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Endoscopic therapy holds an important role in the management of benign biliary strictures. This study compares the long-term outcome of stenting therapy depending on the underlying cause of the stricture.In a retrospective cohort study, 228 patients with benign biliary strictures were identified using an endoscopic database, hospital charts, and cholangiograms between January 1992 and December 2008. Long-term follow-up was evaluated with cholangiograms, transabdominal ultrasound, laboratory parameters, and physical examination. The median follow-up period was 44.7 months.Endoscopic management showed best long-term results in patients with stone-associated biliary stricture. In this subgroup, endoscopic therapy could be successfully completed in 92% (71/77) of the patients. Patients with postoperative biliary stricture had good outcome in 83% (53/64) of cases. Idiopathic strictures presented a successful outcome in 58% (15/26). Biliary strictures caused by chronic pancreatitis had a significantly poorer outcome compared with strictures of other origin. Therapeutic success of endoscopic therapy could only be observed in 31% of patients (19/61).Long-term outcome of endoscopic therapy for benign strictures was significantly dependent on the underlying cause of the stricture. In particular, patients with biliary strictures due to chronic pancreatitis benefit least from endoscopic therapy, whereas patients with stone-associated strictures had the highest therapeutic success rate.

OBJECTIVES: In patients with unresectable pancreatic cancer, estimation of individual prognosis is essential to provide the most suitable biliary stent (self-expanding metal stent or plastic stent). The aim of the current study was to determine prognostic factors for survival in patients with unresectable pancreatic cancer after initial biliary drainage. PATIENTS AND METHODS: The current study included 278 patients with unresectable pancreatic cancer. Prognostic factors for survival were analyzed using the Cox proportional hazards model, the Kaplan-Meier survival estimator, and the Wilcoxon test for difference in survival. RESULTS: In univariate analysis, advanced T stage according to the TNM classification (P = 0.021, Wald test) and the presence of distant metastases (P = 0.001, Wald test) were predictive factors for shorter survival. However, in multivariate analysis, the presence of distant metastasis was the only independent prognostic factor. The median survival time after initial biliary drainage was 3.1 and 6.6 months in patients with and without the presence of distant metastases, respectively. CONCLUSIONS: The presence of distant metastases was identified as the only independent prognostic factor for survival after initial biliary drainage. A self-expanding metal stent should be systematically chosen for patient without distant metastases, whereas polyethylene plastic stents should be preferred in patients with distant metastases.

Cheyne - Stokes respiration (CSR) is common in patients (pts) with chronic heart failure (CHF) and accompanied by an impaired prognosis. Nocturnal adaptive servoventilation (ASV) was recently introduced to treat CSR in CHF. Aim of this study was the investigation of long-term ASV effects on CSR and CHF parameters. In 41 pts with CHF treated according to current guidelines (39 male; 64.8 ± 10years, NYHA ≥ II, LV-EF ≤ 40%) cardiorespiratory polygraphy (PG), cardiopulmonary exercise (CPX) testing and echocardiography was performed before and after 11.6 ± 5.9 months (median 10.3 months) of ASV treatment (AutoSet CS ™ 2, ResMed). In our cohort, mean duration of ASV usage during night was 6:25 ± 1:08 h, while the device was used in 82 ± 21% of possible nights. Apnea-hypopnea-index and apnea-index were reduced from 38.2 ± 11/h to 5.5 ± 7/h and 24.2 ± 14/h to 2.5 ± 5/h, respectively (both p < 0.001). Minimum oxygen saturation rose from 81.4 ± 4.9% to 85.6 ± 4.3% (p < 0.001) while mean oxygen desaturation was reduced from 6.8 ± 2.5% to 4.6 ± 1.8% (p < 0.001). Peak oxygen consumption (VO 2 ) during CPX testing increased from 15.2 ± 3.7ml/kg/min to 17.1 ± 4.7ml/kg/min and predicted peak VO 2 from 60.1 ± 13% to 68.5 ± 18% (both p < 0.05). Left ventricular ejection fraction increased from 29.9 ± 6.6% to 33.3 ± 10.6% (p < 0.05). In selected and compliant pts with CHF and CSR, addition of nocturnal ASV therapy to standard heart failure therapy is able to abolish CSR and improve cardiac function. Whether this improvement in SDB and CHF parameters is accompanied with an improvement in CHF prognosis is not yet known.

The pathohysiology of Cheyne-Stokes-respiration (CSR) in congestive heart failure (CHF) is not fully understood. Increase in pulmonary capillary wedge pressure (PCWP) may lead to stimulation of pulmonary J-receptors and consecutive hyperventilation. The present study investigates the influence of an acute increase in PCWP in CHF pts without sleep disordered breathing (SDB) compared to pts with central (CSR) and obstructive sleep apnea (OSA). Simultaneous left and right heart catheterizations were performed in 29 CHF pts (NYHA ≥ II, LVEF ≤ 40%). PCWP and arterial pCO 2 were measured under standardized settings at baseline and after left ventricular angio- and/or aortography resulting in an acute increase in intravascular volumes. Type and severity of SDB were determined by cardiorespiratory polygraphy the night before or thereafter. NT-proBNP concentration was measured and central CO 2 - receptor sensitivity determined by testing hypercapnic-hyperoxic-ventilatory response (HCVR) according to Read. CSR was diagnosed in 15 pts (apnea-hypopnoea-index [AHI] 32 ± 19/h; 59 ± 11 years; LVEF 32 ± 6%), OSA in 9 pts (AHI 27 ± 29/h; 64 ± 13 years; LVEF 33 ± 5%); 5 pts had no SDB (AHI 1 ± 2/h; 48 ± 13 years; LVEF 32 ± 7%). HCVR and NT-proBNP concentrations were significantly higher in CSR (5.6 ± 6.5l/min/mmHg and 5237 ± 6268pg/ml) compared to OSA (2.2 ± 0.6l/min/mmHg and 1127 ± 874pg/ml) or pts without SDB (1.6 ± 0.6l/min/mmHg and 197 ± 146pg/ml; p < 0.05). PCWP were elevated at baseline and increased significantly after angiography in all groups (CSR: 20.3 ± 6.6 mmHg to 22.9 ± 7.9 mmHg; OSA 22.8 ± 10 to 25.4 ± 11 mmHg; noSDB: 14.2 ± 10 to 17.4 ± 9mmHg; all p < 0.05). Arterial pCO 2 at baseline tended to be lower in pts with CSR. Only in CSR, not in OSA or pts without SDB increase in PCWP was accompanied by a further decrease in pCO 2 (CSR: 36.1 ± 5mmHg to 33.3 ± 5mmHg, p = 0.05; OSA: 38.7 ± 4mmHg to 40.1 ± 6mmHg, p = ns; noSDB: 39.6 ± 6mmHg to 39.7 ± 6mmHg, p = ns). In CHF pts with CSR but not in those without SDB or OSA, acute increase in PCWP stimulates ventilation, together with other factors like an increased central CO 2 - receptor sensitivity this may lead to hyperventilation and a consecutive decrease in pCO 2 below the apnea threshold. Moreover, the present data may explain why CSR in some pts reflects CHF severity.