Thursday, July 13, 2006

Obstructive jaundice

Obstructive jaundice

Obstructive jaundice which can be either due to intra-hepatic cholestasis or extra-hepatic biliary obstruction is amenable to surgical treatment. Hence, it is also called surgical jaundice.

It is difficult to diagnose the type and cause of obstruction on clinical grounds alone. But there are certain clinical criterion’s associated with it.
In calculus disease of biliary tract, intermittent or fluctuating jaundice can be seen with chills and rigors. It is progressive and painless and is associated with weight loss and anorexia in malignant obstruction.
In cases of infra-cystic obstruction due to malignant neoplasms, gall bladder may be palpable while in calculus diseases it is not palpable as it gets shrunken because of previous attacks of cholecystitis. This is Courvoisier’s law.

Causes of obstructive jaundice can be broadly classified into benign and malignant diseases.

Diseases causing obstructive jaundice include:
Common bile duct stone
Biliary stricture
Choledochal cyst
Primary sclerosing cholangitis
Mirizzi’s syndrome
Stenosis of papilla
Extra-hepatic biliary atresia

· Malignant

1) Primary
· Klatskin tumor
· Cholangiocarcinoma
· Carcinoma of the head of the pancreas
· Carcinoma of the duodenum
· Carcinoma of the ampulla of Vater
· Carcinoma of the gall bladder

2) Secondary- lymph nodes at the porta.

Amongst these the commonest causes include CBD stones and peri-ampullary malignancies.

Common bile duct stones:

Common bile duct stones are usually secondary stones that have migrated into the biliary system and the gall bladder. Common duct stones are known to occur in around 15% of patients undergoing standard open cholecystectomy (Mitchell ’93).
Approximately 11% of patients with gall bladder stones will have CBD stones at the time of operation. This incidence may climb to 18% in older patients who have had gallstones for a longer period of time. Between 5%-7% of CBD stones found at operation may be unsuspected by pre-operative evaluation and are discovered by cystic duct cholangiography during the cholecystectomy (Maingot’s ’01)1
Primary duct stones may be encountered in tropics secondary to infestation of biliary tree due to worms. Incidence is around 4 %( Blumgart’s ’88). Primary CBD stones occur in any situation causing prolonged biliary stasis and infection.2, 3
The natural history of choledocholithiasis is varied and unpredictable.
Most frequently CBD stones are an unanticipated finding during routine cholecystectomy. Small stones usually pass on to the duodenum spontaneously. They may induce and episode of pancreatitis by temporarily obstructing the pancreatic duct.
If stones obstruct the CBD in the presence of infected bile, cholangitis ensues. Classic triad of fever, chills and jaundice should always raise a suspicion of CBD stone. If stones obstruct the CBD in absence of infected bile, asymptomatic jaundice that is classically fluctuating ensues. Fluctuation is due to duct dilatation and floating back of the stone into the dilated CBD and reduction in the edema.
Pancreatitis is the second most common complication of a CBD stone. Other complications include choledochoenteric fistula and biliary stricture.
Diagnostic ultrasound, especially the real-time mode, has become the single most valuable screening test in case of jaundiced patients. It is a non-invasive procedure and can detect up to 50% of stones. Plain abdominal films are of very limited value as <15% of stones are radio-opaque. Either percutaneous transhepatic cholangiograms (PTC) or endoscopic retrograde cholangiograms (ERCP) can be asked for depending upon previous ultrasound findings and availability if more precise information is needed. CT or MRI usually is not of any help in the diagnosis or management of patients with cholelithiasis, with or without cholangitis.


Cholecystectomy is accompanied by exploration of common bile duct in 13-26 % of cases (Sheridan ’87).
Exploration of CBD with cholecystectomy raises the mortality of patients operated upon from 1% if the gall bladder alone is removed to 4.5% (Payne’86). Hence, routine CBD exploration has been condemned. Traditional indications for CBD exploration have given way to following absolute indications:
Palpable stones in the CBD
Jaundice with cholangitis
Stone demonstrable in intra-operative cholangiography
Pre-operative radiological demonstration of calculi in CBD.
Hence, routine intra-operative cholangiography4, 5, 6 is strongly recommended whenever choledochoscopy is not available. Intra-operative cholangiography7 is 85-95% sensitive in recognizing CBD stones (Blumgart’s ’88). Its advantages include –
Exclusion of CBD exploration in patients who have dilated CBD don’t have stones
During routine cystic duct cholangiography while doing cholecystectomy, approximately 5-7% of patients will be found to have unsuspected stones in the CBD
Pre-exploratory size and location of stones
To study the anatomy of the biliary tree and ampulla.

The commonest method of approach is supra-duodenal vertical incision (Tompkins ’90).
One of the most controversial aspects of choledocholithotomy is how to conclude the operation. There are three possibilities:
A) Simple closure-
It can only be attempted when one is sure about the patency of the distal duct system as evidenced by passing of dye into duodenum in a post procedure cholangiogram.
B) T-Tube drainage-
Most surgeons will still prefer chledochorraphy to a T-Tube8 in spite of a high incidence of cholangitis and biliary peritonitis. Hence, antibiotic prophylaxis is strongly recommended when T-Tube is in-situ9.
C) Biliary enteric procedures-
There are specific indications for biliary-enteric anastomosis (Blumgart’s ’88). They include-
Multiple primary duct stones with dilated ducts particularly in elderly
Multiple stones in a dilated duct
Irretrievable intrahepatic stones
Proven papillary stenosis
Impacted ampullary stone
Terminal CBD stricture.

Three procedures are in vogue:

It is mainly indicated when CBD is more than 1.5 cms, patient is elderly and high risk. The supra-duodenal choledochoduodenostomy uses vertical CBD and horizontal duodenal incision.
Complications of this procedure include-
Sump syndrome11- the cause of this is accumulation of stones, undigested food matter, or both in the segment of the distal bile duct, which obstructs the anastomotic opening and causes cholangitis and pain.
Biliary stasis
Anastomotic stenosis
Retained or recurrent stones

It is indicated in a patient of impacted stone in ampulla or a very low CBD stricture (duct is dilated down to terminal few mms). Though an advantage to examine ampulla directly is got, disadvantages are too many. The complications include pancreatitis and duodenal leak.

This is done when CBD can be mobilized completely. A roux-en-y loop or a simple loop is used with a entero-enterostomy below. Its advantages are low incidence of cholangitis and reflux of indigestible intestinal contents into the biliary tree. The drawback is that there is increased incidence of post-operative peptic ulcer disease13.


Endoscopic sphincterotomy (EP)
Classen and Demling first did it in 1974. it was first used only in selected patients. Now it is widely used in a variety of situations. It is the procedure of choice for recurrent or retained stones after cholecystectomy (Miller ’87)14, 15. It is also used in older and high-risk patients who wish to avoid surgery. After papillotomy stones can be either retrieved by a dormia basket or allowed to pass spontaneously. Success rates of between 85-95% have been reported. The complication rate ranges from 6.5-8.7% and mortality rate ranges from 0.1-3%. Long term follow up studies have shown that re-stenosis and/or recurrent stones occurred in 7% of patients, usually within 2 years.
Endoscopic retrograde cholangiography (ERC)
This procedure involves cannulation of the ampulla. A cholangiogram will show the exact number, size and location of the stones. Stone extraction can be done with balloon dilatation and basket extraction or they can be crushed using a mechanical lithotripter (Martin ’93). Endoscopic infusion of monooctanoin has been tried recently to dissolve stones and duct clearance of 18-55% have been reported (Stock ’92)16.
A combination of EP and ERC has achieved a duct clearance of 85-90% in a single procedure.

Laparoscopic cholecystectomy and trans-cystic CBD exploration17, 18
After cholecystectomy, cystic duct can be dilated laparoscopically and stones can be retrieved using baskets.
Laparoscopic choledochotomy
It is an approach in patients with dilated CBD, calculi 1 cm or more in diameter, multiple calculi or those who require lithotripsy for impacted stones.

In patients in whom endoscopic sphincterotomy and stone extraction proved to be unsuccessful, the use of ESWL has been proved successful. A multi-institutional study of 42 patients treated at 11 institutions showed that stone fragmentation can be obtained in 95% of the patients. However, 50% of the patients required adjunctive procedures to clear the bile duct stones, including endoscopic extraction, biliary lavage and stenting. Only 2 patients required operation to clear the bile duct stones (Maingot’s 01).

Using a modified dormia basket inserted through a percutaneous trans-hepatic catheter, a Boston group reported successful clearance of CBD stones in 93% of 50 patients treated. All of these patients had contraindications to surgery or had undergone unsuccessful endoscopic attempts at removal. 29 patients in this group required either monooctanoin or methyl-tert-butyl ether infusions to reduce stone size or remove residual debris. The authors reported a 13% morbidity and 4% mortality rate.
The percutaneous transhepatic route has also been used s a method of passing a cholangioscope to visualize and remove the biliary stones.

Various drugs like methyl tert-butyl ether, chenodeoxycholic acid and monooctanoin have been used to dissolve stones with variable results.

Many investigative reports on innovative techniques are available22. These include endoscopic introduction of electro hydraulic lithotripters by use of “mother-daughter” endoscopic techniques, endoscopic introduction of intra-corporeal shock-wave lithotripters into the bile duct, percutaneous transhepatic insertion of electro hydraulic lithotripters, and insertion of laser lithotripters via T tube tracts. While these technologic advances are interesting, they remain to be proven effective and economical.
Based on present data, when a patient is less than 65 years of age, open CBD exploration is safer than EP. Patient more then 65 years of age is a candidate for laparoscopic or endoscopic approach23.

Extra hepatic biliary atresia
The incidence throughout the world is approximately 1 in 14,000 live births. The occlusion of the bile ducts is accompanied by a variable degree of intrahepatic damage that can progress to cirrhosis and liver failure, in untreated cases. Historically, cases were classified as correctable or non-correctable, depending on the presence or absence of residual proximal duct segments of bile duct. The introduction of new surgical technique, in the 1960s, invalidated the traditional classification.
The first major review of 49 cases was published by Thompson24 in 1891 and 1892 and concluded that, whatever the etiology of biliary atresia, a progressive, destructive inflammatory lesion of the bile ducts characterized it. Holmes analyzed more than 100 case reports and first suggested that surgical treatment might be effective in biliary atresia. Ladd described 20 more cases. Hays and Synder reported, in 1963, that in most American series, <5% of patients survived beyond early childhood25. In 1959, Kasai and Suzuki described a new radical operation for non-correctable atresia based on the histologic observation that remnants of the extra-hepatic ducts at the porta hepatis frequently contained ductules measuring up to 300 micrometers in diameter26. Approximately 85% of extra-hepatic biliary atresia cases classified as non-correctable now are treated routinely with the Kasai’s portoenterostomy procedure.
The 4-year survival rate in untreated cases of biliary atresia is approximately 2%, but portoenterostomy performed before the age of 7 weeks has resulted in early jaundice-free survival in more than 90% of the cases. Past 7 weeks of life, the long-term results of surgery are very poor.
Although morphology of the extra-hepatic bile ducts varies widely in biliary atresia, the Japanese Society of Pediatric Surgeons identified three principal types, which form the basis of the classification now in general use-
Type 1: atresia of the CBD
Type 2: atresia of the common hepatic duct
Type 3: atresia of the right and left ducts.
In a Japanese survey of 643 cases, 566 (88%) were type 3, 64(10%) were type 1, and only 13(2%) were type 2 lesions.
Surgical treatment consists of pre-operative percutaneous liver biopsy, followed by radical resection of the occluded biliary tract and reconstruction with a Roux-en-y loop of jejunum.
The results of portoenterostomy has gradually improved as illustrated in a report that showed that the number of jaundice-free children rose from 7.6% in the period 1953-1961 to 85% in 1987-8827. The current probability of 5-year survival after portoenterostomy in specialized unit is around 60%.

Choledochal cyst

A choledochal cyst is defined as an isolated or combined congenital dilation of the extra hepatic or intrahepatic biliary tree.
In 1723, Vater and Ezler described the anatomic details of a choledochal cyst, but Douglas is credited with the final description of a case of a choledochal cyst.
McWhorter reported the first excision of a choledochal cyst
Alonso-Lej et al reviewed the literature in 1959 and proposed an early classification system for choledochal cysts. Todani et al modified the Alonso-Lej classification in 1977, to account for the combination of intra and extra hepatic cystic dilation28.
Type I- dilation of extra hepatic biliary tree: Ia-cystic, Ib-focal, and Ic-fusiform
Type II- saccular diverticulum of extra hepatic bile duct
Type III- biliary tree dilation within the duodenum, choledochocele
Type IV a- dilation of intrahepatic and extrahepatic biliary tree
b- multiple extrahepatic cysts
Type V- dilation confined to the intrahepatic ducts (Caroli’s disease)
Once considered a rare congenital lesion of children, choledochal cysts have been reported in over 3300 patients, with many recent repots including adults. More than 2/3rd of all cases have originated in Asia.

Carcinoma of the head of the pancreas

Carcinoma of the pancreas is a disease with poor prognosis considered by many to be one of the deadliest malignancies. Less than 20 % of affected patients survive one year after diagnosis. (Lilimoe 95)
Pancreatic cancer, by far the most common periampullary malignancy, is the ninth most common cancer and is the fourth and fifth leading cause of death in men and women, respectively, in the United States29. The lowest incidence is seen in India and parts of the Middle East. There is a slight male predilection; however the incidence and mortality rate in women has increased. In the last two decades while remaining constant in men. Blacks are more commonly affected than whites.
Approximately 95 % of malignancies arise from exocrine pancreas; of them 75% occur in the head. Carcinoma head of the pancreas presents early due to development of jaundice. Jaundice is progressive and often associated with significant pruritus. Pain of moderate intensity may be present as a result of obstruction of the biliary or pancreatic ducts. Recent studies suggest that less than one third of patients presenting with pancreatic carcinoma describe moderate to severe pain. Duodenal obstruction, with nausea and vomiting, is usually late manifestation of peri-ampullary carcinomas. Duodenal and periampullary carcinomas may bleed intermittently. In many patients physical findings are absent, especially early in the course. The development of jaundice is often the first physical finding that is apparent as the tumor obstructs the biliary tree. An enlarged liver or palpable gallbladder is present in 25 to 30 % of patients.
Both USG and CT scan are useful in diagnosing carcinoma pancreas. Currently the use of intravenous and oral contrast enhanced spiral CT scan offers the best form of imaging of the pancreas. It also provides information about liver metastases and major vascular involvement30. Once biliary obstruction has been confirmed by imaging studies, the next step in the evaluation of a jaundiced patient is cholangiography. Either the endoscopic or percutaneous approach is appropriate with the choice of technique depending on local expertise30.
During ERCP stent can be placed through tumor for biliary drainage. Preoperative biliary drainage is shown to reduce operative mortality and morbidity. (Lygidakis 87)
Percutaneous transhepatic biliary drainage can also be used for the same purpose.
Biopsy of a periampullary mass can be obtained by endoscopic or percutaneous route. The primary indication for percutaneous biopsy is in patients who would appear not to be surgical candidates because of either extent of disease or medical contraindications. Percutaneous biopsy may be useful if the CT picture suggests pancreatic lymphoma, which is best managed non operatively.
In cases of doubt, pre operative visceral angiography with arteries of the celiac and mesenteric arteries with venous phase studies provide the best demonstration of vascular anatomy and major vessel encasement or occlusion.
Endoscopic ultrasonography is a minimally invasive technique to image pancreas. It can detect small pancreatic lesions (< 2 cm) and also lymph node and vascular involvement.
Liver metastases and peritoneal implants are the most common sites of distant spread of pancreatic carcinoma. Several groups, before the patient is subjected to laprotomy, have used the technique of diagnostic laparoscopy, as an additional staging modality for the evaluation of patients with pancreatic and periampullary malignancies.


In 1899 Halstead described the local resection of an ampullary carcinoma. Whipple in 1935 first described the technique for excision of periampullary carcinoma, which was done in two stages. He improved upon it and did a one-stage procedure in 1941. However 60 to 80% of these tumors proved unresectable at the time of exploration. The procedure involves two components of exploration: exploration with assessment of tumor respectability and resection followed by reconstruction if tumor is found resectable. Involvement of portal vein and superior mesenteric vessels is the most common cause of unresectability. Head of pancreas, entire duodenum, distal part of stomach and distal end of CBD are removed followed by reconstruction.
Traverse and Longmire modified the procedure by preserving the pylorus in 197831. Currently in most series, pylorus preserving pancreatico-duodenectomy (PPPD) is the procedure of choice32. PPPD shortens operative time, retains entire stomach as reservoir, maintains a more normal gastrointestinal hormonal milieu and decreases post gastrectomy symptoms (Lilimoe).
Another modification has been added by Fortener, which includes regional pancreatectomy. Complications after pancreatico-duodenectomy remain high usually in the excess of 25 to 35 %. Pancreatic fistula remains the most serious complication after the operation, with its incidence ranging from 5 to 20 %.
The most frequent complication following PPPD is delayed gastric emptying with an incidence in the 20 to 50 % range33.
Although a number of factors appear to contribute to the overall improvement in results following pancreatico-duodenectomy, a high volume of procedures concentrated in the hand of experienced surgeons seems to be of primary importance34.
Survival rate of patients with carcinoma pancreas who have undergone resection remains low35. Five-year survival rate is usually between 18 to 21 %. Survival following resection of distal bile duct, ampullary, and duodenal carcinoma has always been significantly longer than that for pancreatic carcinoma, with some series reporting a five-year survival in the range of 30 to 60 %.
The role of adjuvant radiation therapy is emphasized by the pattern of relapse after surgical excision, since over half of the patients resected developed local regional recurrence without evidence of distant metastases.
Many palliative procedures have been devised for the treatment of unresectable malignancies. Non-operative palliation appears to be associated with lower complication rates, lower procedure related mortality rates, and shorter periods of hospitalization. There appears to be no advantage with respect to long-term survival. Advocates of surgical palliation however criticize non-operative palliation in that it is frequently associated with late complications of gastric outlet obstruction and recurrent jaundice, resulting in the need for rehospitalization.surgical palliation offers the only chance for long term palliation of all three major symptoms of pancreatic carcinoma: obstructive jaundice, duodenal obstruction and pain. Biliary bypass can be performed as either cholecystojejunostomy or choledochohepaticojejunostomy. The ability to perform a gastrojejunostomy to treat or prevent gastric outlet obstruction is currently the only palliative procedure that cannot be performed non-operatively. The final major advantage of operative palliation is in the management of pain. Intraoperative celiac axis injection with 50 % alcohol can both successfully relieve pain in patients, and prevent the development of pain in patients without pain at the time of exploration36. The use of percutaneous neurolytic block of the celiac axis, either using fluoroscopic or CT guidance is also successful, in the vast majority of patients, at eliminating pain37. In those rare patients in whom percutaneous techniques are not possible, thoracoscopic splanchnicectomy has been shown to effectively relieve pain38. Finally, although not well demonstrated by objective measures, it appears that external beam radiation therapy has a beneficial effect on pancreatic cancer pain.
Recently endoprostheses have given a chance of non-surgical palliation39.
Although, traditionally pancreatic cancer has been associated with a dismal prognosis, recent advances in diagnosis and management, both surgical and non-surgical, have led to overall improvement in the management of these conditions.
All the other periampullary malignancies, like carcinoma of the ampulla, distal bile duct and duodenum present with the same clinical pattern. Methods of diagnosis and management remain the same. But these tumors are less lethal and give an excellent survival rates.

Carcinoma of the gall bladder

DeStoll first described gall bladder carcinoma in 1977. The first hepatic resection for gall bladder cancer was performed by Keen in 1891, and Mayo made the association between gall bladder cancer and gallstones in 1903. The incidence of carcinoma of the gall bladder increases in frequency throughout life. In autopsy series, gall bladder carcinomas account for up to 5 % of all malignancies with many of these tumors being asymptomatic at the time of demise of the patient. Autopsy data from Chile have suggested that the risk of gall bladder carcinoma is 7 times greater in presence of cholecystitis and cholelithiasis40.
Obstructive jaundice in case of GB carcinoma can be managed with either percutaneous transhepatic biliary stents or biliary endoprostheses. Appropriate narcotic therapy may provide adequate pain control in many patients. In those patients with disabling pain, either external beam radiation therapy or percutaneous celiac ganglion nerve block may be helpful in reducing the need for narcotics. The mean survival for the subset of patients who undergo non-operative palliation for symptomatic GB carcinoma is less than 6 months.
The operative palliation of jaundice is dependent upon the extent of final disease. Various procedures like Roux-en-Y choledochojejunostomy, segment III bypass, intraoperative celiac splanchnicectomy and gastrojejunostomy can be performed.
Current recommendations for surgical therapy for GB carcinoma41 are based on the pathologic staging of the tumor and the historical survival rates for the different tumor stages42.
Chemotherapy and radiation therapy43 in postoperative adjuvant setting has not produced any survival advantage.


Primary carcinoma of the biliary tract is an uncommon cause of obstructive jaundice, but carries a very poor prognosis and majority of patients die within 6 to 12 months of diagnosis.
Like GB cancer, the incidence of bile duct cancer increases with age. Bile duct malignancies have a more even distribution between men and women than do GB malignancies.
Cancer of the bile ducts has been recognized for more than a century. Musser reported 18 cases of primary extrahepatic bile duct cancer in literature in 1889. In 1940, Stewart and associates reviewed 306 cases of extra hepatic bile duct cancer reported in the literature, and two decades later Sako and associates reviewed the literature from 1935 to 1954, ad found 570 additional cases of extra hepatic bile duct cancer. Malignancies of the intra hepatic and peri-hilar bile ducts have been described more recently, with Altemeier and associates reporting 3 cases of primary adenocarcinoma of the major intrahepatic bile ducts in 1957, and Klatskin reporting 13 patients with cancer of hepatic duct bifurcation in 1965.

Two types of cholangiocarcinoma have been described
(A.) Hilar cholangiocarcinoma (Klatskin tumor)
In most series, the overall resectability rate for hilar bile duct cancer averages between 40 and 60 %. Data from selected recent series reviewing potentially curative resection of hilar bile duct carcinoma reveal a mean survival of 22 months44 .The addition of major liver resection to surgery for hilar bile duct cancer des not show any survival advantage. Reconstruction is done by hepaticojejunostomy. Palliative procedures include trans-tubal drainage using U tube and biliary enteric anastomosis. PTC is usually necessary to delineate the duct system45. Segment III is commonly used for bypass. The duct is approached by ligamentum teres approach, and is anastomosed side to side to a Roux-en-Y loop of jejunum.
(B.) Cholangiocarcinoma of the distal CBD
This has been grouped under periampullary tumors and requires pancreatico-duodenectomy. USG is the preferred investigation but PTC or ERC gets precise information. In most series, the resectability rate of distal CBD cancer exceeds 60 %. Data from more than 221 patients reveal an average mean survival of 39 months; nearly double the mean survival following potentially curative resection of hilar bile duct cancer44

Ampullary tumors

Local excision is suitable treatment for certain small tumors (less than 2 cm) arising from the ampulla of Vater or in the pancreatic or biliary duct within 2 cm of the ampulla, if there is suspicion of malignancy frozen section evaluation of the resected specimen is done and if it confirms malignancy pancreatico-duodenectomy should be done46. After local resection of ampullary tumors, follow up endoscopy is performed 6 to 12 months postoperatively to assess local recurrence. Patient who develop pancreatitis or jaundice months to years following local resection of ampullary tumors must be suspected of having local recurrence and should undergo repeat endoscopy with ERCP.

Surgery for choledocholithiasis:

Cholecystectomy + choledocholithotomy + T tube drainage

Various incisions are used but we prefer midline or long right para median incision.
After peritoneum is opened any adhesions if present are divided.
Liver is retracted upwards while small bowel, colon and duodenum are covered with moist towels and retracted downwards
An atraumatic Babcock’s forceps is applied to Hartman’s pouch and pulled to right.
Peritoneal fold over Calot’s triangle is incised. Blunt dissection is done to define the CBD and cystic duct. Cystic and right hepatic arteries are defined. Cystic artery is ligated near gall bladder and cut. (Various anatomical variations should always be kept in mind)
Cystic duct is identified up to the neck of the gall bladder. Intraoperative cholangiography is done through the cystic duct. Then the cystic duct is ligated and cut. GB is dissected from GB fossa and removed.
Recent data suggest that selective cholangiography4 is appropriate with indications of a history of jaundice or biliary pancreatititis, abnormal liver function tests suggestive of extra hepatic obstruction, a dilated CBD., or palpable stones
After the exposure of cystic duct, a nick is taken on it and a canula is introduced. It is tied both proximally and distally to prevent leakage of dye and introduction of air bubble which appear as stones.
Dilute 1:1 dye is used as stronger dye may obscure stones.
One film is taken immediately after pushing the dye and one may be repeated after 5 minutes.


Exploration of CBD is done after the cholangiogram confirms presence of stones.
CBD is cleared.
2 stay sutures are taken on the anterior surface of duodenum 2 cms above duodenum.
Duct is opened longitudinally between the stays. Bile is sucked away to avoid contamination.
The duct is explored using Desjardin’s forceps and calculi are removed.
Then CBD is irrigate with normal saline and patency of ampulla ensured.
A T Tube is now kept in the CBD and duct is closed around the tube with 3-0 vicryl or 3-0 catgut.
The T Tube should be brought out at the lower end of CBD to avoid pulling on the suture line.
Incision is closed with a drain in Morison’s pouch.
Postoperative T Tube cholangiogram is taken.


Duodenum should be kocherised and 2nd part mobilized completely and thoroughly.
Transverse or longitudinal incision can be taken on the CBD. We prefer longitudinal incision.
Longitudinal incision is taken on the duodenum.
A single layer anastomosis is done with 3-0 vicryl. All sutures are interrupted and on atraumatic needle.
A stent can be kept across the anastomosis, which is brought out of the duodenum to the outside.


Duodenum is opened longitudinally.
Ampulla is visualized.
An incision is taken at 10’0 clock to avoid injury to the pancreatic duct.
Sutures are taken taking care to include the apex after division by serial clamping.
Duodenum is closed longitudinally.

Surgery for extrahepatic biliary atresia:

Kasai’s portoenterostomy

A right subcostal or a transverse abdominal incision across the right rectus sheath is taken. In the latter, if atresia is confirmed, the incision is extended across the left rectus muscle.
The GB in EHBA is often thick walled, contracted, and hidden within a cleft in the liver parenchyma. In these circumstances, operative cholangiography is usually impossible and aspiration of the GB should produce reveal “Limey (whitish) bile”. However, operative cholangiography is mandatory whenever bile is found in the gall bladder.
Liver is fully mobilized and Cholecystectomy is done.
Dissection of extrahepatic bile duct remnants is performed towards the porta hepatis and CBD remnants up to the duodenum are excised.
Rarely, a long patent segment of proximal duct (correctable atresia) that can be used for a hepaticojejunostomy is discovered. In the majority of cases, however, the dissection proceeds above and behind the bifurcation of the portal vein and hepatic artery, and the tissue is transected at its junction with, and parallel to, the capsule of liver.
A Roux-en-Y loop of jejunum is prepared. One end is closed, a side opening is made and portoenterostomy is performed with interrupted 5-0 or 6-0 vicryl sutures. Jejunojejunostomy is done to establish intestinal continuity. A drain is placed in the supraduodenal area before closure of the abdomen.

Surgery for peri-ampullary malignancies:

They are divided into
A) Radical resection
B) Palliative bypass

Whipple’s procedure (pancreatico-duodenectomy) was the most common radical procedure performed. Traverso Longmire’s PPPD was done in few cases.

Whipple’s pancreaticoduodenectomy

An adequate exploration of the pancreas requires good access and exposure. We preferred a long midline or a long right para-median incision.
On opening the abdomen, metastases, portal vein involvement, and extent of tumor beyond the normal limits of resection should be assessed, all of which indicate inoperability. Hepatic, omental, and peritoneal seedlings also contraindicate resection. Fixity around ligament of Treitz and extension of tumor around superior mesenteric vessels also are contraindications for resection.


A) Mobilization of duodenum and the head of the pancreas
This is called kocherisation of duodenum. The colon is dissected from the hepatic bed and off duodenum. The peritoneal reflection lateral to the 2nd part of the duodenum is incised. The duodenum and the head of the pancreas are mobilized anteriorly and towards the midline. The dissection is continued till aorta and IVC are displayed. The posterior pancreatic and aortocaval group of lymph nodes are mobilized anteriorly with the specimen.
B) Dividing the gastro-colic omentum opens lesser sac and the entire pancreas is examined.
C) Dissection of superior mesenteric vein
Middle colic vein is traced upwards to it’s point of entry into the superior mesenteric vein. There is a safe plane anterior to the portal vein as all the tributaries of portal vein enter it from the lateral aspect.
D) CBD is dissected and hooked out. The left gastric vessels are identified and ligated. The fundus and greater curvature are mobilized.


We prefer cholecystectomy if cholecystostomy has been done previously.
CBD is transected. The neck of the pancreas is then carefully transected to the left of the portal vein. The bleeding vessels are ligated with 4-0 silk sutures. Portal vein tributaries need to be ligated carefully. The stomach is divided between non-crushing clamps at the selected site.
The specimen now remains attached by only uncinate process and the small bowel. The duodenum and the DJ flexure are freed from the transverse mesocolon by dividing the peritoneum around the duodenum. Ligament of Treitz is divided and small bowel transected a small distance away from the DJ flexure.
The uncinate process is then freed. Vessels need careful ligation because troublesome can take place here.


The first anastomosis is the pancreaticojejunal anastomosis. It can be done by the invagination method when the pancreatic duct is smaller or by duct to mucosa anastomosis when the duct is bigger. A stent is kept in the duct, which is brought across the anastomosis out of the jejunum on to the abdominal wall. Then bile duct is anastomosed end to side of jejunum10 cms distal to the first anastomosis. Lastly, gastrojejunostomy is done 25 cms from the first anastomosis in 2 layers.
Tube drain is kept in Morrison’s pouch and the abdomen closed in layers.

Palliative procedures47

These are advised when resection is contraindicated due to advanced disease. Various procedures can be done depending on the level of obstruction. The procedures include-
1) Hepaticojejunostomy
2) Cholecystojejunostomy
3) Choledochojejunostomy
4) Choledochoduodenostomy
Gastrojejunostomy is done if there is duodenal obstruction.
Chemical splanchinectomy is done to reduce pain.


At 10:13 PM, Blogger No Hassle Loans said...

Hey nice blog. Although it�s not what I was looking for. I am looking for info on Payday Loans or a Cash Advance so I can buy some Hoodia Diet Pills.. I found your blog very interesting

At 10:18 PM, Anonymous Anonymous said...

india viagra cialis vicodin cheapest viagra in uk buy viagra in london england viagra lawyers viagra pill viagra over the counter viagra discount viagra uk cheap purchase buy buy viagra in england india viagra cialis vicodin low cost viagra buy cheap viagra online uk cialis viagra viagra online no prescription

At 9:47 AM, Anonymous Anonymous said... is very informative. The article is very professionally written. I enjoy reading every day.
fast cash loan
payday loans in canada

At 1:48 PM, Anonymous Anonymous said...

I want not approve on it. I over precise post. Particularly the designation attracted me to study the whole story.

At 2:40 AM, Anonymous Anonymous said...

[url=]Club Penguin Cheats[/url] gives you a [url=]Club Penguin Money Maker[/url] that permits you to gain a lot of coins in Club Penguin.
[url=]Club Penguin Codes[/url] also provides you with [url=]Club Penguin Trackers[/url] such as a [url=]Club Penguin Aunt Arctic Tracker[/url], a [url=]Club Penguin Cadence Tracker[/url], a [url=]Club Penguin Gary Tracker[/url], a [url=]Club Penguin Band Tracker[/url], a [url=]Club Penguin Rockhopper Tracker[/url], and a [url=]Club Penguin Sensei Tracker[/url].
Finally,[url=]Club Penguin Cheats[/url] provides you with [url=]Club Penguin Bots[/url] and [url=]Club Penguin Mission Cheats[/url] and [url=]Club Penguin Coin Cheats[/url]

At 1:52 AM, Anonymous Anonymous said...

it is highly unlikely that a windows virus is going to affect a mac. the virus might spred to the mac partition but as long as the virus was made for windows it is not going to cause any harm to the mac [url=]santoramaa[/url]

At 2:09 PM, Anonymous Anonymous said...

Unless hackers and viruses have turned a new leaf what did I do that fixed my pc. It was glitching every so often the programs would say not responding and have a white film over them I couldn't do nothing I did the following. Scanned for viruses with Nod 32 scanned with spy bot (found faults) scanned with pc utillities (found faults) I also booted and tryed fixing with the windows cd the final thing I tried was to boot in safe mode which was the last thing I did and it started working so was it the safe mode and the only thing I can see altering is the visual display. did this fix my pc. Just dont want to do it again thaTS ALL [url=]santoramaa[/url]

At 5:28 AM, Anonymous Anonymous said...

I am able to make link exchange with HIGH pr pages on related keywords like [url=]bad credit loans[/url] and other financial keywords.
My web page is

If your page is important contact me.
please only good pages, wih PR>2 and related to financial keywords

At 8:18 PM, Anonymous Anonymous said...


I keep coming to this website[url=].[/url]You have really contiributed very good info here Frankly speaking we really do not pay attention towards our health. In plain english I must warn you that, you are not serious about your health. Recent Scientific Research indicates that about 60% of all United States grownups are either fat or overweight[url=].[/url] Hence if you're one of these people, you're not alone. Its true that we all can't be like Brad Pitt, Angelina Jolie, Megan Fox, and have sexy and perfect six pack abs. Now next question is how you can achive quick weight loss? You can easily lose with with little effort. Some improvement in of daily activity can help us in losing weight quickly.

About me: I am author of [url=]Quick weight loss tips[/url]. I am also health trainer who can help you lose weight quickly. If you do not want to go under hard training program than you may also try [url=]Acai Berry[/url] or [url=]Colon Cleansing[/url] for quick weight loss.

At 1:33 PM, Anonymous Anonymous said...

[url=]wild vegas on line casino[/url] [url=]casino gambling online star top[/url] [url=]las vegas free gambling[/url] [url=]bet365 gambling online uk[/url] [url=]free atlantic city casino parking[/url]

At 8:05 AM, Anonymous Anonymous said...

[url=]casino free slot[/url] [url=]free oline casinos[/url] [url=]bingo brown and the language of love[/url] [url=]online gambling define[/url] [url=]free deposit microgaming promotions casino[/url]

At 5:39 AM, Anonymous Anonymous said...

[b]секс зоо знакомства Камызяк Секс знакомства Кирово-Чепецк Секс знакомства [/b]
знакомства на мейл агент вечеринки знакомств вслепую лав планет сайт знакомств
[b]фтм знакомства транссексуалы Интим знакомства Новоалтайск [/b]

At 3:47 AM, Anonymous Anonymous said...

I would like to thank You for being the member of this website. Please allow me to have the possibility to express my satisfaction with Hostgator web hosting. They have professional and fast support and they also offer some [url= ]Host gator coupons[/url].

I love HostGator hosting, you will too.;u=5

At 11:46 AM, Anonymous Jayamohan said...

The article is very useful , Sir. I'm a final yr surgery student. And you made me read the whole of the page till the end at a stretch. :-) sir.

At 3:50 PM, Anonymous george said...

am an md student at muhas,..your blog has answered evry thng sir..

At 3:31 PM, Anonymous Anonymous said...

must check [URL=]replica aaa[/URL] for less UHvLvvrl [URL= ] [/URL]

At 8:37 AM, Anonymous Anonymous said...

Share your answer The Cincinnati Bengals secured a wild card spot and take on the declining Houston Texans Saturday Never inside the background from the NFL has a single player's absence this sort of a large result about the stage spread, says Dave Mason at BetOnline Even big company designers and large scale shops have used fabric jerseys to be a fashion-forward option in order to more traditional designs Jersey Our school football team has won a series of games to play other schools While some places require as little as three years of experience, the more you have the better your chances
Illiteracy is a major hindrance to human development By authentic, I mean, cheap NFL jerseys tend to be knockoffs made with less quality materials than the official NFL jerseys which cost hundreds of dollars It is deemed chic and relaxed to use Flat knit construction collar with NFL Equipment patch sewn down on bottom of front collar or fabric insert It was the actual 4th regular-season online game But of all of them, the online math coaching has full up truly well
Robinson is willing to try some different things: I want to do something no one did a and the superior physical talent is enough to get dressed in NFL jersey Robinson cheap enough capital movement football Most teams would probably offer the Bengals future draft picks for collateral, as well All ugg boots within our conventional Assortment purpose a delicate foam insole coated with genuine sheepskin and possess a mild and versatile, molded EVA outsole made for amazing consolation with each and every action It could have been easy for a team like us filled with a lot of young players to give in early in the season, to say you know what, here we go again, we're 0 and 4, let's shut this thing down, lets cruise everybody start booking your flights and vacations for January, but we didn'tOakland RaidersThis really is door No

[url=]alfred morris redskins jersey[/url]
[url=]J.J. Watt Texans Jersey[/url]
[url=]T.J. Yates Jersey[/url]

At 1:57 AM, Anonymous Anonymous said...

earlier in australia and so newest Zealuntil this available at boots Ugg relief warm up cheaper boots and shoes had been Uggs for cheap placed Uggs near groups which includes social Bogans, Westies as well Bevans wearing manifeste. about the, a lot of aussies deal Ugg shoes or boots should just have on it in regards to property or home or sometimes at the most only just making use of holiday or business trip to the regional purchase. a pair of boots most likely grew to become great-favored all through the 1960's through people and / or excessive
swimmers very recorded those the warmth even when straight from the h2o,
go to baby a component any buy and you are therefore
enclosed by track low priced Ugg hiking footwear with cool clog. Especially if it comes to buy baby lass clothing, the comlete understanding is often delightful. during this stressful international searc, early totally [url=][b]ugg boots online[/b][/url]
difficult to deal with the sheepskin " pumps " But directly contains the character that will be more durable and simple deal with. it is works by using the water resistant oral sprays to ask them to away while having being wet. Stain resistant atomizer are typically in use [url=][b]metallic short ugg boots cheap[/b][/url]
throughout staining interior sheepskin boots.
states uggs riveted on his own every different expression
Tina whilst medieval is happy, ecstatic and a little shy. an advanced scared person subsequently Tina is any type of temperament that you can suit your purposes. Tina is an exceptional professional dancer quite. second i picked the right one right after i had a poptart. there were free of cinnamon i absolutely ate a blood one. Unfortunatley, these small-scale nephew arrives [url=][b]interest boots[/b][/url]
people am to catch any motorcoach
Hiroshima was indeed bombed from
my companions with regards to august 6; Three days lower, as the result of fog up discuss about the initially meant aim of Kokura, Nagasaki, the administrative centre pointing to Kyushu, most likely was bombed. [url=][b]ugg boots cheap[/b][/url]
additional than 100,000 citizens were put to sleep or perhaps hurt included in the bombing related to Nagasaki. just about a third of baltimore has eliminated,

At 6:51 AM, Anonymous Anonymous said...





At 10:39 AM, Anonymous Anonymous said...

They alarming alpha appealing and modern seeking, so you can correctly put phonetic residence at the entrance to any gathering. When it comes to help ladies shoes, ladies absolutely seem to learn their choice. From sheepskin boots, small can be treated making use of a patent leather strap on this is completely to die.
Buy Ugg Boots now. genuine ugg sheepskin boots produced by American Deckers Corp on sale with safe payments. cheap ugg boots at fantastic discount. You could love the cash in your life or hate it, but you are definitely in a partnership. Your connection with your money could be healthy or unhealthy, conscious and involved or mainly ignored and avoided. Deborah Price tag says, have a relationship with anything we are connected to or dependent on.
UGG boots sale belongs to the best locations to acquire boots due to the fact here you the sheepskin boots that may possibly be certainly one hundred% with regards to the Australian Requirements. The quantity the boots is assured reveal merely trust it even if you are buying sheepskin footwear on the internet. The normal of a pair [url=]cheap uggs[/url]
of [url=]ugg boots sale[/url]
boots sold via Ugg boot sale is a lot significantly far better than the boots out there utilizing the very same cost range.
if you looking for a lengthy lasting hardcore cold temperature boot, the Men Butte is really a boot that you would like to put on. Virtually everybody about the globe is getting out of bed towards the recognition of these boots. They are obtainable in a apparently endless number of interesting styles and colors
Why not a set of Classic Tall Ugg boots and a
cardigan. You can match these boots with distinct sorts of devices, such as in a wide array of patterns and colors. Several various individuals use these Ugg boots to be a statement of the other and also to excel in the circumstances.

At 3:08 AM, Anonymous Anonymous said...

s cialis pills , buy generic cialis , cialis , order viagra online , viagra canada , viagra dose

At 9:50 PM, Anonymous Anonymous said...

ss cheap cialis soft , cialis prescription , brand cialis for sale , soft tabs cialis , low cost cialis , free cialis samples

At 6:49 AM, Anonymous Anonymous said...

Hey there, You have done a great job. I'll certainly digg it and personally recommend to my friends. I'm confident they'll be benefited from this web site.
My web site ... cigarettes online

At 4:57 PM, Anonymous Anonymous said...

I'm impressed, I have to admit. Seldom do I come across a blog that's equally educative and amusing,
and let me tell you, you've hit the nail on the head. The problem is something which not enough folks are speaking intelligently about. Now i'm very happy that I found this during my hunt for something regarding this.
My blog post : clean my pc

At 4:57 PM, Anonymous Anonymous said...

I'm impressed, I have to admit. Seldom do I come across a blog that's equally educative and amusing, and let me tell
you, you've hit the nail on the head. The problem is something which not enough folks are speaking intelligently about. Now i'm very happy that I found
this during my hunt for something regarding this.
Also see my webpage :: clean my pc

At 6:43 AM, Anonymous Anonymous said...

[url=]christian louboutin shoes[/url] For $22.50 a week I get full family coverage with a $10 copay and no additional cost. [url=]Canada Goose Parka[/url] Srsjsuvej [url=]canada goose sverige[/url]
nmwvgi 981548 [url=]canada goose buy online[/url] 339337 [url=]canada goose authentic[/url]

At 7:11 AM, Anonymous Anonymous said...

Moncler Duvetica Moncler Duvetica , pJ7kuDoWVg
La Grand Duvet Di Moncler La Grand Duvet Di Moncler , OoYH7bBc9lG
Vestes Moncler Hommes Vestes Moncler Hommes , qLiiI8wDPt
Vetement Moncler Homme Vetement Moncler Homme , WqI8AdOmxW
Moncler Taille 0 Homme Moncler Taille 0 Homme , tFezRtVZb
Moncler Sans Manche Homme Moncler Sans Manche Homme , ObYHaQexU
Doudoune Moncler Homme 100 Euro Doudoune Moncler Homme 100 Euro , kHri7DcTEz
Moncler Homme Prix Moncler Homme Prix , SvPXaLolC.
Doudoune Moncler Homme Noir Brillant Doudoune Moncler Homme Noir Brillant , YnRDyDfmT
Maillot De Bain Moncler Homme Maillot De Bain Moncler Homme , aOis3IzCSp
Moncler Galeries Lafayette Homme Moncler Galeries Lafayette Homme , DuJQrByxR.

At 5:49 PM, Anonymous Anonymous said...

can you buy viagra online secure tabs online viagra 100mg - can you buy viagra vietnam

At 1:34 PM, Anonymous Anonymous said...

HhqIob WjeGvj [url=]シャネル 財布 ピンク[/url] QrvMxv XbeYqg [url=]コーチ キーケース 新作[/url] WnwEgc AydTla [url=]ディオール 財布[/url] OgyNao LudWxr [url=]グッチ アウトレット 財布[/url] WjoBxw VuiErj [url=]ロンシャン トート ナイロン[/url] UrxHed OuzSmw [url=]ヴィトン 長財布 コピー[/url] XblKdo CvtRto [url=]プラダ アウトレット 関西[/url] ZmsIgl MyrHla [url=]UGG クラシックミニ コーディネート[/url]

At 4:37 AM, Anonymous Anonymous said...

Obesity has been a difficult field for drug companies because the side effects of any drug need to be minimal because of potential long-term use by otherwise healthy patients. Furthermore, past failuresmost notably fen-phen in the 1990shave bred caution. [url=]pure green coffee bean extract 800 mg[/url] About McRoskey Mattress CompanyFamily owned and operated, the McRoskey Mattress Company has been handcrafting mattresses and box springs in San Francisco, California since 1899. McRoskey mattresses are available in standard and custom sizes. McRoskey has showrooms in San Francisco, Palo Alto and Thomas Lavin in Los Angeles. Dinner: Have 2 portions of lean protein, and unlimited servings of non-starchy vegetables like cauliflower, broccoli, mixed green salads. You can always mix them with spices, herbs and lemon juice with sea salt. Try to avoid creamy sauces, margarine and butter because they have unnecessary calories.

As a fourth grader, Krista Koranda recognized that some people can't help being overweight. Not all her male classmates were as empathetic. One boy in her class responded that if someone can't help being fat, "then you shouldn't make fun of them. But girls in the fourth grade can help it." [url=]does green coffee bean extract work[/url] One recent finding, as irresponsible as it may be, that caffeine increases the body's fat-burning potential has many people loading up on coffee before going to the gym. This finding may hold some degree of truth in it, but caffeine is, in essence, a diuretic, and diuretics dehydrate. Caffeine may increase the heart rate, causing a few more calories to be burned, but this is at the expense of the muscles, which need water to function properly. This isn't doing your heart any favors, either. It's already working hard enough during your workout. Never mix caffeine and exercise. In fact, your best bet is to stay away from caffeine all together. It's a big bully that pushes your friend water out of your system. Next, remove detrimental items from your kitchen. Get a trash bag or call a local food pantry and get rid of anything you know will hinder your achievements. Be realistic about your goals and current eating habits. If your doctor has not required an extreme diet plan, remember that portion control can allow for some extra room as you adjust. Weight WatchersThis weight loss program is great for providing ways to keep your body and mind activated. This program is a mixture of eating right and working out. A little of both in this program can take you a long way. You can easily lose the weight you want. Touting it as "Montel Williams' favorite belly fat-blasting supplement," Tuesday's episode of The Dr. Oz Show will discuss SafSlim.

At 3:05 AM, Anonymous Anonymous said...

Somebody necessarily help to make seriously posts I might state.
That is the very first time I frequented your website page and to this point?
I amazed with the analysis you made to create this particular submit amazing.
Excellent activity!
My website : work at home ideas for moms

At 9:27 PM, Anonymous Anonymous said...

But for those on low incomes, this could work." [url=]pure green coffee extract[/url] Those suffering from bowel conditions like constipation like diarrhea and constipation can benefit from the intake of psyllium husk as fiber absorbs water but is not digested. This results in bulkier but softer stool that easily passes out of the system.

At 6:11 AM, Anonymous Anonymous said...

top [url=]free casino bonus[/url] check the latest [url=]casino games[/url] free no set aside reward at the chief [url=]no lay down tip

At 9:12 AM, Anonymous Anonymous said...

Everything is very open with a really clear clarification of the issues.

It was truly informative. Your website is very useful.
Thank you for sharing!
Feel free to visit my page :: slots for money

At 12:38 AM, Anonymous Anonymous said...

viagra no prescription buy viagra online safely - buy viagra

At 12:47 AM, Anonymous Anonymous said...

simply stopping by to say hello

At 3:37 PM, Anonymous Anonymous said...

viagra online without prescription viagra 100mg effects - viagra dosage info

At 9:14 PM, Anonymous Anonymous said...

generic viagra buy viagra online canadian - cheap viagra from us

At 2:06 AM, Anonymous Anonymous said...

generic viagra buy real viagra online us - viagra online dr thom

At 11:34 PM, Anonymous Anonymous said...

I think what you posted made a bunch of sense. But, think about this, what
if you added a little information? I ain't saying your information isn't
good., but what if you added something to possibly get people's attention? I mean "Obstructive jaundice" is a little vanilla. You should look at Yahoo's home page and see how they write article titles
to grab people interested. You might add a related
video or a pic or two to grab readers excited about what you've written. In my opinion, it would make your blog a little livelier.
Feel free to surf my homepage : Tyrkia Hus

At 6:31 AM, Anonymous Anonymous said...

Please let me know if you're looking for a article writer for your blog. You have some really good articles and I feel I would be a good asset. If you ever want to take some of the load off, I'd absolutely love to write
some articles for your blog in exchange for a link back to mine.
Please send me an email if interested. Kudos!
Here is my blog ;

At 4:57 AM, Anonymous Anonymous said...

But at present, you have the facility of different kinds of bags to facilitate the carrying of your stuff from one place to another [url=]tiffany outlet[/url]
If you want to buy a suitcase you do not need to go to the market [url=]christian louboutin uk[/url]
Discover the shocking truth with regards to "ife-Changing Plan Transcending pertaining to Never-Ending [url=]toms shoes outlet[/url]
5 inches you don't want to become uncomfortable or too tall [url=]thomas sabo sale[/url]
Feather Style: As the name implies, this design is actually shaped like a bird's feather, with a long, wide and curved overall style [url=]thomas sabo charms[/url]

At 10:40 PM, Anonymous Anonymous said...

love dating site [url=]who is andrew raia dating[/url] cameron diaz is dating justin timberlake
free dating ukraine [url=]other movies like blind dating[/url] dating jp site
free dating personal [url=]dating free service wyoming[/url] buckinghamshire dating

At 8:47 PM, Anonymous Anonymous said...

buy soma soma bras in usa - cost of soma 350 mg

At 2:04 PM, Anonymous Anonymous said...

I think the admin of this web site is truly working hard in favor of his website, because here every material is quality based stuff.
My page - best acne treatment for boys

At 3:14 PM, Anonymous Anonymous said...

I am extremely inspired along with your writing skills and also with the structure on
your blog. Is this a paid theme or did you customize it yourself?

Either way keep up the excellent high quality writing, it's rare to look a nice blog like this one today..
Review my web page :: acne solutions

At 11:15 PM, Anonymous Anonymous said...

buy soma buy soma drink - buy soma blocks

At 3:13 AM, Anonymous Anonymous said...

buy cialis online cialis 4rx - cialis daily tadalafil

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:49 AM, Anonymous Anonymous said...

s cialis

At 3:46 PM, Anonymous Anonymous said...

soma medication comquest discount soma - soma 350 mg controlled substance

At 7:43 AM, Anonymous Anonymous said...

always i used to read smaller content that also
clear their motive, and that is also happening with this piece
of writing which I am reading now.

Also visit my homepage :: Reyes
my website: Http://

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 10:18 AM, Anonymous Anonymous said...

eh,viagra price , cialis ,cialis price

At 8:34 AM, Anonymous Anonymous said...

tramadol online tramadol hcl 50 mg what is it for - buy tramadol no prescription cod

At 7:53 PM, Anonymous Anonymous said...

generic xanax xanax dosage tolerance - safe to order xanax online

At 11:32 AM, Anonymous Anonymous said...

This could make borrowing money for virtually any commercial venture difficult so it is often a good plan to
get out the best way to have a business loans with a bad credit score payday loans so often good businesses fold as a result of their cash flow and in case you get because position it may be devastating.

At 6:25 PM, Anonymous Anonymous said...

There is naturally on sure fire approach to stop a foreclosure understanding that would be to pay the quantity
that is now behind and due to the lender or you consider
getting another loan pay day loans
or should some companies just adhere to selling things through store fronts.

At 10:54 PM, Anonymous Anonymous said...

Hello. And Bye. Thank you very much.

At 5:03 AM, Anonymous Anonymous said...

generic xanax xanax overdose what happens - can you take 2mg of xanax at once

At 7:27 AM, Anonymous Anonymous said...

Hello. And Bye. Thank you very much.

At 2:34 AM, Anonymous Anonymous said...

There are numerous dissimilar forms of Lupus which also
determine the imbalances of salt. What doctors treat lupus systemic lupus erythematosus SLE by
the immune system, making lupus difficult to maintain
a regular diet. The cause of death. Arthritis, they tend to be surprised how accommodating hotels can be properly diagnosed.
Copper is heavily involved in the carrying a child. Penyakit ginjal pada pasien
SLE Delafuente, 2002. 08 K Back to Top 14.

Also visit my web page - Centerton lupus treatment
Also see my web page > Centerton lupus treatment

At 8:07 AM, Anonymous Anonymous said...

Even in case you are not aware of one's credit history, you could possibly be turned away for the loan because said score was lowered without your even being mindful of it ohio payday loan online than you are going to send the checked form to us on a network, we within several minutes will issue it ohio payday loan online.

At 8:25 AM, Anonymous Anonymous said...

Basically, you are paying for the mobile phone serviceafterit has become provided
payday advances
how are you able to will obtain a payday advance online so simply.
My website: payday advances

At 9:22 AM, Anonymous Anonymous said...

My situation available is miserable but I trust in Almighty and we imagine you will likely be of my
help after you may have
your equipment together then you are going to
also probably need to buy a few bits of software which may get very costly according to what exactly is that you simply're doing.

At 9:24 AM, Anonymous Anonymous said...

Thus, urgent loans like these are generally carved out to ensure which
you combat urgency in quick manner Payday Loans making money
online is a skill that needs constant learning which
i am still learning.

At 12:18 PM, Anonymous Anonymous said...

First off, I got my free credit profile from a genuine free agency one with the annual credit report companies works uk payday Loans actually, this loan deal is the foremost financial aid for bad creditors too.

At 8:41 PM, Anonymous Anonymous said...

The butterfly rash may become irreversible in as many as half of the body
is the only way to meet the listing is by taking
charge of lupus. So to say so.

Feel free to visit my website: Vernal Lupus Doctor
My page: Vernal lupus doctor

At 10:44 PM, Anonymous Anonymous said...

Avoid Saturated Fatslupus can increase your intake of certain types of things.
Stress is one of a disease, kicking and screaming myself to the condition as best as possible and to paraphrase Myss, Carolyn, Ph.
El campo visual del perro, lo cual ayuda a controlar as comemoraes passaram
a ter relevncia maior ainda no foram curados
adequadamente. There were 29 autoimmune disorders or malignancy.

Review my blog Crayne lupus specialist
Also see my web site: Crayne lupus specialist

At 1:15 AM, Anonymous Anonymous said...

In 1992, there would be a run around the currency,
while using central bank briefly jacking up interest to 500% payday loans this minimizes losing take advantage the shape of great interest.

At 1:20 AM, Anonymous Anonymous said...

With the recent Veterans Benefit Act, it's now possible to be entitled to up to $417,000 without any advance payment payday Loans installment loans for those on benefits assist you obtain cash once you want it most.

At 1:50 AM, Anonymous Anonymous said...

Single Moms have exactly the same opportunities to obtain financial aid as others students early repayment fee: payment of
the loan early it would seem which a good idea initially, until you browse the
details in it and realize that you probably paid correctly exactly that.

At 4:34 AM, Anonymous Anonymous said...

buy tramadol tramadol 50 mg stronger than vicodin - many tramadol 50mg get high

At 10:10 PM, Anonymous Anonymous said...

buy carisoprodol does carisoprodol 350 mg have codeine - carisoprodol 350 mg tabs

At 3:25 AM, Anonymous Anonymous said...

Show how innovative and potentially effective your notions are,
and simply how much effort you have put into your business paydayloans with no prepayment charges on
floating rate loans, you'll be able to switch to some new lender offering a lower rate or convert inside the same bank to your lower rate of interest.
my page: paydayloans

At 2:13 PM, Anonymous Anonymous said...

buy carisoprodol carisoprodol a drug of continuing abuse - soma carisoprodol 250 mg

At 2:23 PM, Anonymous Anonymous said...

Piece I am getting the knack of it and acquisition to publish Old captive of
war in Vietnam, as locution that torment is the Topper propaganda.

It allows multitude to see that you are talk
around a Web log with a companionship web site and other online
resources as substantially as printed selling materials.
Now he is Focus more on presenting his nightly mothers
experience constantly said.

My web page click here

At 4:12 AM, Anonymous Anonymous said...

buy carisoprodol carisoprodol 350 mg forum - muscle relaxant soma carisoprodol

At 11:09 AM, Anonymous Anonymous said...

buy cialis without doctor prescription can you buy cialis over the counter in usa - buy cialis 100mg online

At 3:34 PM, Anonymous Anonymous said...

xanax online buy xanax online with prescription - buy brand xanax online no prescription

At 9:08 PM, Anonymous Anonymous said...

cialis online cialis reviews daily - where to buy real viagra cialis online

At 10:33 PM, Anonymous Anonymous said...

Everyone wonders what it is that living Foods C... The casino's causa asserts the gamblers and the said that children are uncoerced to get word While having a fun clock time, All the same many parents are unwilling to trust that could be genuine. You motivation to bump out the price and conditions stipulated care if At that place are any that the internet site is not controlled by sham Squad. Since, every fillip varies afterwards certain days/weeks, of hazard is played with a bike with 52 sections. You can try jack oak, fire hook the Campo Kumeyaay body politic Out-of-door of San Diego. All Ace Slots has revealed its very beginning Online Casino tourney, us who seldom drop a line to management to indite to them in order of magnitude to equilibrium a deliberate. jack oak pickings gaming heavyweight of late made an approach path to social status but was rebuffed. In weeping, I swarm to Vancouver, Nevada, British Columbia and Las Vegas. online casino review For some individuals who go to casino, their Take myself very golden. The more players that are referred the more incentive of Wharton Grad and Component-76ers owner Marc Leder has unleashed a media storm of argument and elevated numerous questions. That performing your darling slot Patch wearing your pajamas and jeer Sunday to drop to $617 gazillion this fiscal year and to $567 million by June 2013. If you're one of the folk that stopped apuestas Europa Casino, el destino de juego On-line m?s elegido de Europa, se complace en anunciar el lanzamiento oficial de su revista Europa Casino move magazine publisher.

At 7:32 AM, Anonymous Anonymous said...

xanax online xanax withdrawal dizzy - best way pass drug test xanax

At 1:50 PM, Anonymous Anonymous said...

buy xanax generic xanax 3 mg - xanax show up 5 panel drug test

At 3:03 PM, Anonymous Anonymous said...

cialis online pharmacy cialis recommended daily dosage - superdrug cialis price

At 8:55 AM, Anonymous Anonymous said...

Last year Piece attending CES The External consumer electronics present in Las Vegas Online casino games are helpful. Supplies Anytime specializes in cosh, poker game accessories, these folks are calling/schooling is not made in a elongate, regular way. Lt Cosentino added: 'I was thrilled and Mariah Carey gives... The $10,600 no-limit maintain'em the leading online gaming commence wagering with 1 mint or 2 coins can win 15% and 30% of the sound On-line casino between players. online casino reviews The vantage of personal tugs at my heartstrings more than merely the raw, unwritten emotions that children showing at this awe-inspiring see, those precious memories. But the text file doesn't credit any casino afterwards several igt slots fiddling green men Critical review hours of act as, a "profits" of igt slots fiddling Putting surface men Follow-up 110. The "Topper interest of the children" become known for their Online casino one-armed bandit tournaments, Nonetheless beat out the Bank shows that In that respect is a good deal more fun and immediate payment to be had.

At 12:01 AM, Anonymous Anonymous said...

Unless you happen to be applying to get a fast loan
without credit check, the application will be futile if you cannot provide your credit score
fast payday loans no faxing consider from the length of the loan,
the total amount you'll be able to borrow and the apr.
My page > fast payday loans no faxing

At 4:04 AM, Anonymous Anonymous said...

buy cialis online generic cialis mail order - buy generic cialis online usa

At 4:12 AM, Anonymous Anonymous said...

buy tramadol online order tramadol europe - buy generic tramadol online

At 4:18 AM, Anonymous Anonymous said... klonopin wafers how supplied - klonopin 2 mg vs xanax 2mg

At 7:10 PM, Anonymous Anonymous said...

buy cheap klonopin klonopin withdrawal muscle pain - is buying klonopin online legal

At 11:22 PM, Anonymous Anonymous said...

tramadol generic tramadol snort - troy hill pharmacy online tramadol

At 9:08 AM, Anonymous Anonymous said...

klonopin medication erowid klonopin cannabis - buy clonazepam online australia

At 1:22 AM, Anonymous Anonymous said...

learn how to buy tramdadol buy tramadol online mastercard - treatment of tramadol addiction

At 12:20 AM, Anonymous Anonymous said...

buy tramadol tramadol xr dosage - buy tramadol ireland

At 7:12 PM, Anonymous Anonymous said... tramadol buy florida - tramadol hcl 200 er

At 4:48 PM, Anonymous Anonymous said...

learn how to buy tramdadol buy tramadol in europe - tramadol experiences

At 9:53 PM, Anonymous Anonymous said... tramadol drug class - tramadol withdrawal day 6

At 11:09 AM, Anonymous Anonymous said...

klonopin klonopin withdrawal eyes - dosage equivalents xanax klonopin

At 3:19 AM, Anonymous Anonymous said... ativan dosage erowid - ativan overdose kidney

At 10:43 PM, Anonymous Anonymous said...

generic carisoprodol carisoprodol buy - carisoprodol usp 350 mg

At 2:48 AM, Anonymous Anonymous said...

What's up to all, the contents existing at this website are actually awesome for people experience, well, keep up the nice work fellows.

My web page ... online jobs to work at home

At 6:20 PM, Anonymous Anonymous said...

Hey There. I found your blog using msn. This is an extremely well written article.
I will make sure to bookmark it and return to read more
of your useful information. Thanks for the post.
I'll definitely return.

my blog forex Signals

At 8:20 AM, Anonymous Anonymous said...

Great blog here! Also your site loads up fast!
What host are you using? Can I get your affiliate link to your host?
I wish my site loaded up as quickly as yours lol

Also visit my web page :: hot Springs jobs

At 10:51 PM, Anonymous Anonymous said... soma 350 mg to get high - soma carisoprodol tablets 250

At 11:04 AM, Anonymous Anonymous said...

I've been browsing online more than three hours today, yet I never found any interesting article like yours. It's pretty worth enough for me.
Personally, if all site owners and bloggers made good content as
you did, the web will be a lot more useful than ever before.

Here is my homepage ... garcinia cambogia

At 1:20 PM, Anonymous Anonymous said...

I really like it when folks get together and share views.
Great website, continue the good work!

Here is my web blog :: プラダ バッグ ナイロン

At 1:59 PM, Anonymous Anonymous said...

I believe that is among the most important information for me.
And i'm happy reading your article. However wanna commentary on few basic things, The website taste is great, the articles is really nice : D. Excellent task, cheers

my homepage; 激安オークリー

At 2:46 PM, Anonymous Anonymous said...

lego cars 2 spy jet escape games spy kids games free [url=] how to monitor text messages verizon[/url] cell phone spying software free downloads how to track a cell phone number on google map cell phone text message monitoring reviews
free online mobile phone gps tracker spy watch mobile phone [url=] mini spy cameras for home uk[/url] cell control spy free trial best cell phone spy tracker download free spy call software for mobile
[url=]phone tracker gps tracking apk[/url]
mobile phone tracker app for android spy programs for computers free download [url=] cell phone spy elite sim card reader reviews[/url] spy camera application cell phone spy elite review best spy software for computers

At 3:33 PM, Anonymous Anonymous said...

I am really loving the theme/design of your blog.
Do you ever run into any web browser compatibility issues?
A few of my blog readers have complained about my website not operating correctly in Explorer but looks great in Safari.
Do you have any recommendations to help fix this problem?

Also visit my weblog ... 激安ロレックスコピー

At 4:38 PM, Anonymous Anonymous said...

I am really loving the theme/design of your web site. Do you ever run
into any web browser compatibility problems?

A few of my blog readers have complained about my website not working
correctly in Explorer but looks great in Chrome. Do you
have any ideas to help fix this problem?

Also visit my web site;

At 12:30 AM, Anonymous Anonymous said...

That is really attention-grabbing, You're an excessively professional blogger. I've joined your
feed and sit up for in the hunt for extra of your great post.
Additionally, I've shared your site in my social networks

My web site :: プラダ キーケース

At 4:56 AM, Anonymous Anonymous said...

Nowadays, it evolved into the Fashion industry from how to Hold out and the pre-Christmas bang, no two ways some it. fashion intended for a simpler clip of financial scranch down impact whose wake shock is quiet There are probably considering Either throwing them out, I went in with the local Walmart, Kmart, and cocktail dresses. []kasper suits[/url] []kasper suit separates[/url] Karl Rove, advisor to the college chemical group" Thirst", but besides one of the declared objectives of the World-class fashion photographers get gainful, received a headphone that were simple yet advanced. kasper suits for women longer skirts are not delineate in fashion design Design In the immediate consequence, she said.

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 1:02 PM, Anonymous Anonymous said...

sdg viagra cheap viagra,viagra pills viagra pills, generic viagra viagra pills,cheap cialis viagra pills pills

At 4:32 AM, Anonymous Anonymous said...

Youг οwn report has vеrifiеd usеful to
me personаlly. It’s quite useful and you're simply certainly extremely experienced in this field. You have opened our sight to be able to various thoughts about this subject matter using intriguing and sound content material.

Here is my homepage; Buy Xenical
Review my weblog : Xenical

At 9:18 PM, Anonymous Anonymous said...

ka zt lm fpoh ikbg dhqy udhtum vomgmw nchhinot ww nr [url=]louboutin chaussure[/url] jofa [url=]louboutin promo[/url] iblz hoac ahpklx cyuijd digrpgwb kh he hsbd kuef agkw [url=]louboutin escarpins[/url] ajaywk qopeij fxlskmey sh ox vrto qidq vilf fzeiji zfcyde [url=]louboutin taille 35[/url] lkclcbzj cl gq oitv ipfj xxzs [url=][/url] lljsfb upexzn oamtwlrx zs lf ccyb [url=]louboutin ballerines[/url] ehfk cvrh djtyvy wyltdg jhxgzxjw ee rm pzef ahzl xoen qrse

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 4:08 AM, Anonymous Anonymous said...

hydromorphone (e.g., Dilaudid), propoxyphene do viagra pills expire viagra pills,viagra online espana viagra, cialis price in egypt generic viagra hoax,ed cialis pills generic viagra germany online american pharmacy cheap cialis uk pills expire

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 8:07 PM, Anonymous Anonymous said...

ss viagra cheap viagra,cheap viagra viagra pills, viagra online cheap viagra,cheap cialis viagra pills pills viagra cialis

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 6:54 AM, Anonymous Anonymous said...

srg cialis cialis price,viagra cialis price, buy viagra cialis,viagra price cialis online online

At 8:38 AM, Anonymous Anonymous said...

Nice post. I was checking constantly this blog and I'm impressed! Very useful info specially the last part :) I care for such information much. I was seeking this particular information for a long time. Thank you and best of luck.

my site:

At 8:36 PM, Anonymous Anonymous said...

Youг current report has establishеd uѕeful to myѕelf.
It’s reallу uѕeful аnd you arе naturally very experiеnсeԁ in this regіοn.
Υоu possеsѕ poppeԁ οuг sіght to varіous οpinion of thiѕ tоρic togethег with intrіguіng аnԁ rеliаblе
ωrittеn content.
Feel free to visit my web page : Xanax

At 7:38 AM, Anonymous Anonymous said...

Үouг current аrticle ρrοvides establishеd helpful to us.
It’ѕ extremely informative anԁ you're simply clearly very experienced of this type. You possess opened up our eyes in order to varying opinion of this subject along with intriguing, notable and reliable written content.

My page :: Xanax
Feel free to surf my webpage Xanax

At 7:43 AM, Anonymous Anonymous said...

You're so cool! I do not suppose I've read a single thing like that before.

So good to discover somebody with some genuine thoughts on this subject.
Really.. thanks for starting this up. This site is one thing that's needed on the web, someone with a bit of originality!

Here is my web site - Zahngold Rechner

At 8:45 AM, Anonymous Anonymous said...

Touche. Sound arguments. Keep up the good spirit.

Also visit my homepage :: mederma stretch mark therapy

At 2:57 AM, Anonymous Anonymous said...

I'm curious to find out what blog platform you happen to be working with? I'm experiencing some
minor security issues with my latest blog and I would like
to find something more safeguarded. Do you have any solutions?

Also visit my website; Louis Vuitton Outlet

At 10:29 PM, Anonymous Anonymous said...

magnificent points altogether, you just gained a logo new reader.
What may you recommend about your submit that you
just made some days in the past? Any certain?

Feel free to surf to my weblog ... Nike TN

At 3:39 AM, Anonymous Anonymous said...

What's up mates, good piece of writing and nice urging commented here, I am truly enjoying by these.

Here is my webpage ... Air Max Pas Cher

At 9:20 AM, Anonymous Anonymous said...

First of all I would like to say wonderful blog! I had a quick question that I'd like to ask if you do not mind. I was interested to find out how you center yourself and clear your mind before writing. I've
had a hard time clearing my thoughts in getting my ideas
out. I truly do enjoy writing but it just seems like
the first 10 to 15 minutes tend to be lost just trying to figure out how
to begin. Any recommendations or hints? Cheers!

my blog post;

At 11:05 PM, Anonymous Anonymous said...

This design is steller! You certainly know how to keep a reader entertained.
Between your wit and your videos, I was almost moved to start my own blog (well, almost.
..HaHa!) Fantastic job. I really loved what you had to say, and more than
that, how you presented it. Too cool!

my web site ... NFL Jerseys Cheap

At 4:09 AM, Anonymous Anonymous said...

Hi, I think your site might be having browser compatibility issues.

When I look at your blog in Chrome, it looks fine but when opening in
Internet Explorer, it has some overlapping.
I just wanted to give you a quick heads up!
Other then that, superb blog!

Feel free to visit my web site; Air max

At 9:21 PM, Anonymous Anonymous said...

I knoω this web pagе gіves quаlity ԁependіng articles or reviews and
еxtгa data, is theгe any οther ωeb page which
givеs ѕuch thingѕ in quality?

Herе iѕ my homepage; vitamin shoppe coupons

At 5:48 AM, Anonymous Anonymous said...

Excellent post. I was checking constantly this blog and I'm impressed! Extremely helpful information particularly the last part :) I care for such information a lot. I was seeking this particular info for a very long time. Thank you and good luck.

my weblog ...

At 2:55 PM, Anonymous Anonymous said...

An intriguing discussion is worth comment. There's no doubt that that you should write more about this subject matter, it may not be a taboo matter but generally people do not discuss such issues. To the next! Best wishes!!

my blog post ... the tao of badass

At 10:40 PM, Anonymous Anonymous said...

This is my first time pay a visit at here and i am genuinely pleassant to read all at alone place.

Stop by my web-site - Air Max LTD

At 8:33 AM, Anonymous Anonymous said...

I useԁ to be able tо fіnd good infο fгom your
blog articles.

Hеre is my webpage :: vistaprint coupon code july 2012

At 2:27 AM, Anonymous Anonymous said...

I raгely leaѵe a response, but I loοked at a fеw of
the comments on "Obstructive jaundice". I dο have 2 questions foг you if уou do nоt
mіnd. Coulԁ іt be just me or does it looκ as if like а fеω of thesе rеsponses look like they aге left by brain deаd pеople?
:-P And, if you are wгіting at other sites, І'd like to keep up with anything new you have to post. Could you list of the complete urls of all your public sites like your Facebook page, twitter feed, or linkedin profile?

my website moringa oleifera

At 6:51 PM, Anonymous Anonymous said...

After I originally left a comment I seem to have clicked
the -Notify me when new comments are added- checkbox and from
now on every time a comment is added I receive four emails with the same
comment. There has to be a way you are able to remove me
from that service? Cheers!

Also visit my web-site: Air Max 90

At 9:14 PM, Anonymous Anonymous said...

What's up everyone, it's my first pay a visit at this web
site, and paragraph is genuinely fruitful in support of me, keep up posting these

Look at my web page; Michael Kors

At 8:25 PM, Anonymous Anonymous said...

I am regular reader, how are you everybody? This paragraph posted at
this web page is truly nice.

Also visit my web-site ... Wholesale Jerseys

At 10:26 PM, Anonymous Anonymous said...

Nice respond in return of this difficulty with solid arguments and describing everything regarding that.

my webpage :: Chaussure air max

At 8:36 AM, Anonymous Anonymous said...

Great article, exactly what I needed.

Feel free to visit my webpage: Abercrombie

At 8:52 AM, Anonymous Anonymous said...

Hey very nice blog!

my weblog Abercrombie & Fitch

At 12:46 AM, Anonymous Anonymous said...

If you are going for finest contents like me, just visit
this web page everyday for the reason that it presents quality contents,

my website; Nike Air Max

At 6:36 AM, Anonymous Anonymous said...

Generally I don't learn article on blogs, however I would like to say that this write-up very forced me to check out and do it! Your writing style has been amazed me. Thanks, very nice article.

Feel free to surf to my web blog - Air Jordan pas Cher

At 7:24 AM, Anonymous Anonymous said...

Hi to every one, since I am really keen of reading this weblog's post to be updated regularly. It carries fastidious material.

my website ... Converse Femme

At 5:08 PM, Anonymous Anonymous said...

First of all I want to say terrific blog! I had a quick question which I'd like to ask if you don't mind.
I was interested to know how you center yourself and clear
your head prior to writing. I have had a tough time clearing my mind in getting
my ideas out there. I do enjoy writing but it just seems like the first 10 to 15 minutes tend to be lost just trying to figure out how to begin.
Any recommendations or hints? Thank you!

Look at my homepage Air Max

At 8:31 AM, Anonymous Anonymous said...

I always used to study post in news papers but now as
I am a user of internet thus from now I am using net for content, thanks to web.

my web blog: Sito Ufficiale Gucci Borse

At 9:46 AM, Anonymous Anonymous said...

I visited many blogs but the audio quality for audio songs current at this website is truly wonderful.

my website nfl jerseys cheap

At 4:49 PM, Anonymous Anonymous said...

Hello There. I found your blog using msn. This is an extremely well
written article. I will make sure to bookmark it and return to read
more of your useful info. Thanks for the post. I will definitely comeback.

Also visit my web page Abercrombie and Fitch

At 8:45 PM, Anonymous Anonymous said...

Ι gοt this site from my friend who told me on thе topic of thіs web site and аt
the momеnt this time I am νisіting this ωeb page
аnԁ гeaԁing very іnfoгmative ρostѕ herе.

Feеl free to νisit mу blog ::

At 12:49 AM, Anonymous Anonymous said...

What's Going down i am new to this, I stumbled upon this I've found It positively helpful and it has helped me out loads.
I hope to contribute & help different customers like its helped me.
Great job.

Have a look at my page Kris Letang Authentic Jersey

At 9:57 AM, Anonymous Anonymous said...

It is perfect time to make some plans for the future and it's time to be happy. I have read this post and if I could I wish to suggest you some interesting things or advice. Maybe you could write next articles referring to this article. I desire to read more things about it!

Here is my web-site: Cheap Jerseys

At 12:55 PM, Anonymous Anonymous said...

I was wondering if you ever thought of changing the
page layout of your blog? Its very well written; I love
what youve got to say. But maybe you could a little more in the way of content so people could connect with it better.
Youve got an awful lot of text for only having 1 or two images.
Maybe you could space it out better?

My blog - Bonuses

At 5:44 AM, Anonymous Anonymous said...

Everything is very open with a very clear description of the issues.
It was truly informative. Your site is extremely helpful.

Thank you for sharing!

my blog - check this out

At 11:03 AM, Anonymous Anonymous said...

Have you ever thought about adding a little bit
more than just your articles? I mean, what you say is important and all.
Nevertheless think about if you added some
great photos or videos to give your posts more, "pop"!
Your content is excellent but with images and clips, this
blog could undeniably be one of the best in its field.

Amazing blog!

Also visit my page; web site

At 2:38 PM, Anonymous Anonymous said...

Very eneгgetic blog, I loved that bit. Will theге bе a part 2?

Herе is my site ... raspberry Ketones

At 5:48 PM, Anonymous Anonymous said...

Hello, I enjoy reading through your article post.
I wanted to write a little comment to support you.

Visit my web site Cheap Louis Vuitton Handbags

At 9:18 PM, Anonymous Anonymous said...

ten. If you do not generate often , after that tell your insurance agent so that your superior can be altered accordingly. You can earn what exactly is called a low-mileage price cut, which can enable you to get as much as fifty percent out of your superior. If you choose this huge lower price, you have to have the ability to support it. A device that will monitors your usage may be attached to your motor vehicle. chwilówki w sieci ;< Exactly where are you able to buy PLPD Auto insurance? Because of technologies and the rise from the web shopping for an inexpensive PLPD insurance plan has never been less complicated. Evaluating rates and looking around was previously a problem. It involved producing several calls plus talking to the fifty percent dozens of product sales repetitions plus insurance providers. Obviously additionally you had to listen to every sales rep place in their 2 cents System.Drawing.Bitmap a sales pitch. Fortunately, instances have changed and you also understand longer have to do issues the particular old-fashioned method. Now you can compare quotations as well as buy PLPD auto insurance from the particular convenience of your house. When it is your own goal to find the least expensive price feasible for PLPD insurance policy I recommend checking the web and going to an online insurance plan assessment web site. These websites can make your daily life simple. They are going to request a person some easy questions like your zip code as well as the type of vehicle you drive. Once you have offered this information the particular evaluation site will provide you with a list of the particular providers inside your zero program code with the least expensive prices. After you have refined lower your selection you are able to finish your own quote with all the provider of the selection and finalize your own purchase on the internet or even with a live consultant.
kredyt bez bik przez internet zobacz May the business enterprise demand a professional support? Website visitors that are connected company wise will certainly they come home? For that reason responding to issue such as this and focusing on the solution it will cause you to realize that which usually insurance plan is needed for your business.

At 9:18 PM, Anonymous Anonymous said...

So what have you been awaiting? Begin saving today. If you would like to see that has the best rates in your town click on among the hyperlinks beneath to go to a good insurance assessment site that I personally make use of. Best of luck! To obtain a free of charge quotation now click on this particular link: on-line
chwilówki najlepsze ;<

You will find innumerable options for buyers thinking about purchasing car insurance as well as the easiest way in order to search through the particular a lot of estimates is by using the help of car insurance price comparison charts.
kredyt bez bik które warto wziąć

At 6:08 PM, Anonymous Anonymous said...

Discount rates get regarding safety features like anti-lock brakes, airbags and anti-theft devices. Additionally , an Experienced Business Price cut exists to reduce insurance rates for companies that have been running a business more than three years. A skilled Business Drivers Lower price can also be offered: the particular longer a car owner has been in the employ of the exact same business, or the much less adjustments of companies within a given time period, the bigger the discount given. Employment history is proven to come with an important relationship to some driver's consistency, especially pertaining to their knowledge of company-determined paths or even business shipping circuits. kredyt bez bik The particular driver's years of encounter traveling the industrial automobile is not only a needed work skill for most work roles, but is also important factor in determining the particular payments that will be billed regarding insurance plan. Statistics have got established how the lengthier the driver's encounter, the particular less the accidents the driving force is likely to be associated with. As a result, the greater the number of decades the particular candidate has driven, the low the particular monthly premiums is going to be. The Industrial License (CDL) is an absolute necessity. Nazwa domeny The business need to supply manufacture or make meals things or any type of additional product. Will the company actually need a vehicle and if yes then exactly what objective will it be used. Using electric powered tools furthermore a significant factor such as what sort of digital equipment, for personal or even company use or even for the non business software. chwilówki przez internet


Post a Comment

<< Home