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BACKGROUND Choledochoduodenal fistula is an uncommon complication secondary to peptic ulcer disease. Determining this diagnosis is challenging especially when confronted with unspecific physical and radiological findings. CASE REPORT Here we report a case of a 29-year-old Ethiopian female who presented to Geitaoui University Hospital in Beirut, Lebanon with epigastric pain and was diagnosed to have of choledochoduodenal fistula. CONCLUSIONS Choledochoduodenal fistula is a rare complication of duodenal ulcer and this case report may help clinicians to identify suspected cases of this entity with similar presentations.

Clinically, acupuncture affects the motility of the extrahepatic biliary tract, but the underlining mechanisms are still unknown. We applied manual acupuncture (MA) and electrical acupuncture (EA) separately at acupoints Tianshu (ST25), Qimen (LR14), Yanglingquan (GB34), and Yidan (CO11) in forty guinea pigs (4 groups) with or without atropinization under anesthesia while Sphincter of Oddi (SO) myoelectric activities and gallbladder pressure were monitored. In both MA and EA groups, stimulation at ST25 or LR14 significantly increased the frequency and amplitude of SO myoelectrical activities and simultaneously decreased the gallbladder pressure as compared to the pre-MA and pre-EA (P < 0.05). On the contrary, stimulation at GB34 or CO11 significantly decreased SO myoelectricity and increased the gallbladder pressure (P < 0.05). Pretreatment with atropine could abolish the effect of stimulation at acupoints ST25, GB34 and LR14 (P > 0.05), although significant myoelectricity increases were still inducible with MA or EA stimulation at CO11 (P < 0.05). In summary, acupuncture has bi-directional effects to gallbladder pressure and SO function, which probably due to autonomic reflex and somatovisceral interactions.

Local and systemic reactions to implanted metallic devices, particularly to those containing nickel, are well documented. Metal ions are released due to exposure of the metal to blood, proteins, other body fluids, and sheer mechanical stress. Metal ions then complex with native proteins and become antigens, which can elicit hypersensitivity reactions. Another case report depicts a specific allergic complication (early stent occlusion) related to metallic biliary stent implantation. We present a case of allergic symptoms, associated with eating, in a patient who developed nickel sensitivity after biliary metal stent placement confirmed by allergic skin testing to the same metallic biliary stent placed one year earlier. Symptoms resolved following partial removal of the non-epithelialized portion of the biliary stent.

Introduction: Surgically altered anatomy complicates endoscopic procedures of the pancreaticobiliary tree. Biliary strictures have been managed using percutaneous transhepatic techniques., Materials and Methods: In recent years device-assisted enteroscopy (e.g., double balloon enteroscope [DBE]) has been used to gain access to the common bile duct. The length of the scope and its narrow, 2.8-mm working channel limit the use of standard endoscopic retrograde cholangiopancreatography (ERCP) devices. Therefore, shorter enteroscopes for ERCP have been developed. A fully covered self-expandable metallic stent (fcSEMS) cannot be used through the narrow channel. In conventional anatomy, benign biliary strictures have been treated using fcSEMS, requiring fewer endoscopies compared with multiple plastic stenting., Results: Here we report the first case of fcSEMS deployment through the working channel of a novel, long DBE with a 3.2-mm working channel, and 2 cases with the conventional narrow-channel DBE, using the rendezvous technique, with fcSEMS insertion on a wire running along the enteroscope., Conclusions: These new techniques, here used on benign biliary strictures, are described in detail.

Background and Study Aims: The use of covered self-expandable metallic stents (cSEMS) in benign biliary indications is evolving. The aim of the study was to assess the safety and feasibility of cSEMS compared with multiple plastic stents in the treatment of benign biliary stricture (BBS) caused by chronic pancreatitis., Patients and Methods: This was a prospective, multicenter, randomized study of 60 patients with BBS caused by chronic pancreatitis. All patients received an initial plastic stent before randomization. At randomization, the stent was replaced either with a single cSEMS or three plastic stents. After 3 months, the position of the cSEMS was checked or another three plastic stents were added. At 6 months after randomization, all stents were removed. Clinical follow-up including abdominal ultrasound and laboratory tests were performed at 6 months and 2 years after stent removal., Results: Two patients dropped out of the cSEMS group before stent removal. In April 2014, the median follow-up was 40 months (range 1 - 66 months). The 2-year, stricture-free success rate was 90 % (95 % confidence interval [CI] 72 % - 97 %) in the plastic stent group and 92 % (95 %CI 70 % - 98 %) in the cSEMS group (P = 0.405). There was one late recurrence in the plastic stent group 50 months after stent removal. Stent migration occurred three times (10 %) in the plastic stent group and twice in the cSEMS group (7 %; P = 1.000)., Conclusion: A 6-month treatment with either six 10-Fr plastic stents or with one 10-mm cSEMS produced good long-term relief of biliary stricture caused by chronic pancreatitis.Study registered at ClinicalTrials.gov (NCT01085747)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Sphincter of Oddi disorder (SOD) is a part of functional gastrointestinal disorder which is a non-calculous obstructive disorder. This disease is more common in middle-aged women with a prevalence of around 1.5% but in patients with post-cholecystectomy syndrome (PCS) the prevalence rate is markedly higher (9-55%). This high variability maybe attributed to lack of uniformity in patient selection criteria, definition of SOD, and the diagnostic method used. Abdominal pain is the most common symptom occurring due to obstruction at the SO leading to ductal hypertension, ischemia from spastic contraction and hypersensitivity of papilla. Clinical diagnosis of SOD can be achieved by Rome III criteria. Various classifications are used (Milwaukee billiary and modified Milwaukee group classification) for billiary and pancreatic SOD. Not a single non-invasive method is diagnostic. Sphincter of Oddimanometry (SOM) is the gold standard method for evaluating and deciding the management of an SOD patient. The symptomatic relief rate varies from 55% to 95%, so risk-benefit ratio should be evaluated with each patient.

Aim: To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis., Methods: Consecutive patients who underwent ERCP procedures at our hospital between January 2008 and June 2013 were retrospectively enrolled in the study (n = 2674). All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation. For patients showing alterations in the gastrointestinal anatomy, a short-type double balloon enteroscope had been applied. Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitoneal space, or upon endoscopic detection of an abdominal cavity related to the perforated lumen. For patients with ERCP-related perforations, the data on medical history, endoscopic findings, radiologic findings, diagnostic methods, management, and clinical outcomes were used for descriptive analysis., Results: Of the 2674 ERCP procedures performed during the 71-mo study period, only six (0.22%) resulted in perforations (male/female, 2/4; median age: 84 years; age range: 57-97 years). The cases included an endoscope-related duodenal perforation, two periampullary perforations related to endoscopic sphincterotomy, two periampullary perforations related to endoscopic papillary balloon dilation, and a periampullary or bile duct perforation secondary to endoscopic instrument trauma. No cases of guidewire-related perforation occurred. The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation; the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively (at a median post-ERCP intervention time of 15 min). Three out of the six total perforation cases, including the single case of endoscope-related duodenal injury, were surgically treated; the remaining three cases were treated with conservative management, including trans-arterial embolization to control the bleeding in one of the cases. All patients recovered without further incident., Conclusion: ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.

We present three cases of pseudoaneurysm caused by self-expandable metal stents that formed arteriobiliary fistulas and caused hemobilia. Diagnoses were made on the basis of dynamic computed tomography or angiography. One patient died because of bleeding and cholangitis, whereas the others were successfully treated by transarterial embolization., (© Georg Thieme Verlag KG Stuttgart · New York.)

A 40-year-old man, resident of a rural area of Rajasthan state of India presented with recurrent biliary colic and fever since last 2 years. Examination was normal and investigations revealed a dilated common bile duct with elevated alkaline phosphatase. Magnetic resonance cholangiopancreatography revealed a dilated biliary system without any evident cause. Patient was subjected to endoscopic retrograde cholangioancreatography and it demonstrated biliary dilatation with a linear filling defect in lower common bile duct, further sphinicterotomy was done and a live Fasciola hepatica was extracted using a biliary basket.

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction. A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography (ERCP) and cytology was benign. A 6 cm fully covered self-expanding metal stent (SEMS) was inserted across the stricture to optimize biliary drainage. However, the SEMS could not be removed at repeat ERCP a few months later. A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later. Fully covered biliary (SEMS) are used to treat benign biliary strictures. This is the first reported case of inability to remove a fully-covered biliary SEMS. Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally, or chemical or mechanical damage to the polymer covering of the stent. Application of the stent-in-stent technique allowed successful retrieval of the initial stent.

Purpose of Review: To summarize the indications, success rates and complications associated with endoscopic sphincterotomy and endoscopic balloon dilation (EBD)., Recent Findings: Pancreatic and/or biliary sphincterotomies are essential components of most current therapeutic endoscopic retrograde cholangiopancreatography (ERCP). A current large body of evidence has established biliary sphincterotomy as effective in extraction of bile duct stones. The most common complications of biliary sphincterotomy are post-ERCP pancreatitis, as well as acute or delayed hemorrhage, the risks for which can be stratified according to well described patient and procedure related factors. Evidence is accumulating that pancreatic sphincterotomy is useful in at least some settings for treatment of sphincter of Oddi dysfunction, chronic pancreatitis, and pancreas divisum. EBD provides an adjunct or an alternative to biliary sphincterotomy for extraction of stones from the bile duct when routine biliary sphincterotomy is inadequate or risk excessive., Summary: Sphincterotomy and EBD are useful in managing a variety of pancreatobiliary conditions. Attention to risks of these procedures is essential for their efficacy and safety.

The patient was a 69 year old man who had been diagnosed with alcoholic chronic pancreatitis and lower common bile duct (CBD) stricture. He subsequently developed cholangitis 2-3 times a year, and we replaced the endoscopic biliary stent (EBS) each time. In April 2010, he was admitted because of complication by a liver abscess and acute cholangitis. We performed percutaneous transhepatic liver abscess drainage. The inflammatory findings then rapidly improved, but the patient developed acute cholangitis due to the sludge and the stones. Then, we placed a partially covered self-expandable metallic stent (C-SEMS) in the lower CBD and performed endoscopic lithotripsy through the C-SEMS, and the cholangitis subsequently improved. Two weeks after, we removed the C-SEMS endoscopically and replaced it with a 10 Fr plastic stent; since then there have been no recurrences of cholangitis. Our experience in this case suggested that when a plastic stent is placed long-term to treat a biliary stricture associated with chronic pancreatitis, it might be useful to also control biliary sludge and stones using a C-SEMS., (© 2012 The Authors. Digestive Endoscopy © 2012 Japan Gastroenterological Endoscopy Society.)

The patient was a 73 year old man for whom surgery under general anesthesia was difficult to perform because of pulmonary emphysema. In April 2003, he visited our hospital complaining of epigastralgia and dorsal pain, and was admitted under a diagnosis of acute exacerbation of chronic pancreatitis. In 2005, acute cholangitis concomitantly developed with acute exacerbation of chronic pancreatitis, for which a plastic stent was placed in the common bile duct. Cholangitis repeatedly developed every 2-3 months thereafter, and admission was required each time to exchange the stent. Surgery was considered but not applicable because of his poor respiratory function, and a partially covered self-expandable metallic stent was inevitably placed in the bile duct. Ten months later, an aberration of the metallic stent in the bile duct occurred, but it was dealt with by placing an additional metallic stent, and no cholangitis or pancreatitis developed until the patient died of respiratory insufficiency 3 years later. Placement of a covered self-expandable metallic stent might be an option for the treatment of benign biliary stricture, especially in patients at high risk from surgery., (© 2012 The Authors. Digestive Endoscopy © 2012 Japan Gastroenterological Endoscopy Society.)

Biliary parasitosis is one of the important causes of biliary obstruction in endemic areas, however due to migration and travel the disease is known to occur in non endemic zones as well. The spectrum of biliary fascioliasis ranges from recurrent biliary colics to acute cholangitis. The long term complications are gall stones, sclerosing cholangitis and biliary cirrhosis. We describe fascioliasis as a cause of recurrent biliary colics in a young male necessitating multiple hospitalizations over a period of four years. Investigative profile had been non-contributory every time he was hospitalized for his abdominal pain prior to the current presentation. He never had cholangitis due to the worm in the common bile duct. It was only at endoscopic retrograde cholangiopancreatography (ERCP) biliary fascioliasis was discovered to be the cause of his recurrent biliary colics. After removal of the live Fasciola hepatica from the common bile duct he became symptom free and is attending our clinic for last 11 months now. Clinical spectrum of biliary fascioliasis is discussed in this report.

Bile-plug syndrome is defined as an obstruction of the common bile duct by bile sludge in full-term infants. It is a correctable cause of obstructive jaundice in infants and is generally treated surgically. Here, we present a case of a 5-month-old infant with bile-plug syndrome, which was treated by percutaneous biliary interventions. To the best of our knowledge, percutaneous treatment of bile-plug syndrome is reported for the first time in an infant. This minimal invasive treatment modality may be a useful alternative to surgery in infants with bile-plug syndrome., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Recent advances in hepatobiliary imaging techniques have led to the increased detection of choledochoduodenal fistula. However, the diagnosis and treatment of choledochoduodenal fistula is still a challenge. In this study, we summarize how patients were diagnosed and treated for choledochoduodenal fistula at our institution. Sixty-six patients with choledochoduodenal fistula were diagnosed and treated in our department from January 2000 to June 2009. Sixty-one patients were treated operatively, whereas five patients were treated with medicine. Patients with choledochoduodenal fistula were confirmed by endoscopic retrograde cholangiography. Of the 61 patients needing surgical intervention, clinical outcomes were excellent in 57 patients, and five patients underwent successful laparoscopic surgery for repairing the choledochoduodenal fistula. Follow-up of these patients for 6 months to 10 years showed they did not suffer from further cholangitis. A patients' past history of biliary disease, upper abdominal pain, fever, and jaundice may lead to choledochoduodenal fistula. Operative therapy, including laparoscopic surgery, was the primary treatment for most patients, regardless of the preoperative diagnosis.

Background: Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis., Methods: Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented., Results: EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued., Conclusions: The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.

Background and Study Aims: This prospective randomized study compared the patency and effective drainage rate of two stents with different materials but similar design, in the palliation of inoperable malignant biliary obstruction., Patients and Methods: A total of 49 patients (26 women, mean age 72.55 +/- 10.75 years, range: 48-91 years) with obstructive jaundice due to inoperable malignant stricture of the distal common bile duct without previous drainage procedure, were randomly assigned to receive 10F Double Layer (DLS) (n = 24) or 10F Tannenbaum (TAN) (n = 25) biliary plastic stent. The diagnosis included pancreatic cancer (n = 33), cholangiocarcinoma (n = 8), ampullary cancer (n = 7) and metastatic lymphadenopathy (n = 1). The duration of stent patency, the effective drainage, and the adverse events were analyzed., Results: Stent placement was successful in all patients with minor complications. The overall median patency rates between the two groups did not differ (107.5 days for DLS group vs. 101 days for TAN group ; p = 0.066). Effective drainage rate at the end of second week was 95.8% for DLS group and 96% for TAN group, (p = 1.00). Proximal stent migration occurred in one patient with TAN stent., Conclusions: The present study demonstrated that both DLS and TAN stents are comparable in terms of placement, overall stent patency, and complications.

Background & Objectives: Ampullary cancer is one of the periampullary tumours with better prognosis, but relapses occur early in some patients. This study was carried out to assess whether pancreatoduodenectomy (PDE, Whipple operation) could be a safe therapeutic procedure for elderly patients with periampullary tumours., Methods: Between 2005 and 2007, 19 patients (12 male, 7 female) aged over 65 yr (range 66 and 83 yr) with diagnosis of ampulloma were operated., Results: Of the 19 patients, 6 underwent local surgical ampullectomy with reinsertion of ductus choledochus and Wirsungi's duct for benign or early cancer lesion and 13 underwent PDE (Whipple operation). Of these 13, only one was in T1 stage, one was in T4 stage, two patients were T3 and the rest in T2 stage. Lesion of lymphatic system had 40 per cent of patients in T2 stage and all in T3 and T4 stages. One patient died of pulmonary embolism several days after operation. Post-operative complications occurred in 3 cases: 1 patient with partial dehiscence of gastroenteroanastomosis - treated by conservative approach, 2 patients with dehiscence of pancreatojejunoanastomosis., Interpretation & Conclusions: Diagnosis and therapy of ampullary tumours is multimodal. With careful patient selection, PDE can be performed in elderly people (>65 yr) safely. The post-operative morbidity in this group is essentially influenced by their multi-morbidity.

Acute pancreatitis with cholangiopathy is an uncommon complication in renal transplant patients. Further, a combination of pancreatitis and cholangiopathy due to CMV disease in renal allograft recipient is further uncommon. We report a renal transplant recipient who developed acute pancreatitis and cholangiopathy with CMV papillitis of the Ampulla of Vater.

The aim of this study was to test the removability of fully covered self-expandable metal stents (FCSEMS) in patients with a benign common bile duct (CBD) stricture. A FCSEMS was inserted in six patients with a CBD stricture due to chronic pancreatitis who were considered to be unfit for surgery, and stent removal was attempted after predefined intervals of 4 and 6 months. FCSEMS were successfully placed in all patients (100 % placement success) and stent extraction was accomplished in four patients (66 % removal rate), all of whom achieved stricture resolution (66 % resolution rate). In one patient a recurrent stenosis developed after 6 months (recurrence rate 25 %). Proximal stent migration occurred in two patients. In conclusion, FCSEMS removal was possible in the majority of patients and results regarding stricture dilation were promising. Nevertheless, before FCSEMS can become an acceptable treatment option for benign CBD strictures, innovative stent design modifications are necessary and removability must be ascertained.

Obstructive jaundice secondary to tuberculosis (TB) is extremely rare. It can be caused by TB enlargement of the head of the pancreas, TB lymphadenitis, TB stricture of the biliary tree, or a TB mass of the retroperitoneum. A 29-year-old man with no previous history of TB presented with abdominal pain, obstructive jaundice, malaise and weight loss. Ultrasonography (US), computer tomography (CT) scan and endoscopic retrograde cholangiopancreatography (ERCP) were suggestive of a stenosis of the distal common bile duct (CBD) caused by a mass in the posterior head of the pancreas. Tumor markers, CEA and CA19-9 were within normal limits. At operation, an enlarged, centrally caseous lymph node of the posterior head of the pancreas was found, causing inflammatory stenosis and a fistula with the distal CBD. The lymph node was removed and the bile duct resected and anastomosed with the Roux-en Y jejunal limb. Histology and PCR based-assay confirmed tuberculous lymphadenitis. After an uneventful postoperative recovery, the patient was treated with anti-tuberculous medication and remained well 2.5 years later. Though obstructive jaundice secondary to tuberculous lymphadenitis is rare, abdominal TB should be considered as a differential diagnosis in immunocompromised patients and in TB endemic areas. Any stenosis or fistulation into the CBD should also be taken into consideration, and biliary bypass surgery be performed to both relieve jaundice and prevent further stricture.

Purpose: To report on the use of biliary manometry for determining treatment completion in living donor liver transplant recipients., Materials and Methods: Twenty of 85 patients (24%) who underwent living donor liver transplantation developed postoperative anastomotic biliary strictures. Fifteen patients underwent transhepatic biliary drainage and percutaneous dilation. In 10 patients, biliary stress manometry was used to assess treatment adequacy after a mean of 2.5 dilation sessions occurring during a mean period of 62 days (range, 5-55 days). An intrabiliary pressure of less than 20-cm H2O after an escalating intrabiliary infusion to 1,200 mL per hour for 3 minutes was defined as the success threshold (in lieu of a capped external catheter "clinical trial")., Results: There were no complications during the infusion study. In all 10 patients in whom manometry was successful, biliary catheters were removed. One patient (who underwent manometry and catheter removal after only one dilation session) required repeat intubation 7 weeks later. The remaining nine patients (90%) remained free of evidence of biliary obstruction at a mean of 8.4 months. With Kaplan-Meier survival analysis, the probability of biliary patency at 3, 6, and 12 months was 90%., Conclusions: This biliary stress manometry protocol offers a promising alternative to the catheter "clinical trial" for determining endpoints for multisession anastomotic biliary stricture dilation in living donor transplant recipients.

Peroral direct cholangioscopy (PDCS) is endoscopic method for diagnosis in the common bile duct (CBD) utilizing an ultra-slim upper endoscope. Clinical utility and problem of this method were investigated in ten patients who had stenosis or obstruction in the CBD with stones or a tumor. Scope shaft had to become the form of a U loop by counterclockwise rotation, to advance the scope in the direction of intrahepatic bile duct. As for one case, although the scope was formed alpha loop without U loop, direct observation of total CBC was possible. Large working channel of the endoscope could take adequate tissue sample by large biopsy forceps. Electrohydraulic lithotripsy and stone extraction with a basket could be accomplished easily and safely by direct visualization with a clear image. Pneumobilia was noted in all cases with insertion of PDCS. Although the abdominal pain and pyrexia with regard to PDCS did not occur, transient leukocytosis was noted.

Background: Iatrogenic ampullary stenosis is a late complication of endoscopic interventions that affects the sphincter of Oddi., Objective: To evaluate the history, endoscopic treatment, and outcome of iatrogenic ampullary stenosis., Design: Patients' charts, endoscopic reports, and x-ray films were reviewed and scored. Long-term follow-up data were obtained by means of contact with attending specialists, general physicians, and patients. Ampullary stenoses were distinguished by 2 types: type I, limited to the intraduodenal portion of the sphincter complex; type II, all other types, including extension of the stenosis into the common bile duct (CBD)., Setting: Tertiary referral center., Patients: All patients treated for iatrogenic ampullary stenosis at our institution during the last 15 years were included., Main Outcome Measurements: Success of endoscopic treatment., Results: Forty-nine patients were included (mean age 54 years; 36 women; type I, n = 18, type II, n = 31). Treatment consisted of extending the sphincterotomy in type I stenoses and included stent treatment and/or balloon dilation in type II. During endoscopic treatment of ampullary stenosis, complications occurred in 8 of 49 patients. There were no procedure-related deaths. Median (range) follow-up after treatment was 2124 (240-4544) days. From an intention-to-treat perspective, endoscopic therapy of ampullary stenosis showed a long-term success rate of 83% in type I and 65% in type II CBD stenosis. In patients identified as treated successfully by endoscopy, blood samples obtained prospectively after a median (range) follow-up of 1971 (99-3320) days did not show signs of clinically relevant cholestasis., Conclusions: Endoscopic therapy is successful in the majority of patients and should be regarded as first-line treatment for iatrogenic ampullary stenosis.