Endoscopic Retrograde Cholangiopancreaticography Research Articles

Diagnostic and therapeutic endoscopic retrograde cholangiopancreaticography after Billroth II gastrectomy – safe provision in a district general hospital

Endoscopic retrograde cholangiopancreaticography (ERCP) is available in many district general hospitals in the UK. Most of the published literature on ERCP in cases with Billroth II gastrectomy reflects teaching hospital experience. The aim of this study was to evaluate this procedure in the district general hospital setting, over a 10-year period. Details of 41 consecutive patients, whom had previously undergone Billroth II gastrectomy and were referred for ERCP were analysed for presenting symptoms and outcome of their ERCP. All procedures were carried out by a single radiologist using a conventional Olympus side-viewing duodenoscope. 48 examinations and 44 therapeutic procedures were carried out in 41 cases. Afferent loop intubation and cannulation of ampulla was successful in 87.5% and 98%, respectively. Two episodes of minor bleeding occurred after sphincterotomy, not requiring blood transfusion. One case of afferent loop perforation (2%) was repaired surgically. There were no cases of pancreatitis or death in this series. The results show that ERCP after a Bilroth II gastrectomy can be safe and successful in the majority of cases when carried out by clinicians with a special interest, including those in a district general hospital However, experience with this procedure will diminish due to fewer indications for Billroth II gastrectomy and emergence of magnetic resonance cholangiopancreatography. It may be advisable to concentrate this technique in a few designated centres with skill and expertise.

Primary Closure of the Common Duct over Endonasobiliary Drainage Tubes

The T-tube remains the standard method of intraductal drainage after open choledochotomy for choledocholithiasis. We studied the use of an endonasobiliary drainage (ENBD) tube as an alternative to the T-tube for postoperative intraductal drainage. A series of 20 patients with documented choledocholithiasis in whom endoscopic methods of stone retrieval failed to clear the common bile duct (CBD) were selected for the study. All patients had ENBD tubes placed preoperatively at endoscopic retrograde cholangiopancreaticography and then were subjected to open choledocholithotomy with primary closure of the choledochotomy over the ENBD. The age of the patients in the study group ranged from 18 to 75 years. Three patients (15%) had acute cholangitis at the time of surgery. Stones were confirmed at surgery in 85% of the patients, and the size of the CBD was found to range from 1.0 to 2.3 cm. All 20 patients underwent closure of the common duct over an ENBD tube without any difficulty. None of the patients experienced biliary complications such as bile leaks, biliary peritonitis, biliary fistula, pancreatitis, or cholangitis. No patient had any residual stone as documented by postoperative cholangiograms. Abdominal drains remained in place for 2 to 4 days, and the ENBD tubes were removed between days 6 and 8. The length of the postoperative hospital stay varied from 7 to 15 days, with 65% of the patients going home before postoperative day 8.

Vanishing Bile Duct Syndrome and Sclerosing Cholangitis in Patients with Critical Illness and Long Term Intensive Care Treatment

Background: Sepsis associated cholestasis in intensive care patients usually subsides with treatment of the underlying cause. However, in a subgroup of these patients a progressive destruction of intrahepatic bile ducts and sclerosing cholangitis with the typically appearance of segmental strictures and cholangiectasies develops. In this respect, a progressive form of sclerosing cholangitis after septic shock and long term intensive care treatment has been described. We herein report the clinical course and endoscopic treatment in patients with sclerosing cholangitis due to critical illness. Patients: Twelve patients (6 male, age: 48.8+12.7, (mean, years+SD)) with sclerosing cholangitis, diagnosed by endoscopic retrograde cholangiopancreaticography were identified. No patient had evidence of preexisting hepato-biliary disease or inflammatory bowel disease. Transfer to the ICU was necessary because of sepsis in 2, extensive surgery in 4, polytrauma in 2, cardiopulmonary resuscitation in 2 and respiratory failure in 2 patients, respectively. All patients needed mechanical ventilation, had a preexisting pulmonary disease and/or developed a severe adult respiratory distress syndrome. Results: Cholestasis or jaundice developed 60 [13-110] days (median[range]) after transfer to the ICU. The laboratory findings were: Bilirubin: 7.5[0.4-62.1], Alkaline Phosphatase: 10.6[2.6-22.5], GGT: 34.0[10.3-91.4], ALT: 2.0[0.8-18.7], AST: 3.6[0.8-34.0],(xULN, median[range]). ERCP demonstrated sclerosing cholangitis in all patients. Severe ductopenia was seen in two patients. In 9 patients endoscopic sphincterotomy was performed. Casts and sludge were extracted in 5 patients. Biliary stenting was performed in one patient with a dominant stenosis. Two patients were lost for follow up. During a median follow up of 11 [4–46] months 7 patients (58%) progressed to liver cirrhosis. Two patients died of liver failure and 2 patients underwent orthotopic liver transplantation. Stabilization or biochemical improvement of cholestasis was achieved in 3 patients. Discussion: Reduced hepatic oxygen delivery may lead to initial bile duct injury in ICU patients. As a second hit septicemia, ischemia, translocation of endotoxins from the gut may further lead to progressing sclerosing cholangitis. Long term outcome of endoscopic treatment is poor as a high proportion of these patients develop liver cirrhosis, for whom liver transplantation should be considered. Background: Sepsis associated cholestasis in intensive care patients usually subsides with treatment of the underlying cause. However, in a subgroup of these patients a progressive destruction of intrahepatic bile ducts and sclerosing cholangitis with the typically appearance of segmental strictures and cholangiectasies develops. In this respect, a progressive form of sclerosing cholangitis after septic shock and long term intensive care treatment has been described. We herein report the clinical course and endoscopic treatment in patients with sclerosing cholangitis due to critical illness. Patients: Twelve patients (6 male, age: 48.8+12.7, (mean, years+SD)) with sclerosing cholangitis, diagnosed by endoscopic retrograde cholangiopancreaticography were identified. No patient had evidence of preexisting hepato-biliary disease or inflammatory bowel disease. Transfer to the ICU was necessary because of sepsis in 2, extensive surgery in 4, polytrauma in 2, cardiopulmonary resuscitation in 2 and respiratory failure in 2 patients, respectively. All patients needed mechanical ventilation, had a preexisting pulmonary disease and/or developed a severe adult respiratory distress syndrome. Results: Cholestasis or jaundice developed 60 [13-110] days (median[range]) after transfer to the ICU. The laboratory findings were: Bilirubin: 7.5[0.4-62.1], Alkaline Phosphatase: 10.6[2.6-22.5], GGT: 34.0[10.3-91.4], ALT: 2.0[0.8-18.7], AST: 3.6[0.8-34.0],(xULN, median[range]). ERCP demonstrated sclerosing cholangitis in all patients. Severe ductopenia was seen in two patients. In 9 patients endoscopic sphincterotomy was performed. Casts and sludge were extracted in 5 patients. Biliary stenting was performed in one patient with a dominant stenosis. Two patients were lost for follow up. During a median follow up of 11 [4–46] months 7 patients (58%) progressed to liver cirrhosis. Two patients died of liver failure and 2 patients underwent orthotopic liver transplantation. Stabilization or biochemical improvement of cholestasis was achieved in 3 patients. Discussion: Reduced hepatic oxygen delivery may lead to initial bile duct injury in ICU patients. As a second hit septicemia, ischemia, translocation of endotoxins from the gut may further lead to progressing sclerosing cholangitis. Long term outcome of endoscopic treatment is poor as a high proportion of these patients develop liver cirrhosis, for whom liver transplantation should be considered.

Salvage Endoscopic Retrograde Cholangio-Pancreaticography in the Management of Non-Iatrogenic Traumatic Bile Duct Injuries

Salvage Endoscopic Retrograde Cholangio-Pancreaticography in the Management of Non-Iatrogenic Traumatic Bile Duct Injuries

The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma

Injuries to the pancreas following blunt abdominal trauma are rare due to its protected retroperitoneal position. Many pancreatic lesions remain unnoticed at first and only become apparent when complications arise or during treatment of other injuries. The mortality rate is between 12 and 30%, and if treatment is delayed it is as high as 60%. Using medical records over the past 5 years, we investigated when and in what circumstances endoscopic retrograde cholangiopancreaticography (ERCP) was used in the diagnosis and treatment of pancreas injuries after blunt abdominal trauma. Penetrating injuries were not taken into consideration. An ERCP was performed on a total of five patients with suspected injuries to the pancreas after blunt abdominal trauma. No duct participation could be determined in three of the patients with a first degree pancreatic lesion. A 44-year-old woman sustained severe internal and external injuries after a traffic accident. Because of the nature of her injuries, pancreatic left resection with splenectomy was necessary. After the operation, a pancreatic fistula diagnosed. The ductus pancreaticus (DP) was successfully treated by stenting with the use of endoscopic retrograde pancreaticography. A 24-year old woman was kicked in the epigastrium by a horse. On the day after the incident, she complained of increasing pain in the upper abdomen, and she had elevated amylase and lipase levels. Computed tomography scan showed free fluid. Less than 48 h after the accident, ERCP was performed and a leakage in the DP in the head-body region (fourth degree) was identified. We placed a stent, and during the subsequent laparoscopy the omental bursa was flushed out and a drainage laid. After 14 days, the patient was sent home. We removed the drainage 4 weeks after the accident, and the stent after 12 weeks. The major advantage of the prompt retrograde discription of the pancreatobiliary system after an accident in which pancreas involvement is suspected is the more precise assessment of the extent of the injuries. If a stent is placed in the same session, it is possible to carry out definitive and interventional treatment.

The endoscopic management of pancreatic fistulas

Interest in the use of therapeutic endoscopy for the treatment of pancreatic diseases has been on the increase for several years. Our aim was to assess the efficacy of endoscopic retrograde cholangiopancreaticography (ERCP) in the treatment of pancreatic fistulas. We evaluated the results of therapeutic ERCP in 50 patients with pancreatic fistula treated at the Helsinki University Central Hospital from 1998 to 2003. The success rate of fistula closure after therapeutic ERCP was 82%. Five patients required operative treatment when ERCP was unsuccessful. There was little morbidity and no procedure-related mortality. Four patients died because severe illnesses made them unfit for any further procedures. ERCP is a safe and effective modality and should be considered as first-line therapy in the management of pancreatic fistula.

Cholecystomegaly: Laparoscopic treatment

A 78-year-old patient was noted to be severely anemic (Hb 4.9) during a hospital admission in August 2002 for lightheadedness. She underwent a thorough workup including an abdominal computed tomography (CT) scan which demonstrated a mildly dilated gallbladder and possible pancreatic mass. Endoscopic retrograde cholangiopancreaticography (ERCP) was performed which showed a mildly dilated common bile duct without filling defects. No abnormalities were identified in the pancreas. During ERCP it was noted that the patient had a large hiatal hernia with Cameron's lesions. She subsequently underwent a laparoscopic fundoplication with resolution of her anemia. The patient did well for 16 months until she presented to her primary care physician with back pain. On physical examination she had a large abdominal mass. She underwent a CT scan that demonstrated marked enlargement of her gallbladder extending below her pelvic brim [Figure 1]. Her liver function tests were normal. MRCP demonstrated normal pancreatic and common bile ducts along with the dilated gallbladder. Due to the large size of the gallbladder and history of ductal dilatation, laparoscopic cholecystectomy was recommended. At the time of operation the gallbladder was found to be massively dilated with a thickened wall [Figure 2]. Needle decompression (with extraction of 200 cm3 of bile) was used to decrease the gallbladder size and make it manageable. The gallbladder was successfully removed laparoscopically using a standard dissection and port placement. The specimen was removed through the umbilical port, which required slight enlargement for extraction. Intraoperative cholangiogram showed normal bile duct size without filling defects. The specimen measured 17 cm × 8 cm × 2 cm. Pathology showed impaction of a stone in the neck of the gallbladder, explaining the dilatation, as well as acute and chronic cholecystitis. At 6-month follow up the patient is doing well and her back pain has resolved. Figure 1 Computerized tomography (CT) scan demonstrating massive gallbladder extending to the pelvic brim Figure 2 Laparoscopic view demonstrating an enlarged gallbladder Since its introduction, laparoscopic cholecystectomy has been the preferred treatment of symptomatic cholelithiasis.[1] Relative contraindications include cirrhosis, coagulopathy, pancreatitis, pregnancy, morbid obesity, and severe cardiorespiratory insufficiency.[2] A theoretical risk with a massively dilated gallbladder is volvulus. Gallbladder volvulus is a rare event with less that 400 cases reported in the literature to date.[3] Volvulus commonly occurs in elderly women with visceroptosis. There are two known anatomic conditions that predispose a patient to volvulus. A gallbladder that is not anchored to the liver bed and only has attachment via the cystic artery and duct is at risk for torsion. Additionally, a gallbladder with a very long mesentery, as can be seen with long-standing massive dilatation, may also undergo volvulus. Unfortunately, neither of these conditions can be definitively diagnosed preoperatively to determine who is at risk. Given the massive size of the gallbladder in our patient we felt laparoscopic cholecystectomy was warranted. This case demonstrates the ability to safely perform laparoscopic cholecystectomy even in the setting of a massively dilated gallbladder. Additionally, it highlights the possibility of an impacted stone when a dilated gallbladder is encountered, even in a chronic setting. A preoperative ultrasound may have diagnosed the impacted gallstone compared to CT.

Carcinoid tumor of the duodenum and accessory papilla associated with polycythemia vera

Carcinoid tumors have been reported in a wide range of organs but most frequently involve the gastrointestinal tract; however, duodenal carcinoid tumors are rare. We report a 50-year-old male patient complaining of multiple melenas for 3 wk. The panendoscopy and endoscopic retrograde cholangiopancreaticography revealed swelling accessory papilla with an ulcer. The biopsy taken showed a carcinoid tumor. The lesion was removed by wide resection. Patient was found to have an abnormal blood cell count during the follow-up period with elevated levels of hemoglobin and hematocrit of 21.2 g/dL and 63.5%, respectively, thrombocytosis of 501,000/microL, and leukocytosis of 20,410/microL. He was diagnosed as a polycythemia vera by a hematologist after further evaluation. He received periodic phlebotomy and hydroxyurea treatment. The response was good and his hematocrit was stabilized by periodic phlebotomy in the range of 44-49% during the last 2 years. The possible origin of UGI bleeding by a duodenal carcinoid tumor, although rare, should be considered. There has been one case report of a duodenal carcinoid tumor that involved accessory papilla of the pancreas divisum and one case report of metastatic carcinoid tumor associated with polycythemia vera. It is different in our patient as compared with the latter report, which mentioned a polycythemia vera patient who was found to have a metastatic carcinoid in the 17 years follow-up period. Chemotherapy had been given before the carcinoid tumor was revealed. Our patient had no previous chemotherapy for polycythemia vera before he was found to have duodenal carcinoid tumor; this excludes the possibility of chemotherapy induced carcinoid tumor, although it had been suspected in the previous report. In our patient, the existence of both diseases may be by predisposition of each other since both diseases have an increased incidence of other neoplasm, or they may be coexistent incidentally.

Periampullary Diverticula Causing Pancreaticobiliary Disease

Our purpose was to determine if the presence of duodenal diverticula predisposes to the development of pancreaticobiliary disease. Between May 1999 and February 2001, 381 patients were examined by endoscopic retrograde cholangiopancreaticography. Of these patients, 51 had periampullary diverticula. In 27 patients the papilla was located inside the diverticulum (Group I), in 19 patients it was located at the edge of the diverticulum (Group II), and 5 patients it was located at a distance closer than 3 cm to the diverticulum (Group III). Seventeen patients in group I and 11 patients in group II had had a previous cholecystectomy. The overall incidence of biliary system stone disease was 22.2% in group I, 36.8% in group II, and 100% in group III. All patients were treated with endoscopic sphincterotomy and three (two in group I and one in group II) developed biliary system disease (cholangitis or pancreatitis). We think that sphincterotomy should be applied regardless of the presence of stone if the papilla is located inside or at the edge of the diverticulum. If the papilla is located 3 cm or more far for diverticulum, it should be considered within the frame of general sphincterotomy indications in the absence of stone disease.

Diagnostic value of MRCP in the management of hilar strictures after extended liver resection

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging method that produces images of the pancreatic duct and biliary tree without the need for oral or intravenous contrast medium enhancement. Diagnostic endoscopic retrograde cholangiopancreaticography (ERCP) can largely be replaced by MRCP, which is associated with a lower morbidity. Although there is considerable research on the use of MRCP in the diagnosis of benign and malignant conditions, there is little or no description on the use of MRCP in the assessment of the post-resection patient. We report the MRCP findings in two cases of hilar stricture post-liver resection not diagnosed by ultrasound, and successfully treated by ERCP and stenting.

Prevention of post-ERCP pancreatitis: are there any pearls for sale?

Poon RT-P, Yeung C, Liu C-L, Lam C-M, Yuen W-K, Lo C-M, Tang A, Fan S-T (Queen Mary Hospital, Hong Kong, China). Intravenous bolus somatostatin after diagnostic cholangiopancreaticography reduces the incidence of pancreatitis associated with therapeutic endoscopic retrograde cholangiopancreaticography procedures: a randomized controlled trial. Gut 2003;52:1768–1773.

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.

Reclassification of “Atypical” Diagnoses in Endoscopic Retrograde Cholangiopancreaticography–Guided Biliary Brushings

To evaluate the usefulness of reclassifying "atypical" diagnoses in reporting biliary cytology using strict morphologic criteria. Cytologic specimens from 139 patients (direct, alcohol-fixed smears or cytocentrifuge preparations) were evaluated. Diagnoses were benign (70), atypical (36) and malignant (33). Using strict criteria--major (nuclear contour, chromatin pattern) and minor (polarity, cell types, nuclear size, nuclear grooves, nucleoli, mitosis, nuclear/cytoplasmic [N/C] ratio)--atypical cases were reevaluated and reclassified. Follow-up (F/U) was available on all cases. Atypical cases, (36) were reclassified as malignant (26), atypical favor benign (2)/reactive (3) and atypical, not otherwise specified (NOS) (5). Cases reclassified as malignant showed irregular nuclear contours, chromatin irregularities and rare mitosis. Nuclear enlargement, nucleoli and cellularity varied widely in all groups. N/C ratio was increased in most reclassified malignant cases. All 26 malignant reclassifications correlated with F/U of malignancy. Benign and reactive cases (5) were negative for malignancy on F/U (4), and in 1 case a metastatic carcinoma involving the biliary tree was found. In the 5 atypical (NOS) cases, F/U showed malignancy (3) and pancreatitis (2). Cytocentrifuge preparations made in our laboratory were of superior quality when compared to other methods of cell preparation. Irregularities in nuclear membrane and abnormal chromatin pattern were the most consistently useful features correlating with malignancy. The sensitivity and specificity of biliary brush cytology can be enhanced by using strict cytomorphologic criteria and proper collection and fixation, all of which decrease atypical diagnoses.

Diagnosis of biliary strictures in conjunction with endoscopic retrograde cholangiopancreaticography, with special reference to patients with primary sclerosing cholangitis.

Strictures of the bile ducts due to malignant changes are difficult to distinguish from benign changes, particularly in patients with primary sclerosing cholangitis (PSC). The aim of this study was to evaluate diagnostic methods for malignancy in biliary strictures in conjunction with endoscopic retrograde cholangiopancreaticography (ERCP). Bile duct strictures were identified during ERCP in 57 patients, who were thus included in the present study. Brush samples from the strictures were taken for cytology and for evaluation of DNA content by flow cytometry. The tumor markers CA 19-9 and CEA were determined both in serum and bile fluid. Two independent radiologists evaluated all cholangiograms. The diagnostic sensitivity, specificity, and accuracy of each diagnostic method were evaluated separately and in combination. 32 patients were found to have malignant strictures and when the four methods: brush cytology, DNA analysis, serum CA 19-9 and serum CEA were combined, a diagnostic sensitivity of 88 % and specificity of 80 % were reached. Seven of the 20 patients with PSC were found also to suffer from cholangiocarcinoma, yielding a sensitivity and specificity of 100 % and 85 %, respectively. Analyses of CA 19-9 and CEA in bile fluid had no diagnostic significance. An ERCP procedure with brush cytology, a DNA analysis, combined with serum analysis of CA 19-9 and CEA, can increase the possibility of distinguishing between malignant and benign biliary strictures, especially in PSC patients.

Familial dysautonomia: deep sedation and management in endoscopic procedures.

Familial dysautonomia is a rare genetic disorder that affects the development of the central nervous system, causing GI dysfunction. Because of an improved prognosis, elective surgical procedures are more common and present a unique problem to the anesthesiologist. All patients reported in the literature underwent these interventions under general anesthesia in the operating theater. We report our preliminary experience with deep sedation in the endoscopy room in patients with this rare syndrome. Four girls (7-16 yr old) underwent percutaneous endoscopic gastrostomy insertion and/or endoscopic retrograde cholangiopancreaticography. Preprocedure management consisted of adequate hydration and anxiolysis. Intraprocedure management consisted of stabilization of an erratic autonomic nervous system. Midazolam (0.1-0.2 mg/ kg) was administered i.v. before the procedure. Deep sedation was accomplished with propofol i.v. (0.5-1 mg/kg) and maintained with a propofol drip (50-100 microg/kg/min). Recovery was managed in the gastroenterology unit of our facility. Body temperature, ventilation, heart rate, blood pressure, oxygen saturation, and end-tidal CO2 were stable during the endoscopies. The patients regained consciousness at the end of the endoscopy and were able to drink or to eat as normal. Pain that could precipitate a crisis was present in two patients and was successfully treated with a simple analgesic. No other complications occurred. This rare genetic disorder presents unique management problems to the anesthesiologist, resulting in morbidity and mortality when general anesthesia is used. Our patients received appropriate management before endoscopy, and we performed the procedure under deep sedation. No complications occurred. We are thus confident that deep sedation in the endoscopy suite is safe in this rare syndrome.

Familial dysautonomia: deep sedation and management in endoscopic procedures

OBJECTIVES: Familial dysautonomia is a rare genetic disorder that affects the development of the central nervous system, causing GI dysfunction. Because of an improved prognosis, elective surgical procedures are more common and present a unique problem to the anesthesiologist. All patients reported in the literature underwent these interventions under general anesthesia in the operating theater. We report our preliminary experience with deep sedation in the endoscopy room in patients with this rare syndrome. METHODS: Four girls (7–16 yr old) underwent percutaneous endoscopic gastrostomy insertion and/or endoscopic retrograde cholangiopancreaticography. Preprocedure management consisted of adequate hydration and anxiolysis. Intraprocedure management consisted of stabilization of an erratic autonomic nervous system. Midazolam (0.1–0.2 mg/kg) was administered i.v. before the procedure. Deep sedation was accomplished with propofol i.v. (0.5–1 mg/kg) and maintained with a propofol drip (50–100 μg/kg/min). Recovery was managed in the gastroenterology unit of our facility. RESULTS: Body temperature, ventilation, heart rate, blood pressure, oxygen saturation, and end-tidal CO 2 were stable during the endoscopies. The patients regained consciousness at the end of the endoscopy and were able to drink or to eat as normal. Pain that could precipitate a crisis was present in two patients and was successfully treated with a simple analgesic. No other complications occurred. CONCLUSION: This rare genetic disorder presents unique management problems to the anesthesiologist, resulting in morbidity and mortality when general anesthesia is used. Our patients received appropriate management before endoscopy, and we performed the procedure under deep sedation. No complications occurred. We are thus confident that deep sedation in the endoscopy suite is safe in this rare syndrome.

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Is a preoperative multidiagnostic approach to predict surgical resectability of periampullary tumors still effective?

Background: Multimodality staging is recommended in patients with periampullary tumors to optimize preoperative determination of resectability. We investigated the potency of currently used diagnostic procedures in order to determine resectability. Methods: Ninety-five consecutive patients with periampullary tumors prehospitally staged resectable underwent preoperative diagnostic tests: helical-computed tomography (CT) with maximum intensity projection of arterial vessels (MIP), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreaticography (MRCP), endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreaticography (ERCP), digital subtraction angiography (DSA), and positron emission tomography (PET). Diagnoses were verified by surgery and histopathology. Results: In 45 patients with benign and 50 patients with malignant periampullary tumors sensitivity for tumor diagnosis was 89% to 96% in CT, MRI, EUS, and PET. Small tumors were best diagnosed by EUS (100%). Diagnosis of malignancy was made with 85% (EUS), 83% (CT), 82% (PET), and 72% (MRI) accuracy. Arterial vessel infiltration was best predicted by CT/MIP with an accuracy of 85%. For venous vessel infiltration MRI reached 85% accuracy. Accuracy rates for local nonresectability were 93% (EUS), 92% (MRI), and 90% (CT). Two and 4 of 8 patients with distant metastases were identified by CT and PET, respectively. The correct diagnosis of malignancy and determination of resectability was made by CT in 71% and by MRI in 70%. Biliary stenting reduced accuracy of CT diagnosis of malignancy from 88% to 73%. Conclusions: CT obtained before stenting was the single most useful test, providing correct diagnosis in 88% and resectability in 71% of patients. If no tumor is depicted in CT, EUS should be added. Uncertain venous vessel infiltration can be verified by MRI or EUS. Angiography should no longer be a routine diagnostic procedure. Equivocal tumors or possible metastasis may be further examined with PET.

Presence of melatonin in the human hepatobiliary-gastrointestinal tract

A variety of speculations about the possible origin and physiological role of the neurohormone melatonin in the gastrointestinal tract exist. However, the experimental evidence supporting any of these theories is not substantial and are missing for humans. We studied the distribution of melatonin which was measured with radioimmunoassay in the following compartments and organs of the human hepatobiliary-gastrointestinal tract: bile (obtained by endoscopic retrograde cholangiopancreaticography), peripheral venous and portal venous blood (obtained from patients undergoing liver transplantation), endoscopically derived biopsies (mainly consisting of mucosa and submucosa) of stomach, duodenum, large intestine as well as in resected liver tissue. Melatonin concentrations in gastrointestinal mucosa were between 136 ± 27 pg/100mg (stomach) and 243 ± 37 pg/100mg (descending colon, each n = 5). Biliary melatonin concentrations (85 ± 45 pg/ml) correlated well with plasma concentrations (55 ± 38 pg/ml, each n = 14) and a considerable amount of melatonin (about 51 ng/24 hours) appears to be excreted into the gut via the bile duct. Melatonin concentrations were slightly higher in portal than in peripheral venous blood and also the liver contained higher concentrations of melatonin than the blood. In conclusion the presence and distribution of melatonin in human gut, bile, liver and portal blood and the various reports on modulatory actions of melatonin on gut and liver functions suggest that melatonin may act as a mediator of inter-organ communication between gut and liver.

Choledochal cyst: a changing pattern of presentation.

The aim of the present paper was to study the spectrum of choledochal cysts and analyse the results of various surgical procedures. A prospective study was undertaken, at University Hospital, Varanasi, India, of 10 patients with choledochal cyst who presented between January 1996 and June 2000. The patients had a median age at presentation of 16.0 years (interquartile range (IQR): 13.75 years). All patients underwent ultrasonography and endoscopic retrograde cholangiopancreaticography for confirmation of diagnosis. Cyst excision was performed in eight patients followed by reconstruction by hepaticoduodenostomy and Roux-en-Y hepaticojejunostomy in four patients each. Two patients underwent cystoduodenostomy. One patient who underwent hepaticoduodenostomy had a minor leak that responded to conservative management. All patients were asymptomatic at a median follow up of 36.5 months (IQR: 31 months). There is a changing trend in the commonest mode and age of presentation; fewer patients are presenting with the classical triad and the mean age of presentation is higher. Reconstruction by hepaticoduodenostomy is equally effective, more physiological and less time consuming as compared to hepaticojejunostomy, if the anastomosis can be achieved without tension.