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Background and Study Aims: Diagnostic imaging of the biliary tract is often required in liver transplant recipients, preoperatively to assess extent of biliary tract disease and postoperatively in patients with a suspected biliary complication due to an abnormal postoperative course., Patients and Methods: Over a six-year period, 115 patients received 127 liver transplantations at our institution. Twenty-three preoperative ERCPs were performed in 17 patients, while 25 ERCPs were performed on 15 patients after liver transplantation., Results: Preoperative ERCP in seven of 17 patients revealed a dominant biliary stricture as a result of primary sclerosing cholangitis (PSC); five of these patients were managed successfully with the placement of biliary endoprosthesis. An additional nine patients with PSC underwent brush cytology of the extrahepatic bile ducts to rule out coexisting cholangiocarcinoma; there were no positive results, although three were found to have coexisting cholangiocarcinoma after examination of the explanted liver. Postoperatively, nine of 15 patients were found to have biliary tract disease. These included five biliary strictures (three treated successfully by endoscopic dilation and stent therapy), two biliary leaks (treated by biliary endoprosthesis), one biloma (treated by percutaneous drainage) and one intraductal stone (treated successfully by sphincterotomy and stone extraction). The remaining six patients showed no abnormality at ERCP, and were subsequently diagnosed with allograft rejection., Conclusions: Diagnosis of biliary complications after hepatic transplantation is often problematic. Definitive characterization frequently requires cholangiography. Interventional biliary procedures, both endoscopic and percutaneous, can be used successfully to treat these complications; however, surgical revision and retransplantation are sometimes required.

Laparoscopic cholecystectomy is an effective and safe treatment for uncomplicated symptomatic cholelithiasis. However, biliary tract injury may be more common with this procedure than with open cholecystectomy. We have encountered 17 patients with a biliary leak among 465 patients undergoing laparoscopic cholecystectomy, the diagnosis being established by clinical and radiographic parameters. The most common site of leakage was the cystic duct stump. Patients underwent endoscopic sphincterotomy and biliary stent placement, with an overall success rate of 96%. No morbidity or mortality related to the endoscopic procedures was encountered. We conclude that biliary leakage after laparoscopic cholecystectomy is uncommon. When it occurs, it can be treated safely and efficaciously by endoscopic means.

Diverse tumors may arise at the ampulla of Vater, although the clinical manifestations for all types of lesions are similar. Carcinoma and benign adenomas are the most important ampullary tumors, and there is evidence that adenomas are premalignant. Endoscopy offers the best prospect of accurate diagnosis, but the sensitivity and specificity of this diagnostic modality is less than expected. In particular, endoscopic biopsies may be falsely negative for carcinoma in a significant percentage of cases. When successful, ERCP may demonstrate dilated pancreatic and bile ducts and in some cases the presence of a tumor mass. The preferred treatment for virtually all ampullary tumors is surgery, the general types of operation being local resection, pancreatoduodenectomy, and biliary decompression procedures. The choice of operation depends on whether the tumor is benign or malignant, its extent, especially if malignant, and an assessment of the patient's ability to withstand radical resection. Although the operative morbidity and mortality is lower for local excision in comparison to pancreatoduodenectomy, there is a greater chance for recurrence of malignant and premalignant neoplasms when the tumor is locally excised.

Upper gastrointestinal polyps and carcinoma, especially of the periampullary area, may occur in patients with familial adenomatous polyposis. Upper gastrointestinal polyps were present in about 43% of patients in the polyposis registry of the Cleveland Clinic who underwent screening esophagogastroduodenoscopy. Approximately one-third of these polyps were neoplastic. Three distribution patterns were recognized: 1. fundic, 2. duodenal, and 3. fundic plus duodenal. Despite the occurrence of a few gastric cancers in patients with familial adenomatous polyposis, the risk of carcinoma of the major duodenal papilla and periampullary area is more significant. It is necessary to examine the duodenal papilla with a side-viewing instrument and to obtain biopsy specimens from this structure in these patients. The major duodenal papilla was abnormal in about one-half of our patients in whom this structure was specifically examined with a side-viewing endoscope. The preliminary results of a trial of endoscopic treatment of upper gastrointestinal polyps and lesions of the major duodenal papilla in patients with familial adenomatous polyposis are described.