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Background and study aims Bezoars are collections of indigestible foreign material that are found within the gastrointestinal tract. Nonoperative approaches such as dietary therapy, enzymatic dissolution, and endoscopic removal have been regarded as the mainstays of therapy. The purpose of this paper is to determine the efficacy of electrohydraulic lithotripsy (EHL) as an alternative form of treatment of gastric bezoars. Patients and methods Between July 1988 and May 1996, 11 patients with large gastric bezoars, defined as those greater than 5 cm in diameter, received endoscopic-guided fragmentation using electrohydraulic lithotripsy. Nine of our patients had a history of ingestion of "Pho Pu Zi", (Cordia dichotoma Frost. f.), one of orange pitch, and one of ingestion of persimmon. Results The 11 patients in the study underwent EHL for the treatment of their gastric bezoars, with a 100% success rate, which was defined as the lack of residual bezoar seen on post-procedure barium study or endoscopy done 2 days after the procedure. Patients were followed-up clinically for 30-68 months, with seven of the 11 patients undergoing a barium study with no residual bezoar noted. No procedure-related complications were seen, except for pharyngeal pain which was most probably secondary to the placement of the silicon overtube. Conclusions Endoscopically guided electrohydraulic lithotripsy is a safe, highly effective, alternative nonsurgical technique for the treatment of gastric bezoars.

Background and study aims Conventional endoscopic ultrasonography (EUS) is a valuable modality for staging the depth of invasion of colorectal cancer. However, there are difficulties with this technique in reaching as far as the cecal area, traversing tight strictures, and obtaining clear images of smaller lesions. Due to these factors, mis-staging often occurs. The literature shows that the miniprobe is superior to EUS, because of its easy manipulation and better diagnostic accuracy. We therefore conducted a prospective study using a balloon-sheathed miniprobe for colorectal cancer staging. Patients and methods Eighty-six patients underwent preoperative staging using a miniprobe combined with an outer balloon sheath. Six patients were excluded from lymph-node examination due to local tumor resection. Acoustic coupling was achieved with or without water immersion. The results were compared with the histopathological findings in the resected specimens. Results The balloon-sheathed miniprobe had an overall accuracy rate of 85 % for T staging, with 100 % in T1; 78 % in T2; 90 % in T3; and 40 % in T4. Lymph-node metastasis was correctly diagnosed in 73 % of cases, with sensitivity and specificity rates of 74 % and 71 %, respectively. It was not possible to obtain clear cross-sectional images using the miniprobe in three patients. Conclusions The balloon-sheathed miniprobe is a good alternative for evaluating colorectal tumor lesions, since it can usually obtain cross-sectional images even in markedly stenosed lesions, and the examination can be performed easily with endoscopy, with or without water-infusion techniques. One major limitation with the probe is the difficulty in evaluating deeper structures, such as lymph-node groups and contiguous organ involvement.

To compare the accuracy between EUS (endoscopic ultrasound), ERCP (endoscopic retrograde cholangiopancreatography), CT (computed tomography), and transabdominal US (ultrasound) in the detection and staging of primary ampullary tumors. We will also try to discuss the influence of endobiliary stent on EUS in staging ampullary tumors.Twenty-one patients with ampullary tumors were evaluated by EUS, ERCP, CT, and US before operation. The accuracy was assessed with TNM staging and compared with the surgical-pathological findings.EUS was superior to CT and US in detecting ampullary tumors, but EUS and ERCP are of similar sensitivity (EUS 95%, ERCP 95%, CT 19%, US 5%). EUS was superior to CT and US in T staging (EUS 75%, CT 5%, US 0%) and detecting lymph node metastasis (EUS 50%, CT 33%, US 0%) of ampullary tumors. The accuracy of EUS in T and N staging of ampullary tumors tended to be decreased in the presence of endobiliary stent (stenting: T 71%, N 75%; nonstenting T 83%, N 100%), but there was no statistical significance.EUS was superior to CT and US in assessing primary ampullary tumors, but it was not significantly superior to ERCP in detecting ampullary tumors. The presence of endobiliary stent may decrease the accuracy of EUS in staging ampullary tumors.

The present study was designed to identify the biochemical tests which could detect the presence of common bile duct stones in patients with symptomatic gallstones, without other invasive investigations. The usefulness of biochemical tests may reduce the necessity of endoscopic retrograde cholangiopancreatography prior to laparoscopic cholecystectomy.3000 patients with symptomatic laparoscopic cholecystectomy scheduled for laparoscopic cholesystectomy were included in the study. 458 patients (201 men, 257 women; mean age, 57.7 +/- 14.6 yrs) were examined with endoscopic retrograde cholangiopancreatography for suspected common bile duct stones. The serum tests for liver function, including a measurement of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, gamma-glutamyltransferase and albumin were obtained on admission prior to the ultrasonography, and the endoscopic retrograde cholangiopancreatography.The six significant factors, including alkaline phosphatase, direct bilirubin, total bilirubin, aspartate aminotransferase, alanine aminotransferase and gamma-glutamyltransferase were identified by the univariate analysis and the multivariate logistic regression analysis which identified alkaline phosphatase and gamma-glutamyltransferase, as the two significant independent factors. A statistical model was developed with a formula of [formula: see text] A curve of receiver operating characteristics was constructed to identify an alkaline phosphatase level greater than 300 U/L or a gamma-glutamyltransferase level greater than 420 mU/mL which would have both higher sensitivity and specificity.Biochemical tests can be a significant aid to the clinician's decision-making when predicting the presence of common bile duct stones in patients with gallstones.

This study is conducted to evaluate the feasibility of percutaneous transhepatic gallbladder drainage prior to laparoscopic cholecystectomy for the treatment of gallbladder empyema. We also determine the sonographic findings, causative organism, clinical signs and symptoms, laboratory data, associated underlying medical disorders and the complications related to both cholecystostomy and laparoscopic cholecystectomy.One hundred and forty-five cases of gallbladder empyema were included in this study which was composed of 80 males and 65 females, aged 22-94 years with a mean age of 71-years. All patients underwent percutaneous transhepatic gallbladder drainage under ultrasound and fluoroscopic guidance, and laparoscopic cholecystectomy was carried out thereafter. We analyzed the clinical presentations (signs, symptoms, laboratory and ultrasonographic findings, concomitant medical disorders), causative organisms and the complications related to percutaneous cholecystostomy and laparoscopic cholecystectomy.Percutaneous transhepatic gallbladder drainage was performed successfully in all patients within 48 hours after clinical diagnosis of acute cholecystitis. Complications related to percutaneous transhepatic gallbladder drainage were bile leakage after tract dilatation noted in 2 patients (1.4%), and 20 (14%) patients had pain at the puncture site which radiated to the right shoulder during the procedure, but resolved spontaneously within an hour later. On admission, 102 (70%) patients presented as right upper quadrant pain, 39 (27%) as epigastric pain, 90 (62%) as fever, 108 (74%) patients had leukocytosis, and 33 (22.7%) patients were septic. AST and ALT were elevated in 57% and 51% of patients, respectively. Alkaline phosphatase was elevated in 56% of patients, and 34% of those patients had combined common bile duct stones. Gallbladder stones were documented in 135 (93%) patients, while the remaining 10 (7%) cases were acalculous. Five (3.4%) patients had combined gallbladder adenocarcinoma, 7 (4.8%) had liver abscess, while 13 (9%) had biliary pancreatitis. The ultrasonographic findings included gallbladder distension (93%), wall thickening (90%), pericholecystic fluid accumulation (15%), intraluminal sludge or stone (93%) and intraluminal air (13.9%). Bile culture were positive in 83% of the cases and showed gram-negative bacteria in 75%, gram-positive in 30%, anaerobes in 7%, while no growth in the remaining 17% of the cases. The common pathogens were Escherichia coli (57%), Enterococcus (27%), Klebsiella pneumonia (18%), Morganella morganii (7.6%), Pseudomonas aeruginosa (4.1%) and Salmonella (0.7%). The total postoperative complication rate was 17%, which included wound infection, bleeding, subhepatic abscess, cystic duct stump leak, common bile duct injury and pneumonia. Postoperative mortality was 2.6%. Conversion rate to open cholecystectomy was 27%. Clinical conditions improved within 48 hours after cholecystostomy in 93% of patients. Time interval between cholecystostomy and elective cholecystectomy was 2-21 days with a mean of 4 days. Total hospital stay was 5-38 days (mean: 11 days).Percutaneous transhepatic gallbladder drainage is a safe and effective procedure for the initial management of gallbladder empyema. We highly recommend this preoperative drainage procedure in patient with sepsis, and for those high-risk patients such as old age and with underlying medical illnesses. This procedure can stabilized the patient so that an appropriate therapeutic planning can be achieved.

Clinical staging of gastric carcinoma is important in designing the strategy of treatment. Early gastric carcinomas can be treated by minimally invasive therapy, whereas advanced gastric carcinomas should be treated by surgery with or without combined chemotherapy. This study was undertaken to evaluate the accuracy and limitations of video type endoscopic ultrasound in preoperative staging of gastric cancer and assessing lymph node metastasis.Seventy-four patients with gastric carcinoma were preoperatively staged using video-endoscopic ultrasonography, performed by the same gastroenterologist.Sixty-three out of the 74 (85%) patients were correctly staged by endoscopic ultrasonography. The diagnostic accuracy rate was 100% for T1, 74% for T2, 87% for T3, and 86% for T4. Overstaging occurred in 11% due to peritumoral inflammation. Understaging occurred in 4% due to microinvasion of carcinomatous tissue or deeper organ invasion. The diagnosis of lymph node metastasis was confirmed in 72% of cases. Sensitivity and specificity was 74% and 86%, respectively.Endoscopic ultrasonography has a high accuracy rate in staging gastric carcinoma but still has its limitations in evaluating regional lymph node metastasis, despite using a new generation video-endoscopic ultrasonography.

A 67 year-old man was admitted to the Tainan Municipal Hospital due to a protruding mass, usually noted during defecation. Digital examination revealed a single, smooth, large mass over the rectum, occupying almost the entire lumen. Colonoscopy, barium enema, and computed tomography (CT) demonstrated a submucosal tumor of the rectum. Endoscopic ultrasound (EUS) study showed that the tumor originated from the muscle layer. Based on the size, margin and echogenicity of the mass, a malignant neoplasm, probably leiomyosarcoma, was diagnosed. Post-operative histologic examination confirmed that the resected tumor was leiomyosarcoma. Existing ancillary procedures like colonoscopy, abdominal CT, magnetic resonance image (MRI), and barium enema are neither reliable nor accurate in locating which layer the lesion originates. Colonoscopic biopsy is disappointing since submucosal tumor is usually inaccessible. EUS study can provide us with a more distinct image with regards to tumor origin, size, margin and echogenicity. This report emphasizes the important role of EUS in the pre-operative diagnosis of submucosal tumors of the rectum. Furthermore, this tool can aid the surgeons whether wide excision or an abdomino-perineal resection should be performed.

To assess the accuracy of a new generation endoscopic ultrasonography (EUS)(GF-M200) in pre-operative staging of recto-sigmoid colon carcinoma invasion and lymph node metastasis.Seventy-three patients with biopsy proven colon cancer were included in this study. These comprised 60 patients with rectal carcinoma and 13 patients with sigmoid carcinoma. All patients were pre-operatively examined by EUS. Pathological findings of the depth of tumor invasion and presence of lymph node metastasis were correlated with EUS.EUS has an overall accuracy rate of 89% in staging of recto-sigmoid cancer. The diagnostic accuracy rate was 83% for T1, 83% for T2, 93% for T3, and 71% for T4. Understaging and overstaging occurred in 6% and 6%, respectively. In determining lymph node metastasis, the overall accuracy rate was 77%, with a sensitivity and specificity rate of 77% and 76%, respectively.EUS is a valuable staging modality in the staging of the depth of tumor invasion, not only for rectal carcinoma but also for tumors located at the sigmoid colon.

The aim of the present study was to determine the usefulness and sensitivity of percutaneous cholangiofiberscopic guided forceps biopsy in patients suspected of intrabile duct diseases. This study also emphasized the use of a video monitor system in which the field of view is magnified; thus, even a small lesion can easily be detected. Furthermore, coordination of both the operator and assistant is easier because both can observe the image together on the video monitor.Percutaneous cholangio-fiberscopic forceps biopsy was performed in 27 patients (14 men, 13 women, aged 37-81 years with a mean age of 61 years). A mature T-tube tract was used as an access for cholangioscopy in 17 cases while the remaining 10 patients underwent percutaneous transhepatic biliary drainage and gradual tract dilatation from 7-French to 16-French. A flexible fiberoptic choledoscope was gently inserted into a mature tract and once an abnormal mucosal lesion was identified, a forceps biopsy was inserted into a working channel of the scope, and 3-5 specimens were taken for histological examination.A histological diagnosis was obtained in 24 cases of the 27 patients (sensitivity 89%) and included cholangiocarcinoma (n=8), papillomatosis (n=3), ampullary adenoma (n=1), ampullary adenocarcinoma (n=1), hepatoma with intrabile duct invasion (n=1), and chronic inflammation (n=10). Post-procedural bleeding was noted in 1 patient.Percutaneous cholangiofiberscopic-guided forceps biopsy is a safe and easy to perform procedure. It yielded a high sensitivity rate for definitive diagnosis of very small or early intrabile duct lesions; thus, a curative therapeutic modality can be appropriately applied. The use of a video monitor system, which magnified the field of view without distorting the quality of the image, plays a crucial role in this technique. Mucin substance is commonly seen in cholangiocarcinoma. The association between bile duct stones and neoplasm needs further evaluation.

Primary tumors of the heart are rare. We report a case of large cardiac angiomyolipoma (hamartoma) that presented as a fat-containing tumor mass on imaging studies, diagnosed radiographically as teratoma. The patient was admitted through the emergency room at Tainan Municipal Hospital because of severe dyspnea. A chest radiograph revealed marked widening of the mediastinum. Echocardiography and computed tomographic scanning of the thorax showed a mass of mixed density with calcification. A teratoma with intrapericardial invasion was suspected. Sternotomy disclosed a large intrapericardial lobulated mass (34 x 30 x 12 cm, 3,150 g) arising from the right atrium, with severe adhesion to the origin of the inferior vena cava. Histopathologic examination demonstrated an angiomyolipoma of the heart. To our knowledge, this is the largest cardiac angiomyolipoma reported. We report this case to emphasize that a differential diagnosis of angiomyolipoma must be included in a patient with a fat-containing cardiac tumor.

This study investigates the clinical features of chronic calcifying pancreatitis (CCP) in Taiwan and also the comparative differences in the disorder as it affects orientals and occidentals.Medical records at seven tertiary hospitals relating to patients diagnosed with CCP between 1976 and 1996 are reviewed and analyzed. Ninety patients were enrolled. Defining the calcification of the pancreas is achieved by plain film, ultrasonography, computed tomography, or histology.CCP afflicts men more frequently than it does women, by a ratio of 3.5:1 (70 men and 20 women). The mean age is 45 years (male: 46 female: 41.4). For fifty-two patients (57.8%), alcohol is the major cause of the condition, while in others, the causes are non-alcoholic (idiopathic: 31; biliary: 4; hereditary: 3). Alcoholism is mainly associated with males and younger sufferers. The major complications are diabetes mellitus (53.3%), cysts or pseudocysts (21.1%), and biliary stricture or stones (20%). Pancreatic adenocarcinoma and splenic vein thrombosis were found in six and five patients, respectively. Three patients died from cancers of other than pancreatic origin (lung: 1;liver: 1;bile duct: 1). Thirty-three patients were treated surgically of which thirteen (39.4%), including one with pancreatic auto transplantation, improved. Fifty-seven patients received medical treatment but only eleven (19.3%) improved.The clinical features of CCP in Taiwan are notably similar to those manifesting in western countries and in Japan. With the changes in life style and increased alcoholic consumption in Taiwan, the prevalence of CCP may increase and its demographic features may alter in the future.

To evaluate the technical feasibility and sensitivity of percutaneous transluminal forceps biopsy of bile duct diseases.Seventeen fluoroscopic-guided transluminal forceps biopsies were performed in 16 patients with obstructive jaundice. The technique was performed through an existing percutaneous transhepatic tract. Multiple specimens were obtained after passing the forceps biopsy into a long 9-French sheath and the specimens were fixed with formalin for histopathologic diagnosis.Adequate samples for histological diagnosis was obtained in 12 of 17 procedures (sensitivity, 71%). Pathologic reports included pancreatic head carcinoma n = 2, cholangiocarcinoma n = 3, hepatoma with intrahepatic-bile duct invasion n = 3, common bile duct tumors n = 3 and chronic inflammation n = 1. Minor complications such as pain was noted in three patients while transient hemobilia was seen in two patients.Percutaneous transhepatic transluminal forceps biopsy is a safe technique which is easy to perform. This can be done through an existing transhepatic biliary tract with a sensitivity rate of 71%.

Intramural duodenal hematoma is rarely seen in adults and may occur as an iatrogenic complication of endoscopic injection for peptic ulcer treatment. In the appropriate clinical setting, the diagnosis is easy with its ultrasonography and computed tomography characteristic findings. In one of our patients, UGI study revealed duodenal obstruction, bowel related lesion in sonography and hyperdense mass lesion in computed tomography. Clinical presentation of severe vomiting and epigastralgia were noted. Laparoscopy confirmed the location of the hematoma and subsequent evacuation was performed. The symptoms were relieved after the operation and a follow-up sonography demonstrated the regression of the duodenal hematoma.

Thoracoscopic (transthoracic endoscopic) sympathectomy, known worldwide as the best method for treatment of hyperhidrosis, is regarded as having two major contraindications: pleural adhesion and coagulopathy. We embarked on this study to prove that it is possible and highly feasible to do thoracoscopic sympathectomy, even in the presence of severe pleural adhesion, as long as the surgeon knows anatomy and is well-trained in performing this procedure. From October 1, 1989, through December 31, 1992, we treated 719 cases of hyperhidrosis palmaris (325 male and 394 female patients), by the thoracoscopic method at Tainan Municipal Hospital. Among them, 24 cases (3.5%), 19 male and 5 female patients, had concomitant pleural adhesions. The causes of pleural adhesion were pulmonary tuberculosis, chronic bronchitis, previous operations for hyperhidrosis, and a few with uncertain origins. Except for the first encountered case of hyperhidrosis with pleural adhesion, which was treated by mini-thoracotomy after failure of a thoracoscopic approach through the right thoracic cavity, the remainder of the 23 cases were treated successfully by the thoracoscopic method. In cases with bilateral pleural adhesions, the right thoracic cavity was more frequently involved and more severely. The incidence of pleural adhesion in hyperhidrosis is 3.5% in our series; all, except the first case, were treated thoracoscopically. Coagulopathy is for us, therefore, the only remaining contraindication of thoracoscopic sympathectomy.

To overcome problems with conventional plastic endoprostheses, a study was conducted to determine the clinical efficacy of self-expandable metallic stents in the palliative treatment of malignant biliary obstruction. From May 1994 to March 1995, 19 self-expandable metallic stents were implanted in 13 consecutive patients with malignant obstructive jaundice due to cholangiocarcinoma (four patients), ampullary carcinoma (six), pancreatic carcinoma (one), and hepatic hilar lymph node metastasis (two). All patients underwent percutaneous transhepatic biliary drainage followed by stent insertion, except for two patients where the T-tube tract was used as access and another with previous placement of a polyethylene internal-external drainage catheter for more than 6 months. When both lobes of the biliary system were to be drained, stents were placed either side by side through punctured, separate hepatic ducts or, using a T configuration, through a single transhepatic tract. Percutaneous transhepatic stent placement was technically successful in all patients. After a mean follow-up of 5.9 months (range, 1-10 mo), 10 of 13 patients were still alive while three had died of nonprocedure-related causes. In 10 patients, total serum bilirubin levels decreased significantly (from 136.8 +/- 157 mumol/L to 34.2 +/- 22.2 mumol/L), while it increased in three patients. Two patients had stent occlusions at 2 and 3 months after stent placement, which required intervention. The overall patency period ranged from 1 to 9 months (mean, 5.1 mo). Our results confirm that the use of metallic stents is effective in the palliative treatment of malignant jaundice.

We present a case of 70-year-old female patient who was admitted due to progressive jaundice. Our clinical impression of cholangiocarcinoma (Klatskin tumor), was confirmed by ultrasound, abdominal CT scan, and percutaneous transhepatic cholangiography. Two self-expanding metallic stents were placed in both intrahepatic ducts through a single transhepatic tract. After successful biliary stenting, the jaundice subsided and she was discharged as improved. However, progressive right upper quadrant pain was noted a few days after discharge and persisted for about 5 months, thus the was readmitted. During admission, she was febrile, exhibiting leukocytosis, with clinical signs of impending septic shock. Gallbladder empyema with hilar cholangiocarcinoma were diagnosed. Percutaneous transhepatic cholecystotomy and drainage (PTCCD) was done to alleviate the symptoms and cholecystectomy was performed thereafter. Pathologic report was compatible with xanthogranulomatous cholecystitis. Post-operative recovery was fair at follow-up examination.

Laparoscopic cholecystectomy is the standard treatment for symptomatic cholecystolithiasis; however, there is debate on the management of patients with concomitant common bile duct stones. Several options have been suggested; endoscopic sphincterotomy and laparoscopic common bile duct exploration seemed to be the preferred methods at this moment.We performed endoscopic sphincterotomy prior to laparoscopic cholecystectomy in 51 cases of acute symptomatic cholelithiasis.Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy procedure-related complication rate was 5.4%, including 1 pancreatitis, 1 cholangitis, and 2 major bleeds. After follow up period of 15-42 months, recurrent stones were found in 2 patients.Endoscopic sphincterotomy combined with laparoscopic cholecystectomy is a safe and effective therapy for symptomatic cholecystolithiasis with concomitant choledocholithiasis. Recurrent stones did occur, but further studies are needed to compare the incidence of recurrent stones after endoscopic sphincterotomy and after laparoscopic common bile duct exploration.

There were few, but conflicting, reports dealing with the clinical significance of c-erbB-2 in biliary tract cancer. We evaluated the expression of c-erbB-2 in normal epithelium of bile ducts (n = 46), gallbladder cancer (n = 11), carcinoma of the ampulla of Vater (n = 18), and intrahepatic cholangiocarcinoma (CC) (n = 18). c-erbB-2 protein is present in 63% (29/46) of surface epithelium in large and septal bile ducts, but not in peripheral small ducts. Overexpression of the gene product was found in 27.8% (5/18) of intrahepatic CC, 27.8% (5/18) of carcinoma of the ampulla of Vater, and 63.6% (7/11) of gallbladder cancer. But, there was no c-erbB-2 overexpression in the hyperplasia or atypical hyperplastic bile duct epithelium (p = 0.002). In terms of prognostic implication, expression of c-erbB-2 did not correlate to the histopathological grade (p = 0.60) and tumor stage (p = 0.63). The results indicate that c-erbB-2 protein may play some roles in physiology of normal bile ducts. Overexpression of the gene product occurs in one forth to about two thirds of carcinoma of biliary tract, and may be used as phenotypic marker for neoplastic transformation. However, the gene product may not be important in the aggressive behavior of tumor.

In order to determine the predictive value of noninvasive investigations for choledocholithiasis, we conducted a prospective preoperative study on 82 patients with symptomatic gallstones who received laparoscopic cholecystectomy. Ultrasonography (US), liver function tests and endoscopic retrograde cholangiography (ERC) were routinely performed in all cases prior to operation. The results showed a strong correlation between noninvasive procedures (liver function tests and US) and the presence of choledocholithiasis as shown by ERC. Using ERC as a reference, the sensitivity and selectivity of ductal dilatation at US and the elevation of alkaline phosphatase (ALP), gamma-glutamyltransferase and total bilirubin in the serum were studied for the detection of common bile duct (CBD) stones. The values of the combination of these tests were also calculated. From receiver operator characteristics curves, the best cut-off point for US in conjunction with ALP was chosen. ERC should be restricted to patients with possible CBD stones, suspected after a combination of the noninvasive US and ALP tests. This study emphasized the necessity and timing of performing ERC as a preoperative modality in the detection of choledocholithiasis in patients who are to undergo laparoscopic cholecystectomy.

Seven cases of acute suppurative cholecystitis underwent percutaneous transhepatic gallbladder drainage followed by laparoscopic cholecystectomy at the Tainan Municipal Hospital. All the patients had frank septic phenomena clinically, including fever, jaundice, leukocytosis and unstable blood pressure. Organisms were cultured from both blood and bile specimens. Ultrasound-guided transhepatic puncture of the gallbladder was performed for bile drainage, and laparoscopic cholecystectomy was subsequently performed two to five days later after the patients had stabilized. No procedure-related complications from either percutaneous transhepatic gallbladder drainage or laparoscopic cholecystectomy were observed. All patients had early recovery, shortened hospital stay and good cosmetic results. These preliminary results show that laparoscopic cholecystectomy is a safe method and can be employed in those patients with symptomatic gallstone associated with suppurative cholecystitis after preoperative biliary drainage.

We report on a patient with spontaneous perforation of the left hepatic duct who presented with abdominal pain, jaundice and fever. The correct diagnosis was not established until extravasation of contrast medium from the left hepatic duct, as demonstrated by the cholangiogram, was observed. The patient developed two bile-stained intraperitoneal encapsulated fluid collections, which were diagnosed by ultrasonography, and high bilirubin levels in the fluid aspirated from the encapsulations, which were also found at operation. Closure of the perforation with sutures, decortication of the encapsulations and choledocholithotomy for stone extraction with T-tube insertion were performed. Recovery was complete at follow-up examinations.

Six cases of recurrent bleeding duodenal ulcer were treated by bilateral truncal vagotomy via a right transpleural thoracoscopic approach and laparoscopic pyloromyotomy at Tainan Municipal Hospital. The vagus nerves were completely transected, which was proved by pathology. Basal acid output and insulin-stimulated maximum acid output were reduced by 68%-77% and 87%-92%, respectively, after vagotomy. On the other hand, there was no delay in gastric emptying on the basis of either patients' complaints or an upper gastrointestinal series of x-rays. Transpleural thoracoscopic bilateral truncal vagotomy and laparoscopic pyloromyotomy are safe, effective and offer more complete transection of the vagus nerves in treatment of complicated peptic ulcer. In addition, this new technique provides shorter hospitalization and an earlier convalescence.

Endoscopic surgery, including thoracoscopic sympathicotomy for treatment of hyperhidrosis, is thought to be safe and entail fewer complications as compared with open methods. A total of more than 719 patients with hyperhidrosis have undergone thoracoscopic T2,3-sympathicotomy for treatment of hyperhidrosis at Tainan Municipal Hospital since October 1, 1989. Most of the complications have been minor; however, two of the patients suffered from sudden cardiac arrest at the time when the left T2,3-sympathetic nerve trunk was transected by the thoracoscopic method. Vigorous cardiopulmonary resuscitation was performed and both patients recovered completely without any sequelae. The purpose of this paper was to discuss the possible mechanism of cardiac arrest in thoracoscopic sympathicotomy, and to emphasise this rare but potentially fatal complication in the treatment of hyperhidrosis palmaris.

Upper abdominal pain secondary to cancer may cause great disability to patients. Surgical sympathetic-splanchnicectomy, or coeliac plexus block, has been used to relieve intractable upper abdominal cancer pain from stomach, liver, gallbladder or pancreas for a long time. There are, however, intrinsic disadvantages when performing these procedures. Due to our long experience of therapeutic thoracoscopy, we recently performed bilateral thoracoscopic sympathetic-splanchnicectomy on 14 patients (eight male and six female) for relief of pain from primary or metastatic upper abdominal cancers. Most of them were satisfied with the immediate pain relief after the operation. In this new era of therapeutic endoscopy, endoscopic surgery will gradually take the place of open methods in treatment of many diseases. It can be anticipated that thoracoscopic lower sympathetic-splanchnicectomy is undoubtedly a good alternative method for management of intractable upper abdominal pain.

A procedure for percutaneous transcystic cholangioscopy requiring only one percutaneous transhepatic fistulous tract to remove stones located in both the gallbladder and bile ducts is described. The procedure begins with percutaneous transhepatic drainage of the gallbladder or bile duct. Stones in the gallbladder and bile duct can be removed under direct vision on transhepatic cholangioscopy. Larger stones can be fragmented by electrohydraulic lithotripsy before removal. In a preliminary trial the procedure proved to be a feasible method for treatment of 13 patients with both gallbladder and bile duct stones as well as septic cholangitis who either refused operation or were considered poor candidates for surgery. On long-term follow-up (mean period 28 months) stone recurrence was observed in three patients.

Radiological imaging and therapeutic interventions were performed in eight patients with biliary complications following laparoscopic cholecystectomy. The diagnostic approach and the outcome of the therapeutic procedures were evaluated. Complications observed were bile leakage from the cystic duct stump (n = 2); erroneous identification of the cystic duct leading to common hepatic duct transection (n = 1) and hepatic duct ligation (n = 2); liver abscess (n = 1); and retained common duct stones (n = 2). Diagnostic ultrasonography is capable of detecting the presence of abnormal fluid collection and the diameter of the common duct with or without the presence of a stone, although bile leaks and retained common duct stones can only be demonstrated by either endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Once a bile leak had been confirmed, therapeutic endoscopic biliary stenting was successfully applied in one patient while the other received percutaneous transhepatic biliary drainage. Definitive diagnosis of retained common duct stone was established by endoscopic retrograde cholangiopancreatography, and immediate endoscopic sphincterotomy with stone extraction was performed. Follow-up radiological imaging was done to determine the effectiveness of the therapeutic procedures applied in each patient. All our patients improved clinically, and further surgical intervention was not needed.

A "sandwich" technique employing steel coils and gelfoam embolization was applied in two cases of hepatic artery aneurysms. Immediate cessation of the bleeding was evident clinically and the post-embolization angiogram showed occlusion of the vascular lesion. Cholecystectomy is one of the most common abdominal operations and it is generally well tolerated, particularly in young and middle-aged patients. Morbidity rates of 5% to 32% and mortality rates of 0.4% to 2.5% have been reported, depending on such factors as age, underlying illness, etc. (1-4). The most frequent complications of cholecystectomy are wound infection, abscess, ductal injury or ligation, and bleeding. This paper describes two cases of hepatic pseudoaneurysm following iatrogenic damage during cholecystectomy which was treated with transarterial embolization.

Endoscopic sphincterotomy (EST) was performed in 53 patients with biliary disease. Indications for sphincterotomy were: 48 patients with choledocholithiasis, 3 patients with malignant biliary obstruction, and 2 patients with papillary stenosis. The procedure was successful in 52 patients (98.1%). In patients with choledocholithiasis, the stones were successfully removed or passed out spontaneously in 42 patients (87.5%). Endoscopic retrograde biliary drainage (ERBD) was successfully carried out in 2 cases of malignant biliary obstruction after EST. The clinical and biochemical evidence of cholestasis resolved in both patients with papillary stenosis. Complications consisted of hemorrhage (2 patients) and cholangitis (1 patient), resulting in one death. The overall complication and mortality rates were 5.7% and 1.9% respectively. Thirty-two patients received regular ultrasound examination follow-up with a mean of 13.4 months. Two patients had recurrent common bile duct stones and one had restenosis of papilla. The conditions were managed by endoscopic therapy. Endoscopic sphincterotomy is a relatively safe and effective means of relieving extrahepatic cholestasis; however, its comparison with surgical techniques needs long-term, randomized studies.