<p><a name="_Toc11147518"></a><strong>An Investigation on the Association Between Biliary Duct Variations and Stone Formation in the Choledochal Duct Caused by These Variations </strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>Abstract</strong></p>
<p><strong>INTRODUCTION and OBJECTIVE: </strong>The aim of the present study was to investigate if there is an association between the diameter of the choledochal duct and choledochal duct stone formation.</p>
<p><strong>MATERIALS and METHODS</strong> The present study consisted of 79 patients who had endoscopic interventions and MRCP procedure with surgery history, and some of whom were followed due to disorders of the liver, gall bladder and biliary tract, and some of whom presented hepatobiliary complaints between 2017 and 2019. The diameter of the choledochal duct was measured from MRCP images and choledochal duct stone was examined; the type was classified according to Huang classification.</p>
<p><strong>FINDINGS:</strong> Among the cases classified, 29 patients were Huang Type A1, 27 patients were Huang Type A2, 16 patients were Huang Type A3 and 7 patients were Huang Type A4. There was not any statistically significant association in terms of choledochal diameter depending on the types. Choledochal duct diameter was statistically higher in female patients when compared with male patients. A statistically significant difference was detected for choledochal duct stone formation according to the age group; individuals over 45 years of age present an increase for choledochal duct stone.</p>
<p><strong>DISCUSSION and CONCLUSION: </strong>Diameter of the choledochal duct was found higher in female patients when compared with male patients; stone formation was found increased in both gender over 45 years of age. This should be considered before surgical procedures and radiological tests.</p>
<p><strong>Key words: </strong>Biliary tract variations, choledochal diameter, choledochal stone.</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p><strong>INTRODUCTION</strong></p>
<p>Biliary stone disease is a common gastrointestinal problem. Prolongation of the average life period results in an increase in elder population; however, an increase in prevalence is also detected due to the changes in nutritional habits (1). Gallbladder stone is one of the most common causes for elective abdominal procedures in general surgery. Although mortality is lower in gall bladder procedures, economical and health effects should be considered due to higher morbidity rates. Under the light of these data, we aimed to make a classification in biliary tract formations according to Huang variation types and to investigate any possible association between common bile duct (CBD) diameter, CBD stone, and gender as well as age.</p>
<p><strong>Materials and Methods:</strong></p>
<p>After approval of the Ethical Committee of Kocaeli University with GOKAEK-2018/18. 2018/86 dated and numbered decision, the present study included 79 patients who had endoscopic interventions and MRCP procedure with surgery history, and some of whom were followed due to disorders of the liver, gall bladder, and biliary tract, and some of whom presented hepatobiliary complaints in Derince Training and Research Hospital within Health Sciences University between 2017 and 2019.</p>
<p>&nbsp;After review of age, gender, clinical presentation, history of any previous surgery were obtained in 79 patients, CBD diameter and cholelithiasis were reviewed on MRCP images in each case. The measurements on the images were performed by the same radiologist and taking the same points for measurement was considered for each case. CBD diameter was measured from the middle point of the distance from the junction point of the cystic duct (CD) and common hepatic duct (CHD) to ampulla of Vater.</p>
<p>The biliary tract is divided into two parts incşuding intrahepatic and extrahepatic biliary tract. As identified by Couinaud, the liver consists of eight individual segments with individual portal circulation and venous blood flow (1). This also consists with anatomically segmental structure of the liver.</p>
<p>Huang <strong>classification</strong> was used to classify anatomic variations of the biliary tract. This method is one of the <strong>classification</strong> methods used for radiological measurements and examinations. Variational states of the biliary tracts were identified and classified differently by the researchers. Couinaud, Champetier, Onkubu, Choi, and Huang made type classifications. Variation classification of the biliary tract is usually done depending on the junction status of the right posterior hepatic duct in general (2). We used Huang classification in our study.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p>
<p>In addition to descriptive statistics, data analyses were performed by Kolmogorov Smirnov test, chi-square test; T-test, Mann Whitney U test, ANOVA analysis, LSD and Tamhane's test as well as correlation analyses (Pearson's and Spearman's) for independent groups.</p>
<p><strong>FINDINGS</strong></p>
<p>The participants included 38 females (53.04±19.56 years) and 41 males (54.7±20.75 years). The youngest female patient was 22 years old and the oldest was 87 years old with a median age value of 56 years. The youngest male case was 19 years old whereas the oldest patient was 91 years old with a median age value of 58 years.</p>
<p>Classification of anatomical variation of the biliary tract revealed the following;</p>
<p>&nbsp;female patients; 11 (27.5%) patients in Huang A1 type, 20 (50%) patients in Huang A2 type, 5 (17.5%) patients in Huang A3 type, and 2 (5%) patients in Huang A4 type. In the male patients, 18 (43.9%) patients were Huang A1 type, 7 (17.07%) patients were Huang A2 type, 11 (26.8%) patients were Huang A3 type,&nbsp; 5 (12.1%) patients were Huang A4 type.</p>
<p>Accordingly, 29 (36.70%) patients were Huang A1 type, 27 (34.2%) patients were Huang A2 type, 16 (20.3%) patients were Huang A3 type, 7 (8.64%) patients were Huang A4 type.</p>
<p><strong>DISCUSSION</strong></p>
<p>The biliary tract may present different anatomic variations both in intrahepatic and extrahepatic locations beyond its normal structure. Biliary tract junction forms may also present different variations; however, the normal anatomic structure is detected in approximately 58% of the global population (3, 4). Beyond identified anatomic pattern, the biliary tract may present intrahepatic or extrahepatic developmental variations (5); since such variations may potentially cause problems in surgical procedures in the patients, they may increase the risk of iatrogenic injury during surgical procedures such as open and laparoscopic gall bladder procedures, liver resection or liver transplantation from alive donor. Different anatomic variations were demonstrated to be associated with stone formation, recurrent pancreatitis, cholangitis and malignancies (4, 6).</p>
<p>Recognition of all variations of the gall bladder and possible association of such variations with cholelithiasis is important to reduce the risks for malpractice and to reduce mortality and complication rates.</p>
<p>The present study investigated any possible association between variations of the extrahepatic biliary tract and cholelithiasis; and there was not any statistically significant association between Huang variation types and cholelithiasis (Table 1).</p>
<p>In the present study, any possible correlation between CHD diameter, CHD-CD angle and CHD stone dimension; consequently, a statistically significant correlation was detected. Another statistically significant output of such correlation was the increase of stone formation in individuals over 45 years of age. Many studies were conducted to search the association between CHD diameter and age, body weight, height s well as BMI. Kaude measured the diameter of the common bile duct on 600 individuals by ultrasound; CHD diameter was 2.8 mm in the individuals below 20 years of age whereas CHD diameter was measured 4.1 mm in the individuals over 71 years of age (7). Recent studies emphasize the effect of aging on CHD diameter. Bachar et al. detected an age-dependent change in CHD diameter by an annual dilatation of 0.04 mm through ultrasound (8). Daradkeh et al. reported that the factors affecting common bile duct diameter were age, cholecystectomy, and BMI (9). Tom et al. conducted a study on 187 individuals and measured a significant increase in CHD diameter by aging (10). Wu et al., Kaim et al., Niederau et al., and Bowie et al. carried out stıdied about CHD diameter increase by aging and their possible causes (11, 12, 13, 14). Kaim et al. stated that age-dependent increase in CHD diameter may appear due to age-dependent increase of the loss in the reticulo-elastic web&nbsp; along with the destruction of longitudinally extending myositis bands and destruction on intermediate connective tissue (11). Adibi and Givechian examined the association between CHD diameter and age, BMI, portal vein diameter and drug addiction; they observed that diameter of CHD increases along with wide portal vein in drug addicts in the advanced age (15) (Table2).</p>
<p>In the present study, stone formation increased in individuals over 45 years of age (Table 3). Many studies of the literature showed that cholelithiasis prevalence increased by age. Attili et al. reported a linear increase in cholelithiasis and cholecystectomy in both genders by aging (16). Barbara et al. stated that the prevalence of cholelithiasis increases by aging between 18 and 65 years of age (17). This is probably due to the fact that stone formation becomes visible and / or manifest in the elder ages because of being a gradual and time-taking process. In our study, it was measured that the individuals with cholelithiasis have increased DCH diameter (Table 4). A statistically significant association of stone formation was observed with CHD diameter increase. This has been explained by the presence of the stone to produce a physical dilatation of the DCH. Boys et al. divided CHD diameter into three groups including 6 mm, 6 to 9.9 mm and over 10 mm; they measured the diameter smaller in the individuals without CHD stone. In that study, the stone formation rate was 14% in the first and second groups, and 39% i the third group (18).</p>
<p>The previous studies show that there are differences in anatomic formations where the stone is developed in male and female patients. Within this context, a significant difference was found in CHD diameter in MRCP images between female and male patients. The normal range for CHD diameter is 4 to 6 mm; CHD diameter below 5 mm is accepted normal whereas a diameter at and above 8 mm is dilated. Mean CHD diameter was measured 9.10±4.91 mm in female patients and 6.28±4.15 mm in male patients. Poralla et al. measured CHD diameter and the pressure inside the canal in their study in both genders; both CHD diameter and the pressure inside the canal were detected higher in male patients when compared with female patients (19). Matcuk et al. detected in their study that CHD diameter is higher in females, and it increases in advanced age and in those who had cholecystectomy in both genders (20). The researchers state that cholelithiasis incidence is more in female patients with differences in biliary tract (21), and this may be therefore expressed with wider CHD diameter in females when compared with males (Table 5).</p>
<p>In this study, cholelithiasis rate was statistically higher in female patients when compared with male patients of the present study; the incidence is 2.3-fold higher in female patients (Table 6). There are many studies focusing on possible risk factors or underlying causes for cholelithiasis among female and male patients.&nbsp; Palermo et al. conducted a study on 1,875 volunteers to investigate the association between cholelithiasis, age, gender, BMI, family history, sedentary life; cholelithiasis incidence was 2.6-fold higher in female volunteers (22). Another previous study reported that age, BMI, history of cholic pain, family history, smoking, and hepatosteatosis were all effective on choleltihiasis and radiological anatomy of the biliary vesicle and biliary duct (23, 24).</p>
<p>Yıldırım (2008) conducted a study under the title of "Incidence of cholelithiasis in adults in the province of Tokat and possible risk factors" on 1,095 individuals in Tokat province of our country; he investigated the effect of gender, age, glucose, ALT, AST, total cholesterol, triglyceride,BMI and anthropometric measurements on frequency of cholelithiasis; he also evaluated anatomic formations and clinical findings through ultrasound.&nbsp; An association was detected between cholelithiasis and female gender, age, fasting glucose, total cholesterol, BMI, triglycerides and waist circumference (25). Some researches reported that stone prevalence in women is 1.7 to 4-fold more than men (26). In our country, Sezer (2016) carried out a study with 865 volunteers and detected biliary vesicle stone in 52 volunteers including 41 female individuals (27).</p>
<p>&nbsp;There are studies indicating that higher cholelithiasis incidence in women may be associated with some factors such as fertility and sex hormones, an increase of estrogen hormone increases cholesterol secretion and causes cholesterol supersaturation 828). Some studies suggest that the risk of cholelithiasis increases in women receiving hormone replacement therapy (29, 30). Some studies demonstrated the association between oral contraceptive use and an increase in the risk of cholelithiasis (31, 32).</p>
<p>A previous study showed that cholesterol and calcium bilirubin crystals in the bile sludge increase by more than 30% (33).</p>
<p>According to the outcomes stated above, gender should be considered in the patients presenting colic pain without symptoms of cholelithiasis; furthermore, MRCP images show that CHD diameter may be wider in women when compared with men, which may increase the rate of small stone accumulation and stone formation in the biliary vesicle.</p>
<p>Consideration of possible dilatation in CHD diameter by aging reveals that age may be a determinant factor in CHD diameter and stone formation in MRCP or radiological images.</p>
<p><strong>&nbsp;</strong></p>
<p><strong>CONCLUSION</strong></p>
<p>Review of the findings of the present study along with literature information, a wider CHD diameter may not necessarily indicate a stone; further studies are needed to investigate the effect of CHD stone existence on gender, and the effect of age on diameter increase.</p>
<p>&nbsp;</p>
<p><strong>Referencess</strong></p>
<p>1.Gazelle G.S, Lee M.J, Mueller PR, Cholangiographic segmental anatomy of the liver. Radiographics 1994;14:1005-1013.</p>
<p>2.Hyodo T, Kumano S, Kushihata F, Okada M, Hirata M, Tsuda T, et al.CT and MR cgolangiography:advantage and pitfalls in perioperative evaluation of biliary tree.British Journal of&nbsp; Radiology 2012;85:887-96</p>
<p>3.Pente SG, Bannura GC. Radiological anatomy of the biliary tract:variations and congenital abnormalities. World Journal of Surgery 1983; 7:271-6.</p>
<p>4.Mortele. K, Ros P.R, Anatomic variants of the biliary tree: MR cholangiographic findings and clinical applications.<em> American&nbsp; Journal of&nbsp; Roentgenology</em>&nbsp; 2001;177:389-394.</p>
<p>5.Berci G. Biliary ducral anatomy and anomalies:the role of intraoperative cholangiography during laparoscopic cholecystectomy.Surgical Clinics of .North America1992;72:1069-1075</p>
<ol start="6">
<li>Sayed A.T, Ramin N, Sayed E.A, Fardad. E, Gholam R.S, Ahad E, Anatomical Variations of Biliary Tree Found with Endoscopic Retrograde Cholangiopancreatography in a Referral Center in Southern İran. <em>Middle East Journal Of Digestive Disease</em>/Vol.9/No.4/October 2017.</li>
</ol>
<p>7.Kaude JV. The width of the common bile duct in relation to age and stone disease. An ultrasonographic study. <em>Euro Journal of&nbsp; Radiology </em>1983, 3: 115-7.</p>
<p>8.Bachar GN, Cohen M, Belenky A, Atar E, Gideon S. et al. Effect of aging on the adult extrahepatic bile duct: a sonographic study. <em>Jornal of&nbsp; Ultrasound in Medicine </em>2003,22: 879-82.</p>
<p>9.Daradkeh S, Tarawneh E, AL-Hadidy A. Factors affecting common bile duct diameter. <em>Hepatogastroenterology </em>2005, 52: 1659-61.</p>
<p>10.Tom C,Ruei-Hung C,ChiaoHung A,MingLii J,ChounChen R.The diameter of the common bile duct in an asymptomatic Taiwanese poplation:Measurment by magnetic resonance cloangiopancreatography.Journal of the Chinese Medical Association,Volume 75,issue 8, August 2012,page 384-388.</p>
<ol start="11">
<li>Kaim A, Steinke K, Frank M, Enriquez R, Kirsch E, Bongartz G et al. Diameter of the common bile duct in the elderly patient: measurement by ultrasound. <em>European Radiology </em>1998; 8(8):1413-1415.</li>
</ol>
<p>12.Niederau C, Muller J, Sonnenberg A, Scholten T, Erckenbrecht J, Fritsch WP et al. Extrahepatic bile ducts inhealthy subjects, in patients with cholelithiasis, and in postcholecystectomy patients: a prospective ultrasonic study. <em>Jornal of&nbsp; Clinical Ultrasound </em>1983; 11(1):23-27.</p>
<p>13.Bowie JD. What is the upper limit of normal for the common bile duct on ultrasound: how much do you want it to be? <em>American Jornal of Gastroenterology </em>2000; 95(4):897-900.</p>
<p>14.Wu CC, Ho YH, Chen CY. Effect of aging on common bile duct diameter: a real-time ultrasonographic study. <em>Jornal of Clinical Ultrasound </em>1984; 12(8):473-478.</p>
<p>15.Adibi A,Givechian B.Diameter of common bile duct:What are the predicting factors?Jornal of Resarch in Medical Sciences,May&amp;June 2007;Vol 2,No 3.121-124.</p>
<p>16.Attili AF, et al. Epidemiology of galstone disease in italy:prevalance data of the Multicenter Italian Study on Cholecystolithiasis(M.I.COL). American&nbsp; Journal of Epidemiology 1995; 141: 158-65</p>
<p>17.Barbara L, et al. A population study on the prevalance of galstone disease: the Sirmione study . Hepatology 1987; 7:913-17</p>
<p>18.Boys JA,Doorly MG,Zehetner J,Dhanireddy KK,Senagore AJ.Can ultrsound common bile duct diameter predict common bile duct Stones in the setting of acute cholecystitis?American Journal of Surgery,Mar,2014;207(3):432-435.</p>
<p>19.PorallaT,Staritz M,Manns M,Klose K,Hommel G,Meyer zum Büschenfelde KH.Age and sex dependency of bile duct diameter and bile duct pressure an ERC manometry study .Zeitschrift fur Gastroenterolgie ,01 May 1985,23(5):235-239.</p>
<p>20.Matcuk GR Jr,Grant EG,Ralls PW.Ultrasound measurements of the bile ducts and gallbladder:normal ranges and effects of age,sex,cholecystectomy and pathologic states .Ultrasound quarterly,30(1):41-48,March 2014.</p>
<p>21.Festi D, Dormi A, Capodicasa S, Staniscia T,&nbsp; Attili A, Loria P, Pazzi P, Mazzella G, Sama C, Roda E, Colecchia A., Incidence of gallstone disease in Italy: Results from amulticenter, population-based Italian study (the MICOLproject). World Journal of Gastroenterology 2008 September 14.</p>
<p>22.Palermo M,&nbsp; Berkowski D.E, Córdoba J.P,&nbsp; Verde J.M, Giménez M.E, Prevalence of cholelithiasis in Buenos Aires,Argentina, Department of Gastrointestinal.Surgery. Hospital de Clínicas José de San Martín, University of Buenos Aires, <em>Argentina.Acta Gastroenterology&nbsp; Latinoam</em> 2013;43:98-105.</p>
<p>23.McMichael AJ, Baghurst PA, Scragg RK. A case-control study of smoking and gallbladder disease:importance of examining time relations. Epidemiolgy 1992;3:519-522.</p>
<p>24.Öztürk H, Beyler A.R, Safra kesesi taşlarında epdemiyoloji ve tedavi, <em>Güncel Gastroenteroloji</em>,1997.</p>
<p>25.Yıldırım.B, Aktürk Y,&nbsp; Fırat M.M, Öztürk B, Özuğurlu F, Şahin İ,ve ark. Tokat ili erişkinleri’nde kolelitiazis sıklığı ve olası risk faktörleri, <em>Akademik&nbsp; Gastroenteroloji Dergisi</em>, 2008; 7 (2): 83-86).</p>
<p>&nbsp;</p>
<p>26.Pancorbo&nbsp; M.C, Carballo F,&nbsp; Horcajo P, Aldeguer M, de la Villa I, Nieto E.Marı´a&nbsp; Gaspar J., de la Morena1 J., Prevalence and Associated Factors for GallstoneDisease: Results of a Population Survey in Spain Department of Internal Medicine and Department of Biochemistry, University General Hospital ofGuadalajara and niversity of Alcala´ de Henares, Madrid, Spain.</p>
<p>27.Sezer B, “Edirne ilinde Asemptomatik Erişkinlerde Kolelitiazis sıklığı”. Uzmanlık tezi. Trakya Üniversitesi Tıp fakültesi İç Hastalıkları A.D.Edirne, 2016.</p>
<p>28.Sun H ,Tang H,Jiang S,Zeng L,En-Qiang C,Tao Z,You-Juan W. Gender and metabolic difference of gallstone disease.World Journal of Gastroenterology,2009 April 21;15(15)1886-1891.</p>
<ol start="29">
<li>Youming D, Bin W, Weixing W, Binghua W, Ruoyu L,Bangchang C. The effect of h(1) calponin expression on gallstone formation in pregnancy. Saudi Medical Journal 2006;27:1661-1666.</li>
<li>Tierney S, Nakeeb A, Wong O, Lipsett PA, Sostre S, Pitt HA,Lillemoe KD. Progesterone alters biliary flow dynamics. Annals of Surgery 1999; 229: 205-209.</li>
<li>Maurer KR, Everhart JE, Knowler WC, Shawker TH,Roth HP. Risk factors for gallstone disease in the Hispanic populations of the United States. American Journal of Epidemiology 1990; 131:836-844.</li>
</ol>
<p>32.Khan MK, Jalil MA, Khan MS. Oral contraceptives in gallstone diseases. Mymensingh Medical Journal 2007; 16: S40-S45.</p>
<ol start="33">
<li>Maringhini A, Ciambra M, Baccelliere P, Raimondo M, Orlando A, Tine F,Grasso R, Randazzo MA, Barresi L, Gullo D, et al. Biliary sludge and gallstones in pregnancy: incidence, risk factors, and natural history. Annals of Internal Medicine. 1993;119(2):116–20.1993;119(2):116–20.</li>
</ol>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p><strong>Table 1</strong> -Investigation of the association between variation type and common bile duct stone.</p>
<table>
<tbody>
<tr>
<td colspan="2" rowspan="2" width="144">
<p>&nbsp;</p>
</td>
<td colspan="3" width="195">
<p><strong>variation</strong></p>
<p><strong>type</strong></p>
</td>
<td rowspan="2" width="238">
<p>p</p>
</td>
</tr>
<tr>
<td width="65">
<p>A1</p>
</td>
<td width="65">
<p>A2</p>
</td>
<td width="65">
<p>A3+A4</p>
</td>
</tr>
<tr>
<td rowspan="2" width="94">
<p><strong>common bile duct stone</strong></p>
</td>
<td width="50">
<p><strong>no</strong></p>
</td>
<td width="65">
<p>20</p>
</td>
<td width="65">
<p>16</p>
</td>
<td width="65">
<p>16</p>
</td>
<td rowspan="3" width="238">
<p>0.678</p>
</td>
</tr>
<tr>
<td width="50">
<p><strong>yes</strong></p>
</td>
<td width="65">
<p>9</p>
</td>
<td width="65">
<p>11</p>
</td>
<td width="65">
<p>7</p>
</td>
</tr>
<tr>
<td colspan="2" width="144">
<p><strong>total</strong></p>
</td>
<td width="65">
<p>29</p>
</td>
<td width="65">
<p>27</p>
</td>
<td width="65">
<p>23</p>
</td>
</tr>
</tbody>
</table>
<p>There was not any difference in common bile duct stone according to the variation types (p&gt;0.05).</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p><a name="_Toc11005778"></a><a name="_Toc11005779"></a><strong>Table 2</strong>. Investigation of the difference between CBD diameter and CD -CHD angle according to the age above and below 45 years</p>
<table width="578">
<tbody>
<tr>
<td width="246">
<p>&nbsp;</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Age_</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Group</p>
</td>
<td width="47">
<p>&nbsp;</p>
<p>N</p>
</td>
<td width="95">
<p>&nbsp;</p>
<p>&nbsp;&nbsp; Mean</p>
</td>
<td width="94">
<p>Std. deviation</p>
</td>
<td width="96">
<p>&nbsp;</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; p</p>
</td>
</tr>
<tr>
<td width="246">
<p>CHD diameter&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 45≥</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 45&lt;</p>
</td>
<td width="47">
<p>&nbsp; 24</p>
<p>&nbsp; 55</p>
</td>
<td width="95">
<p>5.25</p>
<p>8.68</p>
</td>
<td width="94">
<p>3.86</p>
<p>4.71</p>
</td>
<td width="96">
<p>&nbsp;&nbsp;&nbsp; 0.001</p>
</td>
</tr>
<tr>
<td width="246">
<p>CHD-CD angle&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 45≥</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 45&lt;</p>
</td>
<td width="47">
<p>&nbsp; 17</p>
<p>&nbsp; 38</p>
</td>
<td width="95">
<p>45.17</p>
<p>39.34</p>
</td>
<td width="94">
<p>30.08</p>
<p>&nbsp;29.87</p>
</td>
<td width="96">
<p>0,510</p>
</td>
</tr>
</tbody>
</table>
<p>A significant increase was detected in CHD diameter over 45 years of age (p&lt;0.05). There was not any difference detected in CHD-CD angle according to the age group (p&gt;0.05).</p>
<p>&nbsp;</p>
<p><strong>&nbsp;</strong></p>
<p><strong>Table 3: </strong>Investigation of the difference for CHD stone formation according to the age above and below 45 years</p>
<table width="576">
<tbody>
<tr>
<td rowspan="2" width="201">
<p><strong>CHD stone present</strong></p>
</td>
<td colspan="2" width="264">
<p><strong>Age_Group (years)</strong></p>
</td>
<td rowspan="2" width="111">
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;&nbsp;&nbsp;&nbsp; p</strong></p>
</td>
</tr>
<tr>
<td width="139">
<p><strong>&nbsp;</strong></p>
<p><strong>45&lt;</strong></p>
<p><strong>years</strong></p>
</td>
<td width="126">
<p><strong>&nbsp;</strong></p>
<p><strong>45&lt;</strong></p>
<p><strong>years</strong></p>
</td>
</tr>
<tr>
<td width="201">
<p><strong>no</strong></p>
</td>
<td width="139">
<p>20</p>
</td>
<td width="126">
<p>32</p>
</td>
<td rowspan="2" width="111">
<p><strong>0,025</strong></p>
</td>
</tr>
<tr>
<td width="201">
<p><strong>yes</strong></p>
</td>
<td width="139">
<p>4</p>
</td>
<td width="126">
<p>23</p>
</td>
</tr>
</tbody>
</table>
<p>&nbsp;</p>
<p>A statistically significant difference was detected in CHD stone formation according to the age group (p&lt;0.05). CHD stone incidence increases in patients over 45 years of age.</p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><a name="_Toc11005774"></a><strong>Table 4:</strong> Analysis of the association between CHD-CD angle and age as well as CHD.</p>
<table width="579">
<tbody>
<tr>
<td width="154">
<p>&nbsp;</p>
</td>
<td width="104">
<p><strong>&nbsp;</strong></p>
<p><strong>age</strong></p>
</td>
<td width="95">
<p><strong>&nbsp;</strong></p>
<p><strong>CHD diameter</strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </strong></p>
</td>
<td width="116">
<p><strong>CHD-CD angle</strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p>
</td>
<td width="110">
<p><strong>CHD stone dimension</strong></p>
</td>
</tr>
<tr>
<td width="154">
<p><strong>age</strong></p>
</td>
<td width="104">
<p>&nbsp;</p>
</td>
<td width="95">
<p>0.00</p>
</td>
<td width="116">
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 0.43</p>
</td>
<td width="110">
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 0,154</p>
</td>
</tr>
<tr>
<td width="154">
<p><strong>&nbsp;</strong></p>
<p><strong>CHD diameter</strong></p>
</td>
<td width="104">
<p>&nbsp;</p>
<p><strong>0.000</strong></p>
</td>
<td width="95">
<p>&nbsp;</p>
</td>
<td width="116">
<p>&nbsp;</p>
<p>0.106</p>
</td>
<td width="110">
<p>&nbsp;</p>
<p><strong>0.003</strong></p>
</td>
</tr>
<tr>
<td width="154">
<p><strong>&nbsp;</strong></p>
<p><strong>CHD-CD angle</strong></p>
</td>
<td width="104">
<p>&nbsp;</p>
<p>&nbsp;&nbsp;&nbsp; 0.434</p>
<p>&nbsp;</p>
</td>
<td width="95">
<p>&nbsp;</p>
<p>0.106</p>
<p>&nbsp;</p>
</td>
<td width="116">
<p>&nbsp;</p>
</td>
<td width="110">
<p>&nbsp;</p>
<p>0.752</p>
<p>&nbsp;</p>
</td>
</tr>
<tr>
<td width="154">
<p><strong>&nbsp; CHD stone&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </strong></p>
<p><strong>&nbsp; dimension</strong></p>
</td>
<td width="104">
<p>0.154</p>
<p>&nbsp;</p>
</td>
<td width="95">
<p>0.003</p>
<p>&nbsp;</p>
</td>
<td width="116">
<p>0.752</p>
<p>&nbsp;</p>
</td>
<td width="110">
<p>&nbsp;</p>
</td>
</tr>
</tbody>
</table>
<p>A positive correlation was detected between the age and CHD diameter and between CHD stone dimension and CHD diameter (p&lt;0.05). There was not any significant correlation between CHD-CD angle and age, and between CHD-CD angle and CHD stone dimension (p&gt;0.05).</p>
<p>&nbsp;</p>
<p><a name="_Toc11005772"></a><strong>Table 5. </strong>Comparison of CHD diameter (mm) according to the gender</p>
<table>
<tbody>
<tr>
<td colspan="2" width="209">
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; gender</strong></p>
</td>
<td width="56">
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;&nbsp;&nbsp;&nbsp; N</strong></p>
</td>
<td width="83">
<p><strong>&nbsp;</strong></p>
<p><strong>Mean (mm)</strong></p>
</td>
<td width="95">
<p><strong>&nbsp;</strong></p>
<p><strong>Std. Deviation</strong></p>
</td>
<td width="108">
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;P</strong></p>
</td>
</tr>
<tr>
<td width="124">
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><strong>CHD diameter (mm)</strong></p>
<p><strong>&nbsp;</strong></p>
</td>
<td width="85">
<p>&nbsp;</p>
<p>&nbsp;male</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>female</p>
</td>
<td width="56">
<p>&nbsp;</p>
<p>41</p>
<p>&nbsp;</p>
<p>38</p>
</td>
<td width="83">
<p>&nbsp;</p>
<p>6.28</p>
<p>&nbsp;</p>
<p>9.10</p>
</td>
<td width="95">
<p>&nbsp;</p>
<p>4.15</p>
<p>&nbsp;</p>
<p>4.91</p>
</td>
<td width="108">
<p><strong>&nbsp;</strong></p>
<p><strong>0.007</strong></p>
</td>
</tr>
<tr>
<td width="124">&nbsp;</td>
<td width="85">&nbsp;</td>
<td width="56">&nbsp;</td>
<td width="83">&nbsp;</td>
<td width="95">&nbsp;</td>
<td width="108">&nbsp;</td>
</tr>
</tbody>
</table>
<p>Mean CHD diameter was measured 9.1±4.91 mm in female patients and 6.28±4.15 mm in male patients. The mean CHD diameter was measured 7.67 mm.</p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>
<p><a name="_Toc11005770"></a><strong>Table 6</strong>. Comparison of biliary vesicle stone depending on the gender</p>
<table>
<tbody>
<tr>
<td colspan="2" rowspan="2" width="217">
<p>&nbsp;</p>
<p>Biliary Vesicle Stone Formation</p>
</td>
<td colspan="2" width="179">
<p>gender</p>
</td>
<td rowspan="2" width="96">
<p>&nbsp;</p>
<p>p</p>
</td>
</tr>
<tr>
<td width="83">
<p>male</p>
</td>
<td width="96">
<p>female</p>
</td>
</tr>
<tr>
<td rowspan="4" width="148">
<p>&nbsp;</p>
</td>
<td width="69">
<p>no</p>
</td>
<td width="83">
<p>23</p>
</td>
<td width="96">
<p>&nbsp;&nbsp;&nbsp; 8</p>
</td>
<td rowspan="4" width="96">
<p>&nbsp;</p>
<p>0.005</p>
</td>
</tr>
<tr>
<td width="69">
<p>yes</p>
</td>
<td width="83">
<p>10</p>
</td>
<td width="96">
<p>&nbsp;&nbsp; 18</p>
</td>
</tr>
<tr>
<td width="69">
<p>operated</p>
</td>
<td width="83">
<p>8</p>
</td>
<td width="96">
<p>&nbsp;&nbsp; 12</p>
</td>
</tr>
<tr>
<td width="69">
<p>&nbsp;</p>
</td>
<td width="83">
<p>&nbsp;</p>
</td>
<td width="96">
<p>&nbsp;</p>
</td>
</tr>
</tbody>
</table>
<p>A significant difference was found between female and male groups for biliary vesicle stone depending on gender (p&lt;0.05).&nbsp; The biliary vesicle stone formation was significantly higher in female patients (p&lt;0.05).</p>
<p><strong>&nbsp;</strong></p>
<p><strong>&nbsp;</strong></p>