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A 55-year-old man suffered from severe acute abdominal pain. 10 years previously he had been diagnosed with acute pancreatitis. On palpation, there was pronounced abdominal tenderness and guarding.Emergency CT revealed signs of intra- and extrahepatic cholestasis and biliar sludge; serum-lipase was increased.Acute biliary pancreatitis was diagnosed. After admission the patient's condition deteriorated; acute renal failure and respiratory insufficiency developed. After 4 weeks of intensive care he was discharged to a rehabilitation facility via normal ward. At that time pancreatic sonography showed a walled-off necrosis. 7 weeks later colicky abdominal pain occurred again. Altough there were no signs of infection, suction-irrigation drainage was administered. This led to a secondary infection of the necrotic cavity, and 20 sessions of endoscopic necrosectomy were performed for 3 month. Then the patient was discharged to follow-up treatment in a stable condition.Even in supposedly "usual" acute pancreatitis complications can lead to a prolonged course. Sterile necroses should be managed very cautiously.

Jaundice corresponds to elevated bilirubin- levels, whereat one has to distinguish between direct and indirect serum-bilirubin. In the present Mini Review causes and differential diagnosis of jaundice are outlined. Ultrasound-diagnostic plays a major role in identifying intrahepatic or extrahepatic jaundice. Attention is given to the differential diagnosis of elevated liver enzymes in presence of jaundice, pointing out the distinction between hepatocellular and cholestatic parameters as well as the differentiation in acute or chronic increase. Moreover, the consequences of liver enzyme elevations including further diagnostic procedures, are highlighted. Finally, possibilities and limitations of modern diagnostic tests for liver fibrosis are briefly overviewed.Ikterus ist identisch mit dem Vorliegen eines erhöhten Bilirubinspiegels, wobei zwischen direktem und indirektem Bilirubin unterschieden wird. In vorliegender Zusammenstellung wird auf die Ursachen und Differenzialdiagnose beim Vorliegen eines Ikterus eingegangen. Beim intra-und extrahepatischen Ikterus kommt dem diagnostischen Ultraschall eine wegweisende Bedeutung zu. Die Differenzialdiagnostik erhöhter Leberwerte beim Vorliegen eines Ikterus wird angesprochen, wobei zwischen hepatozellulären und cholestatischen Parametern sowie akuten und chronischen Zuständen unterschieden wird. Weiter wird auf die Folgen einer Leberenzymerhöhung sowie die weiterführenden diagnostischen Verfahren eingegangen. Schliesslich werden Möglichkeiten und Grenzen der modernen Fibrosediagnostik erwähnt.Jaunisse signifie la présence d'un taux élevé de bilirubine. On distingue entre une hyperbilirubinémie directe et indirecte. Dans la présente compilation sont mentionnées les causes et le diagnostic différentiel de l'ictère. En ce qui concerne la caractérisation de la jaunisse intrahépatique et extrahépatique, l'échographie diagnostique joue un rôle majeur. Le diagnostic différentiel des taux d'enzymes hépatiques élevés en présence d'un ictère est adressé, en soulignant la distinction entre jaunisse hépatocellulaire et cholestatique, ainsi qu'une augmentation aiguë ou chronique. Ensuite, les conséquences de l'élévation des enzymes hépatiques, y compris d'autres procédures de diagnostic sont mises en évidence. Enfin, une attention est dirigée vers les possibilités et les limites des tests de diagnostic modernes pour la fibrose du foie.

After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis.Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis.The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations.A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage.

Whether the treatment of benign ampullary tumors should be performed as transduodenal surgical excision or endoscopic ampullectomy depends on the size and spread of the tumor. In this videopaper we report technical hints on the surgical resection.Surgical resection is indicated for benign ampullary lesions if endoscopic resection is not possible. In addition, local resection can be performed in cases with high risk of malignancy or in a palliative intention.The duodenum is mobilized by the Kocher maneuver. It is recommendable to perform a cholecystectomy to introduce a flexible catheter antegrade into the common bile duct through the cystic duct for identification of the papilla of Vater by digital palpation. An anterolateral oblique duodenotomy is made and thereby the tumor of the papilla is exposed, followed by a submucosal injection of epinephrine to elevate the tumor. Afterwards a 5-10 mm margin is scored circumferentially in the mucosa around the adenoma. The extent of the excision is based on the preoperative and intraoperative assessment; a submucosal or full thickness (for transmural lesions) excision can be performed. After submucosal excision the mucosa of the ampulla is approximated to the mucosa of the duodenum. In cases with full thickness ampullectomy the borders of the pancreatic and bile duct are approximated and then the entire complex is sutured to the full wall of the duodenum. Furthermore in some cases with extensive resection a separate reconstruction of the pancreatic and bile duct may be required. A terminal assessment of the ductal patency is imperative. The duodenectomy is closed and a paraduodenal drain is placed.Transduodenal resection of periampullary tumors can be technically demanding, but provides a stage-adapted treatment modality for benign and premalignant lesions of the papilla of Vater.

Tumors of the pancreatic head commonly consist of carcinomas whereas other entities are rare exceptions. Extrapulmonary sarcoidosis is well-known but is extremely rare when detected as a mass in the pancreatic head. In general the diagnosis of sarcoidosis requires histologic examination with verification of non-caseous, epithelioid cell-like granulomas. Systemic therapy consists of steroids when the patient exhibits symptoms or in the case of progression of the disease. However, in some cases extended abdominal resections are also required to confirm the diagnosis and/or to treat symptoms.

In most cases pancreatic cancer appears in a non-curatively resectable stage at time the diagnosis is made. Thus, palliative treatment concepts come to the fore in these patients. Patients without metastases, but presenting with marginally resectable or locally non-resectable tumours should not be treated in a palliative therapeutic scheme. These patients should be enrolled in neoadjuvant radiochemotherapy trials. After finishing treatment and restaging, a potentially curative resection can be achieved in approximately one-third of these patients. Within the scope of the best possible palliative care, excision of metastases together with resection of the primary cancer represents a therapeutic option to be contemplated in selected cases. For distinct locally unresectable or metastasised advanced pancreatic cancer, treatment of bile duct or duodenal obstruction is an essential part of the comprehensive palliative therapy. However, both endoscopic / percutaneous stenting procedures and surgical bypass makeshifts constitute safe and highly effective therapeutic alternatives in this context. In the case of operative drainage of the biliary tract the prophylactic creation of a gastro-intestinal bypass (double bypass) is recommended. The decision on a surgical versus an endoscopic procedure for palliation depends considerably on the tumour stage and the estimated prognosis and has to be determined interdisciplinary and individually in each case.

Duplication of the gallbladder is a rare congenital anomaly. An incidence of 2.5:10,000 has been published in autoptic studies.We carried out an analysis of the published case reports of the last 30 years to examine those cases in which an accessory gallbladder was pre- or intraoperatively detected or missed and to evaluate the implications of the time of diagnosis of the duplication on the surgical therapy.28 case reports were analysed. If the duplication of the gallbladder was recognised pre-operatively or during operation, both gallbladders could be removed via laparoscopy in 80 % of the cases. Missing the second gallbladder can lead to persisting symptoms, postoperative complications as well as a recrudescence of the cholecystolithiasis with following reoperation. If a reoperation for a missed second gallbladder was necessary, only 14.3 % of these operations could be performed via laparoscopy.We report the case of a missed gall-bladder duplication with an acute cholecystitis causing a reoperation 17 years after the initial operation. A laparoscopic cholecystectomy was possible even though the initial operation was performed through open surgery.If recognised in preoperative examinations or during surgery a laparoscopic cholecystectomy of both gallbladders is possible in the majority of cases with duplicated gallbladder.

Iatrogenic bile duct injuries represent a severe complication after cholecystectomy. For the attending physician therapy and management of these injuries are a challenge. Inadequate and delayed treatment can lead to stenoses at a late stage, which can necessitate further surgical intervention.In a study data of 74 patients, who were treated in our clinic for bile duct injuries following cholecystectomy, were analysed retrospectively.A total of 8 patients with late stage bile duct strictures following iatrogenic bile duct injury including the subsequent therapy could be identified. The data of these patients were analysed in respect of cause and strategies to prevent late stage stenoses. In 62 patients the bile duct injury occurred following laparoscopic and in 12 patients following open cholecystectomy. In 16 patients the injury was combined with a vascular lesion. The interval between primary intervention and definitive therapy was 11 days in 53 patients and 1-15 years in 21 patients. In 8 patients the reason for the re-operation after a long interval (1-15 years) was a late stage stenosis. A hepatico-jejunostomy was performed subsequently and during follow-up 5 / 8 patients were symptom-free; 7 patients were re-operated due to a stenosed primary biliodigestive anastomosis and 3 patients each due to atrophy of the right liver lobe and recurrent cholangitis. One patient complained of recurrent cholangitis and a further patient of symptoms due to adhesions.If treated inadequately bile duct injuries occurring during cholecystectomy can in the long-term lead to considerable problems such as recurrent cholangitis, late stage stenoses and even to secondary biliary cirrhosis. Therefore, a complex inter-disciplinary therapeutic concept aiming at timely treatment is necessary.

We report four cases of autoimmune pancreatitis in an 18-, a 22- and a 26-year-old male patient and a 20-year-old female patient. The 20-year-old female patient was admitted to the hospital with upper abdominal pain and jaundice, the 18-year-old patient with recurrent acute pancreatitis and cholestasis, the 26-year-old patient with right upper abdominal pain for four weeks and laboratory findings suggesting an acute pancreatitis. The 22-year-old patient presented with painless jaundice. EUS-guided fine needle aspiration was performed in all patients. The cytological findings and the EUS were decisive for the diagnosis of autoimmune pancreatitis in all four cases. In contrast, no patient showed elevated IgG4, or antibodies for carboanhydrase-II, for lactoferrin, or rheumatoid factor, serum markers reported to be positive in autoimmune pancreatitis. All patients were treated successfully with steroids, one patient relapsed after discontinuing the steroid medication and required renewed therapy. These case reports demonstrate that autoimmune pancreatitis should be considered in the differential diagnosis in cases of pancreatitis and/or jaundice also in western countries. As demonstrated, the diagnosis should not be based solely on the elevation of IgG4 or autoantibodies.

Autoimmune pancreatitis (AIP) is a rare disorder. Typical clinical symptoms include extrahepatic cholestasis, abdominal pain, and weight loss.The case of a patient with cholestatic icterus and double duct sign is reported, who underwent surgery (Whipple operation) because of suspected pancreatic cancer. Histology of the resected pancreas head revealed AIP. Due to this diagnosis, measurement of IgG4 showed a significantly elevated serum level. Postoperatively, cholestasis parameters remained elevated, which was interpreted as associated sclerosing cholangitis. Therapy with corticosteroids led to normalization of the cholestasis within 4 weeks.AIP should be taken into account as differential diagnosis to pancreatic cancer, especially in cases without clear demarcation of a pancreatic tumor. Measurement of IgG4 may be an important parameter to avoid unnecessary surgery.

The term autoimmune pancreatitis (AIP) describes a nonalcoholic, chronic lymphoplasmocytic pancreatitis. The lymphoplasmocytic infiltration is characterized by periductal localization of predominantly CD4-positive T cells, fibrosis, and acinar atrophy, frequently resulting in stenosis of the main pancreatic and distal common bile ducts. Imaging studies often reveal a diffuse narrowing of the pancreatic main duct and swelling of the pancreatic head wrongly suggesting the presence of a malignant tumor. Clinical signs include mild abdominal pain, jaundice, recurrent episodes of acute pancreatitis, and even new-onset diabetes mellitus. Additionally, AIP can be associated with other autoimmune diseases such as Sjögren's syndrome, primary sclerosing cholangitis, chronic inflammatory bowel diseases, and retroperitoneal fibrosis. Serological markers include autoantibodies and increased levels of gamma globulin and especially IgG4. Steroids seem to be effective in improving clinical symptoms as well as in the resolution of pancreatic and bile duct narrowing. This distinguishes AIP from other forms of pancreatitis and from pancreatic neoplasms. Further studies of the underlying pathophysiologic mechanisms, prognosis, and new diagnostic tools are needed to provide adequate and effective treatment in the future. In this article, we summarize the current knowledge about AIP and present 17 cases that underwent surgical resection at our institution from 2003 to 2004.

Because of recurrent abdominal pain, jaundice and elevated liver function tests, a sixty-two-year old man had been referred to hospital several times within the preceding six months. By means of ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonant cholangiopancreatography, dilated extrahepatic bile ducts were diagnosed. Stones and a tumorous process were excluded. ERCP showed hypermotility of the upper gastrointestinal tract. Quantitative hepatobiliary scintigraphy demonstrated retention of activity in the intra- and extrahepatic bile ducts and delayed transit of activity to the duodenum as signs of papillary dysfunction. Drug anamnesis revealed that the patient had started migraine treatment with Zolmitiptan, a 5-HT (1B/1D)-receptor agonist of the second generation, six months before the beginning of the cholestasia syndrome. Because of the known increase in amplitudes of oesophageal motor waves and of lower oesophageal sphincter tone by Sumatriptan, a 5-HT (1B/1D)-receptor agonist of the first generation, Zolmitriptan treatment was stopped. Thereupon, laboratory findings normalised and the patient has been feeling well for more than one year. Serotonin is an important monamine neurotransmitter that acts both in the CNS and in the gastrointestinal tract on identical receptors and is transported by the same systems. Thus it is not surprising that therapeutic measures which influence the serotoninergic system in the CNS are also effective in the enteric nervous.

Hepatobiliary problems are not uncommon in general practice. Many cases can be solved on the basis of a thorough history, clinical examination, blood tests and abdominal ultrasound. The focus of this tutorial paper lies on a number of possible pitfalls in the workup of such problems, based on brief case histories. Atypical presentations of lithogenic biliary obstruction, with or without cholangitis, are discussed as a relatively frequent cause of management difficulties. Furthermore, certain caveats in the interpretation of tumor marker CA19-9, prothrombin time/INR, and ferritin are highlighted.

During the past years several endoscopic and interventional techniques have been developed for the treatment of bile duct strictures and have had a strong impact on therapeutic regimens. Benign stenoses of the bile duct are mainly caused by cholecystectomy or liver resection or by inflammatory diseases. Insertion of an endoprosthesis insertion or balloon dilation is clinically successful in 60 to 90 % of these patients and will result in adequate opening of the stricture. To date, only bile duct stenosis in chronic pancreatitis are not improved satisfactorily by endoscopy. The insertion of an endoprosthesis is a cornerstone in the treatment of malignant obstructive jaundice in patients with cancer. Several comparative studies have demonstrated the advantages of self-expanding metal stents (SEMS) over plastic prostheses in terms of patency. A selective use of SEMS is mandatory, as the costs for SEMS are high and many patients with malignant jaundice will die with their first plastic prosthesis in situ without stent occlusion. In patients with hilar cholangiocarcinoma, the combination of photodynamic therapy and endoprosthesis insertion might result in a survival advantage. The use of bioabsorbable stent materials or coating of the stent with antiproliferative drugs will improve the treatment results in the future.

Although there are growing possibilities of interventional endoscopic treatment of benign and malignant stenosis of the distal common bile duct the definitive operative drainage by terminolateral hepaticojejunostomy is in many cases the therapy of choice. In patients with chronic pancreatitis and bile duct stricture the modified duodenum preserving pancreatic head resection ("Beger operation") enables a resection of the inflammatory mass together with a drainage of the bile. Of 391 patients from our clinic being operated due to a bile duct stricture 337 underwent a biliary drainage together with a pancreatic head resection. Early postoperative biliary complications were in 0.3 % strictures of the duct and 1.5 % bile fistulas. Half of those complications could be managed conservatively. In high volume centers the operative therapy of distal common bile duct stenosis is a safe procedure with high patency rate.

One of the most common causes of extrahepatic cholestasis is bile duct obstruction by gallstones, bile duct strictures in chronic pancreatitis involving the head of the pancreas, or tumors in the region of the pancreas, bile ducts or gallbladder. While choledocholithiasis usually gives rise to classical clinical signs (obstructive jaundice, typical pain, and fever in the case of cholangitis), tumors often become symptomatic only when far advanced. In addition to laboratory parameters, diagnostic imaging techniques, in part with a therapeutic intervention option (ERCP), are of central importance. The aim of treatment is the elimination of the obstruction and, if possible the underlying disease.

Since the introduction of laparoscopic cholecystectomy (LC), a decrease in the practice of intraoperative cholangiography (IOC) has been reported. Are there actually reasons for carrying on IOC during LC? Depending on the management of common bile duct (CBD) stones treatment a different IOC regime is recommended. If the single-stage laparoscopic extraction of ductal calculi during LC is preferred, routine IOC is generally necessary to detect all CBD stones for desobstruction via ductus cysticus or choledochotomy. When therapeutic splitting is favoured, including two-stage management with endoscopic desobstruction and later LC, routine IOC can be foregone. However, selective practice of IOC can help to reduce the rates of unnecessary preoperative investigations from 40-60 % to 20 % when postoperative endoscopic desobstruction demonstrates similar success rates of about 95 %. Regarding the preventive character of laparoscopic IOC to CBD injuries, a routine investigation should be adopted by institutions with injury rates0.4 % and in the learning phase of young surgeons. For all other institutions a selective practice should be recommended when difficult intraoperative conditions render recognition of the anatomical situation more difficult or for identification of dissected non-bleeding ducts near the triangle of Calot.

Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis.A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice.In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.

Cholestasis is known as an etiologically diverse clinical entity which requires a broad differential diagnostic workup. In the majority of patients, history, clinical examination, clinical chemical analysis, and abdominal ultrasound enable the differentiation between extrahepatic and intrahepatic cholestasis. This review summarizes our current knowledge in the diagnosis of cholestatic disorders.In regard to clinical practice, diagnostic tools and new developments in imaging and molecular genetics are discussed including an algorithm for the diagnostic workup of cholestatic patients.Ultrasound and computed tomography have represented the most important primary imaging techniques in hepatobiliary disorders over the last 2 decades. The direct visualization either by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) still remains the gold standard in the evaluation of the extrahepatic bile duct. In the past decade, magnetic resonance cholangiopancreatography (MRCP) has increasingly been established as a noninvasive alternative, thereby reducing the necessity of ERCP as an invasive exploration of the biliary system. Liver biopsy is indicated for the histologic grading and staging of intrahepatic cholestatic disorders. Recently, molecular genetic studies have elucidated several mutations in genes of hepatobiliary transporters which are responsible for hereditary forms of cholestasis in man. Thus, molecular genetics may be of interest in single cases of unclassified cholestasis or familial syndromes and will contribute to the routine diagnosis of hereditary cholestatic syndromes in the future. In summary, application of these diagnostic tools will finally lead to an unequivocal diagnosis in the majority of cholestatic patients with consecutive rational therapy.

In spite of dynamic development of modern diagnostic and therapeutic methods, the long-term results of surgical therapy in pancreatic cancer are still unsatisfying. The aim of this study was to analyse long-term results of surgical palliation for pancreatic cancer in a pancreatic surgery centre.We performed a retrospective analysis of 418 patients who underwent non-resective, palliative procedures for pancreatic cancer between 1975 and 1999. In order to compare two consecutive periods of time, the patients were divided in 2 groups; group I treated from 1975 to 1990 (n = 204), and group II from 1991 to 1999 (n = 214).Of all patients qualified for surgery, 281 (67.2 %) underwent surgical bypass, 107 (25.6 %) laparotomy, and in 30 cases surgical intervention was limited to implantation of endoprosthesis. A significant tendency towards double (i. e. biliary and gastric) anastomosis was observed (32.3 % vs. 74.8 %; p0.01) in patients who underwent bypass procedures. The postoperative morbidity was 16.3 %. The postoperative mortality rate was 5.7 % and significantly (p0.01) decreased from 10.3 % (group I) to 1.4 % (group II). No differences neither in mortality nor morbidity related to the type of performed surgery were found. The mean time of hospital stay was 15.5 +/- 6.9 days and showed no differences related to the type of intervention. Jaundice or symptoms of gastric outlet obstruction were observed in 16 % of patients in the follow-up period and concomitantly performed biliary and gastric bypasses were associated with the lowest rate of the late gastrointestinal obstruction (4 %). The median survival time was 169 days and only 4 % of patients survived 12 months. The univariate analysis of prognostic factors showed that location and stage of the tumour, the type of surgical intervention and bypass procedure influenced 1-year survival. The multivariate analysis using Cox proportional hazard model proved that only stage and location of the tumour had independent prognostic value.Surgical palliation for pancreatic cancer can be performed with acceptable morbidity and mortality rates. For tumours located in the head and body of the pancreas combined biliary and gastric bypass should be preferred. For cancers located in the tail of the pancreas gastric bypass should be performed routinely. Because surgical palliation can prevent gastric outlet obstruction by gastroenterostomy, endoscopic biliary stenting should be only performed in patients with pancreatic head cancers and simultaneous evidence of distal metastases as well as in older patients with high comorbidity.

Indication for emergency ERCP (48 hours after onset of symptoms) with stone extraction from the common bile duct (CBD) in patients with biliary pancreatitis remains controversial. In our hospital emergency ERCP with stone extraction from CBD is part of the therapeutical concept in patients with biliary pancreatitis. The aim of the study was to elucidate retrospectively results and impact of this concept on morbidity and lethality in surgical intensive care patients. We included all patients with a documented indication for emergency ERCP. Among 4 466 patients (1. 1. 1999-31. 12. 2000) treated in the SICU, 37 (0.9 %) required an emergency ERCP due to a biliary pancreatitis. (26 females/11 males, 62.0 +/- 15.4 years). After ERCP stones were present in 32 of the 37 patients with subsequent successful endoscopic extraction in all cases but one. The mean duration from admission to ERCP was 11.6 +/- 10.1 hours. Bilirubin as well as amylase and lipase decreased after ERCP (p0.05). Only in one case an elevation of pancreatic enzymes over the pre-ERCP values was observed, an aggravation of pancreatitis was not seen in our series. In 5 of the 37 cases bile duct stones were not found after ERCP despite strong clinical suggestion (elevation of bilirubin and pancreatic enzymes, ultrasound). During the observational period 2 patients died, in one case possibly due to the ERCP. Emergency ERCP removed in our series the pancreatitis causing agent. Still considering the limitations of a retrospective study these positive results are stimulating us to continue with our therapeutical concept.

Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

An obstruction of the afferent loop after Billroth-II-resection is an extremely rare late complication of this procedure. We report on a 76-year-old female patient with a history of Billroth-II-resection 11 years ago who was admitted due to acute pancreatitis and obstructive jaundice. Abdominal sonography lead to the suspicion of a dilated afferent loop, which could be proven by means of magnetic resonance imaging. A tumorous lesion as cause of the obstructive jaundice was not detectable. Intraoperatively a volvulus of the small intestine and strangling adhesions near the Braun's anastomosis were seen, causing the obstruction of the afferent loop. Following reposition of the small intestine and adhesiolysis the patient gained a quick relief of symptoms and the jaundice disappeared completely.

Interventional ERCP in patients with cholestasis. Degree of biliary bacterial colonization and antibiotic resistance. Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The aim of our prospective study was to investigate the presence and degree of biliary bacterial colonization by means of bile aspiration during ERCP in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient. In addition, analysis of risk factors was performed that would predispose to the development of cholangitis.80 patients with clinical and laboratory evidence of biliary obstruction underwent ERCP with initial aspiration of bile via the cannulation catheter. This material was used to culture aerobic and anaerobic bacteria and determine the colony count/ml bile, followed by identification of each species and antibiotic resistance testing. The minimal inhibitory concentration for Levofloxacin, Ciprofloxacin, Piperacillin, Ampicillin, Ceftriaxone, Imipenem, Gentamycin und Metronidazole was determined. Immediately after the ERCP or if the body temperature (after ERCP) rose to38 degrees C blood cultures were obtained. In 45 (56 %) patients biliary colonization with bacteria could be identified (56 %). In 20 patients a single isolate was cultured, in 25 cases mixed infection was present. A total of 83 species were isolated. The most common bacteria were E. coli, Enterococcus and Klebsiella. 9.6 % of all isolates were obligatory anaerobes. In 9 of 80 patients bloodcultures tested positive for bacterial growth (rate of bacteremia: 11.3 %). 10 patients had acute cholangitis clinically before ERCP, 13 patients developed signs of infection after ERCP. Statistically significant factors contributing to the risk of infection were age of the patient, the clinical condition of the patient before ERCP and the biliary colony count. Patients with development of infection after ERCP showed a significantly higher incidence of bacterial colonization of the biliary tree and a higher colony count. In all bacterial species Imipenem (4.5 %) or Levofloxacin (2.2 %) exhibited the lowest rate of in-vitro resistance. Based on these data, the implementation of Levofloxacin in combination with anaerobic coverage is advantageous as a calculated therapy for patients with acute cholangitis.

Combined endoscopic and percutaneous transhepatic approach in postsurgical common bile duct occlusion.A 48-year-old patient was transferred to our hospital suffering from acute cholangitis due to complete bile duct occlusion one year after a laparoscopic cholecystectomy. Main complaints were fever over 40;C and chills, accompanied by right upper quadrant abdominal pain and jaundice.Cholestastic enzymes, transaminases and leucocytes were increased. Transabdominal utrasound showed massive dilatation of the intrahepatic bile ducts. ERCP was performed and revealed a complete and impassable obstruction of the proximal common bile duct.The bile duct occlusion following cholecystectomy was the reason for the patient inverted question marks cholangitis. Neither via ERCP nor via the percutaneous transhepatic approach was it possible to make a communication between the proximal and the distal biliary system, none of the guidewires being able to pass the obstruction. However, we finally managed to pass the obstruction in a combined endoscopic-percutaneous transhepatic rendezvous technique. The patient received a percutaneous large-calibre plastic prosthesis (Yamakawa type). 4 months after the procedure the stenosis could hardly be detected.Endoscopic treatment is successful in most patients with post-cholecystectomy bile duct strictures. Therefore, repeated surgery is usually not necessary. Even in complete bile duct occlusions, the combined endoscopic-percutaneous transhepatic method can re-open the obstruction and is therefore a possible alternative to surgery in selected cases.

The follow-up of patients with severe bile duct lesions after laparoscopic cholecystectomy often shows secondary complications. We report on a female patient suffering from long-lasting complications after bile duct injury and early reconstruction by end-to-end anastomosis via a T-tube drainage. More than 5 years later and after multiple dilatation and stenting of the bile duct stenosis the patient was treated with an expanding metal stent. The severe cholangitis persisted. So the patient was operated on: bile duct and connected stent were resected. The reconstruction was performed with an isoperistaltic jejunal conduit. More than 24 months later the patient is healthy and at work again.

During the last decades, the mortality following pancreatic resections has decreased tremendously due to advances in operative technique and perioperative management. In order to examine if similar improvements have been achieved for surgical palliation of obstructive jaundice, we conducted an analysis of our series of surgical bypass procedures.Data from all patients undergoing surgical palliation after exploration for pancreatic carcinoma, were prospectively recorded.Between 1.11.93 to 1.11.99 a total of 348 patients were treated with a tumor of the pancreas. 74 of these patients received a bypass procedure: there were 40 double bypass, 20 biliary and 14 gastric bypass procedures. Overall morbidity and mortality was 35% and 1.2% respectively. Median in-hospital stay was 12 days (range 6-37). Median survival time was 5 months (range 1-25). Neither the type of surgical palliation, age nor perioperative risk assessment according to the ASA classification affected perioperative mortality. In contrast, jaundiced patients had significantly more postoperative complications than non-jaundiced patients (58% versus 18%; p = 0.001).Surgical palliation can nowadays be performed with great safety. A double bypass procedure consisting of a hepatojejunostomy combined with a gastrojejunostomy seems to be the procedure of choice for patients with unresectable pancreatic carcinoma.

Benign, non-parasitic liver cysts are usually asymptomatic and found incidentally by abdominal ultrasound or CT scan. We present the case of a 68-year-old patient who showed obstructive jaundice due to a hemorrhagic liver cyst compressing the choledochal duct. Due to the location of the cyst in the porta hepatis with partial compression of central liver vessels and the meanwhile organized hematoma, operative therapy was preferred in order to prevent secondary complications such as portal vein thrombosis and to exclude a malignant neoplasm.

Obstructive jaundice caused by a parasitosis is very rare. It can be a complication of a cystic echinococcosis. We present the case of a 33-year-old man who suffered from cystic echinococcosis with an affection of the liver for several years. As a complication an echinococcal cyst had ruptured into the biliary tract and had led to an occlusion of the ductus hepatocholedochus. By means of ERCP the membrane of the echinococcal liver cyst was extracted in toto. Cholangioscopy followed and showed a free biliary tract without remaining cyst fragments. After these interventions the blood parameters normalized and the patient recovered. An additive chemotherapy with albendazole was started.

Local injection of depot-corticosteroids into benign esophageal strictures has been proven to maintain the effects of bougienage or balloon dilation.Eight consecutive patients with benign common bile duct (CBD)-strictures (postoperative, n = 6, primary-sclerosing cholangitis, n = 2) were enrolled in this pilot trial. All had undergone initial balloon dilation and insertion of a 10F-plastic prostheses without relevant effects on the stricture diameter four to six weeks before. Than all patients underwent another balloon dilation and insertion of a 10F-Tannenbaum-stent. In the same session injection of 2 x 10 mg of triamcinolone (Volon A, Bristol-Myers Squibb, München) into the CBD-wall at the stricture site by means of a sclerotherapy needle was performed. Four to six weeks later ERC was repeated and balloon dilation and/or stent exchange was performed whenever indicated.The initial mean diameter of the CBD-stenoses was 1.81 +/- 0.65 mm. The mean serum levels of the alkaline phosphatase (AP) and of bilirubin were 455 +/- 188 U/L and 4.9 +/- 2.2 mg/dl, respectively. After the initial balloon dilation and stent insertion no significant improvement had been registered (1.9 +/- 0.7 mm). However, after local triamcinolone injection and the second dilation/stent insertion the diameter of the CBD-stenosis increased significantly to 3.68 +/- 0.96 mm (p0.01). No adverse affects were recognized. Three patients had complete recovery of their CBD-stenosis after a third dilation, the remaining five patients were cured after two or three additional balloon dilations with intermittent stent exchange. Thereafter, no recurrence of a CBD-stenosis was observed during a median follow-up of twelve months. At completion of the study the mean serum AP- and bilirubin level were 195 +/- 87 U/L and 1.2 +/- 0.4 mg/dl, respectively.Local application of depot corticosteroids is a feasible and safe procedure for therapy of benign CBD-stenoses. The results of this pilot trial justify a randomized study.

Iatrogenic bile duct lesions are serious complications during laparoscopic cholecystectomy and include biliary leakage and major bile duct injury. The incidence of biliary lesions following laparoscopic cholecystectomy is up to threefold higher than that of the open procedure. A total of 108 patients with bile duct lesions after laparoscopic cholecystectomy were treated at our institution. Endoscopic treatment was successful in 68 cases, 6 patients were treated by external drainage, and 34 patients required surgical therapy. Selection criteria for the type of treatment included the etiology, anatomical situation, and diagnostic interval of the biliary lesion. We suggest a classification of bile duct injury and a proposal for diagnosis and treatment of these complications.

A new papillotome was designed to overcome certain drawbacks of the needle-knife, that is most commonly used for precut sphincterotomies. The intention was to develop an instrument at least as good as the needle-knife or the Erlangen-type precut papillotome for precut procedures. In addition, it had to be suitable for direct cannulation of the biliary or pancreatic duct.According to a prospective protocol 54 patients in whom a papillotomy was indicated were examined with the new instrument. The protocol allowed three futile attempts to cannulate or two inadvertant cannulations of the pancreatic duct with a standard cannula and hydrophilic guide wire before a precut was performed. The new baby-papillotome has a diameter of only 1 mm and a short 10 mm cutting wire. Similar to a guide wire it is introduced via a 6F- or 7F-introducer catheter.Cannulation of the desired duct (the bile duct in 48 patients, the pancreatic duct in five patients, Billroth II anatomy in three patients) was successful within one session in 98% (53/54). In one patient, the bile duct was successfully cannulated in a second session using the baby-papillotome, resulting in an overall success rate of 100%. Primary cannulation using the new papillotome without precut was obtained in 24% (13/54). Complications were mild pancreatitis in one patient and nonsignificant bleeding in three (immediate endoscopic hemostasis in all, no transfusions, no drop of hematocrit). There were no serious complications.The new baby-papillotome is suitable for precut as well as for primary cannulation. In this first series, the desired duct was cannulated in 98% within the first session with a low complication rate. Further studies of the new instrument seem desirable.

The aim of the prospective study was to evaluated the efficacy and the complications of 2,820 ERCP-examinations in 1,717 consecutive patients (performed over a three-year period). The rate of success was 82.8% for diagnostic ERCP, 96.6% for endoscopic sphincterotomy, 76.8% for the extraction of stones on common bile tract, 87.5% for drainage in bile tract obstruction, respectively. The rate of all complications amounted to 7.9% (4.9% diagnostic ERCP, 9.2% therapeutic ERCP, in detail: 3.8% acute pancreatitis, 2.1% cholangitis, 1.3% bleeding, 0.2% perforation, 0.5% other respectively). The total mortality was 0.1% (three cases of death). The frequency of complications increased with the number of procedure at the papilla Vateri in patients, who underwent needle knife papillotomy in combination with standard papillotomy.

A 36-year-old female patient was transferred to our unit for surgical treatment of a biliary tract obstruction. ERC disclosed an obliteration of the common hepatic duct involving the hepatic bifurcation. Primary sclerotic cholangitis and carcinoma of the bile duct could not be confirmed histologically in the biopsy specimens. Tumor markers and autoimmune antibodies were normal. Histological examination of the ductus choledochus during the operation was not conclusive and a malignant lymphoma was considered. The macroscopic appearance comprised obliterative alterations extending to the right hepatic duct. Therefore, resection of the extrahepatic bile duct, right hemihepatectomy and hepaticojejunostomy were performed. The final histological statement revealed a lymphoepithelial carcinoma. The postoperative course of the patient was uneventful, and the patient is in good condition without any signs of recurrent disease 12 months after the operation. This tumor has been described as occurring as a neoplasm of the stomach and salivary glands exclusively and as being of low-grade malignancy. Additional histological evaluations confirmed the diagnosis of lymphoepithelial carcinoma.