Effectiveness Of Endoscopic Therapy Research Articles

Effects of endoscopic therapy and surgical resection on long-term survival outcomes in patients with duodenal gastrointestinal stromal tumors: a surveillance, epidemiology, and end result program analysis.

With the rapid development of endoscopic technology, endoscopic therapy (ET) has gradually become a new treatment choice for gastrointestinal stromal tumors (GISTs). However, due to the low incidence of duodenal GIST and the difficulty of ET, there is a lack of data to compare the long-term results of ET and surgical resection. Duodenal GIST patients from 2004 to 2015 were selected from the surveillance, epidemiology, and end result (SEER) database. We used the Kaplan-Meier method and log-rank test to describe the 5- and 10-year survival differences between the ET and the surgery groups. The multivariate Cox proportional hazard model was used for analyzing the risk factors influencing the prognosis of patients. We used a 1:1 propensity score-matched (PSM) to reduce confounding factors, and then we compared survival differences between the two groups again. A total of 294 patients with duodenal GIST were enrolled, including 41 (13.9%) patients with ET and 253 (86.1%) patients with surgical resection. Before PSM, the long-term survival of patients with duodenal GIST after ET and surgical resection was similar [5-year overall survival (OS) (79.7 vs. 79.3%, p = 0.876), 10-year OS (66.5 vs. 68.1%, p = 0.876)]. After adjusting the relevant variables using multivariate Cox analysis, we found that the ET and surgery groups were comparable in OS and cancer-specific survival (CSS). After PSM, there was also no significant difference between ET and surgical resection for long-term OS and CSS. Our study found no significant difference in long-term survival between ET and surgical resection in patients with duodenal GIST. However, to obtain high-quality evidence, more extensive sample size studies are needed in the future to evaluate the long-term effects of ET on patients.

S659 Peptic Ulcer With Adherent Clot—Treat It or Leave It: A Systematic Review and Metanalysis of Randomized Trials

Introduction: Peptic ulcer diseases (PUD) remain the most common cause of hospitalized upper GI bleeding patients (30%-60%). Upper endoscopy is needed for diagnosis, stratification, and endoscopic hemostatic therapy of these ulcers depending on the presence of stigmata of increased risk of rebleeding. PUDs with adherent clot (Forrest classification IIb) are at 20-30% risk of rebleeding with a 7% mortality rate. Recent ACG guidelines could not reach a recommendation for or against endoscopic interventions for ulcers with adherent clot resistant to vigorous irrigation. This systematic review and meta-analysis aims to analyze the randomized studies for the treatment of PUD with adherent clot. Methods: The OVID/Medline and Google Scholar databases were screened through June 2021 for randomized studies reporting outcomes (rebleeding and mortality rates) in patients with adherent clot undergoing either endoscopic or medical intervention. Random effects models were used for the meta-analysis. I2 statistics were used to interpret heterogeneity, with I2>75% indicating substantial inter-study variation. A sensitivity analysis was performed using the leave one out method. A p-value < 0.05 was considered statistically significant. Results: Initial database search yielded 1568 articles, of which 8 randomized studies were finally included (Table 1). The total sample size consisted of 713 patients with adherent clot; of which 359 underwent endoscopic intervention while 354 were treated with medical therapy alone (proton pump inhibitors). Meta-analysis of re-bleeding and mortality rates between endoscopic and medical treatment groups revealed a decreased risk of rebleeding with endoscopic intervention (OR 0.247, 95%CI: 0.122-0.498, P=< 0.001) (Figure 1A). Mortality rates (OR 0.573, 95% CI: 0.273-1.204, P=0.151) (Figure 1B), and rates of surgery did not differ significantly between the two cohorts (OR 1.177, 95%CI: 0.598-2.317, P=0.638). However, there was heterogeneity in the type of endoscopic interventions used. Conclusion: The results of our meta-analysis show that endoscopic interventions could benefit patients presenting to the hospital with UGIB due to PUD with adherent clot by decreasing risk of rebleeding. However, there was no effect of endoscopic therapy on mortality. Further, high-quality randomized controlled studies are needed to guide the endoscopists about managing PUD with adherent clot.Table 1.: Mortality in post-bariatric surgery patients that had UGIB (OR).Figure 1.: A. Demographics and mean ago of the study population. B. Group comparisons using a post hoc test.

Zenkers diverticulum - effectiveness of endoscopic therapy.

Zenkersdiverticulum is the most common type of esophageal diverticulum with aprevalence of 0.01 to 0.11%, usually found in middle-aged and older patients. The prevalent symptoms are dysphagia and regurgitation. Treatment is recommended in symptomatic patients and consists of myotomy of the cricopharyngeal muscle. Both surgical and endoscopic methods are used in the treatment of Zenkersdiverticulum. With technical advances, flexible endoscopy has come to the forefront in the treatment of Zenkersdiverticulum, especially in older polymorbid patients. Its advantages include lower morbidity and mortality, shorter surgery time, the possibility of performing the procedure without general anesthesia, and ashorter hospital stay, including early oral food intake. In this paper we present our own experience with endoscopic treatment of Zenkersdiverticulum and at the same time we provide areview of effectiveness with other methods of treatment.

Effectiveness of Endoscopic Therapy in Patients With Barrettʼs Esophagus (BE) With Early Cancer Is Comparable to That of BE With High-Grade Dysplasia (HGD): Results From an International, Multi-center Consortium: 2017 Category Award (Esophagus)

Introduction: Endoscopic therapy, the current treatment of choice for BE patients with HGD, is also a noninvasive alternative to surgery for treatment of BE with intra-mucosal cancer (IMC). There are limited data comparing the outcomes of endoscopic therapy in BE patients with IMC and HGD. We aimed to compare the rates of complete eradication of intestinal metaplasia (CE-IM), complete eradication of dysplasia (CE-D) and recurrent IM (Re-IM) between the two groups -IMC and HGD.Table: Table. Baseline characteristics and outcomes of endoscopic therapy in IMC and HGDMethods: We reviewed all BE subjects with HGD and IMC who underwent endoscopic therapy in a multicenter prospective registry. Patients were treated with endoscopic mucosal resection if visible lesions were noted and/or mucosal ablation (RFA, cryotherapy, APC) for the flat BE. Patients who underwent at least four EGDs with endoscopic therapy were included in the study. CEIM and CED was defined as histologic absence of intestinal metaplasia (IM) and dysplasia respectively. Re-IM was defined as histologic evidence of BE (IM, dysplasia or esophageal adenocarcinoma (EAC)) after achieving CEIM. Rates of CEIM, CED and Re-IM were calculated for the two study groups - IMC and HGD. Cox proportional hazard models were used to compare the outcomes of endoscopic therapy between the two groups. Results: 276 subjects (70 with IMC and 206 with HGD) with BE who underwent endoscopic therapy were included in the study. The median (IQR) age was 66.0 (58.0, 73.0) years. 232 (84.1%) were males. There were no differences in baseline characteristics (age, sex and BE segment length) between the IMC and HGD groups (table 1). In the IMC group, 57 (81.4%) and 62 (88.6%) subjects achieved CE-IM and CE-D respectively. In the HGD group, 173 (84.0%) and 185 (89.8%) subjects achieved CE-IM and CE-D respectively. There was no statistical difference in the proportion of subjects who achieved CE-IM (P=0.62) and CE-D (P=0.77) in the two groups. On multivariate analysis adjusting for age, sex and BE length, there was no statistical difference in the CE-IM (IMC vs HGD; HR 1.15, 95% CI 0.38 - 3.51, P=0.81) and CE-D (IMC vs HGD; HR 1.21, 95% CI 0.31-4.66, P=0.79) rates between the two groups. There were 25 (43.9%) Re-IM in the IMC group and 60 (34.7%) Re-IM in the HGD group (P=0.21). Conclusion: In this large well-defined cohort of BE patients, effectiveness of endoscopic therapy in IMC is comparable to that of HGD. Consideration of endoscopic therapy in BE patients with early cancer could reduce the need for invasive surgery.

Value of balloon closure combined with endoscopic therapy for gastric varices with portasystemic shunt

Objective To evaluate the clinical effect of balloon closure combined with endoscopic therapy on spontaneous gastrorenal shunt(SGRS) and spontaneous splenorenal shunt(SSRS). Methods The data of 33 patients of gastric varices with SGRS or SSRS diagnosed in the Chinese PLA General Hospital between January 2009 and February 2016 were collected. All patients were treated with the balloon retrograde distributary channel blocking technique and endoscopic histoacryl injection. Patients′ clinical data, complications and effect of endoscopic therapy were retrospectively analyzed. Results In the 33 patients of gastric varices, gastrorenal shunt was found in 28(84.8%) cases and splenorenal shunt was found in 5(15.2%) cases. After the balloon blocking technique, 24 cases (72.7%) were occluded successfully. Four cases failed in occlusion of SSRS due to tortuosity. There were no postoperative ectopic embolism, infection, hepatic encephalopathy, liver function deterioration, and other complication. Early latex varices were found in 21 cases after three months follow-up. Conclusion The balloon blocking technique combined with tissue adhesive injection could safely and effectively avoid the risk of ectopic embolism and plays an important role in the treatment of gastric varices in merger portasystemic shunt. Key words: Endoscopes; Esophageal and gastric varices; Balloon embolization; Portasystemic shunt

Disseminated Gastrointestinal Histoplasmosis Resulting in Benign Ileal Stricture in a Patient with Hyperimmunoglobulin M Syndrome

Gastrointestinal histoplasmosis (GIH) is common in patients with disseminated disease affecting both immunocompetent and immunocompromised patients. However, it is often unrecognized due to a lack of specific signs and symptoms. It has only rarely been reported to cause small bowel obstruction (SBO), and the majority of reported cases were in patients with AIDS. We describe a case of GIH presenting with ileal stricture in a patient with hyperimmunoglobulin M (IgM) syndrome. A 37-year-old male with a past medical history of congenital hyper-IgM syndrome treated with regular immune globulin infusions and recently diagnosed disseminated histoplasmosis confirmed by laparoscopic mesenteric lymph node biopsy. The patient was status post a two week course of amphotericin B switched to maintenance itraconazole following undetectable urine histoplasma antigen level and significant clinical improvement. Shortly after initial completion of therapy, the patient had suffered a complicated course with three admissions over the course of two weeks with abdominal pain and CT confirmed SBO with each episode treated conservatively. Upon the patient's fourth presentation, gastroenterology was consulted for further investigation. CT enterography demonstrated 6 cm nodular thickening across the terminal ileum and a tight ileal stenosis. Additionally, a urine histoplasma antigen was elevated. Colonoscopy with ileoscopy confirmed stenosis and dilation was achieved with CRE balloon dilator. Biopsy of the stricture showed active ileitis without granulomas. Given his previous history of disseminated histoplasmosis associated with imaging and laboratory abnormalities, GIH was highly suspected. The patient elected to continue itraconazole rather than amphotericin B due to its side effect profile. Urine histoplasma antigen level was undetectable at 1-month follow-up and no further SBO episodes occurred. GIH is usually characterized by segmental inflammation and ulceration of the GI tract. However, these findings may be incorrectly attributed to malignancy and inflammatory bowel disease leading to the inappropriate use of immunosuppressive medications. This case demonstrates the diagnostic value of CT enterography and urine histoplasma antigen in GIH when pathology results are non-diagnostic as well as the effectiveness of endoscopic therapy. It also highlights the unusual occurrence of a short segment of stricture as the result of an otherwise disseminated process.Figure 1Figure 2

710 Use and Perceived Effectiveness of Endoscopic Therapies in Recurrent Acute Pancreatitis (RAP) Patients Treated At US Referral Centers

710 Use and Perceived Effectiveness of Endoscopic Therapies in Recurrent Acute Pancreatitis (RAP) Patients Treated At US Referral Centers

Sa1481 Outcomes of Endoscopic Therapy for Barrett'S High Grade Dysplasia and Early Esophageal Cancer in a Community Hospital Setting

Sa1481 Outcomes of Endoscopic Therapy for Barrett’S High Grade Dysplasia and Early Esophageal Cancer in a Community Hospital Setting Riad H. Al Natour*, Andrew Catanzaro, Eugene Zolotarevsky, Anthony T. Debenedet, Naresh T. Gunaratnam Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI; Huron Gastroenterology Associates, Ypsilanti, MI Background: Barrett’s high grade dysplasia (BEHGD) and early (T1a) esophageal adenocarcinoma (eEAC) can be successfully treated endoscopically by radiofrequency ablation (RFA) and mucosal resection (EMR). These treatment modalities have been proven successful in high-volume academic medical centers. Effectiveness of endoscopic therapy for BEHGD and eEAC in a community hospital setting is unknown. Methods: All consecutive patients (pts) with BEHGD and eEAC treated endoscopically at our institution between August 2007 and August 2014 were prospectively enrolled in a database. All pts had biopsy proven BEHGD or eEAC confirmed by two expert GI pathologists. All pts were treated by EMR and/or RFA every 2-3 months until complete eradication of dysplasia (ED) and intestinal metaplasia (CEIM). Once therapeutic end-point was reached, pts were enrolled in surveillance program with serial endoscopies per protocol. Results: A total of 194 pts underwent endoscopic therapy for dysplastic BE. Sixty-four (33%) pts had advanced dysplasia (BEHGD 34 and eEAC 30) with median length Barrett’s of 4 cm (Interquartile range (IQR), 2-7 cm). Forty-eight pts had EMR. Median treatment interval was 9 months (IQR, 4-24 months). Median follow up was 3 years (IQR, 1.4-4.4 years). Fifty-nine (92%) pts maintained long-term remission of dysplasia and 52 (81%) pts intestinal metaplasia. One pt failed to regress BEHGD six months into therapy. Dysplasia was downstaged in 4 (6%) pts. Relapse after CEIM occurred in 9 (14%) pts with NDBE (6), BELGD (1), BEHGD (1) and eECA (1). After retreatment, CEIM was again achieved in 5 pts, and ED in 3 pts. Pts with long segment BEO6 cm were more likely to relapse (OR 4.2; pZ0.03). There were no procedure-related esophageal perforation, severe hemorrhage, or complications requiring hospitalization. Twelve pts (10 having prior EMR) developed a symptomatic stricture, which responded to dilatation. There was no procedure or disease-related mortality. Conclusions: Endoscopic management of BEHGD and eEAC can be provided effectively in a community hospital setting. Complete eradication and long-term remission of dysplasia and intestinal metaplasia can be achieved in majority of pts without major morbidity or mortality.

Paclitaxel-eluting balloon dilation of biliary anastomotic stricture after liver transplantation.

To investigate the safety and effectiveness of endoscopic therapy with a paclitaxel-eluting balloon (PEB) for biliary anastomotic stricture (AS) after liver transplantation (LT). This prospective pilot study enrolled 13 consecutive eligible patients treated for symptomatic AS after LT at the University Hospital of Münster between January 2011 and March 2014. The patients were treated by endoscopic therapy with a PEB and followed up every 8 wk by endoscopic retrograde cholangiopancreatography (ERCP). In cases of re-stenosis, further balloon dilation with a PEB was performed. Follow-up was continued until 24 mo after the last intervention. Initial technical feasibility, defined as successful balloon dilation with a PEB during the initial ERCP procedure, was achieved in 100% of cases. Long-term clinical success (LTCS), defined as no need for further endoscopic intervention for at least 24 mo, was achieved in 12 of the 13 patients (92.3%). The mean number of endoscopic interventions required to achieve LTCS was only 1.7 ± 1.1. Treatment failure, defined as the need for definitive alternative treatment, occurred in only one patient, who developed recurrent stenosis with increasing bile duct dilatation that required stent placement. Endoscopic therapy with a PEB is very effective for the treatment of AS after LT, and seems to significantly shorten the overall duration of endoscopic treatment by reducing the number of interventions needed to achieve LTCS.

Safety and effectiveness of endoscopic therapy in patients with colonic polyps

Safety and effectiveness of endoscopic therapy in patients with colonic polyps

Endoscopic Management of Esophageal Cancer After Definitive Chemoradiotherapy

Concurrent chemoradiotherapy (CRT) is a potentially curative non-surgical option for locally advanced esophageal cancer, with pathological complete response (CR) ranging from 13 to 49 %. The rate of persistent and recurrent disease within the esophagus remains high at 40-60 %, and treatment of these tumors may improve disease-free survival. The aim of this review is to assess the efficacy of salvage endoscopic therapies for recurrent esophageal cancer. Medline and Embase were searched for relevant studies published in the English-language literature that reported use of endoscopic modalities, including photodynamic therapy (PDT), endoscopic mucosal resection (EMR), and spray cryotherapy, as salvage therapies for esophageal cancer. A total of 12 studies were identified. In small case series of PDT, CR varied from 20 to 100 %, with 1-, 3-, and 5-year overall survival rates of 65-80, 34-47, and 36 %, respectively. Data from three studies of EMR in squamous cell cancer show CR in 50 % of cases, with 3- and 5-year overall survival of 56-81 and 49 %, respectively. Endoscopic spray cryotherapy has recently been used in this setting with an observed CR of 37.5 %. Endoscopic salvage therapies are options for those patients with disease limited to the superficial esophageal wall and those who are unfit to undergo salvage esophagectomy. Widespread application of endoscopic salvage therapies is limited by the lack of awareness and guidelines for endoscopic surveillance post-CRT and limited data on the effectiveness of endoscopic therapies.

Long-Term Biliary Endoscopic Sphincterotomy Restenosis: Incidence, Endoscopic Management, and Complications of Retreatment

Ampullary restenosis is a late complication of biliary endoscopic sphincterotomy. Long-term data are limited regarding both the rate of restenosis and complications resulting from repeat therapy. To determine the incidence of post sphincterotomy restenosis and the effectiveness of endoscopic therapy in the management of this entity. A retrospective review of medical charts and the endoscopic retrograde cholangiopancreatography (ERCP) database to identify patients with ERCP and biliary endoscopic sphincterotomy during the period 1998-2002 at the University of Iowa Hospitals was conducted. All subjects were contacted by phone and asked about the recurrence of their pancreatobiliary symptoms after the first ERCP and whether they sought any medical treatment for these symptoms. The primary outcome was restenosis of the sphincterotomy site and the secondary outcome was complications of endoscopic treatment of sphincterotomy restenosis. A total of 202 patients underwent ERCP and biliary endoscopic sphincterotomy on an intact major papilla. Of these, n = 80 patients (54.7 +/- 19 years of age, 76% female) consented and enrolled in the study. Among these, n = 13 (16%) developed ampullary restenosis in 1-62 (median 16) months after the index ERCP. These 13 patients underwent a total of 24 ERCPs (range 1-4 for each patient) for repeat biliary sphincterotomy and biliary stenting, if needed. Repeat biliary endoscopic sphincterotomy was successful in 12/13 (92%) patients. Complications of repeat biliary endoscopic sphincterotomy were seen in three patients: mild pancreatitis (n = 1), severe bleeding (n = 1), and severe duodenal perforation (n = 1). Long-term restenosis is an important sequella of biliary endoscopic sphincterotomy. Repeat biliary endoscopic sphincterotomy is an effective treatment modality, but complications are not negligible.

Long-term effect of endoscopic injection therapy with combined cyanoacrylate and ethanol for gastric fundal varices in relation to portal hemodynamics

The understanding on the long-term effect of endoscopic therapy for gastric fundal varices (FV) is still insufficient. The aim of this study was to evaluate the relationship between the long-term effect of the endoscopic injection therapy with combined cyanoacrylate (CA) and absolute ethanol (ET) for FV, and the portal hemodynamics. The subjects of this retrospective study were ten consecutive cirrhotic patients with bleeding FV treated by endoscopic injection therapy with combined CA and ET. Percutaneous transhepatic portography was done after the completion of endoscopic treatment to assess portal hemodynamics. All the patients showed hemostasis by CA injection and complete obturation of FV by combined therapy of 5.6 +/- 2.1 (3-9) times without any severe complications except for gastric ulcer in one case. Five patients had recurrence (50%), and three of them showed rebleeding (30%). The other five patients had no recurrence during a mean observation period of 5.58 years (1190-2735 days). Although recurrence did not correlate with portal venous pressure, it was significantly frequent in patients without advanced portosystemic collateral vessels (5/7, P = 0.0384) compared to patients with them (0/3). Endoscopic injection therapy combining CA and ET may be effective for FV. Significant development of portosystemic collateral vessels would support long-term therapeutic effect after this treatment.

Aspectos clínicos y tratamiento endoscópico de la hemorragia digestiva por lesión de Dieulafoy

the aim of the study was to assess the incidence, clinical presentation, location, and response to endoscopic therapy of gastrointestinal bleeding from Dieulafoy's lesion. ALL consecutive episodes of gastrointestinal bleeding due to Dieulafoy's lesion seen between 2000 and 2006 were retrospectively reviewed. All main clinical and endoscopic data were collected: type and effectiveness of endoscopic therapy, rebleeding, complications, and mortality during hospitalization. WE found 41 patients, 26 males and 15 females, median age of 71.19 years. Dieulafoy's lesion accounted for 1.55% of all gastrointestinal bleeding episodes during the study period. The incidence of Dieulafoy's lesion was 2.2 cases/100.000 inhabitants/year. Active bleeding at endoscopy was present in 85.36%, and comorbidity in 92.68%. The stomach was the most frequent location (60.97%), followed by duodenum (29.26%). Endoscopic therapy achieved initial hemostasis in all cases. Three patients (7.31%) initially treated with epinephrine injection showed rebleeding and properly responded to a second session of endoscopic therapy. No surgery was needed. The mortality rate during hospitalization was 4.87%. Dieulafoy's lesion is an uncommon, but potentially severe cause of gastrointestinal bleeding. It may be found in any location within the gastrointestinal tract. Endoscopic therapy is effective and safe. Injected epinephrine alone is associated with a higher risk of rebleeding.

Appropriate Use of Intravenous Proton Pump Inhibitors in the Management of Bleeding Peptic Ulcer

Rebleeding from peptic ulcers is a major unsolved problem in the management of acute upper gastrointestinal bleeding. Our goal was to review what is known and what remains to be learned about the effectiveness of antisecretory therapy for acute upper gastrointestinal bleeding. We reviewed the data regarding the effectiveness of endoscopic therapy, the prediction of those at increased risk for rebleeding, and the effectiveness of antisecretory drug therapy in preventing rebleeding with or without endoscopic hemostasis. Proton pump inhibitor therapy without endoscopic hemostasis is ineffective clinically for stopping bleeding or preventing rebleeding. Endoscopic hemostasis remains the cornerstone of therapy. The data are consistent with the notion that reliable maintenance of the intragastric pH at > or = 6 after endoscopic hemostasis is associated with the lowest rebleeding rates. H2-receptor antagonists are ineffective for achieving this goal. Intermittent bolus and oral administration of proton pump inhibitors are equivalent and fail to achieve this goal, which can only be accomplished by bolus administration of a proton pump inhibitor (e.g., 80 mg) followed by a constant infusion (e.g., 8 mg/hr). Whether the combination of endoscopic hemostasis and pH control is equal or superior to selected second-look endoscopy is unknown. A treatment algorithm is suggested.

Intravenous proton pump inhibitors: requiem for endoscopic therapy?

Intravenous proton pump inhibitors: requiem for endoscopic therapy?

Therapeutic pancreatic endoscopy.

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreatic diseases is continuing to evolve. This article reviews recent publications spanning a wide range of topics related to therapeutic pancreatic endoscopy: Over the last 12 months, several case series have added to the literature on the short-term and long-term effectiveness of endoscopic therapy of pseudocysts, pancreatic abscesses and fistulas. Identification of a communication between pancreatic duct and a pseudocyst has been suggested to predict response to percutaneous drainage. The importance of identifying pancreatic leaks in patients with severe pancreatitis has been stressed. In addition, endotherapy has been reported to be effective in patients with idiopathic chronic pancreatitis. Endoscopic removal of pancreatic stones after extracorporeal lithotripsy has been shown to result in long-term improvement in clinical outcomes in patients with chronic calcific pancreatitis. Other interesting publications addressed new techniques and tricks to achieve access to the difficult pancreatic duct. Finally, no review of pancreatic endotherapy would be complete without a reminder--as recently stated by a National Institutes of Health consensus panel--that there is considerable need for higher-quality and controlled trials in this and other areas of interventional endoscopy.

Management of biliary complications after orthotopic liver transplantation

In this retrospective analysis we report our results after liver transplantation regarding biliary complications (bc) and the effectiveness of endoscopic therapy. In the last 4 1/2 years we found 13 biliary leaks (7 in combination with a stenosis, 3 at the T tube insertion site), 9 biliary stenosis, 3 papillary stenosis, 2 biliary aggregates and one case of ischemic type biliary lesion, resulting in an overall complication rate of 30%. 10 (36%) "bc" could be treated successfully endoscopically, whereas 8 (32%) patients are still under observation with an endoprosthesis in the biliary tract. 10 endoscopic trials were without the desired effect, requiring a surgical reintervention. In 4 cases a thrombosis of the hepatic artery was responsible for the unwanted course.