars, resulting in a longer no probing (Np) period per insect, and a longer Np phase. A relatively short phloem phase and ingestion time of the phloem sieve elements were also observed in Albion. These results suggest that the trichomes act as a physical barrier creating difficulties for C. fragaefolii to feed, thereby altering its feeding behavior in the four cultivars studied.

Monophasic estrogen-progestogen therapy and sexuality in postmenopausal women.

OBJECTIVE: This study aimed to evaluate the effects of monophasic estrogen-progestogen therapy on the sexuality and climacteric symptoms of postmenopausal women. PATIENTS AND METHODS: A prospective, randomised, double-blind, crossover, placebo-controlled, single-centre study was carried out over a total of 12 consecutive months in 40 postmenopausal women with an intact uterus who had no contraindications to hormone therapy. Patients received 17beta-estradiol 2mg in combination with norethisterone acetate 1mg (Cliane) daily for 6 months or one placebo tablet daily for 6 months. The tablets were identical in appearance. After 6 months, the groups were crossed over and the patients were followed up for another 6 months. The groups were homogenous with respect to age, height, bodyweight, body mass index and race. For the statistical analysis, the group receiving hormone therapy was referred to as group A and the placebo group was designated group B, irrespective of the placebo/hormone therapy sequence. RESULTS: In group A there were fewer hot flashes (F=22.85, p<0.01) and an improvement in sexual interest (F=5.55, p<0.05). The sequence in which the medication was received resulted in a statistically significant difference with respect to dyspareunia (F=9.65, p<0.01) and satisfaction with the duration of penetration (F=6.58, p<0.05). In the intrapatient analysis of variation with respect to orgasmic capability and the presence of dialogue with partner regarding the couple's sexual life, whether the placebo was taken prior to or following hormone therapy was significant (F=17.12, p<0.001 and F=7.10, p<0.05, respectively). CONCLUSIONS: Monophasic estrogen-progestogen therapy has a beneficial effect on sexuality and on hot flashes in postmenopausal women.

Biological parameters and fertility life table of Aphis forbesi Weed, 1889 (Hemiptera: Aphididae) on strawberry.

This study provides the first contribution of the biology and life table of Aphis forbesi Weed, 1889 (Hemiptera: Aphididae), an important strawberry pest throughout the world. This species lives in the crown and leaf petioles of the plant. It is difficulty to rear this species in laboratory due to protocooperation with ants observed only in the field. We studied the life cycle of A. forbesi on the leaves of the Albion strawberry cultivar at 25 ± 2 °C, 60 ± 10% relative humidity, and a 12-h photophase. The experiment was randomised with 100 replicates. The parameters of the fertility life table were calculated using TabVida. In the population studied, 25% and 46% had four and three instars, respectively. A mean of 1.43 nymphs per female per day was generated. The mean reproductive period was seven days and the mean longevity was 10 days. In every 11 days there is a generation of A. forbesi, where each female has the potential to generate between 6 to 9 individuals daily, increasing its population by 1.2 times. The average life cycle was 16.8 days. High viability observed in all instars and the resulting values of R0, rm and λ suggest that A. forbesi has the capacity to increase their numbers in a short period of time, while generating high populations in strawberry crops, requiring differential management.

A new technique of gastroenterostomy for palliative treatment of pancreatic head carcinoma.

BACKGROUND/AIMS: Most of the patients with pancreatic cancer can be only palliatively treated. Although 30% of the patients submitted to palliative biliary bypass will require further treatment for duodenal obstruction, prophylactic gastric bypass still remains a controversial issue in the management of unresectable pancreatic head carcinoma. The main disadvantage of current techniques of gastrojejunostomy is postoperative vomiting due to impaired gastric motility and circulus vitiosus through the nonobstructed duodenum. A new technique of prophylactic gastrojejunostomy is described herein as an attempt to obviate these complications. METHODOLOGY: An antecolic isoperistaltic gastrojejunostomy was fashioned at the gastric mid-body above the angulus. The afferent limb was partitioned close to the gastrojejunostomy and a Braun type entero-enterostomy constructed joining the afferent and the efferent limbs. Following the gastrojejunostomy a Roux-en-Y choledochojejunostomy was performed. RESULTS: In 19 patients consecutively submitted to this procedure no postoperative mortality or complications occurred. Nasogastric suction was interrupted at postoperative day 3 and oral feeding resumed on the next day. Neither early nor late postoperative vomiting was observed. CONCLUSIONS: These encouraging preliminary results suggest that this procedure may have its place in the palliative treatment of pancreatic head carcinoma.

Distal pancreatectomy without splenectomy and with preservation of splenic vessels.

BACKGROUND/AIMS: Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. METHODOLOGY: Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas. RESULTS: The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality. CONCLUSIONS: Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.

Surgical treatment of pancreatic ascites and pancreatic pleural effusions.

BACKGROUND/AIMS: Massive ascites and pleural effusions are uncommon but well-documented complications of chronic pancreatitis. The present study reviews the results of surgical management of pancreatic ascites and pleural effusions of pancreatic origin. PATIENTS AND MATERIALS: From forty-nine patients with chronic pancreatitis presenting with ascites and/or pleural effusion of pancreatic origin, 31 were surgically treated. RESULTS: Nineteen had ascites only, ten pleural effusions and two presented with both conditions. Diagnosis of the internal pancreatic fistula was based on the findings of high amylase levels and elevated albumin content of the peritoneal and pleural exudates. Failure of medical therapy was the indication of surgical treatment in all patients. Thirteen were submitted to internal pancreatic drainage, 17 to external drainage and one to distal pancreatic resection. Eight of 17 externally drained patients were reoperated for intraperitoneal abscesses (2), infected pseudocyst (1), pain recurrence (3) and pancreatic fistula (2); whereas reoperation occurred in only one of the 13 patients submitted to internal drainage (p < 0.05). CONCLUSIONS: Internal pancreatic drainage was the ideal surgical treatment for patients with pancreatic ascites and/or pleural effusion that did not respond to medical treatment. When this was not feasible external drainage was successfully used as an alternative to pancreatic resection.

Pancreatic head tumors with portal vein involvement: an alternative surgical approach.

BACKGROUND/AIMS: One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion. METHODOLOGY: Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step. RESULTS: Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality. CONCLUSIONS: This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.

Surgical treatment of cicatricial biliary strictures.

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.

Insulinoma: diagnostic strategies and surgical treatment. A 22-year experience.

BACKGROUND/AIMS: The efficacy of preoperative localization methods and the results of the surgical treatment of insulinoma were studied. METHODOLOGY: Fifty-nine patients referred for surgical treatment were studied and the results of the diagnostic tools for tumor localization were compared with findings at surgical intervention. The influence of the type of surgical procedure in the immediate and late postoperative course was also studied. RESULTS: Ultrasonography had a sensitivity of 30%, computed tomography 25%, angiography 54%, portal vein sampling 94%, endoscopic ultrasonography 27% and magnetic resonance 17%. Intraoperative palpation localized 98.2% of the tumors and by the addition of intraoperative echography, all lesions were identified. In 55 patients with benign lesions, 22 enucleations, 25 distal pancreatectomies, 7 pancreatectomies plus enucleation and one duodenopancreatectomy were performed. Malignant tumors were treated by pancreatic resection, postoperative hepatic artery embolization and systemic chemotherapy. There was no postoperative mortality. Pancreatic fistula was the most common complication. Three patients who underwent distal pancreatectomy developed late diabetes (9.3%). CONCLUSIONS: Extensive preoperative investigation, mainly with invasive methods, is not indicated and by combining intraoperative palpation and echography most of the cases can be adequately dealt with. Preservation of pancreatic tissue with enucleation and preservation of the spleen are the best choice for treatment of benign insulinomas.

Carcinoid tumor of the gallbladder.

The carcinoid tumor is a relatively rare type of endocrine tumor, which arises mainly in the gastrointestinal tract. Primary gallbladder and biliary duct system carcinoids comprise less than 1% of all carcinoid tumors arising from any tissue or organ in the body. We describe a case of carcinoid tumor of the gallbladder in a 39-year-old man. There have been only 32 cases described in the literature.

[Surgical treatment of insulinoma: study of 59 cases]. / Tratamento cirúrgico dos insulinomas--Estudo de 59 casos.

UNLABELLED: After establishing the diagnosis of an insulinoma the next step is its localization in order to perform the most suitable management approach. PURPOSE: To evaluate the methods used for the diagnosis of insulinoma and the localization of its site as well as the results of the surgical treatment. METHODS: Fifty nine consecutive patients with pancreatic insulinomas were studied. The discriminative power of the preoperative investigations in the localization of insulinomas was analysed. Special attention was focused to the intra operative methods of tumor localizations. The early and late results of the surgical treatment were also investigated. RESULTS: There were 55 benign cases and 4 malignant tumors. Preoperative localization was attempted by using ultrasonography (positive in 28.1%) CT imaging (positive in 25%), selective arteriography (positive in 54.1%), endoscopic ultrasonography (positive in 27.2%) and assay of portal plasma insulin levels (positive in 94.4%). In 54/55 cases (98.2%) the tumors were identified intraoperatively by palpation. By addition of intraoperative ultrasonography all lesions were identified and successfully removed without mortality. Five patients had multiple endocrine neoplasias all with multiple lesions in the pancreas. In patients with benign lesions 29 enucleations and 32 resections were performed. Pancreatic fistulas were the most common complication (29/59). Excluding the patients with malignant lesions the recovery rate was 98.1%. Three patients who underwent corporo caudal pancreactectomy developed diabetes. CONCLUSIONS: The preoperative localization is not necessary, since a combination of palpation and intraoperative ultrasonography can deal with most cases. Enucleation when possible is the best choice for benign lesions.

Feeding behavior of two exotic aphid species on their original hosts in a new invaded area.

Greenidea ficicola Takahashi and Greenidea psidii van der Goot (Aphididae: Greenideinae) are Asian aphid species newly introduced in Brazil associated with Moraceae and Myrtaceae. The feeding behavior of G. ficicola and G. psidii was investigated on their respective host plants, Ficus benjamina (Moraceae) and Psidium guajava (Myrtaceae), using the Electrical Penetration Graph (EPG). Fifteen females of each aphid species were monitored during 24h using a DC-EPG GIGA-4 monitor. The time spent in phloem phase (waveforms E1 and E2) was 13.6% of the total recording time for G. ficicola and 0.8% for G. psidii. The average time in the pathway phase (waveforms C and pd) represented 50% of the total time for both species. Aphids spent more time in non-penetration and stylet pathway activities than in the phloem phase or actual feeding. The principal component analysis (PCA) showed that the two species formed different groups in relation to EPG parameters, despite some overlapping. The probing patterns with multiple penetrations of short duration in the sieve elements for both species may indicate apparent unsuitability for sustained feeding on their respective host plants. These results suggest that these two exotic species are in the process of adaptation to their host plants in their new environment and/or the plants may present either chemical or physical barriers against these insects.

Biological parameters and fertility life table of Aphis forbesi Weed, 1889 (Hemiptera: Aphididae) on strawberry / Parâmetros biológicos e tabela de vida de fertilidade de Aphis forbesi Weed, 1889 (Hemiptera: Aphididae) em morangueiro

Abstract This study provides the first contribution of the biology and life table of Aphis forbesi Weed, 1889 (Hemiptera: Aphididae), an important strawberry pest throughout the world. This species lives in the crown and leaf petioles of the plant. It is difficulty to rear this species in laboratory due to protocooperation with ants observed only in the field. We studied the life cycle of A. forbesi on the leaves of the Albion strawberry cultivar at 25 ± 2 °C, 60 ± 10% relative humidity, and a 12-h photophase. The experiment was randomised with 100 replicates. The parameters of the fertility life table were calculated using TabVida. In the population studied, 25% and 46% had four and three instars, respectively. A mean of 1.43 nymphs per female per day was generated. The mean reproductive period was seven days and the mean longevity was 10 days. In every 11 days there is a generation of A. forbesi, where each female has the potential to generate between 6 to 9 individuals daily, increasing its population by 1.2 times. The average life cycle was 16.8 days. High viability observed in all instars and the resulting values of R0, rm and λ suggest that A. forbesi has the capacity to increase their numbers in a short period of time, while generating high populations in strawberry crops, requiring differential management.

Resumo Este trabalho apresenta a primeira contribuição ao estudo de biologia e tabela de vida de fertilidade de Aphis forbesi, Weed, 1889 (Hemiptera: Aphididae), uma importante praga de morangueiro no mundo. Esta espécie se desenvolve na coroa e pecíolo do morangueiro. O desenvolvimento desta espécie em laboratório apresentou dificuldades, possivelmente devido à protocooperação com formigas, observada em campo durante coletas. O ciclo de vida de A. forbesi foi estudado em folhas de morangueiro cultivar ‘Albion’ a 25 ± 2 °C, 60 ± 10% umidade relativa, e fotofase de 12 horas. O experimento foi inteiramente casualizado com 100 repetições. Os parâmetros da tabela de vida de fertilidade foram calculados usando o software TabVida. Na população estudada observou-se que as ninfas apresentaram três e quatro instares, sendo 46 e 25% respectivamente, dos indivíduos que completaram o ciclo de vida. Foi gerada uma média de 1,43 ninfas/ fêmea/ dia. O período reprodutivo médio foi de 7 dias e a longevidade média 10 dias. A cada 11 dias ocorre uma geração de A. forbesi onde cada fêmea tem capacidade de gerar de 6 a 9 indivíduos aumentando em 1,2 vezes a população. O ciclo de vida de A. forbesi durou em média 16,8 dias. A alta viabilidade observada em todos os estádios, e os valores de R0, rm e λ sugerem que A. forbesi tem a capacidade de aumentar seu número em um curto período de tempo, gerando altas populações no cultivo do morangueiro, exigindo manejo diferenciado.

Effects of the addition of methyltestosterone to combined hormone therapy with estrogens and progestogens on sexual energy and on orgasm in postmenopausal women.

OBJECTIVE: To evaluate the effect of the addition of methyltestosterone to estrogen and progestogen therapy on postmenopausal sexual energy and orgasm. METHODS: Sixty postmenopausal women in a stable relationship with a partner capable of intercourse, and presenting sexual complaints that appeared after menopause, were randomly divided into two groups: EP (n = 29) received one tablet of equine estrogens (CEE) 0.625 mg plus medroxyprogesterone acetate (MPA) 2.5 mg and one capsule of placebo; EP + A (n = 31) received one tablet of CEE 0.625 mg plus MPA 2.5 mg and one capsule of methyltestosterone 2.0 mg; The treatment period was 12 months. The effects of treatment on sexual energy were assessed using the Sexual Energy Change Scale. The ability to reach orgasm in sexual relations with the partner was verified through monthly calendars and by calculating the ratio between monthly frequency of orgasms in sexual relations and monthly sexual frequency. RESULTS: There was a significant relationship between improvement in level of sexual energy and the addition of methyltestosterone to CEE/MPA treatment (p = 0.021). No significant effect on orgasmic capacity was noted after the treatment period. CONCLUSION: Addition of methyltestosterone to CEE/MPA therapy may increase sexual energy, but might not affect the ability to obtain orgasm in sexual relations.

Clinical and pathologic prognostic factors for curative resection for pancreatic cancer.

BACKGROUND: Pancreatic cancer is the fifth leading cause of cancer-related deaths in the world. Operative resection is the only therapeutic option with curative potential for this disease. OBJECTIVE: The aim of the present study was to correlate clinical and pathologic parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma. METHODS: Surgical resection with curative intent (R0 and R1 resections) was performed in 65 pancreatic cancer patients between 1990 and 2006. The overall results of surgical treatment were retrospectively analyzed and compared with the clinicopathologic features of these patients. RESULTS: Pylorus-preserving pancreatoduodenectomy was performed in 37 patients (56.9%), classic resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. The inhospital mortality was 5% (three patients). Postoperative complications occurred in 28 patients (43%). Mean survival and five-year survival rate after curative resection were 27 months and 9.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and involvement of resection margin were significant prognostic factors on univariate analysis. Multivariate analysis showed tumor differentiation and neural invasion as prognostic factors. CONCLUSION: Patients with pancreatic cancer, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.

[Lymphoma of the biliary tract: report of 2 cases]. / Linfoma das vias biliares: relato de dois casos.

We report two cases one a primary non Hodgkin lymphoma of the hepatic common duct and the other a secondary involvement of the biliary tract in a patient with a Hodgkin's disease. In the first case a local resection of the biliary lymphoma was undertaken being the patient alive six months after the procedure. The second case died early after the operative biliary external drainage in a septic shock before any specific treatment could be initiated.

[A new technique of intrahepatic cholangiodigestive shunt in the right lobe of the liver]. / Nova técnica de derivação colangiodigestiva intra-hepática no lobo direito do fígado.

Intra-hepatic cholangiojejunostomy in the left liver lobe is a well standardized procedure. For the right lobe however this procedure may be tedious, difficult and followed by early and late complications. A new technique is described based on two principles: minimal sacrifice of hepatic parenchyma and establishment of latero-lateral cholangio-intestinal anastomoses. Five patients were submitted to this procedure and one of them is alive without jaundice three years after the operation. It's concluded that this technique can be indicated in cases of biliary obstruction in which the anastomoses of the left duct cannot be performed because of local changes and in cases with cholangitis.