Pancreas divisum: observation, endoscopic drainage, and surgical treatment results in 65 patients.

Sixty-five patients with symptomatic pancreas divisum were treated by endostents, surgery, or observation. In 35 patients, endoscopic stenting either alone (20) or followed by surgery (15) was the primary therapy. Of 30 patients not stented, 10 underwent elective surgery and 20 were followed. Treatment was based on symptoms and biochemical and radiologic tests. The results of surgical decompression correlated favorably with endoscopic drainage. In untreated patients, the natural history of pancreas divisum was benign. Surgery is safe and effective in symptomatic patients, although multiple operations may be required for recurrent symptoms or progressive disease.

Mechanical lithotripsy of common duct stones.

Over the past 8 years we have utilized various types of mechanical lithotriptors to crush common bile duct stones. The procedure was performed in 93 patients with an overall success rate of 94%. However, because many accessories were in a developmental stage, entrapment of stones was not always possible on the first attempt, and the procedure was repeated in some patients a second or third time. During the interim, while awaiting another attempt at lithotripsy, cholangitis was prevented by leaving a prosthesis in place. A variety of lithotriptor models from different manufacturers have proven effective. We recommend that endoscopists use these devices to rid the bile duct of retained stones.

Effectiveness of endoscopic drainage for pancreas divisum: endoscopic and surgical results in 31 patients.

Thirty-one patients with symptomatic pancreatitis and pancreas divisum were treated prospectively by inserting an endoprosthesis into the dorsal pancreatic duct for drainage. Pain was a feature characteristic of all 31 patients; of these 92% had an improvement in their subjective complaints of pain after sphincterotomy and insertion of a prosthesis in the minor papilla. During a two-year follow-up period, 84% (26/31) of the group showed improvement in all the signs and symptoms associated with their pancreatitis, and this improvement was sustained in all patients for at least several months. A group of twenty-six patients subsequently underwent pancreatic surgery for recurrent symptoms. Those patients who had improved with endoscopic drainage did significantly better following surgical drainage than those who had shown little or no improvement with an endoprosthesis. On the basis of the above preliminary results, we recommend preoperative insertion of an endoprosthesis into the dorsal duct as a therapeutic predictor of eventual surgical outcome.

The needle knife: a valuable tool in diagnostic and therapeutic ERCP.

Using monopolar electrocautery technique, we have used both an electrified guide wire and a needle-tipped sphincterotome to successfully enter the common bile duct, subsequently image it, and perform therapeutic procedures when by virtue of the patient's anatomy, or because of tumor, this had not been possible using conventional ERCP catheters. In an initial group of 45 patients using the needle-tipped sphincterotome, clinically significant complications occurred in 3 patients but were not of a serious nature. The technique was an effective method for achieving both diagnostic ERCP and therapeutic maneuvers in 43 of 45 patients. We stress that this technique should only be attempted by those with long experience in ERCP and related procedures.

Duodenoscopic sphincterotomy in patients with gallbladders in situ: report of a series of 1272 patients.

We present a prospective, unrandomized, uncontrolled series of 1272 patients in whom endoscopic sphincterotomy (ES) was performed, and who had not previously undergone cholecystectomy. These patients were culled from our combined experience of a total of 4177 patients in whom ES was performed over the last 13 yr. Of the group reported here, 1208 patients had demonstrable gallbladder stones, and 64 had acalculous gallbladders. The group included 896 females and 396 males whose mean age was 73.3 yr and who ranged from 17 to 101 yr old. Cholangitis was present in 317 patients (25%), and gallstone pancreatitis in 134 (10.5%) patients. After sphincterotomy, 109 patients (8.6%) developed cholecystitis; 23 developed this within 48 h, and 86 developed this within 10 days of the procedure. Emergency surgery was performed on 25 of these patients, and 84 responded to medical therapy alone. Two deaths occurred within 30 days of sphincterotomy (0.15%), in both cases following emergency surgery in elderly patients. One hundred-eight patients underwent elective cholecystectomy within 3 yr of their sphincterotomy because of recurrent symptoms referrable to the biliary tract. In a subset of 337 patients in whom long-term followup was possible, two patients died of complications related to recurrent cholecystitis, both at approximately 2 yr after sphincterotomy. Although followup was less than optimal in this large series of patients, the data presented here suggest that an intact gallbladder is not a contraindication to ES in the management of common bile duct stones, and that the morbidity and mortality of ES compare favorably over the long and short term with surgical management.

Treatment of malignant biliary obstruction by endoscopic implantation of iridium 192 using a new double lumen endoprosthesis.

Iridium 192 seeds contained in a ribbon were preloaded into a new double lumen 11 Fr endoprosthesis which was then inserted into malignant strictures of the bile duct and ampulla and left in place for 48 hours until 5000 rads were delivered to the tumor. The procedure was carried out in 14 patients (7 women, 7 men; mean age, 63.2 years; range, 46 to 86 years). Six patients were treated for cholangiocarcinomas, four with pancreatic carcinomas, and four with ampullary carcinomas. No complications occurred. The mean survival of the group was 7 months (range, 3 days to 27 months). This new technique provides both intraluminal brachytherapy and biliary drainage and is inserted intraduodenally across the papilla of Vater avoiding puncture of the liver and external hardware required by the percutaneous technique and hardware necessitated with a nasobiliary tube. Following removal of the iridium prosthesis, a large caliber endoprosthesis is inserted for continued decompression. Because of proven efficacy of endoprostheses, this new technique should be considered when intraluminal irradiation is indicated.

Optimal palliation of malignant bile duct obstruction: experience with endoscopic 12 French prostheses.

Large-caliber prostheses, 11.5-12 French, were placed in 167 patients (183 attempts, 91% success) presenting with obstructive jaundice. Thirty-three patients had additional prostheses placed to selectively decompress intrahepatic ducts obstructed by cholangiocarcinoma. In this prospective unrandomized series, there were 43 lesions of the common hepatic duct, 123 of the common bile duct (96 pancreas, 27 cholangiocarcinoma) and 17 ampullary. Transient fever responding to parenteral antibiotics occurred in 11 patients who did not receive prophylaxis, whereas only 2 patients who received antibiotics prior to the procedure developed fever subsequently. Four patients bled subsequent to sphincterotomy, 1 requiring a 2-unit transfusion. Pancreatitis occurred in only 1 patient. The mean hospital stay was only 3 days, range 1-10 days, with most patients being discharged within 48 hours. No procedural deaths occurred. The patency rate of this new, larger 12 Fr. prosthesis is significantly longer than that for the 10 Fr. stent, 190 days for 12 Fr., 150 days for 10 Fr. Given the advantages of the larger prosthesis, i. e., increased patency and function and decreased rehospitalization rate, the authors recommend this method of palliation for obstructive jaundice.