Search

Background Ideal surgical treatment for acute duodenal injuries should offer a definitive treatment, with low morbidity and mortality. It should be simple and easily reproducible by acute care surgeons in an emergency. Duodenal injury, due to major perforated or bleeding peptic ulcers or iatrogenic/traumatic perforation, represents a surgical challenge, with high morbidity and mortality. The aim was to review definitive surgery with pancreas-sparing, ampulla-preserving duodenectomy for these patients. Methods Pancreas-sparing, ampulla-preserving D1–D2 duodenectomy was used for patients presenting with major duodenal injuries over a 5-year interval. The ampulla was identified and preserved using a transcystic/transpapillary tube. The outcomes were recorded. Results Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65–84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170–377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1–11) days), and the overall mean hospital stay was 17·8 (range 10–32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications. Conclusion Pancreas-sparing, ampulla-preserving D1–D2 duodenectomy for emergency treatment of major duodenal perforations is feasible and associated with satisfactory outcomes.

Background The fate of the portal vein (PV) after pancreatoduodenectomy, especially its long-term patency and associated complications, has received little attention. The aim of this study was to explore the long-term patency rate of the PV after pancreatoduodenectomy, focusing on risk factors for PV stenosis/occlusion and associated complications. Methods Serial CT images of patients who underwent pancreatoduodenectomy for periampullary cancer between January 2000 and June 2012 in a single institution were evaluated for PV stenosis or occlusion. Results A total of 826 patients were enrolled. The PV stenosis/occlusion rate after pancreatoduodenectomy was 19·6 per cent and the 5-year patency rate 69·9 per cent. The most frequent cause of PV stenosis/occlusion was local recurrence followed by postoperative change and PV thrombosis. Patients who underwent PV resection had a higher PV stenosis/occlusion rate than those who did not (51 versus 17·4 per cent; P < 0·001). The 3-year patency rate was highest in patients with cancer of the ampulla of Vater and lowest in patients with pancreatic cancer (91·9 versus 55·5 per cent respectively; P < 0·001). Multivariable analysis showed that risk factors for PV stenosis/occlusion included primary tumour location, chemoradiotherapy and PV resection. PV stenosis or occlusion without disease recurrence was observed in 17·3 per cent of the patients. PV resection and grade B or C pancreatic fistula were independent risk factors for PV stenosis/occlusion. Among 162 patients with PV stenosis or occlusion, five (3·1 per cent) had fatal recurrent gastrointestinal bleeding. Conclusion PV stenosis or occlusion is common after pancreatoduodenectomy, particularly if the PV has been resected and/or chemoradiotherapy was given after surgery. Although recurrence is the most frequent cause of PV stenosis/occlusion, this complication is found in a significant proportion of patients without disease recurrence.

Background High-volume institutions are associated with improved clinical outcomes for pancreatic cancer. This study investigated the impact of centralizing pancreatic cancer surgery in the south of the Netherlands. Methods All patients diagnosed in the Eindhoven Cancer Registry area in 1995–2000 (precentralization) and 2005–2008 (implementation of centralization agreements) with primary cancer of the pancreatic head, extrahepatic bile ducts, ampulla of Vater or duodenum were included. Resection rates, in-hospital mortality, 2-year survival and changes in treatment patterns were analysed. Multivariable regression analyses were used to identify independent risk factors for death. Results Some 2129 patients were identified. Resection rates increased from 19·0 to 30·0 per cent (P < 0·001). The number of hospitals performing resections decreased from eight to three, and the annual number of resections per hospital increased from two to 16. The in-hospital mortality rate dropped from 24·4 to 3·6 per cent (P < 0·001) and was zero in 2008. The 2-year survival rate after surgery increased from 38·1 to 49·4 per cent (P = 0·001), and the rate irrespective of treatment increased from 10·3 to 16·0 per cent (P < 0·001). There was no improvement in 2-year survival in non-operated patients. After adjustment for relevant patient and tumour factors, those undergoing surgery more recently had a lower risk of death (hazard ratio 0·70, 95 per cent confidence interval 0·51 to 0·97). Changes in surgical patterns seemed largely to explain the improvements. Conclusion High-quality care can be achieved in regional hospitals through collaboration. Centralization should no longer be regarded as a threat by general hospitals but as a chance to improve outcomes in pancreatic cancer.

Background This study compared multislice computed tomography (MSCT) with endoscopic ultrasonography (EUS) in the diagnosis and staging of pancreatic and periampullary malignancy. Methods Data were collected prospectively on patients having MSCT and EUS for suspected pancreatic and periampullary malignancy. Results Eighty-four patients had MSCT and EUS, of whom 35 underwent operative assessment (29 resections). In assessing malignancy, there was no significant difference between MSCT and EUS, and agreement was good (82 per cent, κ = 0·49); the sensitivity and specificity of MSCT were 97 and 87 per cent, compared with 95 and 52 per cent respectively for EUS (P = 0·264). For portal vein/superior mesenteric vein invasion, MSCT was superior (P = 0·017) and agreement was moderate (72 per cent, κ = 0·42); the sensitivity and specificity were 88 and 92 per cent for MSCT, and 50 and 83 per cent for EUS. For resectability, there was no significant difference and agreement was good (78 per cent, κ = 0·51). EUS had an impact on the management of 14 patients in whom MSCT suggested benign disease or equivocal resectability. Conclusion MSCT is the imaging method of choice for pancreatic and periampullary tumours. Routine EUS should be reserved for those with borderline resectability on MSCT.

Background Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy. Methods A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990. Results Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2·62 (95 per cent confidence interval (c.i.) 1·91 to 3·60)). A higher overall morbidity rate was also demonstrated in this group (RR 1·43 (95 per cent c.i. 1·26 to 1·61)), as was a higher mortality rate (RR 2·51 (95 per cent c.i. 1·61 to 3·91)). Conclusion Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.

Background It is not known whether pylorus-preserving duodenopancreatectomy is as effective as the classical Whipple procedure in the resection of pancreatic and periampullary tumours. A prospective randomized trial was undertaken to compare the results of the two procedures. Methods Clinical data, histological findings, short-term results, survival and quality of life of all patients having surgery for suspected pancreatic or periampullary cancer between June 1996 and September 2001 were analysed. Results Two hundred and fourteen patients were randomized to undergo either a standard or a pylorus-preserving Whipple resection. After exclusion of 84 patients on the basis of intraoperative findings, 130 patients (66 standard Whipple operation and 64 pylorus-preserving resection) were entered into the trial. Of these, 110 patients with proven adenocarcinoma (57 standard Whipple and 53 pylorus-preserving resection) were analysed for long-term survival and quality of life. There was no difference in perioperative morbidity. Long-term survival, quality of life and weight gain were identical after a median follow-up of 63·1 (range 4–93) months. At 6 months, capacity to work was better after the pylorus-preserving procedure (77 versus 56 per cent; P = 0·019). Conclusion Both procedures were equally effective for the treatment of pancreatic and periampullary cancer. Pylorus-preserving Whipple resection offers some minor advantages in the early postoperative period, but not in the long term.

Background Following pylorus-preserving pancreatoduodenectomy (PPPD), most surgeons use gastrointestinal reconstruction with an end-to-side duodenojejunostomy placed distally to the pancreatojejunostomy and choledochojejunostomy. In contrast, the authors have consistently used PPPD with the Imanaga reconstruction (PPPD-Imanaga) which consists of end-to-end duodenojejunostomy, end-to-side pancreatojejunostomy and choledochojejunostomy, performed in that order. In this study, the movement of bile and food after PPPD-Imanaga was evaluated to document the functional advantages of this method. Methods Twenty-four patients who had undergone PPPD-Imanaga were subjected to hepatobiliary and gastrointestinal dual scintigraphy. The interval between operation and scintigraphy ranged from 28 days to 67 months. Six of the 24 patients underwent repeated dual scintigraphy for the observation of temporal changes in gastrointestinal function. Results The incidence of biliogastric reflux and bile stasis in the jejunal loop was markedly decreased at times later than 2 months after operation. Delay of gastric emptying and bile evacuation, sometimes accompanied by stasis in the jejunal loop, affected the mixing status of bile and food at 1 h after the beginning of imaging. A majority of the patients, however, had a satisfactory mixing status at 2 h. Conclusion The Imanaga reconstruction appears to be a recommendable procedure following PPPD, in light of the bile and food movement achieved in the gastrointestinal tract.

BackgroundSpiral computed tomography (CT) allows high-resolution examination of the pancreas, surrounding vascular structures, lymph nodes and liver. Endoscopic ultrasonography (EUS) also allows high-resolution imaging of the pancreas and adjacent structures but is an invasive procedure. With the availability of spiral CT, the role of EUS in the investigation of patients with suspected pancreatic or ampullary tumours is unclear.MethodsForty-eight patients with clinical suspicion of a pancreatic or ampullary tumour underwent both spiral CT and EUS. Thirty-four patients had surgical exploration, of whom 17 underwent pancreatic resection and 17 had biliary and gastric bypass. The results of spiral CT and EUS were compared with the operative findings.ResultsThe final histological diagnosis was ductal adenocarcinoma (24 patients), ampullary carcinoma (six), serous cystadenoma (two) and chronic pancreatitis (two). EUS demonstrated 33 and spiral CT 26 of the 34 primary lesions. EUS was particularly useful in the assessment of small resectable tumours missed by spiral CT. The sensitivity and specificity of EUS and spiral CT for detecting involvement by the tumour of the superior mesenteric vein, portal vein and lymph nodes were similar, but EUS was less effective at evaluating the superior mesenteric artery.ConclusionEUS is an important additional investigation after spiral CT in patients with a suspected pancreatic or ampullary tumour.

Background Transient gastric stasis immediately after pylorus-preserving pancreatoduodenectomy (PPPD) is a common complication, but the cause remains unknown. Changes in gastric emptying were investigated in patients undergoing PPPD for periampullary malignancy. Methods In 14 patients undergoing PPPD, liquid- and solid-phase gastric emptying were evaluated before and after operation (mean 38 (range 27–53) days after operation). Two pharmacological gastric-emptying tests were used: the acetaminophen test for liquid-phase emptying and the sulphamethizole capsule food test for solid-phase gastric emptying. Results All patients exhibited delayed solid emptying but fairly good liquid emptying. Conclusion Gastric function in the early postoperative period after PPPD is characterized by delayed solid-phase but good liquid-phase emptying.

Background Treatment of ampullary adenoma is complicated by difficult preoperative staging, malignant potential and a high recurrence rate. This study was designed to assess the accuracy of diagnosis and staging by endoscopic biopsy and endosonography, and to compare the results of local resection and pancreaticoduodenectomy (Whipple procedure). Methods All 23 patients, diagnosed by endoscopic biopsy and surgically treated by local resection (n = 12) or pancreaticoduodenectomy (n = 11) between 1984 and 1994, were analysed retrospectively. Results Pancreaticoduodenectomy was associated with more complications (seven of 11 patients versus three of 12) and a longer hospital stay (36 versus 18 days) than local resection. After local resection tumour excision was incomplete in half of the patients. One patient died after a Whipple procedure. Endoscopic biopsy did not identify infiltrating carcinoma in seven of the 23 patients. Endoscopic ultrasonography had a 44 per cent accuracy rate for tumour invasion and was false positive for lymph node metastases in five of 16 patients. After local resection one recurrence was observed during follow-up and one possibly died from turnour recurrence. Conclusion Diagnosis and staging of ampullary adenomas by endoscopic biopsy and endosonography ws unreliable. Local resection seems a viable alternative for patients whose general condition does not allow a Whipple procedure.

Significant complications continue to occur in a minority of patients undergoing pancreaticoduodenectomy; these frequently have fatal consequences. Analysis of 458 patients undergoing the Whipple procedure in this institution from 1972 to 1994 revealed that 16 patients with malignant periampullary tumours (ampullary, eight; pancreatic, seven; bile duct, one), and one patient with chronic pancreatitis subsequently required completion pancreatectomy. Postoperative difficulties after pancreaticoduodenectomy and indications for re-exploration were multifactorial: leakage (n = 8), pancreatitis (n = 7), bleeding (n = 1), and a delayed report of cancer at the margin of the pancreatic transection (n = 1). Completion pancreatectomy was often difficult (mean operating time 2.7 h, mean estimated blood loss 1897 ml). There was considerable significant postoperative morbidity (41 per cent) and mortality (24 per cent) after completion pancreatectomy. Patients who survived completion pancreatectomy lived a mean of nearly 4 years (range 4 months to 9.7 years, median 2.6 years). Tumour recurrence led to death in ten of 13 patients. Three patients remain alive and free of recurrence each more than 8 years after resection. Re-exploration and subsequent completion pancreatectomy after pancreaticoduodenectomy is rarely necessary, but if clinical manifestations occur secondary to failure of the pancreaticojejunostomy, early surgical intervention may maximize survival.

Between 1983 and 1994, 66 patients with cancer of the ampulla of Vater were studied to identify prognostic factors and determine who might benefit from radical resection. Three patients (4.5 per cent) died after operation. Radical resection including lymphadenectomy resulted in potentially curative (R0) resection in 92 per cent. The rate of nodal positivity increased with tumour diameter. Patients with up to two positive lymph nodes had a more favourable prognosis than other patients (P < 0.001). Median survival time for all patients was 41 months; the 5-year survival rate was 35 per cent. Radical resection and lymphadenectomy should therefore be the treatment of choice for patients with tumours of the ampulla of Vater.

A retrospective study of 310 patients with carcinoma of the head of the pancreas or periampullary region was performed. Preoperative bile drainage by placement of a stent reduced the number of postoperative complications, especially bleeding (P = 0·03). The operative mortality rate was nil in patients with periampullary cancer aged under 70 years and 23 per cent in those over 70 years of age (P < 0·001). In the last 2 years of the study, the mortality rate following resection decreased to 2 per cent. Tumour-containing resection margins did not influence survival after resection (P = 0·48). Tumour dimension of pancreatic and periampullary cancer and the presence of tumour in locoregional lymph nodes (N1a) resected with the primary tumour in cancer of the head of the pancreas were of no prognostic value. Following palliative resection of carcinoma of the pancreatic head, median survival was significantly better than when no resection was performed (10·1 versus 3·9 months, P < 0·001). In conclusion, even palliative resection may benefit some patients. Preoperative bile drainage is indicated in those with jaundice. Resection should be performed, irrespective of tumour size, provided that the unit's operative mortality rate is sufficiently low.

Duodenal adenomas occur almost inevitably in patients with familial adenomatous polyposis (FAP) whereas gastric adenomas are rare. FAP patients are also at high risk of duodenal cancer. Within the duodenum, adenomas cluster around the ampulla of Vater, as do the majority of duodenal cancers, suggesting that bile plays a role in tumour development. We therefore tested duodenal bile from 29 postcolectomy FAP patients (27 of whom had duodenal adenomas) and 24 non-FAP patients for mutagenicity, using techniques that detect point mutations in bacteria. Results which appeared to show that FAP bile was more mutagenic than control bile could be accounted for by a feeding effect, elimination of which also eliminated ‘mutagenicity’. Under the conditions of our assays we conclude that if bile is an important factor in genesis of duodenal tumours, it does not act by inducing point mutation.

Between 1984 and 1987, 176 Norwegian patients with histologically verified unresectable pancreatic adenocarcinoma were randomized to double-blind treatment with oral tamoxifen (30 mg daily; 48 men and 44 women) or placebo (47 men and 37 women). Analysis of oestrogen receptor activity in the carcinomas was not performed. There were no statistically significant differences between the two groups according to age, Karnofsky performance index, tumour node metastasis (TNM) stage, operative treatment or other patient characteristics. The tamoxifen or placebo treatment continued to death or to 10 months after accrual into the trial was stopped. In the tamoxifen group, the mean and median survivals were 205 and 115 days, respectively. These values did not differ statistically from the 192 and 122 days, respectively, observed in the placebo group. Additional retrospective analyses of sex and stage revealed no beneficial effect of tamoxifen upon survival. For women in stage III (any TN1 M0), mean and median survivals were 255 and 191 days, respectively, compared with values of 84 and 45 days, respectively, in the placebo group (P = 0·011). After 2·5 years, three (7 per cent) women in the tamoxifen group were still alive compared with no survivors in the placebo group. No male patients survived beyond 2·5 years. This therapeutic result in a small subgroup of women is probably incidental and not an effect of tamoxifen.

Background According to some studies, the number of lymph nodes with metastases in relation to the total number of removed lymph nodes, the lymph node ratio (LNR), is one of the most powerful predictors of survival after resection in patients with pancreatic cancer. However, contradictory results have been reported, and small sample sizes of the cohorts and different definitions of a microscopic positive resection margin (R1) hamper the interpretation of data. Methods The predictive value of LNR for 3-year survival was assessed using a Cox proportional hazards model. From 1992 to 2012, all patients with pancreatic and periampullary cancer operated on with pancreatoduodenectomy were selected from a database. Clinicopathological characteristics were analysed. Microscopic positive resection margin was defined as the microscopic presence of tumour cells within 1 mm of the margins. A nomogram was created. Results Some 760 patients were included. Predictive factors for death in 350 patients with pancreatic ductal adenocarcinoma included in the nomogram were: R1 resection (hazard ratio (HR) 1·55, 95 per cent c.i. 1·07 to 2·25), poor tumour differentiation (HR 2·78, 1·40 to 5·52), LNR above 0·18 (HR 1·75, 1·13 to 2·70) and no adjuvant therapy (HR 1·54, 1·01 to 2·34). The C statistic was 0·658 (0·632 to 0·698), and calibration was good (Hosmer–Lemeshow χ2 = 5·67, P =0·773). LNR and poor tumour differentiation (HR 4·51 and 3·30 respectively) were also predictive in patients with distal common bile duct (CBD) cancer. LNR, R1 resection and jaundice were predictors of death in patients with ampullary cancer (HR 7·82, 2·68 and 1·93 respectively). Conclusion LNR is a common predictor of poor survival in pancreatic, distal CBD and ampullary cancer.

Exocrine pancreatic function was measured in 14 patients after pancreaticoduodenectomy for periampullary neoplasms in order to assess the patency of a sutureless pancreatico-enteric anastomosis. Pancreatic function was examined by the p-aminobenzoic acid/p-aminosalicylic acid (PABA/PAS) test 3–160 months after operation and compared with age- and sex-matched controls. There were no significant differences between mean (s.e.m.) serum PABA concentrations 3 h after ingestion of N-benzoyl-l-tyrosyl-PABA (25·5 (3·6)) μmol/l for patients, 26·1 (2·0 (μmol/l for controls)). However, the mean (s.e.m.) PABA excretion index was significantly lower in the patients (0·58 (0·08)) than in the controls (0·76 (0·04)). Four patients required pancreatic enzyme supplements for control of diarrhoea. Self-limiting pancreatic leaks occurred in two patients. The results suggest that the sutureless pancreatico-enteric anastomosis has an acceptably low leakage rate but that pancreatic exocrine function is diminished following pancreaticoduodenectomy with this technique. However, the majority of patients require no enzyme supplements and no significant tendency to late stenosis of the anastomosis was demonstrated.

Communication with the biliary tree is the most common complication of hydatid disease of the liver and up to a few years ago surgery was the only way to treat it successfully. The introduction of endoscopic sphincterotomy represented a great advance in the management of this disease. We report the results obtained with this technique in ten patients after surgical treatment of hepatic hydatid disease open to the biliary tree. The results were satisfactory in all cases, with no morbidity or mortality. Endoscopic sphincterotomy is now the first choice treatment for surgical complications of hepatic hydatid disease open to the biliary tree, as well as the drainage procedure of choice in patients with cholangitis due to hydatid disease.

Of 36 patients with carcinoma of the ampulla of Vater who underwent surgery between 1971 and 1990, 31 had a radical operation. There was one operative death. The overall 5- and 10-year survival rates were 56 and 37 per cent respectively. Survival was significantly influenced by tumour stage (P = 0·0002), lymph node status (P = 0·006) and the degree of differentiation of the lesion (P = 0·01). Three patients developed local recurrence after local excision of the tumour. Local or hepatic recurrence was common, even 5 years after pancreatoduodenectomy (four of 18 patients who suffered relapse). Radical resection can be curative in selected patients with ampullary carcinoma but late recurrence suggests the need for careful lifelong follow-up.

Summary Endoscopic sphincterotomy (ES) is a simple, effective and remarkably safe method of treatment of choledocholithiasis and papillary stenosis. In this series, ES was technically successful in 255 (86·1 per cent) of 296 patients in whom it was attempted. Forty-nine of the successful cases had papillary stenosis complicated by pain, cholangitis and/or jaundice in patients after cholecystectomy; 205 had choledocholithiasis, of whom 164 had a cholecystectomy and 41 were poor surgical risks and did not have cholecystectomy. One patient had a tumour of the ampulla of Vater. ES has been performed as an emergency in 16 subjects because of severe septic cholangitis in 11 and acute biliary pancreatitis in 5. Of the 205 patients with choledocholithiasis, spontaneous passage of calculi after ES occurred in 151 cases (73·6 per cent), and instrumental extraction of stones was possible in 44 (21·5 per cent); 10 patients (4·9 per cent) had residual stones and required surgery. In this series the overall success rate of ES in removing common bile duct stones was 82 per cent in 238 cases; in the patients with benign papillary stenosis ES was successful in relieving symptoms and biochemical cholestasis in 72 per cent of 57 cases. Complications occurred in 18 cases (7 per cent): cholangitis in 4 (1·6 per cent) and haemorrhage in 14 (5·4 per cent). Two patients (0·8 per cent) with acute bleeding following ES died; in one of these surgery had been performed to arrest the haemorrhage, but the patient died 3 days after operation of hepatorenal failure. The other complications were treated conservatively without mortality.

One hundred patients with pancreatic and periampullary carcinoma have been reviewed. Diabetes mellitus may be an early presentation. Painless jaundice has a relatively good prognosis. Fifteen patients have had curative procedures with a 31 per cent operative mortality. Mortality is influenced by age and serum bilirubin levels. Where palliative procedures are undertaken, this should include biliary diversion and gastro-enterostomy.

Eighty-seven patients with carcinoma of the periampullary region treated by the author are reviewed. The clinical presentation and investigations are reported, and it is emphasized that the poor prognosis of this disease is due to the delay in presentation and diagnosis. Consequently, in most cases treatment can only be palliative, and the various forms of treatment are discussed.

Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23·0 per cent of all cases of gallstone-related acute cholangitis and 14·4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4·3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 percent; P = 0·10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5·7 per cent) with acute cholangitis alone (P

Surgical exploration of the common bile duct carries considerable risks in elderly and frail patients. Peroral, fibreoptic duodenoscopy allows access to the papilla of Vater in sedated patients and the opportunity to perform a diathermy sphincterotomy for removal of bile duct stones. We have attempted sphincterotomy in 134 patients, most of whom had previously undergone cholecystectomy and had some contraindication to a further operation. Sphincterotomy was technically successful in 129 patients (96 per cent), and all duct stones were removed in 119 patients (92·5 per cent of successful sphincterotomies). The technique failed only once in 95 patients with stones less than 14 mm diameter. Immediate complications occurred in 10 patients, 3 of whom required emergency surgery; 1 patient died. Endoscopic diathermy sphincterotomy is a major therapeutic advance in the management of elderly and high risk patients with bile duct stones. No significant adverse effects have yet been revealed in follow-up studies. However, the possibility of long term complications dictates the need for caution in offering this procedure to young patients who are fit for reoperation.

Patients with normal gallbladders were subjected to computer-assisted Tc-HIDA cholescintigraphy at fixed intervals after major surgery. Hepatic time–activity curves showed that hepatic excretion of the material was first reduced and later a reduction of hepatic uptake followed. The gallbladder responded first by dilatation and reduction of motility and later by delay in or even absence of visualization. Postoperative dilatation was confirmed with real-time ultrasonography. No tracer passed into the duodenum in the early postoperative stage indicating spasm of the sphincter of Oddi. Healthy volunteers were studied with and without morphine and with and without a 24 h fast. The sphincter of Oddi closed after morphine but not after fasting. Transient non-visualization of the gallbladder after surgery makes the diagnosis of postoperative cholecystitis more difficult.

Recurrent pyogenic cholangitis is a condition prevalent in Asia. Surgery has been the only form of treatment when extrahepatic and/or intrahepatic biliary dilatation, irregularity, debris and calculi are present. Endoscopic sphincterotomy was attempted in 134 such patients, the majority of whom had calculi confined to the common bile duct, and in whom 85.8 per cent were over 60 years old, 61.2 per cent had previous biliary surgery, and 36.6 per cent had an associated major medical illness. Sphincterotomy was successful in 88 per cent of patients, good results were obtained in 81.3 per cent, and stone removal was achieved in 91.7 per cent of those with demonstrable biliary calculi. Major complications occurred in 7.5 per cent, resulting in emergency surgery in 3 per cent and death in 1.5 per cent. The mortality of surgical sphincteroplasty in 143 patients with this condition who were over 60 years old was known to be 7 per cent. Five of 109 patients without residual calculi after endoscopic sphincterotomy developed mild to moderate symptoms after a follow-up period of 6 months to 6 years (median 2.3 years). Endoscopic sphincterotomy is a safe and effective form of treatment in patients with recurrent pyogenic cholangitis whose calculi are confined to the common bile duct.

Forty-one patients presented to our hospital between 1959 and 1983 with periampullary carcinoma. Twenty-six (63 per cent) underwent radical surgery, eight (20 per cent) local excision of the tumour, six (15 per cent) had bypass procedures and one was treated by endoscopic sphincterotomy (2 per cent). Potentially curative resection was performed in 83 per cent of the 41 patients. The operative mortalities for radical, local and bypass surgery were 7·7 per cent, 25 per cent and 16·6 per cent respectively. The degree of tumour differentiation significantly affected survival while local spread did not significantly affect survival in patients treated radically. The 5 year survival rates (calculated actuarially) for radical, local and bypass surgery were 34,44 and 0 per cent respectively.

Six patients are described to illustrate the operative management of tubulovillous neoplasms of the duodenum. Pancreaticoduodenectomy is appropriate for associated invasive carcinoma. Transduodenal submucosal excision of tubulovillous neoplasms with resection and reconstruction of the distal bile and pancreatic ducts if necessary is a satisfactory alternative when the neoplasm has not penetrated the muscularis mucosae.

The indications and results of 394 endoscopic sphincterotomies (ES) performed over a 6 year period from a single centre are described. The indications for ES were common bile duct (CBD) calculi (81 per cent), papillary stenosis (9 per cent), periampullary tumours, insertion of endoprostheses, sump syndrome and biliary dilatation for benign strictures. ES was achieved in 98 per cent of patients. In the calculus group the CBD was cleared of stones in 93·3 per cent following a successful ES (92 per cent overall success rate for CBD clearance). Early complications (⩽ 1 month) occurred in 41 patients (10-4 per cent) of which haemorrhage accounted for nearly half. Emergency surgery following ES was undertaken in 15 patients (3·8 per cent). There were 13 deaths within one month of ES (3·3 per cent) of which three were directly attributable to ES (0·8 per cent). The diagnosis and management of complications following ES is important with increasing numbers of patients being treated from outside the referral centre.

Sphincter of Oddi motility was evaluated in post-cholecystectomy patients with indwelling T tubes during fasting and after feeding. A triplelumen catheter was positioned to record from the sphincter of Oddi and duodenum. The sphincter of Oddi was characterized by phasic contractions independent of duodenal contractions. During fasting duodenal wave frequency exhibited four phases, whereas only two phases could be identified from the sphincter of Oddi. A prolonged phase A in the sphincter of Oddi corresponded to duodenal phases I, II and IV. A short phase B in the sphincter of Oddi just preceded the onset of duodenal phase III and was temporally related to it. Sphincter of Oddi basal pressure increased during duodenal phases III and IV. After ingestion of food, sphincter of Oddi basal pressure, wave amplitude and duration decreased, but the frequency remained unchanged. Conversely, duodenal frequency increased but there was no change in amplitude. Thus, the human sphincter of Oddi and duodenum exhibited independent motility demonstrating distinct phases during the interdigestive period. After food, sphincter of Oddi motility altered in a manner which would facilitate the passive flow of fluid into the duodenum.

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n=6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6·3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63·3 per cent) and 11 patients had a poor outcome (36·7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0·0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean ± s.d. mm, 12·6 ± 3·6 versus 8·8±1·8, P = 0·0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0·02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0·003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.

The author reports his experiences with a technique which is extremely helpful not only in distinguishing between intra- and extrahepatic cholestasis but also in establishing preoperatively the aetiology of the jaundice, in this way helping the surgeon to choose the best surgical procedure. The technique employed, the criteria of selection of the patients, the complications, and the results obtained in 53 patients are described. To date, 53 patients have undergone percutaneous transhepatic cholangiography, and a total of 56 examinations have been performed in the radiography department under local anaesthesia. In 1 patient a severe bile leakage occurred with signs and symptoms of biliary peritonitis and peralytic lesions. The biliary tree was outlined in 41 patients out of 47 (87.2 per cent) with obstructive jaundice. In 6 patients the method failed (12.8 per cent).

The incidence of pancreatitis complicating biliarytract operations is reported from a prospective survey of 75 patients. This study confirms that pancreatitis is much more frequent after choledochotomy than after cholecystectomy alone. Biochemical pancreatitis was demonstrated in over a third of the patients in whom the duct was explored. The validity of elevated serum amylase in the diagnosis of this complication is established provided that clinical evidence of pancreatitis is also present. The significance of amylasaemia in the immediate postoperative period in the absence of clinical signs is questioned. Reflux of duodenal contents into the pancreatic duct may be provoked by operative damage to the sphincter of Oddi. In these patients clinical pancreatitis invariably occurred. The avoidance of sphincterotomy in the prevention of this potentially serious postoperative complication is advised. Since pancreatitis was more common after negative exploration of the common bile-duct the value of operative cholangiography in the avoidance of this complication is discussed.

Thirty-one cases of carcinoma of the ampulla of Vater and duodenum have been classified on the basis of pathological criteria. Two types of tumour were discernible. Nine were polypoid papillary adenocarcinomas occurring at the ampulla of Vater; 19 were adenocarcinomas without a papillary pattern, of which 4 were duodenal tumours and 15 were ampullary. There were 3 ampullary tumours of mixed type. The carcinomas without a papillary structure were more invasive, more often associated with abdominal pain, more frequently misdiagnosed, and were associated with a higher mortality-rate. The data were insufficient to draw firm conclusions as to the prognosis but the clinical behaviour was related to the pathology of the tumours. Lesions in the ampullary region were associated with jaundice which was often intermittent. Lesions outside the ampullary area presented early with vomiting of pyloric type but without jaundice. The importance of a high index of suspicion in dealing with these lesions and the value of barium-meal examinations are emphasized. It is noted that pancreaticoduodenectomy for ampullary carcinoma has a mortality of less than 25 per cent if performed by an experienced surgeon and can be considerably lower in clinics specializing in this condition. We suggest that the pathological classification of these tumours used in this paper may form the basis for further investigations into the diagnostic and prognostic problems which these tumours present. This classification of ampullary tumours is a factor to be considered in assessing the indications for pancreaticoduodenectomy.