Microbiota studies in the bile duct strongly suggest a role for Helicobacter pylori in extrahepatic cholangiocarcinoma.

Biliary tract cancer or extrahepatic cholangiocarcinoma (ECCA) represents the sixth commonest cause of cancer in the gastrointestinal tract in western countries. We aimed to characterize the microbiota and its predicted associated functions in the biliary tract of ECCA and benign biliary pathology (BBP). Samples were taken from 100 patients with ECCA and 100 patients with BBP by endoscopic cholangio-pancreatography for DNA extraction. Ten patients with ECCA and ten with BBP were selected for microbiota studies using the V4-16S rRNA gene and sequenced in Illumina platform. Microbiota analyses included sample-to-sample distance metrics, ordination/clustering and prediction of functions. Presence of Nesterenkonia sp. and Helicobacter pylori cagA and vacA genes were tested in the 100 ECCA and 100 BBP samples. Phylum Proteobacteria dominated all samples (60.4% average). Ordination multicomponent analyses showed significant microbiota separation between ECCA and BBP (p 0.010). Analyses of 4002 operational taxonomic units with presence variation in at least one category probed a separation of ECCA from BBP. Among these, Nesterenkonia decreased, whereas Methylophilaceae, Fusobacterium, Prevotella, Actinomyces, Novosphingobium and H. pylori increased in ECCA. Predicted associated functions showed increased abundance of H. pylori virulence genes in ECCA. cagA and vacA genes were confirmed by PCR in ECCA and BBP samples. This is the first microbiota report in ECCA and BBP to show significant changes in microbial composition. Bacterial species unusual for human flora were found: Methylophilaceae and Nesterenkonia are reported in hypersaline soils, and Mesorhizobium is a nitrogen-fixing bacterium. Enrichment of virulence genes confirms previous studies suggesting that H. pylori might be associated with ECCA.

[Diagnostic and therapeutic endoscopic cholangiopancreatography in biliary leak after liver transplantation. Report of 2 cases]. / Colangiopancreatografía endoscópica diagnóstica y terapéutica en fuga biliar posterior a trasplante hepático. Reporte de dos casos.

BACKGROUND: The most common biliary tract complications after orthotopic liver transplantation are anastomotic strictures and bile leaks. These remain important causes of morbidity, frequently prompting surgical approach and/or biliary drainage. OBJECTIVE: To report our experience using endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of biliary tract complications in patients with hepatic transplantation. PATIENTS/METHODS AND RESULTS: We present two patients with hepatic transplantation who developed bile peritonitis secondary to biliary leaks diagnosed by ERCP, both treated with sphincterotomy and biliary endoprostheses. Bile leaks rapidly resolved after endoscopic sphincterotomy and stent placement. CONCLUSIONS: ERCP is a useful diagnostic and therapeutic intervention for post-transplantation biliary tract complications.

[Insertion of biliary endoprosthesis as ambulatory procedure]. / Colocación de endoprótesis biliares como procedimiento ambulatorio.

BACKGROUND: Because of possible complications, it has been common practice to admit to the hospital most if not all patients undergoing therapeutic ERCP. Therefore, little descriptive data exist on the safety of out-patient therapeutic ERCP for endobiliary stent placement. OBJECTIVE: To assure quality patient care and patient safety, we reviewed our experience with out-patient therapeutic ERCP for palliation of benign and malignant common bile duct obstruction by means of endobiliary stent insertion. PATIENTS-METHODS AND RESULTS: A retrospective review of all therapeutic ERCPs for palliation of benign and malignant common bile duct obstruction with endobiliary stents was performed from January 1, 1998, through December 31, 1999. One hundred forty therapeutic ERCPs were performed to place an endobiliary stent for benign and malignant common bile duct obstruction. Seventy-two procedures were performed on out-patients, sixty-eight on in-patients. There was no significant difference between out-patient and in-patient groups with regard to age, gender, need for endoscopic sphincterotomy, and complication rate. In patients had one procedure-related complication; out patients had four. There was no procedure-related mortality in either group. CONCLUSIONS: Therapeutic ERCP for palliation of benign and malignant common bile duct obstruction with endobiliary stents can be safely and successfully performed on an out-patient basis for selected patients. This should result in substantial cost savings.

[Incidence and relation of endoscopic sphincterotomy to the proximal migration of biliary prostheses]. / Incidencia y relación de esfinterotomía endoscópica en la migración proximal de prótesis biliares.

BACKGROUND: Endoprostheses are commonly used in the treatment of biliary disorders. The frequency of and potential risk factors for stent migration, however, remain largely unknown. OBJECTIVE: To determine how often biliary duct stents migrate proximally and to quantify the influence of specific risk factors on the occurrence of stent migration. PATIENTS METHODS AND RESULTS: We analyzed the occurrence of stent migration among the 410 stents for which follow-up data were available between January 1995 to December 1998. In 272 cases, we performed endoscopic sphincterotomy. Results demonstrated incidence rates of 4.4% for proximal biliary stent migration iatrogenic strictures were significantly associated with proximal biliary stent migration. CONCLUSIONS: Iatrogenic strictures were significantly associated with proximal common bile duct migration and the association between sphincterotomy and proximal migration failed to reach statistical significance.

[Benign esophageal strictures in toddlers and pre-school children. Results of endoscopic dilation]. / Estenosis esofágica benigna en pacientes lactantes y preescolares. Resultados de dilatación endoscópica.

BACKGROUND: The most frequent causes of dysphagia in children are benign strictures and therefore require special consideration. OBJECTIVE: To evaluate safety and efficacy of endoscopic dilation in children with benign esophageal strictures. MATERIAL-METHODS-RESULTS: Twenty four consecutive children of 1.5 to 5.5 years (mean 3.5), with benign esophageal strictures were evaluated in a prospective manner over a 3-year period. The most frequent causes of esophageal stricture were caustic ingestion (Group A) and in Group B were included other benign strictures. Dilation was done on a weekly base using Savary-Gilliard bougies and was considered adequate, if the esophageal lumen could be dilated to 11 mm with complete relief of dysphagia. Of the 24 patients, 16 had corrosive strictures, 6 complications of gastroesophageal reflux and 2 post surgical strictures. Group A required a significantly higher number of session (14.3 +/- 10.84 vs 7.0 +/- 2.94 p: > 0.05), less free-time dysphagia (1.1 +/- 0.39 vs 2.6 +/- 0.95 months p: < 0.01) and a higher number of recurrences (3.12 +/- 1.12 vs 1.25 +/- 0.95 p: < 0.01). Two esophageal perforations occurred during a total of 292 dilation sessions (0.68%). There was one fatality. CONCLUSIONS: Benign esophageal strictures in children can be treated effectively and with acceptable safety by means of endoscopic dilation.

[Colonic polyps in children. Experience with polypectomy]. / Pólipos colónicos en niños. Experiencia en polipectomía.

BACKGROUND: Colonic polyp, the most common gastrointestinal tumor in children, is considered a cause of rectal bleeding in the pediatric population. Colonoscopy is the "gold standard" procedure in diagnosis and therapeutic. OBJECTIVE: To know the incidence and symptomatology of colonic polyps in children to remark on the usefulness of the endoscopic examination. PATIENTS-METHODS AND RESULTS: Between 1985 and 1996, over 1,000 colonoscopies were performed on 50 children between 8 months and 14 years old. The patients had colonic polyps and lower gastrointestinal bleeding. In 40 cases polyps were solitary, 82% were located in rectum sigmoid, and 80% of polyps were found to be juvenile (retention). There were no complications associated with diagnostic and therapeutic endoscopy. CONCLUSIONS: The endoscopic method was shown to be very useful for diagnosis as well as treatment of the colonic polyps in children.

[Disappearance of the radiographic image of a macroprolactinoma after treatment with bromocriptine]. / Desaparición de la imagen radiográfica de un macroprolactinoma con bromocriptina.

A young woman with amenorrhea-galactorrhea induced by a prolactin (PRL) secreting pituitary macroadenoma, was treated with bromocriptine 5 mg/day per os. Serum PRL levels were normal at 6 weeks and menstruation appeared at 8 weeks of treatment. When twenty months of treatment were completed, a tomographic study of the pituitary was unable to show any enlargement. Controversies related to macroprolactinomas treatment are discussed and it is suggested that treatment with dopamine agonists must be the elective treatment for patients with macroprolactinoma.

[True hermaphroditism with bilateral ovotestis]. / Hermafroditismo verdadero con ovotestis bilateral.

A nineteen years old woman with ambiguous external genitalia was studied. This condition had been previously identified as a newborn, but her parents refused medical attention and it was reared as a girl. At 12-years, she began spontaneous mammary development, appearing pubic and axillary hair, and clitoral enlargement. The menarche occurred at 15-years and it was followed by irregular periods. Physical examination, showed absence of hirsutism and acne, normal mammary development equivalent to grade V of Tanner. The external genitalia showed fused labio-scrotal folds with an small introitus. The urethral meatus was absent and was later located inside the introitus. There was a big phallus similar to an adult penis with a normal glans, flexed by a chordee. Hormonal determinations discarded congenital adrenal hyperplasia. The karyotype was 46,XX and testosterone levels were in adult male range. Pelvic ultrasonography disclosed a normal uterus and both gonads in confirmed by laparoscopy identifying bilateral ovotestis. Testicular tissue was removed and plastic reconstruction of female genitals was done.

[Self-expanding metal prosthesis as palliative treatment in esophageal cancer]. / Prótesis metálicas auto-expandibles como tratamiento paliativo en cáncer de esófago.

BACKGROUND: Current non-surgical or endoscopic therapeutic modalities in esophageal cancer include dilatation, thermocoagulation, injection of alcohol or chemotherapeutic agents, photodynamic therapy, intracavitary irradiation, and placement of plastic or metallic prostheses. None of these procedures, however, has proved to be a simple and well-tolerated like the last one. AIM: Achieve palliation of dysphagia, in patients with nonresectable esophageal cancer treated with a metal self-expanding endoprosthesis. PATIENTS--METHODS AND RESULTS: Twelve patients (6 men and 6 women, mean age 58) with dysphagia caused by non-resectable esophageal cancer were treated with a metal self-expanding endoprosthesis. Prior to treatment, they had mean dysphagia grade of 3.5. Histologic diagnosis was squamous carcinoma in 4 cases, and adenocarcinoma in 8. Six tumors were located at the gastroesophageal junction, 4 in the distal esophagus, and 2 in the mid-esophagus. None of the patients had cervical esophageal tumor. All procedures were performed under mild intravenous sedation. Stent insertion was technically successful in 91.6%, and led to a reduction of dysphagia from a mean score of 3.5 to a mean score of 0.5 at first and 4th weeks. Ninety-one percent of the patients continued to swallow during follow-up (average follow-up: 10.5 weeks, range 1 day-35 weeks). Early complications (within 30 days) included retrosternal pain in 2 patients which resolved in a few days and one patient with recurrent bleeding from the tumor site. CONCLUSIONS: Self-expanding metal stents placement is a relatively simple and atraumatic procedure, it is safe and effective in treatment of malignant dysphagia.

[Endoscopic cholangiopancreatography (ERCP) in pediatric patients]. / Colangiopancreatografía endoscópica (CPE) en pacientes pediátricos.

BACKGROUND: While Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is widely employed in the management of adult pancreaticobiliary disease, its use in children has been limited. AIMS: To evaluate if ERCP diagnostic and therapeutic, is a safe and useful procedure in the diagnosis and treatment of pancreatobiliary disorders in children. PATIENTS, METHODS AND RESULTS: We reviewed our experience with 72 ERCPs performed in 50 children (age 7-17 y, mean 14.5 y). The procedures were performed using standard adult side-viewing duodenoscopes. We used general anesthesia in 25 and conscious sedation in 47. In 38 patients we performed one, in 7/2, in 2/3, in 1/4 and in 2/5 ERCPs. The biliary or pancreatic ducts were successfully cannulated in 98%. Abnormal papilla accounted for the unsuccessful attempt. Abnormalities were found in biliary ducts in 54% and pancreatic duct in 24%, including choledocholithiasis (10), stenosis of the papilla (5), benign biliary stenoses (5), recurrent pancreatitis (4), pancreatic fistula (4), bile duct leak (3), cholelithiasis (3), chronic calcifying pancreatitis (2), pancreas divisum (2) and choledochal cyst (1). Endoscopic sphincterotomy was performed in 19 patients, 15 on biliary segment and four on pancreatic segment. Stents were placed in the biliary duct in nine patients and in pancreatic duct in six patients. Complications included abdominal pain and elevated amylase in three patients (6%), which resolved rapidly. CONCLUSIONS: ERCP in children and adolescents is a safe and underutilized diagnostic and therapeutic procedure.

[Precut sphincterotomy: efficacy and complications]. / Esfinterotomía de precorte: eficacia y complicaciones.

BACKGROUND: The use of precut sphincterotomy has been criticized as potentially unsafe. Despite this, a number of tertiary referral center have reported their successful use of this technique to increase the rate of common bile duct cannulation and therapeutic procedures. AIM: To evaluate precut papillotomy and correlate the complication rate. METHODS-PATIENTS AND RESULTS: We performed precut sphincterotomy in 120 patients in whom attempts at standard common bile duct cannulation and sphincterotomy were unsuccessful. Bile duct diameters were correlated to the complication rate. Cannulation of the common bile duct and endoscopic sphincterotomy was successful immediately after precut sphincterotomy in 103 patients (86%), and was successful in 12 of the 17 patients who underwent repeat ERCP, for a total cannulation and sphincterotomy rate of 96%. Eight patients (6.9%) experienced complications: six bleeding, and two retroduodenal perforation. There was no procedure-related mortality, and complications were managed medically except on patient with bleeding who required surgical intervention. CONCLUSIONS: Precut sphincterotomy was effective and safe in facilitating cannulation and sphincterotomy in patients in whom standard cannulation attempts failed. Excluding patients with small duct size may further reduce the complication rate.

[Endoscopic management of biliary fistula]. / Manejo endoscópico de la fístula biliar.

OBJECTIVE: To assess safety and efficacy of endoscopic therapy for patients with a postoperative biliary fistula. BACKGROUND: Biliary fistula that occur after operations on the biliary tract may be due to bile duct injury or distal bile duct obstruction. These fistulas has been managed with surgical correction. At present, endoscopic methods of improving biliary drainage has been found to be highly successful in the management of postsurgical biliary leaks. PATIENTS-METHODS-RESULTS: By endoscopic cholangiopancreatography (ERCP) we diagnosed 35 patients (23 females and 12 males) with postoperative biliary fistula. Four patients had history of laparoscopic cholecystectomy. We used endoscopic sphincterotomy (18 cases) or endoprosthesis placement (17 cases) in the treatment. Seventeen patients with fistula plus common bile duct (CBD) stones and one patient with benign papillary stenosis were treated with endoscopic sphincterotomy alone. Seventeen patients without CBD stones were treated with only endoprosthesis placement. A second ERCP confirmed healing of the leakage after 4-16 weeks. CONCLUSIONS: Postoperative bile leakage could be diagnosed safely and effectively by ERCP, subsequent endoscopic management in most cases is successful. Sphincterotomy alone is the preferred treatment for biliary fistula-complicating surgery for gallstone disease. Alternatively, when a fistula is large, endoscopic placement of an endoprosthesis can be proposed as the first treatment.

Dissolution of pancreatic lithiasis by direct citrate application into the pancreatic duct in two patients with chronic idiopathic pancreatitis.

Several experimental and clinical studies have shown that citrates are useful in dissolving calcifications and proteic plug in pancreatic ducts both of alcoholic etiology and in patients with chronic pancreatitis. Until now, using citrates to dissolve stones in clinical studies was performed orally with satisfactory medium-term results, including control of abdominal pain and eradication of shadows on X-rays. Laboratory studies have shown that these concretions dissolve quickly when such compounds are applied directly. This paper reports 2 women aged 27 and 40 with histories of chronic abdominal pain, and who, by abdominal X-ray and endoscopic retrograde cholangiopancreatography (ERCP), were shown to have multiple calcifications in the main and accessory pancreatic ducts. In both patients, endoscopic sphincterotomy of the bile and pancreatic segments of the sphincter of Oddi and introduction of a nasopancreatic catheter and intraductal infusion of citrates were performed. Radiological controls showed fragmentation and disappearance of calcifications. Clinically, there was complete absence of abdominal pain in the first week following the procedure. This is the first human study of intraductal administration of citrates to dissolve pancreatic lithiasis with highly favorable results.

[Precut sphincterotomy in impacted choledocholithiasis at the Vater's ampulla]. / Esfinterotomía de precorte en coledocolitiasis impactada en el ampula de vater.

BACKGROUND: Endoscopic sphincterotomy is an established treatment for common bile duct stones. Stone impaction at the ampulla makes deep cannulation and standard sphincterotomy more difficult. The use of precut papillotomy may facilitate stone extraction, although risks may be greater. AIM: To evaluate precut papillotomy in impacted common bile duct stone at the ampulla of Vater. PATIENTS AND METHODS: Between October 1990 and September 1995, 27 of 345 patients with common bile duct stones underwent needle knife precut papillotomy after conventional sphincterotomy failed due to impacted ampullary stone. This facilitated deep cannulation and subsequent standard sphincterotomy in 12 patients. RESULTS: Eleven patients had spontaneous expulsion of the stone when precut papillotomy was extended. Oedema or bleeding precluded stone extraction in 3 patients, and these stones were removed at a second endoscopic retrograde cholangiopancreatography (ERCP) session. Mild bleeding occurred in one patient and hemotransfusion was necessary. There was no perforation or pancreatitis following the procedure. CONCLUSIONS: Precut papillotomy is effective in the treatment of impacted common bile duct stone at the ampulla of Vater. It's a technique that should be performed only by an experienced endoscopist and does not increase the complications risk.

[Safety and efficacy of sphincterotomy using guided and precut techniques. A 5-year experience]. / Seguridad y eficacia de la esfinterotomía guiada y con técnica de precorte. Experiencia de 5 años.

BACKGROUND: Endoscopic sphincterotomy (ES) by itself is safe and effective, with acceptable rates of morbidity and mortality. However, for various reasons ES cannot be successfully completed in all cases, and other treatment options must be considered, including precut or guided sphincterotomy. Results from studies evaluating precut sphincterotomy are conflicting. AIM: The aim of this prospective trial was to assess the safety and efficacy of standard, guided and precut endoscopic sphincterotomy. PATIENTS AND METHODS: During a period of 5 years, endoscopic retrograde cholangiopancreatography (ERCP) was performed 1,000 times. Of five hundred seven patients, 364 were women and 143 men, had biliary obstruction and were candidates for ES, which was successful in 477 (94%). Sixteen (3.3%) complications occurred, but only 6 (1.25%) were serious. Procedure-related mortality occurred in one patient (0.2%). RESULTS: In 346 patients (68.2%) we performed standard ES, in 86 (16.9%) precut, in 45 (8.9%) guided and in 30 (6.0%) ES cannot be successfully completed. Morbidity rate for endoscopic management of three-sphincterotomy types is similar, with 3.7% in standard ES, 2.3% in precut and 2.2 in guided sphincterotomy. CONCLUSIONS: Standard ES, precut and guided sphincterotomy are safety and efficacy and complication rate can be lowered if the procedure is strictly focused to local anatomy and therapeutic requirements.

[Palliative treatment of esophageal cancer with transendoscopic injection of alcohol]. / Tratamiento paliativo de cáncer esofágico mediante inyección transendoscópica de alcohol.

BACKGROUND: Few patients who present with dysphagia from esophageal cancer are curable. The rates of surgical resecability are low and the reported 5-yr survival rates are < 10%. Nonsurgical, endoscopic palliation of obstructing gastrointestinal cancers has became popular with stents, Nd: YAG laser, BICAP tumor probe, self-expanding metallic stents. Because of limited availability and extraordinary cost of equipment, most gastrointestinal endoscopy units can't afford their acquisition. Endoscopic injections of ethanol are useful for palliation of malignant dysphagia. AIMS: To examine if injections of ethanol are useful, in our patients, for palliation of malignant dysphagia. PATIENTS, METHOD AND RESULTS: Six male patients with dysphagia caused by inoperable or unresecable esophageal cancer were treated by endoscopic injection of ethanol to induce tumor necrosis. Prior to treatment, patients had a mean dysphagia grade of 3.6. After treatment, an optimum dysphagia grade (mean 0.8) was achieved with a mean of 6 injections treatments. There were no complications associated with endoscopic injection of ethanol. Mean patient survival rate was 286 days (range: 36-973). CONCLUSIONS: These results suggest that injections of ethanol to induce tumor necrosis have considerable potential for palliation of malignant dysphagia in patients with exophytic neoplasm.

[Extraction of foreign bodies in the esophagus. Experience in 215 cases]. / Extracción de cuerpos extraños en el esófago. Experiencia en 215 casos.

OBJECTIVE: To analyze our experience in management of foreign bodies in esophagus. BACKGROUND: At present, the flexible endoscope is usually the instrument of choice for foreign bodies of the esophagus. The rigid endoscope is less expensive, but the advantages of the flexible endoscope are numerous. MATERIAL, METHODS: Management of 215 foreign bodies of esophagus are reported. The flexible endoscope was used to manage these foreign bodies. The patients comprised 151 children and 64 adults. RESULTS: In children, coins were the commonest foreign bodies (119 cases), whereas in adults, the commonest cause was impacted meat (35 cases). Two hundred fourteen foreign bodies (99.5%) were successfully managed endoscopically. The surgery rate was 0.5%. There was no morbidity or mortality. In fifteen adults we diagnosed significant associated medical conditions: benign esophageal stricture in eleven, esophago-gastric junction carcinoma in one, two patients with esophageal motility disorders and remaining with Plummer-Vinson Syndrome. CONCLUSIONS: The forward-viewing flexible endoscope has became the instrument of choice in diagnosis and management of esophageal foreign bodies.

[Management of difficult cases of biliary lithiasis]. / Manejo de la litiasis biliar difícil.

UNLABELLED: To assess that insertion of a biliary endoprosthesis is a safe and effective treatment in patients with retained common bile duct stones (CBDS). BACKGROUND: Before 1974, surgical exploration including cholecystectomy with choledochotomy was the only effective treatment for CBDS. However, morbi-mortality increases rapidly in the elderly and is over 10% in patients over 65, particularly if other serious medical conditions are present. Endoscopic sphincterectomy is now an established procedure, with a success rate of about 90%, complications are relatively rare, and mortality is about 1%. However, the size and number of the stones, the appearance of the terminal bile duct and presence of peripapillary diverticulum influence the outcome. At the present time technique of fragmenting the stones using intracorporeal electrohydraulic, extracorporeal shock waves or laser lithotripsy would be seen to be an attractive alternative approach. Endoprosthesis insertion is a safe, effective and cheap treatment in CBDS. PATIENTS, METHODS AND RESULTS: 40 patients with unextractable CBDS were studied and treated with endoscopic stenting. Four patients were lost for follow-up. The remaining patients comprised 29 females and 7 males, with a mean age of 67 years. Four patients underwent surgical treatment for post-sphincterotomy haemorrhage (1 patient), internal endoprosthesis migration (1 patient) and peripapillary diverticulum (2 patients). In 7 high-risk patients with large CBDS, recurrent obstructive jaundice was successfully treated by replacing the endoprosthesis. In 6 of them we added medical treatment with ursodeoxycholic acid and after 24 months follow-up, the stones disappeared. In 13 patients the endoprosthesis were inserted temporally, and in a second approach we removed the CBDS by mechanical lithotripsy. The remaining 12 patients were still alive without symptoms after a follow-up of 24 months. CONCLUSIONS: On the basis of these findings we therefore concluded that endoscopic insertion of a biliary endoprosthesis is a safe and effective treatment for CBDS in patients in whom endoscopic sphincterotomy and attemps to remove the stones are not successful.

[The endoscopic treatment of carcinoma of Vater's ampulla]. / Tratamiento endoscópico del carcinoma de ampula de Vater.

UNLABELLED: The ampullary carcinoma is a rare tumor. Its early and accurate diagnosis will lead to early treatment and subsequent better prognosis. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be one of the best diagnostic tools. Furthermore an endoscopic biliary drainage procedure: endoscopic sphincterotomy or endoprosthesis placement, can be performed immediately following the diagnostic procedure. PATIENTS AND METHODS: Endoscopic drainage was attempted in 20 patients with a success rate of 90 percent. There were 8 females and 12 males, with a mean age of 71 years (range 43-92), and were admitted to the hospital with obstructive jaundice. Endoscopic insertion of a biliary endoprosthesis (9 cms long 3.2 mm [10 Fr] diameter), was successful in 18 patients whom made uneventful recovery and their jaundice resolved completely. RESULTS: In 18 of them an endoscopic sphincterotomy was carried out. Two patients developed cholangitis, the endoprosthesis were removed and a new one inserted. The survival rate of these patients was 3 and 18 months respectively. Failure of endoscopic sphincterotomy or endoprosthesis insertion in 2 remaining patients, was ascribed to an inability to cannulate the papilla due to infiltrating tumor. The median survival time in 15 remaining patients was 4 months (1-18 months) and died by metastatic disease. Five patients underwent Whipple's procedure, and all survived the operation. Two died, by metastatic disease, with a median survival time of 16 months and 3 still alive at 46, 25 and 18 months post-operatively. Carcinoma of the ampulla of Vater is not resectable in 25-50% of the patients because of metastatic disease, deep extension of the tumor or general contraindications for major surgery. CONCLUSIONS: Endoscopic sphincterotomy or endoprosthesis insertion as a definitive treatment modality should be reserved for poor surgical candidates and those patients with limited life expectancy due to metastatic disease.