Critical appraisal of therapeutic endoscopy in biliary tract diseases.

Endoscopic treatment (by sphincterotomy) is now the preferred method for patients with retained or recurrent bile duct stones after surgery. It is also applicable to many acutely ill or high-risk patients who have not undergone cholecystectomy. Endoscopic stenting is preferable to the percutaneous transhepatic method for palliation of malignant biliary obstruction in patients unfit or unsuitable for surgery.

Endoscopic treatment of a bile duct stone containing a surgical staple.

We report a case of a pigmented gallstone which formed around a surgical staple in the bile duct. The stone was removed and retrieved endoscopically. A brief review of bile duct foreign bodies and gallstones is presented.

A comparison of right versus left hepatic duct endoprosthesis insertion in malignant hilar biliary obstruction.

Endoscopic endoprosthesis insertion plays an increasingly important role in the palliation of jaundice in patients with unresectable malignant hilar biliary obstruction (HBO). Drainage of both obstructed lobes in Types II and III HBO is not necessary to achieve adequate palliation, providing 25% of the liver volume is drained by a single endoprosthesis. The anatomy of the main hepatic ducts suggests some benefit may accrue from preferential drainage of the left hepatic duct.

Lithotripsy for bile duct stones.

Fragmentation of bile duct stones by mechanical, electrohydraulic, and laser intraluminal lithotripsy has greatly facilitated the ability to remove stones that are otherwise difficult to remove by standard manipulative techniques. Even these approaches fail when stones lack access or are impacted within the biliary tree. Extracorporeal shock-wave lithotripsy (ESWL) was evaluated in the United States in a multicenter trial with 56 patients.

Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization.

Transcatheter embolization is a well-established and effective method for the control of bleeding from the upper gastrointestinal tract and often represents the preferred alternative to more invasive surgical management. The applications of this technique for the management of bleeding following endoscopic sphincterotomy have not been reported previously. Of five patients referred for arteriography with life-threatening postsphincterotomy bleeding, active bleeding from branches of the gastroduodenal artery was demonstrated in four.

Is duodenal diverticulum a risk factor for sphincterotomy?

It is uncertain whether ERCP and associated procedures are more difficult when the papilla is inside or adjacent to a duodenal diverticulum. We have therefore reviewed the data from 2458 consecutive, prospectively reported ERCPs between November 1983 and March 1988. Three hundred and eight patients (12.

Extracorporeal shock-wave lithotripsy of bile duct calculi. An interim report of the Dornier U.S. Bile Duct Lithotripsy Prospective Study.

A multi-institutional study to evaluate the efficacy, clinical application, and safety of extracorporeal shock-wave lithotripsy (ESWL) with the Dornier HM-3 or HM-4 lithotripter for bile duct calculi (BDC) was initiated in September, 1987. Symptomatic patients who entered into this prospective trial had BDC in the common bile duct and/or the intrahepatic, cystic or lobar ducts of the liver that were inaccessible or untreatable by papillotomy or percutaneous stone extraction. The study excluded gallbladder stones.

Nonsurgical palliation of jaundice in pancreatic cancer.

The endoscopic approach to biliary drainage came late on the scene; some of the published results reflect early experience with inadequate techniques. Now it is clear that the endoscopic approach is preferable to the percutaneous method. When palliation of jaundice is required (in a patient without impending duodenal obstruction), there is a simple choice between surgical bypass or endoscopic stenting.

Endoscopic therapy of the sump syndrome.

Seventeen consecutive patients with the sump syndrome were treated at the Middlesex Hospital between November 1983 and December 1987. Fifteen were treated primarily by endoscopic sphincterotomy and two primarily by resective surgery because of coincident severe painful chronic pancreatitis. Endoscopic sump clearance was successful in thirteen out of fifteen cases (87%) with no morbidity or mortality.

Endoscopic biliary therapy using the combined percutaneous and endoscopic technique.

Between September 1985 and December 1987, 74 patients underwent attempted endoscopic biliary therapy using a combined percutaneous transhepatic and endoscopic transpapillary approach (combined procedure). All patients had had failed endoscopy-alone procedures and had contraindications to surgery. The indication was palliation of malignant biliary obstruction in 66 cases (41 common bile duct, 25 hilar), assistance with sphincterotomy for the removal of common bile duct stones in 6 cases, and management of benign biliary stenosis in 2 cases.

Additional endoscopic procedures instead of urgent surgery for retained common bile duct stones.

One hundred and twenty seven patients were treated by nasobiliary drainage, or stenting, to prevent biliary obstruction after endoscopic failure to clear stones from the common bile duct. At presentation, 91 (72%) patients were jaundiced and 39 (31%) had cholangitis. Placement of either a nasobiliary drain or stent was successful in 124 (98%) patients.

Pancreatic duct dilatation after secretin stimulation in patients with pancreas divisum.

Pancreas divisum is the most common anatomical variant of pancreatic ductal anatomy. It has been suggested that obstruction at the accessory papilla in subjects with pancreas divisum can be assessed by measurement of ductal diameter by ultrasonic examination after a maximal secretory stimulus with i.v.

Obstructive pancreatitis: unusual causes of chronic pancreatitis.

Fifty-eight consecutive surgical pancreatic resections for chronic pancreatitis were examined. Eight cases were identified with obstructive pancreatopathy; all underwent pancreato-duodenectomy. Histological examination revealed that obstruction in three cases was due to duodenal wall cysts, and in two patients it was associated with pancreas divisum (the accessory papilla was obstructed by a neuroendocrine tumour in one case and by ectopic pancreatic tissue in the other).

Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge.

To assess whether the use of large stents is justified, we have retrospectively reviewed the results of 8 French gauge (FG) stents with pigtails and 10 FG straight stents in the palliation of biliary obstruction due to malignancy. The incidence of cholangitis following stent insertion was significantly lower with 10 FG stents, 3 (5%), compared with 8 FG stents, 13 (34%), p less than 0.001, chi 2.

Papillotomy and functional disorders of the sphincter of Oddi.

The term "functional" as applied to disorders of the sphincter of Oddi is indefinite since it encompasses a spectrum of disorders from histopathologic fibrosis of the sphincter to sphincteric dysfunction without evident pathologic transformation. Although there are several approaches to the diagnosis of sphincter of Oddi dysfunction, the diagnosis still depends on the exclusion of other causes of obstruction. Reports of surgical sphincteroplasty in patients with this diagnosis suggest that the outcome is unpredictable.

Modified dual label Schilling test for pancreatic exocrine function.

The modified dual-label Schilling test, as further developed in kit form by Amersham International plc (UK), has been assessed in two separate centres. Since the outcome was similar in each centre, the results in 66 subjects were amalgamated. Using a cut-off point for the 58Co/57Co ratio of 0.

Biliary stent blockage with bacterial biofilm. A light and electron microscopy study.

Clogging of endoscopic stents necessitates their replacement in many patients with malignant obstructive jaundice and limits their use in benign strictures. We studied the basic mechanism of clogging to find ways to prevent it. We did light and electron microscopy studies of blocked and functioning stents, which were prepared so that organic structures would be preserved.

Total pancreatectomy for chronic pancreatitis.

The operation of total pancreatectomy is performed rarely. Its role in the management of patients with chronic pancreatitis remains to be elucidated. We have reviewed our series of 29 total pancreatectomies for benign disease [14 women median age 39 years; 15 men median age 34 years].