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Background and Study Aims: The use of covered self-expandable metallic stents (cSEMS) in benign biliary indications is evolving. The aim of the study was to assess the safety and feasibility of cSEMS compared with multiple plastic stents in the treatment of benign biliary stricture (BBS) caused by chronic pancreatitis., Patients and Methods: This was a prospective, multicenter, randomized study of 60 patients with BBS caused by chronic pancreatitis. All patients received an initial plastic stent before randomization. At randomization, the stent was replaced either with a single cSEMS or three plastic stents. After 3 months, the position of the cSEMS was checked or another three plastic stents were added. At 6 months after randomization, all stents were removed. Clinical follow-up including abdominal ultrasound and laboratory tests were performed at 6 months and 2 years after stent removal., Results: Two patients dropped out of the cSEMS group before stent removal. In April 2014, the median follow-up was 40 months (range 1 - 66 months). The 2-year, stricture-free success rate was 90 % (95 % confidence interval [CI] 72 % - 97 %) in the plastic stent group and 92 % (95 %CI 70 % - 98 %) in the cSEMS group (P = 0.405). There was one late recurrence in the plastic stent group 50 months after stent removal. Stent migration occurred three times (10 %) in the plastic stent group and twice in the cSEMS group (7 %; P = 1.000)., Conclusion: A 6-month treatment with either six 10-Fr plastic stents or with one 10-mm cSEMS produced good long-term relief of biliary stricture caused by chronic pancreatitis.Study registered at ClinicalTrials.gov (NCT01085747)., (© Georg Thieme Verlag KG Stuttgart · New York.)

We present three cases of pseudoaneurysm caused by self-expandable metal stents that formed arteriobiliary fistulas and caused hemobilia. Diagnoses were made on the basis of dynamic computed tomography or angiography. One patient died because of bleeding and cholangitis, whereas the others were successfully treated by transarterial embolization., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: There is a paucity of in vitro methods for evaluating ERCP accessories. We hypothesize that the time taken to perform a simulated single stent or multiple stents placement is different for stenting systems with or without the capability of intraductal ductal release (IDR) of the guide wire., Patients and Methods: We conducted an un-blinded in vitro comparison of ERCP accessories using a mechanical simulator during hands-on ERCP practice workshops. A total of 21 U.S. participants and 20 Chinese participants with various level of ERCP experience took part in the different practice workshops. Accessories with and without the capability of intraductal release of guide wire were compared. Total time required for completing a simulated stenting procedure with single or multiple stents and the respective simulated fluoroscopy time were recorded., Results: There was no significant difference in the time taken for placement of a single stent using either stenting systems. Stenting system capable of intraductal release of the guide wire required significantly shorter time to complete placement of three stents., Conclusions: Using time required to complete a specific task, i. e. biliary stenting, the mechanical simulator permits the performance of different accessories by the same group of operators to be evaluated objectively.

The aim of this study was to test the removability of fully covered self-expandable metal stents (FCSEMS) in patients with a benign common bile duct (CBD) stricture. A FCSEMS was inserted in six patients with a CBD stricture due to chronic pancreatitis who were considered to be unfit for surgery, and stent removal was attempted after predefined intervals of 4 and 6 months. FCSEMS were successfully placed in all patients (100 % placement success) and stent extraction was accomplished in four patients (66 % removal rate), all of whom achieved stricture resolution (66 % resolution rate). In one patient a recurrent stenosis developed after 6 months (recurrence rate 25 %). Proximal stent migration occurred in two patients. In conclusion, FCSEMS removal was possible in the majority of patients and results regarding stricture dilation were promising. Nevertheless, before FCSEMS can become an acceptable treatment option for benign CBD strictures, innovative stent design modifications are necessary and removability must be ascertained.

An exceptional cause of obstructive jaundice is reported in the present case. A 51-year-old woman progressively developed jaundice with pruritus, and abdominal ultrasonography revealed dilated intra- and extrahepatic bile ducts. Endoscopic retrograde cholangiography and endoscopic ultrasonography showed a tumor in the distal common bile duct, but failed to determine the nature of the lesion, and the patient underwent a pancreaticoduodenectomy. The final diagnosis was an inflammatory pseudotumor of the common bile duct. Inflammatory pseudotumors are uncommon, without evident pathogenesis, and are described in many organs. The localization in the common bile duct is exceptional. The prognosis is good, and a more conservative approach is possible if the diagnosis is certain before surgery.

We report the case of a 44-year-old woman who suffered from biliary-type pain after cholecystectomy, dysphagia, and weight loss. Examinations revealed sphincter of Oddi dysfunction (SOD) and achalasia. Complete relief of symptoms was achieved by endoscopic sphincterotomy and pneumatic dilation of the distal esophagus. This case report demonstrates for the first time the concomitant manifestation of two motility disorders of the upper gastrointestinal tract, i.e. achalasia and SOD. At present, any causal relationship seems speculative; however, both diseases were successfully treated using endoscopic procedures.

Background and Study Aims: A new balloon-expandable Teflon endoprosthesis was developed for endoscopic placement in the biliary tree. After deployment to its maximum diameter the stent is hardened by exposure to UV light. We present our preliminary results with a prototype 18 Fr prosthesis., Patients and Methods: Three patients with a distal common bile duct obstruction due to unresectable pancreatic head carcinoma were treated with this stent. Insertion of the stent was the only palliative procedure. Patients were followed up until stent dysfunction or death., Results: Stent placement was successful in all patients and no procedural complications occurred. Distal migration occurred in one patient, clogging of the stent after 149 days in another., Conclusion: In patients with a malignant biliary stricture this newly developed expandable endoprosthesis is effective in relieving obstructive jaundice. The technique has potential advantages over placement of current expandable metal mesh stents.

A case of a 72 year old man is reported who developed a choledochoduodenal fistula due to distal biliary obstruction by a tumor of the papilla. A metal stent, introduced through this fistula into the common bile duct, dislodged and passed spontaneously with the feces. Plastic stents were then successfully inserted.

Sphincter of Oddi dyskinesia (SOD) is among the less frequent causes of acute recurrent pancreatitis. We report on a patient with frequent pain attacks accompanied by pancreatic enzyme elevation, in whom a transitory decrease of the SO pressure following endoscopic botulinus toxin injection was a diagnostic clue for SOD. The patient's symptoms resolved for 4 months, after which time recurrent symptoms paralleled the reoccurrence of the elevated SO pressure. Endoscopic sphincterotomy of the biliary sphincter relieved her symptoms for the subsequent follow-up period which is now 10 months.

Background and Study Aims: Endoscopic exploration of the common bile duct is generally more difficult and hazardous in patients with a Billroth II gastrectomy than in patients with normal anatomy. Hydrostatic dilation of the papilla, which we term "endoscopic sphincteroclasy", provides a useful alternative to sphincterotomy in such patients., Patients and Methods: Endoscopic sphincteroclasy was carried out in five patients with a Billroth II anastomosis. There were four men and one woman, aged 58 to 90 years. One patients was cirrhotic, with impaired coagulation. Four presented with typical cholangitis, and one had pain and jaundice. The common bile duct was dilated in all five patients. Four had choledocholithiasis and one had a cholangiocarcinoma., Results: Sphincteroclasy was carried out with balloon dilators mounted on 0.035-inch guide wires. Immediate extraction of stones was achieved in three of the four patients with choledocholithiasis. In one case, a control endoscopic retrograde cholangiopancreatography was necessary to remove residual stones, without additional dilation. Insertion of the endoprosthesis was possible without difficulty in the patient with a malignant stricture. None of the patients required a sphincterotomy. No complications were observed up to six months after the sphincteroclasy., Conclusions: We recommend the use of endoscopic sphincteroclasy in patients with a Billroth II gastrectomy who require endoscopic therapy, as well as in patients in need of emergency bile duct decompression who have impaired coagulation.

Background and Study Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is an established modality for the diagnosis and treatment of pancreaticobiliary disorders. In contrast to ERCP in patients who have not undergone gastrectomy, ERCP in patients with a Billroth II gastrojejunostomy or a Roux-en-Y anastomosis is considerably more difficult. It was nevertheless considered that ERCP might be possible in most patients with gastrectomies, and this hypothesis was tested., Patients and Methods: A total of 2256 patients were admitted to our hospital for ERCP from 1990 to 1994. Of these, 65 (3%) had gastrojejunostomies, either with Billroth II reconstructions or with the Roux-en-Y procedure. ERCP was always performed with a conventional side-viewing endoscope., Results: We examined the 65 patients with gastrojejunostomies. Of these, 91% had Billroth II anastomoses and 9% had received Roux-en-Y reconstructions. We successfully reached the papilla of Vater with the endoscope in 92% of the patients with Billroth II gastrojejunostomies (54 of 59), but in only 33% of the patients with Roux-en-Y reconstructions (two of six). In 8% of the cases of Billroth II anastomosis, it was not possible to advance the endoscope into the duodenal stump, due to intestinal stenoses (5%) or excessive intestinal length (3%). Failure in case of regular Billroth II anatomy occurred only in patients who had not received Braun enteroenterostomies. Failure also occurred in 67% of the Roux-en-Y gastrojejunostomy cases due to excessive intestinal length., Conclusions: Most patients with Billroth II gastrojejunostomy (92% of those in the present study) and some patients with Roux-en-Y anastomosis (33% of those in the present study) can be investigated by ERCP and endoscopically treated in cases of pancreaticobiliary disorder. Braun enteroenterostomy has no negative impact on the endoscopic access to the papilla of Vater in patients with Billroth II gastrojejunostomy. Surgical reconstruction of the gastrointestinal tract to perform gastrojejunostomy should also take endoscopic requirements into account. In view of both the potential postoperative complications and endoscopic requirements, the jejunojejunostomy should be placed nearer to the gastrojejunostomy than 60 cm, and the afferent loop should be as short as possible.

Patients with malignant biliary stenosis due to pancreatic head cancer often have the associated problem of duodenal obstruction. We report here the case of a 78-year-old woman with this clinical situation, who was treated with self-expanding Gianturco metal stents placed in the distal common bile duct and, nine months later, placed in the descending duodenum. The patient's frequent vomiting resolved, and she was able to tolerate peroral solid food; jaundice also decreased (bilirubin pre-stenting: 7.8; post-stenting: 1.2). Self-expanding metal stents therefore appear to be effective for the palliative treatment of malignant duodenal stenosis as well as biliary stenosis.

During a four-year period up to May 1993, 118 patients (mean age 69 years) with malignant bile duct stenoses were treated with a total of 127 selfexpanding 10-mm metal endoprostheses (Wallstent), most of them endoscopically (n = 102). Technical problems during and shortly after implantation occurred in five cases (4.2%), but could all be solved endoscopically. Serum bilirubin decreased from a mean of 8.0 mg/dl at presentation to a mean of 2.0 mg/dl after stenting. Nineteen patients died within the first three months (5% within the first 30 days); recurrent obstruction, as manifested by recurrent jaundice or cholangitis, or both, was encountered in 14%. Fifty-one patients who survived longer were followed up until death or for a minimum of 12 months (mean follow-up: 12 months). Stent patency rates in this group were 86% (six months), 72% (12 months) and 64% (18 months), survival for these time periods being 63%, 35% and 17%, respectively. No significant stent-related complications were noted; stent occlusion occurred in 12% of patients after a mean of 168 days, and was successfully managed endoscopically (thermal cleaning, implantation of further stents) in all cases. We conclude from our long-term follow-up data that patients surviving longer than three months are the ones most likely to benefit from Wallstent insertion for malignant jaundice.

This report describes 2 cases of calcified cavernous transformation of portal vein of unknown etiology. In both cases the revealing symptom was jaundice due to extrinsic compression of the common bile duct by the cavernoma. Only 4 other cases have been previously described in the literature. The cause of the jaundice was discovered only during surgery and confirmed by arteriography. Endoscopic retrograde cholangiography allowed both the diagnosis and the palliative treatment of the stricture of the distal common bile duct. Surgical treatment could not be performed.

The present state of papillary stenosis is reviewed. ERCP manometry has become the most important means of evaluating sphincter of Oddi dynamics. Pressure measurements in the sphincter segment appear useful to differentiate patients with sphincter of Oddi dysfunction from patients with an organic stenosis. The author's experience with sphincter of Oddi manometry, with endoscopic sphincterotomy and hydrostatic balloon dilation of the sphincter of Oddi, and the results of an international inquiry, are presented.

No controlled studies document either clinical or biochemical efficacy following balloon dilation of the sphincter of Oddi. Because of this and the unacceptable rates of pancreatitis and cholangitis associated with sphincter dilation when compared with the other available modalities of sphincterotomy, stent placement and surgery, this technology currently has little place when dealing with a spastic or stenotic sphincter mechanism.

A combined endoscopic and surgical procedure was performed in 69 patients suffering from gallbladder lithiasis with suspected associated lithiasis of the common bile duct (CBD). The procedure was spread over two days: Day 1 - Endoscopic retrograde cholangiopancreatography (ERCP) revealed choledocholithiasis in 50 cases and papillary sclerosis in 4 cases. In 15 patients, the common bile duct was found to be normal. Fifty-four endoscopic sphincterotomies were performed. Among the 50 cases of choledocholithiasis, endoscopic removal of the stones was judged complete in 44 cases and incomplete in the other 6. Day 2 - Cholecystectomy was carried out in all the patients. Peroperative cholangiography confirmed the results of the pre-operative ERCP with respect to the CBD in all the patients except one, and a choledochotomy was necessary in 6 patients. Results were as follows: The average length of hospitalization was 12.4 days. No residual choledocholithiasis was noted. The morbidity of the procedure was 7.2%, and the mortality 1.4% unrelated to the technique. The diagnostic and therapeutic significance of the procedure is discussed.

The term "functional" as applied to disorders of the sphincter of Oddi is indefinite since it encompasses a spectrum of disorders from histopathologic fibrosis of the sphincter to sphincteric dysfunction without evident pathologic transformation. Although there are several approaches to the diagnosis of sphincter of Oddi dysfunction, the diagnosis still depends on the exclusion of other causes of obstruction. Reports of surgical sphincteroplasty in patients with this diagnosis suggest that the outcome is unpredictable. Operative mortality ranges from 0.6% to 6.0% and morbidity from 3.3% to 18%. Operative sphincteroplasty appears to have no adverse sequelae long-term, although there are few reports of extended follow-up. In our experience, about 10% of patients undergoing endoscopic sphincterotomy for calculi have recurrent biliary problems during extended follow-up, but most problems were not formidable. In large series of patients undergoing endoscopic sphincterotomy, papillary stenosis is the indication for the procedure in about 5% of cases. With this indication, immediate complications occur with greater frequency compared to endoscopic sphincterotomy for choledocholithiasis. The validity of every proposed test for sphincter dysfunction and/or stenosis has been challenged, and the diagnosis must still be considered imprecise. This fundamental problem makes it difficult to interpret the results of endoscopic sphincterotomy. It also necessitates a cautious approach to management of this disorder by endoscopic sphincterotomy. Other methods of sphincter manipulation such as endoscopic balloon dilation have not been studied extensively. Although endoscopic sphincterotomy has been performed in a few patients with idiopathic recurrent pancreatitis, the procedure must be considered experimental in this group of patients.