Endoscopic Biliary Decompression Research Articles

The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock.

Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression. To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock. Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011. Among 260 patients (mean age 69years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n=96), survivors (n=164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P<0.001) and lower median serum lactate on admission (3.4 vs. 4.6mmol/L, P<0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8h from shock, P<0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22h, P<0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P<0.04 for all; c-statistic 0.896). Patients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12h) could potentially improve outcomes in this high-risk patient population.

Endoscopic palliation of malignant biliary strictures.

Malignant biliary strictures often present late after the window for curative resection has elapsed. In such patients, the goal of therapy is typically focused on palliation. While historically, palliative measures were performed surgically, the advent of endoscopic intervention offers minimally invasive options to provide relief of symptoms, improve quality of life, and in some cases, increase survival of these patients. Some of these therapies, such as endoscopic biliary decompression, have become mainstays of treatment for decades, whereas newer modalities, including radiofrequency ablation, and photodynamic therapy offer additional options for patients with incurable biliary malignancies.

A Rare Case of Oriental Cholangiohepatitis

Introduction: Oriental cholangiohepatitis is commonly seen in Asian with prevalence of < 1% in Western countries. It is thought to be secondary to parasitic infection of bile system with concomitant biliary infection that leads to production of beta-glucuronidase that play key roles in bilirubin precipitation, stone and stricture formation. Case: A 73 year-old caucasian female with history of diabetes mellitus presented with nausea, vomiting, epigastric abdominal pain, diarrhea for 1 week. Reported 70-lb weight loss over past year. CT scan was concerning for possible pancreatic mass, omental metastasis, numerous tumor nodules in mesentery and possible thrombus in portal vein. Labwork showed ALP 230, albumin 1.6, CA 19/9 45.2. US Liver showed moderate intrahepatic biliary dilation, dilated proximal common duct measuring 1.4cm. MRCP showed moderate intra and extrahepatic biliary ductal dilatation with multiple large filling defects within both intrahepatic and extrahepatic bile ducts, consistent with stones (Fig 1). EUS was done which showed normal visual exam, diffuse pancreas with mixed echogenicity. FNA of pancreatic head/body negative for malignancy. ERCP showed CBD of 1.8 cm with atleast 4 (˜1cm stones) with largest being ˜1.2cm (Fig 2). Biliary sphincterotomy was performed followed by mechanical lithotripsy, balloon extraction. A 10 Fr 9cm plastic biliary stent was placed in CBD proximal to retained stones. Repeat ERCP was done in OR with laser lithotripsy and residual stone removal in 2-3 weeks.Figure 1Figure 2Discussion: It is a serious condition owing to its intractability, frequent recurrence and predisposition of cholangiocarcinoma. Presenting symptoms include abdominal pain, jaundice, cholangitis and can lead to production of strictures and liver abscesses. US liver is first diagnostic modality as it can clearly show intrahepatic stones and biliary dilation. MRCP is the best non-invasive imaging that shows intrahepatic stones, biliary strictures and hepatic abscess. Direct cholangiography remains the gold standard with sensitivity of almost 100% in the detection of obstruction. The goals of treatment include treating cholangitis (fluids/antibiotics), preventing recurrence, clearance of stones, correction of strictures, restoration of biliary drainage and to stop the progression of the disease. There is no definitive treatment owing to the complicated nature of the disease. Urgent endoscopic biliary decompression prevents patient from going into shock. Hepatic resection has shown to reduce the risk of recurrence of stones, since it removes not only intrahepatic stones but also the associated pathological bile ducts damaged by strictures. Liver transplantation is usually the only treatment option in cases of diffuse liver parenchyma involvement and development of cirrhosis.Table 1: Grading the severity of hepatolithiasis

Inoperable pancreatic cancer patients who have prolonged survival exhibit an increased risk of cholangitis.

Endoscopically placed metal stents, which are patent for 4-9 months, have been the favored decompressive strategy for biliary obstruction due to inoperable pancreatic cancer in order to minimize interventions. However, in the past decade chemotherapeutic options have improved survival. This raises the question of whether metal stents will continue to be the optimal method of decompression. We performed a study to determine the outcome of patients with non-operatively managed pancreatic adenocarcinoma with regards to the development of cholangitis. We reviewed all ERCP performed for malignant distal biliary obstruction in between December 1999 and December 2005 at University of California, San Francisco (UCSF). Only patients who received chemotherapy for pancreatic adenocarcinoma were included. Patients who underwent surgical biliary diversion procedures were excluded. PRIMARY OUTCOME MEASUREMENT: The primary outcome was the development of cholangitis requiring hospitalization. Among 200 patients with malignant distal biliary obstruction who underwent endoscopic biliary decompression procedures, 54 met study criterion. Metal stents were employed in 90.7% of these cases. The median survival of this population was 12.7 months (range: 2.6-34.6 months). Only 3 of 26 patients (11.5%) surviving one year or less developed cholangitis compared to 13 of 28 (46.5%) who survived more than one year. Thus patients surviving greater than one year had a five fold increase in the odds of developing cholangitis (odds ratio: 4.92; P=0.017). This cohort of inoperable pancreatic cancer patients undergoing chemotherapy survived longer than the expected patent period of metal stents employed for biliary decompression. The occurrence of cholangitis requiring hospitalization does increase markedly among long term survivors.

Evidence-Based Management of Common Gallstone-Related Emergencies.

Gallstone-related disease is among the most common clinical problems encountered worldwide. The manifestations of cholelithiasis vary greatly, ranging from mild biliary colic to life-threatening gallstone pancreatitis and cholangitis. The vast majority of gallstone-related diseases encountered in an acute setting can be categorized as biliary colic, cholecystitis, choledocholithiasis, and pancreatitis, although these diagnoses can overlap. The management of these diseases is uniquely multidisciplinary, involving many specialties and treatment options. Thus, care may be compromised due to redundant tests, treatment delays, or inconsistent management. This review outlines the evidence for initial evaluation, diagnostic workup, and treatment for the most common gallstone-related emergencies. Key principles include initial risk stratification of patients to aid in triage and timing of interventions, early initiation of appropriate antibiotics for patients with evidence of cholecystitis or cholangitis, patient selection for endoscopic biliary decompression, and growing evidence in favor of early laparoscopic cholecystectomy for clinically stable patients.

Su1768 Endoscopic Biliary Decompression of a Non-Functioning Ventriculo-Gallbladder Shunt in a Child With Refractory Hydrocephalus

Su1768 Endoscopic Biliary Decompression of a Non-Functioning Ventriculo-Gallbladder Shunt in a Child With Refractory Hydrocephalus

Comparison of the safety and effectiveness of endoscopic biliary decompression by nasobiliary catheter and plastic stent placement in acute obstructive cholangitis

Endoscopic retrograde biliary drainage (ERBD) using a plastic stent is suggested to be as effective as endoscopic nasobiliary drainage (ENBD) with a nasobiliary catheter for temporary biliary drainage in acute obstructive cholangitis. However, there are few studies that have compared the two methods. We therefore compared the safety and effectiveness of endoscopic biliary decompression by nasobiliary catheter versus plastic stent placement in these patients. A total of 94 screened patients with acute obstructive cholangitis were randomised to undergo emergency endoscopic biliary drainage with ENBD (n = 47) or ERBD (n = 47). Clinical outcomes and adverse events were compared. Patient backgrounds were similar in the two groups. Endoscopic biliary drainage was successfully achieved in all patients. Eleven patients underwent unscheduled endoscopic retrograde cholangiopancreatography (ERCP) to replace the nasobiliary catheter, 10 due to a catheter (1 in the ENBD group) or stent (9 in the ERBD group) blockage and 1 due to catheter migration. Clinical manifestations were similar, however, there was a significantly lower patient discomfort score in the ERBD group (p <0.05). The mean serum gamma-glutamyltransferase and total bilirubin concentrations after ERCP were significantly higher in the ERBD than ENBD group (p <0.001). Complication rates were similar in the ENBD and ERBD groups. However, the incidence rate of blockage in ERBD was statistically higher than ENBD (p = 0.015). Endoscopic biliary decompression is an effective treatment for patients with acute obstructive cholangitis. In contrast to other studies, we found an increased rate of blockage in the ERBD group and a greater decrease in liver enzyme levels in the ENBD group.

Bile Duct Leaks from the Intrahepatic Biliary Tree: A Review of Its Etiology, Incidence, and Management

Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management.

Decreasing Hospitalization and In-hospital Mortality Related to Cholangitis in the United States

The aim of this study was to determine trends in hospitalization rates and in-hospital mortality of cholangitis and also determine predictive factors of in-hospital mortality. The Nationwide Inpatient Sample database was utilized for inpatient data analysis from 1988 to 2006. Patients with primary cholangitis International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) discharge diagnosis were included. Age-adjusted procedure rates for endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement and sphincterotomy were also analyzed. Analysis of variance was used to evaluate trends, and linear Poisson multivariate regression model was used to control for variations in age, sex, time of diagnosis, and ethnicity. Logistic regression analysis was performed to determine predictive factors of in-hospital mortality. The age-adjusted hospitalization rate of cholangitis decreased 24.8% from 2.34 per 100,000 in 1988 to 1.76 per 100,000 in 2006 (P < 0.01). The age-adjusted in-hospital mortality of cholangitis increased 9.2% from 165.0 to 181.6 per 100,000 from 1988 to 1998 (P < 0.01), and then declined 73% to 48.9 per 100,000 in 2006 (P < 0.01). The age-adjusted procedure rates for ERCP with biliary stenting increased from 0.55 to 15.23 per 100,000 from 1988 to 2006 (P < 0.01), as did the age-adjusted rates for ERCP with sphincterotomy from 1.06 to 35.64 per 100,000 (P < 0.01). The hospitalization rate of cholangitis has been declining over the past 2 decades. The overall trend in mortality peaked in 1998 and has shown a subsequent decline that may in part be related to increased utilization of endoscopic biliary decompression.

Interventional EUS as an alternative to endoscopic biliary decompression through the duodenal papilla is feasible and safe

Interventional EUS as an alternative to endoscopic biliary decompression through the duodenal papilla is feasible and safe

Endoscopic management of post-cholecystectomy biliary fistula

ObjectiveBile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries. MethodsA retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion. ResultsControlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen. ConclusionsThis review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

Diagnosis and treatment of bronchobiliary fistula

To explore the diagnosis and treatment modalities of bronchobiliary fistula (BBF). 2 cases of bronchobiliary fistula were reviewed. The etiology, clinical presentations, diagnosis methods, treatment modalities and prognosis of BBF were studied. BBF can be caused by many diseases, which include liver or lung hydatid cyst, amoebic or bacterial liver abscess, subphrenic abscess and biliary lithiasis. Iatrogenic BBF is increasing in recent days. The characteristic presentation of BBF is recurrent bilioptysis. Diagnosis of BBF is not very difficult with the primary disease,characteristic clinical presentations and image studies. Treatment modalities of BBF include endoscopic drainage, biliary stent or biliary decompression, and surgery. Bilioptysis is the characteristic presentation of BBF. Treatment of BBF should be immediately and appropriated while the diagnosis confirmed. Key words: Bronchobiliary fistula; Radiofrequency ablation; Liver metastasis carcinoma; Biliary lithiasis

Papilla Vaters Tumor in Elderly: an Interdisciplinary Issue

Tumors of the papilla Vater are very rare. Papilla Vater’s tumors are benign or malignant tumors in the ampulla of Vater and periampullary region. Blockage of ampulla leads to the development of obstructive jaundice; intermittent cholangitis, epigastric discomfort and weight loss. Treatment possibilities include endoscopic ampulectomy, surgical transduodenal excision of tumors of the ampulla and pancreatoduodenectomy (PDE). Prognosis depends on histological typing of the tumor and their clinical stage. We report a case of papilla Vater’s tumor in elderly with comorbidities based on literature review. A 68-year-old female patient was referred for evaluation of intra and extra hepatic bile duct dilatation noted on abdominal ultrasonography. She complained of intermittent epigastric and right upper abdominal pain, with yellowish skin for two months. The laboratory findings showed leukocytosis, hyperbilirubinemia, abnormal liver function test, and high Ca 19-9. An endoscopic retrograde cholangiopancreatography (ERCP) revealed a distal obstruction caused by papilla Vater’s tumor. Abdominal computed tomography (CT) with contrast, revealed a dilated common bile duct and pancreatic duct. The histologic evaluation was highly suggestive for dysplasia. She is now on a schedule for a Whipple procedure. To make a true diagnosis and optimal treatment of papilla Vater’s tumor is multimodal. By doing a comprehensive geriatric assessment, with a careful modality selection, a Whipple procedure can be performed in elderly (65 years) safely. The post operative morbidity and mortality depends on their multi morbidity. Surgical, endoscopic, or radiologic biliary decompression; relief of gastric outlet obstruction; and adequate pain control may improve the quality of life but do not affect overall survival rate. By building a great interdisciplinary teamwork, the quality of life increased as follows. Keywords: papilla Vater tumor, elderly, Whipple procedure

The safety and effectiveness of endoscopic biliary decompression by plastic stent placement in acute suppurative cholangitis compared with nasobiliary drainage

Endoscopic retrograde biliary drainage (ERBD) by using a plastic stent is suggested to be as effective as endoscopic nasobiliary drainage (ENBD) for temporary biliary drainage in acute suppurative cholangitis (ASC). However, there are few studies that compared ERBD and ENBD in ASC. We compared the safety and efficacy of ERBD and ENBD for temporary biliary drainage in patients with ASC. A case series. A tertiary-referral center. Eighty patients with ASC underwent endoscopic biliary drainage with ENBD (n = 41) and ERBD (n = 39). Clinical outcomes, including complications related to ERCP and complications related to the type of the indwelling catheter. Endoscopic biliary drainage was successfully achieved in all patients (100%). There were no significant differences in the demographic data between the 2 groups. There were no differences in the improvement of clinical and laboratory parameters between the 2 groups. Overall ERCP-related complication rates in the ENBD and ERBD groups were 31.7% and 38.5%, respectively (P = .527). Hyperamylasemia occurred in 18 patients, 12.2% in the ENBD group (5/41) and 33.3% in the ERBD group (13/39) (P = .024). Without endoscopic sphincterotomy (EST), there was no statistically significant difference in the incidence of hyperamylasemia between the 2 groups. However, with an EST, hyperamylasemia was more frequent in the ERBD group (12/28 [42.9%]) than in the ENBD group (3/27 [11.1%]) (P = .008). A single-center experience. Endoscopic biliary decompression, whether by ERBD or ENBD, is an effective treatment for patients with ASC. However, more frequent hyperamylasemia with ERBD and EST deserves further evaluation.

Incidence and Management of Bile Leakage after Partial Liver Resection

Background/Aims: Bile leakage after partial liver resection still is a common complication and is associated with substantial morbidity and even mortality. Methods: A total of 234 consecutive liver resections without biliary reconstruction, performed between January 1992 and December 2004, were analyzed for postoperative bile leakage. Results: Postoperative bile leakage occurred in 6.8% of patients (16/234). In univariate analysis, male gender (p = 0.037), major liver resection (p = 0.004), right-sided hepatectomy (p = 0.005), prolonged operation time (p = 0.001), intraoperative blood loss >500 ml (p = 0.009), red cell transfusion (p = 0.02), tumor size (p = 0.026), duration of vascular occlusion (p = 0.03) and surgical irradicality (p = 0.001) were risk factors. No independent risk factors were associated with bile leakage after liver resection. Bile leakage originated from the resection plane in 10 patients (63%). Endoscopic biliary decompression was performed in 9 patients as initial treatment, and percutaneous drainage of the bile collection was used in 4 patients. Bile leakage resolved spontaneously in 3 patients. Conclusions: Bile leakage is a persisting complication and in this study occurred in 6.8% of patients after partial liver resection. Percutaneous drainage of bile collection with or without endoscopic biliary decompression are effective interventions in the management of most cases of bile leakage.

Endoscopic management of inoperable cholangiocarcinoma using iridium-192

We report a well tolerated endoscopic technique of administering intraluminal radiotherapy to 14 patients with inoperable cholangiocarcinoma, in which the iridium-192 wire source was inserted down a nasobiliary catheter placed within a previously inserted endoscopic biliary prosthesis, thus allowing bile flow to continue during treatment. Radiotherapy was commenced 2 weeks after biliary decompression, when the median serum bilirubin level had fallen from 213 to 34 mumol/l. A total radiation dose of 6000 cGy at 0.5 cm from the source was administered over a median of 85 h (range 77-116 h). In four patients there was a transient increase in serum bilirubin during iridium treatment and, in two cases (14 per cent), this was associated with mild cholangitis. Both cases resolved rapidly once the iridium wire and nasobiliary catheter were removed. The median hospital stay after treatment was 2.5 days (range 0-28 days). The late complications associated with stent blockage were minimized by routinely changing stents at 4-6 monthly intervals; ten of the patients have so far undergone from one to five (median three) stent changes. Five patients have died at 3.6-8.2 months (median 4.8 months) following iridium treatment; four had extensive type III hilar lesions at diagnosis. Nine patients are still alive at 5.4-31.0 months (median 16.4 months). The overall median survival after iridium therapy is 10.5 months. This technique of endoscopic biliary decompression before internal iridium administration minimizes complications by allowing biliary drainage during treatment. The role of this treatment in patients with inoperable cholangiocarcinoma awaits the results of randomized, controlled trials.

Outcomes of emergency common bile duct exploration: impact of preoperative endoscopic decompression.

Emergency common bile duct exploration (CBDE) is still required in patients acutely ill with complicated biliary tract stone disease when endoscopic decompression fails to reverse their condition. This study looks at the clinical profile of patients requiring emergency CBDE and examines the various factors influencing the postoperative outcome. Clinical records of patients with emergency CBDE in Singapore General Hospital from January 1991 to December 1998 were reviewed. Factors influencing postoperative outcomes, for example, pre-existing medical problems, hepatic parameters, the impact of endoscopic procedures (if any) and indications for surgery, were correlated with postoperative morbidity and 30-day mortality. The records of 100 patients were available for review. Major indications for emergency CBDE were cholangitis (51%) and intraoperative findings of common bile duct obstruction during emergency laparotomy (23%). Six patients had emergency CBDE because of iatrogenic complication of attempted therapeutic endoscopic retrograde cholangiopancreaticography (ERCP) for biliary stones. Overall mortality was 14.0% and 8.0% had retained stones. Mortality was significantly influenced by age, prior biliary disease, preoperative endoscopic biliary decompression in acute cholangitis (33.3%vs 9.4%, P = 0.035) and endoscopic complications. Among patients requiring emergency CBDE, uncomplicated preoperative endoscopic biliary decompression benefits patients with acute cholangitis.

Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: A prospective randomized trial

Background: Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones. Methods: Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39°C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score). Results: Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group). Conclusion: Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter. (Gastrointest Endosc 2002;56:361-5.)

Laparoscopic palliation of unresectable pancreatic cancers: preliminary results.

To assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. Prospective study. Teaching hospital, Italy. 6 patients (4 men and 2 women, range 53-72 years, median 64) who presented between July 1995 and April 1997 with inoperable pancreatic cancer. Laparoscopic gastroenterostomy for duodenal obstruction. Four patients had already had endoscopic biliary decompression. 2 patients also had laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. Morbidity and mortality. The procedure was completed laparoscopically in all patients. There was no perioperative mortality and morbidity was low (1 bleeding from the drain and 1 paralytic ileus). The median postoperative stay was 4.5 days (range 4-6). Laparoscopic gastroenterostomy, together with cholecystojejunostomy in selected patients with inoperable pancreatic cancer, offers a less invasive alternative to open surgery with a short hospital stay and rapid return to normal activity.

Laparoscopic gastrojejunostomy in the palliation of pancreatic cancer: reflections on the preliminary results.

The aim of this study was to assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. Between July 1994 and January 1996, five patients underwent laparoscopic gastroenterostomy for duodenal obstruction due to pancreatic cancer. There were four men and one woman, ranging in age from 53 to 72 years (median 63). Four patients already had endoscopic biliary decompression. One patient underwent laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. The procedure was completed laparoscopically in all patients. There was no perioperative mortality, and the morbidity was low. The median post-operative stay was 4 days (range, 4-6). Laparoscopic gastroenterostomy associated with cholecystojejunostomy in selected cases offers a less invasive alternative than open surgery, with a shorter hospital stay and more rapid return to normal activity.