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Thirty-four patients with suspected common bile duct stones were randomized to undergo endoscopic cholangiography and stone removal prior to open cholecystectomy or to have open cholecystectomy, operative cholangiography, and common bile duct exploration. Sixteen underwent the first protocol, and 18 the second. Analysis of the ability to clear stones from the common bile duct, morbidity, mortality, hospital stay, length of operation, and hospital cost showed no difference in outcome between patients treated by either method. These data suggest there is neither an advantage nor a disadvantage to treating patients with suspected duct stones by precholecystectomy endoscopic cholangiography and stone removal.

Dieulafoy disease is a rare abnormality of the arteries beneath the mucous membranes that line the gastrointestinal (GI) tract. It causes erosion in these arteries that leads to ruptures in the arteries and resultant bleeding in the upper (GI) tract. Bleeding arteries can be detected using an endoscope, an instrument that can be inserted in the GI tract to visualize the interior of the tract, but if the bleeding is not continuous or if clotted blood has covered the rupture, endoscopy may not be useful. Treatment to stop the bleeding can be greatly enhanced if the locations of the ruptures are found prior to surgery. No reports have characterized the clinical and radiologic findings associated with this disease. This study examined the clinical and radiologic findings associated with Dieulafoy disease. The cases of nine patients with the disease are reviewed. All nine patients underwent endoscopic examination and three underwent arteriographic examination (X-rays of arteries.) In eight cases, the disease was not diagnosed until surgery was performed. In the other case, arteriography was used to diagnose the disease. Arteriography was helpful in locating the rupture, but was not diagnostic in two other cases where it was performed. The arteries appeared eroded, but otherwise normal on the X-rays. Endoscopy was not useful in diagnosing Dieulafoy in any of the cases. Eight of the nine rupture sites were found in the stomach. Bleeding was stopped in all patients, but five patients died from other causes. These results indicate that in patients with upper GI tract bleeding where endoscopic examination cannot find the cause of the bleeding, Dieulafoy should be considered. Arteriography results should help locate the rupture site. Embolization or blocking blood flow in the artery branch where the bleeding is suspected should be considered so that surgery can be avoided. (Consumer Summary produced by Reliance Medical Information, Inc.)

One hundred consecutive patients with bleeding esophageal varices were treated with a new endoscopic ligating device that effects strangulation of varices using small elastic 'O' rings. Treatments were continued after initial hospitalization to achieve variceal eradication. Follow-up ranged from 6 to 26 (mean: 15) months. Bleeding was controlled until discharge from hospital or death in 18 of 21 patients who were actively bleeding at index endoscopy. Overall, 26 patients died during the study, 12 during the index hospitalization. Cause of death was organ failure in 21, exsanguination in 3, and cancer in 2. Forty-one of 88 initial survivors experienced 72 episodes of recurrent bleeding (1 to 4 per patient). All but five rebleeds occurred before eradication. Sixty of 88 patients (68%) who survived index hospitalization had their varices eradicated. A median of 5 (1 to 12) treatments was required. Nine patients eventually had other forms of treatment for recurrent bleeding. Only 3 non-bleeding complications resulted from 462 endoscopic treatment sessions. We conclude that endoscopic ligation controls active variceal bleeding and eradicates varices with efficacy similar to that of selerotherapy and with minimal risk of complications., Esophageal varices are enlarged and swollen veins at the lower end of the esophagus that may hemorrhage suddenly, which has a high mortality. Endoscopic treatment of these varices may be an alternative to treatment by sclerotherapy, which is injection of a sclerosing, or hardening, agent directly into the esophageal varices to stop the bleeding. Significant complications occur in up to 20 percent of sclerotherapy cases. A report is presented of 100 patients with bleeding esophageal varices who were treated with a new endoscopic ligating technique. This technique places small elastic 'O' rings around the varices, which strangles them. The average age of the patients was 52 years old, and there were 67 men in the study. There were 21 patients who had active bleeding at the time of endoscopic ligation; bleeding was controlled in 18 of these patients (86 percent). Patients were followed for an average of 15 months. Twenty-six patients died during the study, 12 of whom died during the initial hospitalization. Of the 88 patients who survived initially, 41 patients had 72 episodes of rebleeding. All but 5 cases of rebleeding occurred before the varices had been eradicated. Of the 88 patients who survived the initial hospitalization, there were 60 patients who had their ulcers eradicated. Each patient required an average of five treatments. Three non-bleeding complications occurred in the 462 treatment sessions. Endoscopic esophageal ligation may have some advantages over sclerotherapy. Endoscopic ligation requires only visualization of the varices, followed by ligation; sclerotherapy requires precise placement of the injection of the sclerant into the varices. Additionally, use of an overtube during ligation appears to provide some protection from aspiration during the procedure. (Consumer Summary produced by Reliance Medical Information, Inc.)

• Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85 526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.(Arch Surg. 1989;124:787-790)

• Fiberoptic angioscopy was performed with 2.5- and 3.3-mm angioscopes in 25 arteries and grafts in 19 patients. Radiologically normal and abnormal arteries and anastomotic sites were examined. All vessels and grafts were visualized and images of normal arterial wall, subclinical and obstructing atherosclerotic plaque, and suture lines were defined. Unexpected endovascular findings were noted in five patients (26%) and included large amounts of free-floating clot (one patient), atherosclerotic debris (two patients), and membranelike obstructions (two patients). Angioscopy required three to ten minutes and resulted in no complications. Experience with the flexible angioscope indicates that satisfactory visualization and specific recognition of angiographically unsuspected problems can be obtained. The flexible angioscope is faster and appears more etiologically specific than arteriography.(Arch Surg 1987;122:279-282)