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A retrospective analysis of complications arising from 300 consecutive attempts at endoscopic retrograde cholangiopancreatography (ERCP) in 278 patients was undetaken to determine the rate and severity of complications. An over-all complication rate of 5% (15 cases) was documented. Complications were categorized in terms of those arising from endoscopy itself or from the administration of pharmacological agents (7 cases), and those observed after the injection of radioopaque contrast into the biliary tree or pancreas (8 cases). Complications which might be considered coincidental to a patient's underlying illness were not excluded. Complications were significantly more frequent after injection of diseased duct systems. Brief, self-limited pancreatitis after retrograde pancreatography occurred in 5 of 90 patients with pancreatic disease. No cases of pancreatitis were observed after retrograde pancreatography in 102 patients without pancreatic disease X2 = 5.82, P less than 0.025). Sepsis occurred after retrograde cholangiography in 3 of 56 patients with extrahepatic biliary obstruction. In the absence of extrahepatic obstruction, cholangiography was performed without complication in 85 cases (X2 = 3.62, P less than 0.1), although 25 of these had intense cholestasis due to hepatic parenchymal disease. This analysis provides the basis for modifications of ERCP technique and management that may reduce the future incidence of complications. This study suggests that the incidence and severity of complications that arise from ERCP compare favorably with procedures of equivalent diagnostic yield.

A case of traumatic pancreatitis with a radiopaque calculus producing pain by obstructing the distal pancreatic duct is presented. Preoperative ductal anatomy was defined by a percutaneous pancreatogram that established the presence of mechanical duct obstruction as the cause of pain, and the potential for operative relief of duct obstruction. A remission from pain resulted from pancreatic duct decompression by a lateral pancreaticojejunostomy. The potential value of percutaneous pancreatography is discussed.

The combination of upper gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography was evaluated as a primary diagnostic procedure in 91 consecutive patients suspected of pancreatic or biliary tract disease. In 77 (85%) of the patients, the origin, nature, or extent of disease was established by endoscopy (13 patients), pancreatography (25 patients), or cholangiography (39 patients). This combined technique compares favorably with other means of diagnosing pancreatic or biliary tract disease.

A case of choledochocele, missed during exploratory laparotomy but managed by endoscopic biliary surgery, is presented.

Endoscopy combined with endoscopic retrograde cholangiopancreatography is a unique tool providing a broad, precise yield of diagnostic information about diseases of the upper gastrointestinal tract. In the absence of gross anatomic disease, its diagnostic accuracy should exceed 90 per cent and risk be minuscule. The incidence of complications and, therefore, risk to the patient and proportional to the magnitude and remedial nature of the disease processes found. In the absence of diagnostic procedures for diseases of the biliary tree and pancreas that are riskless, the relationship of endoscopic retrograde cholangiopancreatography risk to diagnostic value and patient salvage emphasizes the value of endoscopy combined with endoscopic retrograde cholangiopancreatography as the diagnostic procedure of choice for patients with suspected disease of the biliary tract or pancreas. The unique value of endoscopic retrograde cholangiopancreatography in providing rapid visualization of diseases of the upper gastrointestinal tract mucosa combined with cholangiography and pancreatography is dramatized in the patient with upper abdominal pain syndrome with or without jaundice. In the face of a rapidly evolving illness and the potential need for early surgical intervention, barium studies are relatively contraindicated and have a poor diagnostic yield. By contrast, endoscopic retrograde cholangiopancreatography combined with endoscopy rapidly rules out, or, in the presence of disease of the upper gastrointestinal tract, permits the immediate use of subsequent diagnostic procedures. An experience with more than 1,000 procedures reveals that endoscopic retrograde cholangiopancreatography is an invaluable tool for the diagnosis and management of disease of the pancreas and biliary tract.