Single-operator cholangioscopy is useful for visual assessment of bile duct pathology.

INTRODUCTION: Single-operator cholangioscopy (SOC) is increasingly used for evaluation of the biliary tree following endoscopic retrograde cholangiopancreaticography (ERCP). This study aimed to determine the visual and histological success rates of SOC at a single Danish tertiary referral centre. METHODS: All patients undergoing SOC between 2008 and 2015 were retrospectively included from a prospectively maintained database. Patient characteristics and proced-ure-related variables were obtained from medical records. A visual and a histological success rate were determined according to predefined criteria. RESULTS: In total, 54 patients underwent SOC, most often due to suspicion of malignancy (n = 53; 98%). In one case, access to the common bile duct failed, and in six cases malignant disease was missed. Thus, the cholangioscopies were successful in 47 of 54 procedures corresponding to a visual success rate of 87%. Nine patients (17%) had a mean of 1.3 ± 1.0 SOC-guided biopsies taken. The extracted tissue was inadequate for histological evaluation in seven of nine cases, corres-pond-ing to a histological success rate of 22% (two out of nine tissue samples were eligible for histological diagnosis). CONCLUSIONS: Considering the reasonable visual success rate, SOC seems to be a useful extension of ERCP during diagnostic work-up for detection of malignant disease in the biliary tree. However, one biopsy per patient is insufficient for histological verification of common bile duct malignancy. TRIAL REGISTRATION: The Danish Health Authority (3-3013-1299/1) and The Danish Data Protection Agency (RH-2015-229). FUNDING: none.

One-day diagnosis for hepatobiliary and pancreatic lesions: An innovative patient-centered care pathway organization.

OBJECTIVE: Reducing the time required for diagnosis is one of the major challenges to improving and accelerating the management of patients. The aim of this work is to describe an organizational innovation in the management of patients with hepatobiliary or pancreatic diseases, and to report the initial results. MATERIALS AND METHODS: A multidisciplinary and multi-professional working group designed and instituted a patient-centered organizational system that optimizes the investigation of liver and pancreatic diseases, in order to achieve diagnosis in one day. From January 2017 to June 2017, all patients referred for consultation for hepatobiliary or pancreatic pathology were included in this new management pathway. Data were collected prospectively in a standardized form. RESULTS: Fifty-six patients with hepatobiliary or pancreatic disease were evaluated in the program during dedicated slots over a total of 20 days. Of these, four patients underwent evaluation in the program twice. The average number of patient slots in the program was three per day (range: 1-5). An additional computed tomography (CT) and/or magnetic resonance imaging (MRI) was required in 23 (41.7%) of the visits. These imaging studies were performed the same day, including nine patients who required both types of imaging (16.7% of cases). "One-day diagnosis" established an accurate diagnosis by the end of the day in 49 patient encounters (81.7%). Overall assessment of this organization was considered excellent by 46 (83%) of patients. CONCLUSION: An organizational innovation has made it possible to effectively diagnose hepatobiliary or pancreatic pathology within one day in the majority of cases, with good patient satisfaction. It is now necessary to evaluate the medico-economic aspect of this organization, and more generally to develop a methodology for multidimensional evaluation of organizational innovations.

Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013.

BACKGROUND AND AIMS: Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States. METHODS: We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures. RESULTS: Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures has increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals. CONCLUSIONS: Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of the increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Large urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

Pancreaticobiliary Juice Reflux in Patients With a Morphologically Normal Ductal System: Assessment Using Unenhanced MRI With Spin Labeling.

OBJECTIVE: The purpose of this article is to evaluate pancreaticobiliary reflux and to assess its correlation with clinical findings in patients without morphologic pancreaticobiliary maljunction by using a new MRI technique. MATERIALS AND METHODS: A total of 320 consecutive patients with suspected pancreaticobiliary diseases underwent MRCP and flow analysis by MRI. MRI flow analysis, clinical, and laboratory findings of each patient were retrospectively reviewed. The visible pancreaticobiliary reflux was graded on a 5-point confidence scale. RESULTS: Among all 320 patients with pancreatic juice reflux, 14.1% had reflux scored as grades 4 and 5 combined, and 5.0% had reflux scored as grade 5. By univariate analysis and multivariate analysis, a relatively long common channel was found to be the only significant causal factor for pancreatic juice reflux. Of patients with pancreatic juice reflux of grade 4 or 5, 11.1% (5/45) also had biliary malignancies; 18.8% (3/16) of those with pancreatic juice reflux of grade 5 had biliary malignancies. Conversely, pancreatic juice reflux of grade 4 or 5 occurred in 35.7% (5/14) of patients with biliary malignancies, and reflux of grade 5 occurred in 21.4% (3/14) of those patients. CONCLUSION: It was possible to evaluate pancreaticobiliary reflux using an MRI technique that may be suitable as a screening tool. Our results revealed that pancreaticobiliary reflux is relatively frequent in individuals without pancreaticobiliary maljunction.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view.

INTRODUCTION: Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear. METHODS: Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost. RESULTS: Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs. CONCLUSION: Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Ultrasonography assessment of hepatobiliary abnormalities in 3359 subjects with Opisthorchis viverrini infection in endemic areas of Thailand.

A cross sectional study on hepatobiliary abnormalities in opisthorchiasis was performed in 8936 males and females aged from 20 to 60 years from 90 villages of Khon Kaen province, Northeast Thailand. All were stool-examined for Opisthorchis viverrini infection by standard quantitative formalin/ethyl acetate concentration technique. Of these, 3359 participants with stool egg positive underwent ultrasonography of the upper abdomen. The hepatobiliary abnormalities detected by ultrasound are described here. This study found a significantly higher frequency of advanced periductal fibrosis in persons with chronic opisthorchiasis (23.6%), particularly in males. Risks of the fibrosis included intensity of infection, and age younger than 30 years. Height of left lobe of the liver, cross-section of the gallbladder dimensions post fatty meal, sludge, and, interestingly, intrahepatic duct stones were significantly associated with the advanced periductal fibrosis. Eleven suspected cholangiocarcinoma (CCA) cases were observed. This study emphasizes the current status of high O. viverrini infection rate and the existence of hepatobiliary abnormalities including suspected CCA in opisthorchiasis endemic areas of Thailand.

Sonographic assessment of ceftriaxone-associated biliary pseudolithiasis in Chinese children.

In this randomized, single-blind, case-controlled, prospective study, the incidence and outcome of ceftriaxone-associated biliary pseudolithiasis in Chinese children was evaluated via ultrasonography. A total of 108 children diagnosed with hepatobiliary infection or pneumonia were randomized to receive ceftriaxone or ceftazidime. Serial gallbladder sonograms were obtained on days 1, 5 - 7 and 10 - 14 of therapy. Gallstones were detected in 43.10% of patients in the ceftriaxone-treated group and in 2.00% of the ceftazidime-treated group. The incidence of pseudolithiasis was significantly higher in the ceftriaxone-treated than the ceftazidime-treated group. Biliary precipitation abnormalities appeared after 2 - 7 days of treatment. After gallstones were found, the drug was stopped and symptoms resolved within 1 - 2 days. This study suggests that the risk of ceftriaxone-associated biliary pseudolithiasis should be considered when treating Chinese children.

Clinicians' attitudes towards endoscopic ultrasound: a survey of four European countries.

OBJECTIVE: Despite the documented effectiveness of endoscopic ultrasound (EUS) in research studies, data on the utilization of this technology in clinical practice are scarce. The aim of this study was to assess EUS availability and accessibility as well as EUS utilization among clinicians from different European countries. MATERIAL AND METHODS: A direct mail survey was sent to members of the national gastroenterological associations in Sweden, Norway, Greece, and the United Kingdom. RESULTS: Out of 2361 clinicians with valid addresses, 593 (25.1%) responded. Overall, EUS was available to 43% of clinicians within their practice but availability varied from 23% in Greece to 56% in the United Kingdom. More than 50% of respondents evaluating patients with esophageal cancer, rectal cancer, or pancreaticobiliary disorders had utilized EUS during the previous year, but utilization varied considerably among different countries, being more frequent in the United Kingdom. In logistic regression analyses, factors independently related to EUS utilization were mainly EUS availability and accessibility as well as perceived utility of EUS (p <0.05 for all). Respondents considered the lack of trained endosonographers (79%) and high cost (52%) as the main barriers to wider EUS use. CONCLUSIONS: The majority of responding clinicians use EUS but overall utilization varies considerably among different countries. There is considerable variation in EUS service availability and accessibility among countries which, together with perceived usefulness of EUS, is a major determinant of EUS utilization. A shortage of trained endosonographers and the high cost are major barriers to wider EUS use. The findings of this study might help to define policies aimed at development of EUS services.

Update on 3D and multiplanar MDCT in the assessment of biliary and pancreatic pathology.

The development of multidetector row computed tomography (MDCT) has led to the acquisition of true isotropic voxels that can be postprocessed to yield images in any plane of the same resolution as the original axially acquired images. This, coupled with rapid MDCT imaging during peak target organ enhancement has led to a variety of means to review imaging information beyond that of the axial perspective. Postprocessing can be utilized to identify variant biliary anatomy to guide preoperative planning of biliary-related surgery, determine the level and cause of biliary obstruction and assist in staging of biliary cancer. Postprocessing can also be used to identify pancreatic ductal variants, visualize diagnostic features of pancreatic cystic lesions, diagnose and stage pancreatic cancer, and differentiate pancreatic from peripancreatic disease.

Prospective, randomized comparison of mechanical and electronic radial endoscopic ultrasound systems: assessment of performance parameters and image quality.

OBJECTIVE: Implementation of electronic image technology in endoscopic ultrasonography (EUS) should improve image quality, but systematic data are scarce. The purpose of this study was to compare the image quality and performance of an electronic and a mechanical radial echoendoscope. MATERIAL AND METHODS: Eighty consecutive patients (42 M, mean age 56 years) in a tertiary referral center, without gross pathology (advanced tumors excluded), were prospectively randomized to EUS with the mechanical or electronic echoendoscope. Images from five standardized positions (pancreatobiliary and upper gastrointestinal (GI) tract) were taken by two examiners of differing experience. Time to acquire images was noted. Penetration depth was also measured. Image quality variables (overall quality, contrast, and structure discrimination) were assessed blindly on the basis of randomly shuffled images during three independent evaluations by the same experienced examiner (mean values were taken), using a visual analogue scale (VAS) from 1 (excellent) to 10 (inadequate). RESULTS: Time needed to achieve visualization of the distal common bile duct (CBD) was significantly shorter with the electronic scope (49.7+/-8.6 versus 97.4+/-8.5 s; p<0.001). Image quality with the electronic scope was rated significantly better for all variables assessed, whereas EUS penetration depth was similar in both groups. There were no differences in examiner experience. CONCLUSIONS: Electronic EUS provided better quality images according to the examiner's subjective assessment. An objective advantage was faster identification of the distal CBD.

Ultrasonographic and spiral CT evaluation of simple and complicated acute cholecystitis: diagnostic protocol assessment based on personal experience and review of the literature.

PURPOSE: The aim of this study was to identify and classify the ultrasonographic and computed tomography (CT) signs of simple and complicated acute cholecystitis and to define the correct diagnostic protocol. MATERIALS AND METHODS: We retrospectively reviewed 35 patients (23 men and 12 women; mean age 66.6 years) presenting with acute cholecystitis who were assessed by emergency ultrasonography (US) (30/35 cases) and spiral CT (12/35 cases); all patients underwent emergency surgery. The US signs were analysed and classified as major criteria (wall thickening and stratification, distension, Murphy's sign), minor criteria (bile stones, sludge, and biliary tract dilatation), and complication signs (gas collections, aerobilia, fluid collection, difficult or missed identification of the gallbladder). Imaging results were compared with histological findings (gold standard), and accuracy, sensitivity, specificity, and positive and negative predictive values (PPVs and NPVs) were assessed for each modality. Concordance between the US and CT findings was also evaluated for cases undergoing both examinations; additional findings provided by one or the other modality were also assessed. RESULTS: US had an accuracy of 66.6%, a sensitivity of 37.5%, a specificity of 70%, a PPV of 100%, and an NPV of 58.3%. CT had 100% accuracy, sensitivity, and specificity. Concordance between US and CT was observed for diagnosis of complications, but CT provided additional findings in all cases. The majority of complicated cases undergoing US examination (68.7%) revealed more than two major criteria and one minor criterion or at least one sign of complication. CONCLUSIONS: If more than two major signs associated with one minor sign or at least one sign of complication are present at US, CT is mandatory to recognise and thoroughly evaluate the type of complication and indicate appropriate treatment.

Preoperative assessment of the aberrant bile duct using multislice computed tomography cholangiography.

BACKGROUND: This study aimed to determine the frequency of anatomic variations of bile ducts (aberrant bile ducts) using multislice helical computed tomography (MCT) cholangiography. METHODS: MCT scanning was performed after slow infusion of 100 mL meglumine iotroxate. Overlapping axial images, taken at 0.5-mm intervals, were reconstructed to create a multiplanar reconstruction with volume rendering. We analyzed anatomical variations of the biliary tree by MCT cholangiography. RESULTS: In a total of 113 patients, MCT cholangiography provided clear images of aberrant bile ducts in 18 patients. Major type (draining a particular segment of the liver) was found in 9 cases (8%) and minor type (draining a particular subsegment of the liver) in 9 cases (8%). CONCLUSIONS: Preoperative MCT cholangiography provides important information about the precise biliary anatomy and can reveal unexpected aberrant bile ducts prior to biliary surgery, especially laparoscopic cholecystectomy.

MR and ultrasound in screening of patients with suspected biliary tract disease.

PURPOSE: The diagnostic value and cost-efficiency of MR imaging were compared with US before endoscopic retrograde cholangiopancreatography (ERCP) in patients with clinically suspected biliary tract disease. MATERIAL AND METHODS: In a prospective study of 219 patients, 85 were examined with both MR and US before ERCP. RESULTS: To find the correct diagnosis in the jaundiced patients the sensitivity of US, MR and ERCP was 53%, 93%, and 89%, respectively. In the patients with abdominal upper quadrant pain and normal serum bilirubin, the sensitivity of US, MR and ERCP was 50%, 100% and 70%, respectively. Examination with MR costs four times more than US. Screening with US and supplemental MR in non-diagnostic cases would cost 80% of the total amount compared to screening with MR only. CONCLUSION: MR had a higher sensitivity than US for diagnosing biliary tract disease and MR was superior to US in visualising stones in the common bile duct and in diagnosing the cause of cholestasis. However, screening with US and supplemental MR in non-diagnostic cases is at present most cost-effective. With increased accessibility and slightly lower costs, MR will probably replace US as screening method in patients with suspected biliary tract disease.

Prospective assessment of magnetic resonance cholangiopancreatography for noninvasive imaging of the biliary tree.

BACKGROUND: Traditionally, ERCP has been the only reliable method for imaging the biliary tree, but it is invasive and carries a risk of complications. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for imaging the biliary tree. The aim of this study was to prospectively assess the accuracy of MRCP in a large number of patients. METHODS: Consecutive patients referred to a teaching hospital for ERCP were eligible for study entry. MRCP was performed within 24 hours before ERCP. MRCP findings were compared with ERCP findings or, when the initial ERCP was unsuccessful, with results of repeat ERCP, percutaneous transhepatic cholangiography, or surgery. RESULTS: One hundred forty-six patients underwent 149 ERCP/MRCP procedures, of which 129 were evaluable with successful MRCP and ERCP or an ERCP-equivalent study. Diagnoses included choledocholithiasis in 46 and biliary stricture in 12 patients. The sensitivity, specificity, positive, and negative predictive values for MRCP in the diagnosis of choledocholithiasis were 97.9%, 89.0%, 83.6%, and 98.6%, respectively. All 12 strictures were diagnosed by MRCP (sensitivity 100%, specificity 99.1%). CONCLUSIONS: MRCP is an accurate, noninvasive alternative to ERCP for imaging the biliary tree. Choledocholithiasis and biliary strictures can be reliably diagnosed or excluded by MRCP. MRCP should be used increasingly in patients with suspected biliary obstruction to select those who require a therapeutic procedure.

Feasibility of an ultrasound service on district health care level in Botswana.

OBJECTIVE: To assess the clinical benefit and financial feasibility of an ultrasound service in a district hospital in Botswana. METHOD: An ultrasound service was established in the study hospital. Clinical and ultrasound-aided diagnoses were compared in patients who met eligibility criteria laid down in an indication list. RESULTS: We enrolled 2309 patients over 18 months. The most frequent indications for ultrasound were pregnancy-related diagnoses followed by gynaecological and hepato-biliary disorders. Ultrasound assistance improved case management in 696 cases (30%) and led to an immediate change in management in 151 patients. Ultrasound diagnosis was used as gold standard to assess the accuracy of the clinical diagnosis of incomplete abortion (sensitivity 24%; positive predictive value, PPV 66%), pelvic mass (sensitivity 53%; PPV 69%), ectopic pregnancy (sensitivity 75%; PPV 28%), and gall bladder stones (sensitivity 30%; PPV 32%). CONCLUSIONS: Ultrasound improved case management for a wide diversity of clinical problems encountered on district health care level. The service proved to be affordable for the Botswana health care system.

Assessment of biliary bicarbonate secretion in humans by positron emission tomography.

BACKGROUND & AIMS: Positron emission tomography (PET) allows imaging and quantitative analysis of organ functions in basal and stimulated conditions. We have applied this method to the study of biliary bicarbonate secretion in humans. METHODS: PET was performed in 5 healthy subjects and 13 patients with hepatobiliary disorders after intravenous injection of NaH11CO3. In each case the study was performed in basal conditions and after secretin stimulation. Positron emission from the hepatic area was scanned, and normalized uptake values for parenchymal and hilar regions were estimated. RESULTS: In healthy individuals, the injection of NaH11CO3 resulted in a peak uptake of the label in parenchymal and hilar regions 2-3 minutes after the injection. In both normal and cirrhotic subjects, secretin administration increased bicarbonate uptake in the parenchymal region, followed by accumulation of the label in the perihilar area. Normal basal uptake with absent response to secretin was registered in extrahepatic biliary obstruction and in untreated primary biliary cirrhosis (PBC). The secretin response was present in patients with PBC undergoing treatment with ursodeoxycholic acid. CONCLUSIONS: PET allows investigation of biliary bicarbonate secretion in humans. An impaired response to secretin was observed in cholestatic conditions. Preliminary data suggest that ursodeoxycholic acid might improve the response to secretin in PBC.

25 years of endoscopic sphincterotomy in Erlangen: assessment of the experience in 3498 patients.

BACKGROUND AND STUDY AIMS: The aim of the study was to investigate the evolution of endoscopic sphincterotomy (EST) over a period of 25 years at its birthplace in Erlangen, Germany. PATIENTS AND METHODS: A total of 3498 consecutive ESTs between 1973 and the end of 1997 were reviewed with respect to indications, technology, success, complications, therapy of complications and mortality. In order to demonstrate changes in the course of time, the results have been compiled separately for four time periods (A-D). RESULTS: During the 25 years' practice of EST in Erlangen the frequency of ETSs has increased constantly and significant changes have been observed concerning the spectrum of indications: Bile duct stones (total 55.1%) decreased continuously from 91.1% (period A) to 35.7% (period D). In contrast, the proportion of ESTs applied for malignant obstruction (total 22.1%) rose successively from 1.1% (period A) to more than 25% (periods B-D). Chronic pancreatitis as an indication for EST was established in period B (1.0%) and accounted for 20.2% of all procedures in period D (total 8.0%). Several new indications (summarized as "others") increased from 1.8% in period A to 11.9% in period D (total 6.7%) whereas biliary pancreatitis and scarred papillary stenosis remained constantly below 5%. Whereas the "Erlangen sphincterotome" was the only sphincterotome used in period A, it was almost completely replaced by guide-wire sphincterotomes in period D. With the introduction of the needle knife the precut technique became popular and was used with increasing frequencies: period B 31.9%, period C 34.1%, period D 41.9%. The success rate in total was 95.2%. For each time period the highest success rate of EST was obtained for bile duct stones (96-98%), whereas EST appeared to be more difficult in case of malignant obstruction (93.3%) or chronic pancreatitis (90.2%), but for both indications growing experience resulted in an increase in the success rates (85.7% to 94.9% and 90.9% to 94.0%, respectively). Complications occurred in 7.9% of cases. The complication rate declined significantly from 10.5% in period A over 7.6% in period B to 6.3% in period C. Prospective data acquisition in period D revealed a significant increase in the detection of mild forms of acute pancreatitis, resulting in a slight increase of the complication rate (8.4%). Needle-knife papillotomy did not significantly increase the complication rate. Whereas in period A 41% of all complications were managed by surgery, this value dropped over 28% (period B) and 7.5% (period C) to ultimately 1.6% in period D. The method-related mortality was nearly constant over the whole period of time (0.6%). CONCLUSIONS: Despite a continuous shift of indications and a changing mixture of learning endoscopists and EST experts over 25 years, the practice of EST at its birthplace in Erlangen has shown a constantly high success rate, a decreasing complication rate and an acceptable but mainly unchanged mortality rate. Currently, nearly all complications can be successfully managed nonoperatively.

Sincalide: a cholecystokinin agonist as an aid in endoscopic retrograde cholangiopancreatography--a prospective assessment.

Although several approaches to overcome difficult bile duct cannulation and gain free biliary access have been popularized, the use of gastrointestinal peptide hormonal agents such as sincalide, a cholecystokinin agonist, as an alternative method has not been evaluated. I have carried out a prospective, nonrandomized assessment of the use of sincalide for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Overall, sincalide was used in 23% (32/136) of ERCPs in 26.6% (29/109) patients. Sincalide was successfully used to (a) obtain a cholangiogram after initial failure using only a standard catheter in 12 of 19 patients; (b) precisely locate the papilla and bile duct orifice in five of five patients; (c) locate the bile duct opening to obtain a cholangiogram and free cannulation during needle-knife papillotomy or weeks later in five of seven and three of three patients, respectively; and (d) gain free access (deep cannulation) to the bile duct after a cholangiogram in 5 of 10 patients. The selected use of sincalide appears to enhance the success of diagnostic and therapeutic ERCP; however, perseverance alone may account for some of this success. Controlled, randomized trials comparing sincalide or nothing, sincalide or a sphincterotome, or sincalide or glide or guide wire in patients in whom initial attempts to obtain a cholangiogram are unsuccessful are warranted.

[Problems in the echographic assessment of the kinetic capacity of the walls of the gallbladder and its sphincter apparatus]. / Nekotorye voprosy ékhograficheskoi otsenki kineticheskoi sposobnosti stenok zhelchnogo puzyria i ego sfinkternogo apparata.

The function of bile secretion is an intricately regulated process. Apart from hormonal control there exists conditioned-reflex regulation (vagus-sympathicus--n. phrenicus dex.). Such a many-sided influence appear to facilitate the development of discoordination of the gallbladder motor-evacuatory function. The present paper addresses advantages of echography in studying the functional status of the bile-secretion system. A technique of assessing the gallbladder kinetics in its interrelation with the sphincter apparatus is proposed, with their various combinations having been identified. A correct assessment of their interrelations, differentiated approach to therapy will, we believe, help in attempts to reduce the recurrence rates and the gravity of the course of the hepatobiliary system inflammatory diseases.

Assessment of gallbladder function using ceruletide in oral cholecystography.

A dose of 0.3 micrograms/kg body weight of ceruletide was assessed for its effect on gallbladder contraction and bile duct delineation following oral cholecystography. Nausea, vomiting, and abdominal pain sometimes occurred after ceruletide. No relationship was found after ceruletide administration between the radiologic appearances of the biliary tract and reproduction of the patients' biliary-type symptoms. Ceruletide cholecystography is regarded as an inaccurate investigation of biliary tract function.