Furthermore, tamoxifen has been used primarily to treat patients with nonbreast cancers, including hepatocellular, pancreatic, renal cell, ovarian, and melanoma carcinomas.3 Above all, we believe that although the use of tamoxifen for the prevention of breast cancer is exceptionally low, the use of tamoxifen for cancer prevention and treatment will become more popular and extensive with GS-1101 in vivo the decision-making process. Zhihua Liu Ph.D.*, Yanlei Ma Ph.D.*, Huanlong Qin M.D.*, * Department of Surgery, Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, People’s Republic of China. “
“A 65-year-old man was admitted to hospital with probable cholangitis.

He described intermittent pain in the upper abdomen over the preceding 2 weeks and subsequently developed nausea, vomiting CHIR-99021 datasheet and fever. Ten years previously, he had been treated by laparoscopic cholecystectomy for cholelithiasis. On examination, he had mild tenderness on palpation over the upper abdomen. His serum bilirubin and white cell count were normal but there were abnormalities in liver enzymes including gammaglutamyl transpeptidase (478 IU/L), alkaline phosphatase (210 IU/L) and alanine aminotransferase (67 IU/L). A plain radiograph of his

abdomen revealed several clips in the right upper quadrant as well as a clip that had migrated medially and inferiorly. A computed tomography scan of his abdomen revealed metallic radiodense material in the distal bile duct (arrow, Figure 1). At endoscopic retrograde cholangiopancreatography,

there was an elongated filling-defect in the distal bile duct with a narrow lower bile duct. As the clip could not be removed by endoscopic sphincterotomy, laparotomy was performed and a small pigmented stone was removed with a metal clip in the center of the stone (Figure 2). There were no post-operative complications. After cholecystectomy, approximately 5–10% of patients are subsequently diagnosed with bile duct stones. Some of these stones are retained stones but the majority seem likely to reform within the bile duct. Risk factors for recurrent bile duct stones include previous bile duct stones, periampullary diverticula, dilatation of the bile duct and a gallbladder that remains MCE in situ. An additional issue is the migration of sutures or clips from the cystic duct stump into the bile duct. Many of these seem likely to pass spontaneously into the duodenum but, if this does not occur, the foreign body can act as a nidus for further stone formation. In a recent compilation of 69 case reports of clip migration (J Gastrointest Surg 2010; 14:688–96), the median time from cholecystectomy to clinical presentation was 26 months. The median number of clips on the cystic duct stump was six but usually only one migrated into the bile duct.