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Background and aims Anastomotic strictures are well-known complications after bilioenterostomy. Endoscopic procedures are usually not possible in patients with a bilioenterostomy. Hence, percutaneous transhepatic biliary drainage (PTBD) has become the treatment of choice for the management of these patients. The main goal of the present study was to analyze the long-term follow-up of PTBD in such patients. Methods and patients Between January 1996 and December 2006, 44 patients with benign anastomotic stricture after bilioenterostomy were identified by an analysis of the PTBD database, hospital charts, and cholangiograms. Results In 27/44 patients the percutaneous transhepatic biliary drain was successfully removed after 19.9 +/- 16.1 months (treatment success in 61.4 %). During a mean follow-up of 53.7 +/- 28.4 months after removal of the drain, no evidence was found of recurrent strictures in these patients. Ten out of 44 patients carry permanent drains (22.6 % of patients with ongoing treatment, mean follow-up 46.4 +/- 54.7 months) without the option for further surgery owing to concomitant disease (n = 2) or because they refused further surgery (n = 8). In 7 out of 44 patients (16 %) PTBD treatment was deemed to have failed and the patients underwent repeat operation. Conclusions PTBD should be considered the treatment of choice in patients with benign anastomotic stricture after bilioenterostomy, especially after stricturing of a hepatojejunostomy.

INTRODUCTION: Simulators facilitate the acquisition of technical skills for endoscopy. Here, we describe the development, introduction, and first evaluation of a novel generation of mechanical endoscopic retrograde cholangiopancreatography (ERCP) simulation models with simulated fluoroscopy, the X-Vision ERCP Training System. METHODS: A custom-made modular ERCP simulation system was built with the use of universally obtainable materials and tools. The trainee controls ERCP activities on two screens: the aspect of the papilla and duodenum is shown on the conventional endoscopy monitor, and the trainee’s actions in the equivalents of the pancreaticobiliary ducts are shown on the viewing screen of the model. Thereby, the latter screen serves as a substitute for fluoroscopy. Currently, four different models are available, allowing simulation of selective cannulation of the pancreatic or bile duct, intubation of differently arranged papillae, stent placement, and sphincterotomy of a biopapilla. The X-Vision ERCP Training System was first used during an ERCP course attended by 26 endoscopists. Trainees were supervised by an ERCP expert and an experienced ERCP nurse at each training model. The training system was evaluated by the participants and experts using a specific questionnaire. RESULTS: During the course there were no technical problems related to the X-Vision ERCP Training System. After sphincterotomy the organic papillae could easily be exchanged within less than 15 seconds. Overall, the X-Vision ERCP Training System achieved favorable results in all categories assessed. CONCLUSION: The new X-Vision ERCP Training System is simple and effective. A first evaluation in the context of an ERCP course showed impressive results.

We report about detailed hemodynamic changes and one major cardiac complication occurring after submucosal injection of epinephrine (1 : 10 000) for management of upper gastrointestinal bleeding in a series of four consecutive patients. Cardiac contractility and afterload, determined by the cardiac index and the systemic vascular resistence index (SVRI), were assessed by transpulmonary thermodilution using the Pulse Contour Cardiac Output monitoring system (PiCCO; Pulsion Medical Systems, Munich, Germany), and the mean arterial pressure and heart rate were recorded. We observed a distinct rise in both mean arterial pressure and heart rate, and this effect was pronounced in the three patients with esophageal lesions. The increase in the mean arterial pressure was caused by an elevation of the cardiac index in two patients, a rise in both cardiac index and SVRI in one patient, and a rise in the SVRI only in the fourth patient. One patient, who had received 30 ml epinephrine for treatment of a bleeding Mallory-Weiss tear, developed an acute myocardial infarction during the postprocedural follow-up period. In conclusion, submucosal injection of epinephrine may cause significant hemodynamic changes that can potentially lead to adverse cardiac events. Close cardiac monitoring during and after submucosal application of epinephrine therefore seems a prudent precaution. In the treatment of esophageal lesions, the total amount of epinephrine injected should be carefully titrated, so that the lowest possible volume that achieves adequate hemostasis is used.

A 53−year−old woman with a 17−year his− tory of multiple sclerosis, presented with abdominal pain and bowel distension. The computed tomography (CT) scan showed massive dilation of the colon (Fig− ure 1). The patient had a long history of chronic intestinal pseudo−obstruction, which so far had always resolved after co− lonoscopic decompression and placement of a colon tube. This time once again, after endoscopic evacuation of the trapped air, the patient s situation improved rapidly. In the course of the hospital stay it be− came clear that decompression was need− ed every third day. Therefore, we aimed for a permanent solution, and we chose an endoscopic approach.