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Simple Summary The need for prognostic and predictive biomarkers in pancreatic neuroendocrine neoplasms (PNENs) is great. Overexpression of somatostatin receptors (SSTRs) provides a molecular basis for imaging these tumors with 68Ga-labeled somatostatin (SST) PET/CT and for treatment with somatostatin analogs. We evaluated all 5 somatostatin receptors (SSTR1-5) with immunohistochemistry and prospectively compared the results with both [68Ga]Ga-DOTANOC and [18F]F-FDG PET/CT in a cohort of 21 non-functional (NF) PNENs. SSTR2 was the only SSTR subtype to correlate with [68Ga]Ga-DOTANOC PET/CT. High SSTR5 expression correlated with a low Ki-67 proliferation index, suggesting a better prognosis for these patients. Thus, our results confirm that SSTR2 has the highest impact on SSTR PET signaling of PNENs. Abstract Purpose: The aim of this study was to correlate immunohistochemical (IHC) tissue levels of SSTR1-5 with the receptor density generated from [68Ga]Ga-DOTANOC uptake in a prospective series of NF-PNENs. Methods: Twenty-one patients with a total of thirty-five NF-PNEN-lesions and twenty-one histologically confirmed lymph node metastases (LN+) were included in this prospective study. Twenty patients were operated on, and one underwent endoscopic ultrasonography and core-needle biopsy. PET/CT with both [68Ga]Ga-DOTANOC and [18F]F-FDG was performed on all patients. All histological samples were re-classified and IHC-stained with monoclonal SSTR1-5 antibodies and Ki-67 and correlated with [68Ga]Ga-DOTANOC and [18F]F-FDG PET/CT. Results: Expression of SSTR1-5 was detected in 74%, 91%, 80%, 14%, and 77% of NF-PNENs. There was a concordance of SSTR2 IHC with positive/negative [68Ga]Ga-DOTANOC finding (Spearman’s rho 0.382, p = 0.043). All [68Ga]Ga-DOTANOC-avid tumors expressed SSTR2 or SSTR3 or SSTR5. Expression of SSTR5 was higher in tumors with a low Ki-67 proliferation index (PI) (−0.353, 95% CI −0.654–0.039, p = 0.038). The mean Ki-67 PI for SSTR5 positive tumors was 2.44 (SD 2.56, CI 1.0–3.0) and 6.38 (SD 7.25, CI 2.25–8.75) for negative tumors. Conclusion: SSTR2 was the only SSTR subtype to correlate with [68Ga]Ga-DOTANOC PET/CT. Our prospective study confirms SSTR2 to be of the highest impact for SST PET/CT signal.

Background Predicting the aggressive behavior of non-functional pancreatic neuroendocrine tumors (NF-PNET) remains controversial. We wanted to explore, in a prospective setting, whether the diagnostic accuracy can be improved by dual-tracer functional imaging 68Ga-DOTANOC and 18F-FDG-PET/CT in patients with NF-PNETs. Methods Thirty-one patients with NF-PNET (90% asymptomatic) underwent PET-imaging with 18F-FDG and 68Ga-DOTANOC, followed by surgery (n = 20), an endoscopic ultrasonography and fine-needle biopsy (n = 2) or follow-up (n = 9). A focal activity on PET/CT greater than the background that could not be identified as physiological activity was considered to indicate tumor tissue. The imaging results were compared to histopathology. The mean follow-up time was 31.3 months. Results Thirty-one patients presented a total of 53 lesions (40 histologically confirmed) on PET/CT. Thirty patients had a 68Ga-DOTANOC-positive tumor (sensitivity 97%) and 10 patients had an 18F-FDG-positive tumor. In addition, one 68Ga-DOTANOC-negative patient was 18F-FDG-positive. 18F-FDG-PET/CT was positive in 19% (3/16) of the G1 tumors, 63% (5/8) of the G2 tumors and 1/1 of the well-differentiated G3 tumor. 68Ga-DOTANOC-PET/CT was positive in 94% of the G1 tumors, 100% of the G2 tumors and 1/1 of the well-differentiated G3 tumor. Two out of six (33%) of the patients with lymph node metastases (LN+) were 18F-FDG-positive. The 18F-FDG-PET/CT correlated with tumor Ki-67 (P = 0.021). Further, the Krenning score correlated with tumor Ki-67 (P = 0.013). 18F-FDG-positive tumors were significantly larger than the 18F-FDG-negative tumors (P = 0.012). 18F-FDG-PET/CT showed a positive predictive value of 78% in the detection of potentially aggressive tumors (G2, G3, or LN + PNETs); the negative predictive value was 69%. Conclusions 18F-FDG-PET/CT is useful to predict tumor grade but not the LN+ of NF-PNETs. Patients with 18F-FDG-avid NF-PNETs should be referred for surgery. The 68Ga-DOTANOC-PET/CT also has prognostic value since the Krenning score predicts the histopathological tumor grade. Trial registration The study has been registered at ClinicalTrials.gov; Non-functional Pancreatic NET and PET imaging, NCT02621541.

Objective: Endoscopic stents are used to relieve obstructive jaundice. The purpose of this prospective randomized study was to compare the patency of antireflux and conventional plastic biliary stent in relieving distal malignant biliary obstruction. Materials and Methods: All jaundiced patients admitted to hospital with suspected unresectable malignant distal biliary stricture between October 2009 and September 2010 were evaluated for the study. Eligible patients were randomized either to antireflux or conventional plastic stent arms. The primary endpoint was stent patency and the follow-up was continued either until the stent was occluded or until 6 months after the stent placement. Results: At an interim analysis, antireflux stents (ARSs; n = 6) had a significantly shorter median patency of 34 (8–49) days compared with the conventional stent (n = 7) patency of 167 (38–214) days (P = .0003). Based on these results, the study was terminated due to ethical concerns. Conclusion: According to these...

Objective Gastrointestinal fistulae are a heterogenous entity originating from various etiologies. When occurring, these fistulae are associated with considerable morbidity and even mortality. One third of the fistulae heal spontaneously and the rest have traditionally required major revisional surgery at a later stage. Even after surgery, the healing rate remains at a level of 75% to 90%. During the last years, gastrointestinal fistulae have been successfully treated endoscopically with fibrin glue. Methods All (n = 8) consecutive patients with diagnosed internal upper or lower gastrointestinal fistula treated endoscopically with fibrin glue. Results During the minimum follow-up of 11 months, 7 of 8 patients (87.5%) were successfully treated endoscopically, and in only 1 case (12.5%) with a major diagnostic delay, a reoperation was required. Conclusions Our results support the view that endoscopic treatment with fibrin glue may be considered as a first-line therapy to treat small caliber gastrointestinal fistulas.

Deep biliary cannulation is the key for successful endoscopic retrograde cholangiopancreatography (ERCP) procedures. Guidewire-assisted cannulation is associated both with a higher success rate and a reduced risk of post-ERCP pancreatitis compared with standard catheter cannulation. However, to our knowledge there are no prospective, randomized studies comparing the use of different guidewires in biliary cannulation. The goal of this study was to compare the performance of an angled-tipped guidewire (AGW) with a straight-tipped guidewire (SGW) in achieving successful deep biliary cannulation. Patients with intended biliary cannulation of an intact papilla were prospectively randomized to angled- or straight-tipped hydrophilic guidewire arms in a tertiary, referral, university hospital setting. Randomized cannulation method was applied either until successful cannulation of the bile duct or until 2 min had passed. Crossover was not included in the study protocol. The main outcome measurements were the cannulation success rate and duration of cannulation. Of the 239 consecutive patients, 155 patients were randomized: in the final analysis 70 patients were included in the AGW arm and 83 patients in the SGW arm. Cannulation time [median; seconds (s)] was shorter with the AGW compared with the SGW (20 vs. 63 s, p = 0.01). There was no difference in the cannulation success rate or the complication rate between the two study groups. AGW may facilitate biliary cannulation in ERCP.

Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks.All esophageal stent placement procedures (174 procedures for 157 patients) at the authors' unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave's syndrome (n = 4), or an anastomotic leakage (n = 2).The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease.Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.

Iatrogenic bile duct injury carries high morbidity. After the introduction of laparoscopic cholecystectomy the incidence of these injuries has at least doubled, and even after the learning curve, the incidence has plateaued at the level of 0.5%.A total of 32 patients sustained biliary tract injuries of the 3736 laparoscopic cholecystectomies performed in and around Turku University Central Hospital between January 1995 and April 2002. The data concerning primary treatment and long-term results were collected and analyzed retrospectively.The overall incidence for bile duct injuries, including all the minor injuries (cystic duct leaks and bile duct strictures), was 0.86%; for major injuries alone the incidence was 0.38%. Nineteen percent of the injuries were detected intraoperatively. All the cystic duct leaks were treated endoscopically with a 90% success rate. Of the bile duct strictures 88% were treated successfully with endoscopic techniques. Ninety-three percent of the major injuries, including tangential lesions of common bile duct and total transections, were treated operatively. The operation of choice was either hepaticojejunostomy or cholangiojejunostomy in 69% of the cases; the rest were treated with simple suturing over a T-tube or an endoscopically placed stent. The long-term results, with a median follow-up period of 7.5 years, are good in 79% of the operated patients and in 84% of the whole study population. Mortality rate was 3% and acute or chronic cholangitis was seen in 13% of the patients during follow-up.Most of the minor bile duct injuries, including cystic duct leaks and bile duct strictures, are well treatable with endoscopic techniques, whereas most of the major injuries require operative treatment, which at optimal circumstances gives good results.

Context and Objective: Fluorine-18-l-dihydroxyphenylalanine (18F-DOPA) positron emission tomography (PET) is a promising method in localizing neuroendocrine tumors. Recently, it has been shown to differentiate focal forms of congenital hyperinsulinism of infancy. The current study was set up to determine the potential of 18F-DOPA PET in identifying the insulin-secreting tumors or β-cell hyperplasia of the pancreas in adults. Patients and Methods: We prospectively studied 10 patients with confirmed hyperinsulinemic hypoglycemia and presumed insulin-secreting tumor using 18F-DOPA PET. Anatomical imaging was performed with computed tomography (CT) and magnetic resonance imaging (MRI). All patients were operated on, and histological verification was available in each case. Semiquantitative PET findings in the pancreas using standardized uptake values were compared to standardized uptake values of seven consecutive patients with nonpancreatic neuroendocrine tumors. Results: By visual inspection of 18F-DOPA PET images, it was possible in nine of 10 patients to localize the pancreatic lesion, subsequently confirmed by histological analysis. 18F-DOPA uptake was enhanced in six of seven solid insulinomas and in the malignant insulinoma and its hepatic metastasis. Two patients with β-cell hyperplasia showed increased focal uptake of 18F-DOPA in the affected areas. As compared to CT or MRI, 18F-DOPA PET was more sensitive in localizing diseased pancreatic tissue. Conclusion: 18F-DOPA PET was useful in most patients with insulinoma and negative CT, MRI, and ultrasound results. In agreement with previous findings in infants, preoperative 18F-DOPA imaging seems to be a method of choice for the detection of β-cell hyperplasia in adults. It should be considered for the detection of insulinoma or β-cell hyperplasia in patients with confirmed hyperinsulinemic hypoglycemias when other diagnostic work-up is negative.

Since its introduction in the late 1980s laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Unfortunately, the rate of iatrogenic biliary duct injuries (BDIs) has at least doubled after the adoption of the laparoscopic method. Population-based studies reporting the distribution of laparoscopic BDI patients according to gender and the severity of the BDI are mostly lacking. The purpose of the present study was to analyze the BDIs sustained during laparoscopic cholecystectomy in and around Turku University Central Hospital, with a special reference to the distribution of patients according to gender and the severity of the BDI. A total of 3,736 laparoscopic cholecystectomies (2,627 female patients, 1,109 male) was performed in and around Turku University Central Hospital from 1995 to 2002 (by the end of April). The number and severity of BDIs and the gender of BDI patients were recorded, and the risk of BDI during laparoscopic cholecystectomy was calculated for the total patient population and for both genders separately. The risk of BDI was 0.86% for the total patient population, 0.95% for female and 0.63% for male. The most conspicuous finding was that the female gender was predominant in the severe types of BDI. However, the risk of mild BDI seemed to be fairly equal in both genders. We conclude that female gender seems to be a risk factor for severe iatrogenic BDI during laparoscopic cholecystectomy.

In this study, we evaluated and compared the value of spiral computed tomography, transabdominal ultrasonography, laparoscopy, and laparoscopic ultrasonography in staging gastric cancer in 37 patients; there was a special interest in the additional information provided by laparoscopic ultrasonography. Although laparoscopy was unreliable or hindered by adhesions in 11% of the patients, the benefit of laparoscopy for staging was evident especially for the detection of peritoneal carcinomatosis that was missed by the other diagnostic modalities. Laparoscopic ultrasonography did not change the stage of the disease nor the decision whether to proceed with laparotomy for any of the patients. The decision whether to proceed with laparotomy was correctly predicted in 95% of the cases.

Accurate diagnosis of the nature of pancreatic cysts is challenging but more important than ever, in part because of the increasing number of incidental cystic findings in the pancreas. Preliminary data suggest that (18)F-FDG PET/CT may have a significant influence on clinical decision making, although its role is still evolving. Our aim was to prospectively compare the accuracy of combined (18)F-FDG PET and contrast-enhanced CT ((18)F-FDG PET/CT), multidetector CT (MDCT), and MR imaging in differentiating malignant from benign pancreatic cysts.Thirty-one consecutive patients with pancreatic cysts were enrolled in the study. They underwent a protocol including (18)F-FDG PET/CT, MDCT, and MR imaging combined with MR cholangiopancreatography, all of which were evaluated in a masked manner. The findings were confirmed macroscopically at surgery or histopathologic analysis (n = 22) or at follow-up (n = 9).Of the 31 patients, 6 had malignant and 25 had benign lesions. The diagnostic accuracy was 94% for (18)F-FDG PET/CT, compared with 77% and 87% for MDCT (P0.05) and MR imaging, respectively. (18)F-FDG PET/CT had a negative predictive value of 100% and a positive predictive value of 75% for pancreatic cysts. The maximum standardized uptake value was significantly higher in malignant (7.4 ± 2.6) than in benign lesions (2.4 ± 0.8) (P0.05). When the maximum standardized uptake value was set at 3.6, the sensitivity and specificity were 100% and 88%, respectively. Furthermore, when compared with MDCT and MR imaging, respectively, (18)F-FDG PET/CT altered the clinical management of 5 and 3 patients, respectively.(18)F-FDG PET/CT is an accurate imaging modality for differentiating between benign and malignant pancreatic cysts. We recommend the use of (18)F-FDG PET/CT in the evaluation of diagnostically challenging pancreatic cysts.

Although the price of biliary metal stents is manyfold higher when compared to plastic stents, the lower frequency of recurrent obstructions makes metal stents superior to plastic stents for endoscopic palliation of malignant biliary stricture in most patients. Is this the case in extremely elderly patients as well? A retrospective data review comprising prospective data collection and double-entry bookkeeping of therapeutic endoscopic retrograde cholangiopancreatographies (ERCP) with biliary strictures referring to malignancy in 14 patients aged 90 years or older at our institution in 1997-2007. Plastic stents were successfully inserted in 11 out of 14 patients, yielding a technical success rate of 79 %. In the remaining three patients, high biliary obstruction was relieved percutaneously in two cases while the general condition of one patient was so poor that terminal care decision was made in that case. There was no recurrent biliary obstruction in any of the patients with plastic stents prior to death which occurred after a mean of 2.8 months, giving a clinical success rate of 100 %. To be concluded, in extremely elderly patients with malignant obstructive jaundice, palliation with plastic stent is effective enough.

Female gender is a well-known risk factor for the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the underlying mechanism for this increased risk has remained unknown. We hypothesize that cannulation difficulty might play a part in this association. The aim of the current study was to determine whether the female papilla is more difficult to cannulate than the male papilla.Prospective data collection with emphasis on cannulation was conducted in 364 consecutive biliary ERCP procedures performed by very experienced ERCP endoscopists through native papilla in a tertiary referral university hospital.Although the cannulation times seemed to be longer and alternative cannulation techniques seemed to be needed more frequently for successful cannulation in female than male patients, no statistically significant differences (p = 0.061 and 0.054, respectively) in the cannulation process could be found between the genders.The study was not able to confirm that the cannulation of the female papilla is more troublesome than the cannulation of the male papilla.

Even in experienced hands, a common problem at endoscopic retrograde cholangiopancreatography (ERCP) is difficulty in reaching a selective cannulation of the common bile duct or pancreatic duct. The success rate of biliary cannulation has improved markedly in many centers after the adoption of double-guidewire-assisted cannulation technique in cases in which the guidewire repeatedly passes into the pancreatic duct although the common bile duct is intended. Here, we describe 2 novel applications of the double-guidewire technique for difficult cannulation in ERCP. In particular, we emphasize that in addition to difficult biliary cannulation, double-guidewire technique may prove useful in difficult pancreatic cannulation. The double-guidewire technique is feasible also in cases in which the guidewire repeatedly passes into the cystic duct instead of the intended common hepatic duct and intrahepatic radicals. ERCP endoscopists should be aware of all modifications of double-guidewire technique to further increase the success rates of selective cannulations in ERCP.

A total of 170 patients undergoing upper gastrointestinal surgery requiring a jejuno-jejunal enteroanastomosis were randomized into two groups according to the method to be employed at the enteroanastomosis. The most common procedures were partial gastrectomy for benign disease (84 patients), partial or total gastrectomy for malignant disease (35 patients), and bilioenteral bypass (31 patients, 25 for malignant disease). The enteroanastomosis was created by manual suture (3-0 Dexon®, two layers) in 89 patients and with the Biofragmentable Anastomosis Ring (Valtrac-BAR®) in 81 patients. Both end-to-side (101 patients) and side-to-side (69 patients) reconstructions were done. No ruptures or obstructions of the jejuno-jejunal anastomosis occurred. The postoperative recovery of the gastrointestinal tract was similar in the two groups in duration of nasogastric drainage, intravenous fluid therapy, and intestinal paralysis. Nor was there any difference between the groups in the duration of the postoperative hospital stay. Ten patients, 7 in suture-group and 3 in BAR-group, died postoperatively of causes unrelated to the enteroanastomosis. Thus the mortality rate was 7.9% in the suture group and 3.7% in the BAR group. The biofragmentable ring offers a safe alternative to manual sutures for small bowel anastomoses.

Immunohistochemical characteristics of a mucinous islet-cell carcinoma of the pancreas are described. The tumour presented with jaundice in a 59-year-old male. It consisted of polygonal atypical cells forming a reticular pattern, and invaded the common bile duct. In DNA flow cytometry, the tumour cells showed a clear-cut aneuploid peak. Intercellular mucin was abundant. A panel of antisera and monoclonal markers was applied in the immunohistochemical analysis. In addition to general epithelial and endocrine markers, the tumour cells showed a focal positive immunoreaction with anti-glucagon, anti-insulin, anti-vasoactive intestinal polypeptide, anti-pancreatic secretory trypsin inhibitor and anti-phospholipase A2 antigen. At the ultrastructural level, mucous and neuroendocrine granules were demonstrated in the same tumour cells.

In a small proportion of patients, fundoplication fails and a reoperation is required. However, there are few reports on the symptomatic outcome after reoperative antireflux surgery. The aim of this study was to evaluate the results after fundoplication revision.All patients (n=71) undergoing fundoplication revision between 1997 and 2005 were included in this study. The follow-up data were collected both from the hospital records and during postoperative control visits, including a personal interview using a structured questionnaire; follow-up was completed by 61 patients (88.4%).The primary fundoplications included both open (n=21) and laparoscopic (n=40) approaches; 92% (n=56) of the reoperations were open procedures. The morbidity rate was 21% and the reoperation rate 16%. Fifty-six percent (n=34) of the patients regarded the result of their reoperative surgery as excellent, good or satisfactory at a mean follow-up of 51 months; 66% of the patients had no significant reflux symptoms after re-fundoplication. With the benefit of hindsight, 77% of the patients would again choose to undergo re-fundoplication, but only 48% of the patients would again primarily choose surgical treatment. Mortality rate was 1.4% (n=1) and in three patients the reoperative treatment required total gastrectomy.These suboptimal results show that surgical treatment for gastro-oesophageal reflux disease in general is far from being perfect and this is even more marked after reoperative antireflux surgery, as fundoplication revision can result in severe complications. This emphasizes the importance of proper patient selection for both initial and reoperative antireflux surgery.

The majority of recent large series on endoscopic retrograde cholangiopancreatography (ERCP) complications have been multicenter studies reflecting varying degrees of experience and ERCP volume; major ERCP complications are associated with low case volume. The aim of this study was to report and analyze the frequency of severe and fatal complications associated with ERCP at a single specialized surgical high-volume referral center (Turku University Central Hospital). All scheduled ERCP procedures (n = 2788) at our unit between January 1997 and December 2005 were included and the procedure-related severe and fatal complications were assessed by retrospective chart review. Complications were classified as severe or fatal according to standardized guidelines. The number of ERCP procedures performed was 2555, of which 71% were therapeutic and 29% were diagnostic. Seventeen (0.8%) severe complications were identified in 16 patients, of whom 15 underwent a therapeutic endoscopic procedure. Of the 17 severe complications, perforation constituted five cases (0.2%), pancreatitis occurred in five patients (0.2%), bleeding in five cases (0.2%), and two patients suffered from purulent cholangitis (0.1%). Procedure-related mortality was 0.08% (n = 3). In our study the rate of severe or fatal complications of ERCP is low in experienced hands at a high-volume center, comparing favorably to corresponding complication rates of multicenter series, which further supports the importance of centralizing ERCP procedures in high-volume advanced centers.

Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis.Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups.Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p0.0005).In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies.

During endoscopic retrograde cholangiopancreatography (ERCP), incising through the wall of the major papilla with an electrocautery needle-knife is a method for achieving access into the bile duct. This procedure, often referred to as a "precut," may be used when cannulation attempts via the orifice of the papilla are unsuccessful. Potential complications include hemorrhage, duodenal perforation, and acute pancreatitis.The 172 patients who underwent an attempt of a needle-knife assisted ERCP during the years 1997-2003 at our institution were retrospectively evaluated.A selective bile duct cannulation was achieved after needle-knife incision in 148 out of 172 patients (86%) at the primary session. In 10 additional patients (6%), a repeated procedure proved successful for cannulation. In the remaining 14 patients (8%), the biliary cannulation failed and was not attempted again. Complications after needle-knife assisted ERCP occurred as follows: three patients (2%) presented with late bleeding after the ERCP and three patients (2%) developed acute pancreatitis. None of the patients required operative treatment for complications. There was no mortality.The use of the needle-knife markedly improves the success rate of selective biliary cannulation in ERCP without increasing the rate of complications.

To study the relationship between the diameter of the common bile duct and the incidence of bile duct stones in non-jaundiced patients with recurrent attacks of right epigastric pain after cholecystectomy.Retrospective study.University hospital, Finland.57 consecutive, non-jaundiced patients admitted for elective endoscopic retrograde cholangiopancreatography (ERCP) because of attacks of right epigastric pain after cholecystectomy.Measurement of maximum diameter of the common bile duct and presence or absence of bile duct stones.Diameter of bile duct (10 mm or less was regarded as normal) and presence or absence of stones.33 patients had normal-sized bile ducts and in 24 they were widened. Only 2/33 patients with normal-sized ducts (6%) had stones, compared with 11/24 (46%) with wide ducts (p = 0.0008). However, the degree of ductal dilatation did not seem to have any influence on the presence or absence of stones.Bile duct stones are unlikely after cholecystectomy in patients who are not jaundiced and have a normal-sized common bile duct. However, nearly half of the patients with a wide common bile duct had stones, but the degree of dilatation was not important.

Cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct are a clinical challenge. In a number of these patients dilatation of the common bile duct is explained as a normal postoperative state following cholecystectomy and the recurrent pain attacks are of origin other than bile disorder, but in some cases dilatation of the common bile duct and attacks are caused by bile duct stones. The aim of the present work was to study the value of common plasma liver function tests in predicting bile duct stones in the group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. The study population comprised 24 consecutive non-icteric cholecystectomized patients admitted for elective endoscopic retrograde cholangiopancreatography because of attacks of right epigastric pain and dilated common bile duct in ultrasonography. All the liver function tests seemed to assist in separating patients with bile duct stones (n=11) from those without (n=13). Alanine aminotransferase levels were significantly higher (p=0.05) in patients with bile duct stones than in those without, but also alkaline phosphatase (p=0.07), gamma-glutamyl transferase (p=0.09) and bilirubin (p=0.09) levels seemed to be higher in patients with bile duct stones than in those without, although the differences in these values did not reach statistical significance. In conclusion, common plasma liver function tests assist in separating patients with bile duct stones from those without in this small but clinically important group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. However, the actual value of these measurements is limited in clinical decision making since overlapping of values occured.

Pseudocysts are common complications of acute pancreatitis, whereas subsequent colonic complications such as necrosis, stenosis, and fistula associated with pseudocysts are rare. 1 External pancreatic fistulas 2 and other GI fistulas 3 have been treated successfully with fibrin glue. A case of endoscopically glued pseudocystocolonic fistula is presented herein.

To compare the distribution of interstitial collagens (type I and III) and basement membrane collagen (type IV) in cancerous and normal colon.Retrospective study.University hospital, Finland.13 patients with colorectal cancer of different stages and grades.Indirect immunofluorescence labelling for type I, III, and IV collagens of fresh frozen tissue samples, both normal and cancerous, cut into serial sections 6 microm thick.In normal mucosa, the epithelial basement membrane showed an intense immunoreaction for type IV collagen. Type I and III collagens were localised to the interstitial stroma underlying it. The membrane in cancer samples was characterised by discontinuities and thinning as estimated by immunolabelling for type IV collagen. Furthermore, immediately adjacent to the membrane type I and III collagen positivity was fragmented. The cancerous stroma showed a strong positive immunosignal for type I and III collagens.Both the epithelial basement membrane and the collagenous matrix immediately beneath it are degraded in malignant tissue. This may suggest the simultaneous activation of several degradative enzymes (as type I and III collagens are at least in part degraded by different enzymes from type IV collagen) or alterations in the expression of collagen subtypes in normal compared with malignant tissue.

Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study.Some 110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups.Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result.Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Late results after colonic anastomoses performed with the biofragmentable anastomosis ring (BAR; Valtrac ®; Davis & Geck, Wayne, NJ) were evaluated in 30 patients who had undergone a left-sided colonic or rectosigmoid anastomosis a mean of 24.5 (range, 12–38) months earlier. Patients were asked about their late postoperative recovery and their bowel habits. A barium enema was performed, and then a flexible endoscopy was done, during which the anastomotic area was evaluated both in macroscopic terms and histologically. One of the patients had died, and three refused to participate in the investigation. Of the remaining 26 patients, one had been reoperated on 22 months after the primary sigmoid resection. The reason for reoperation was an anastomotic stricture. One of the patients was admitted to the hospital during the study and was operated on for reasons not related to the anastomosis. Twenty-four patients underwent the study scheme. All had recovered uneventfully. Sixteen anastomoses could not be identified radiologically and seven not even during endoscopy. Histologically, there was mild-to-moderate fibrosis and scarring in 17 anastomoses, and, in the seven that could not be identified, only normal colonic mucosa was found. The late results of BAR anastomoses are satisfying, and the rate of complications is acceptable.

One hundred and fifty consecutive patients undergoing colonic surgery were randomized into two groups: 71 underwent hand-suture with a two-layer anastomosis of resorbable suture material (3/0 Dexon) and 79 were fitted with the biofragmentable anastomotic ring (Valtrac–BAR). Five patients, two treated using the BAR and three by suturing, developed anastomotic leakage which required a Hartmann-type reoperation. This was successful in four; one patient in the suture group died after reoperation. One patient who underwent suture had an early anastomotic stricture with fatal sequelae. Three other patients (one in the BAR group and two in the suture group) died after operation from other causes. Thus the mortality rate was 6 per cent in the suture group and 1 per cent in the BAR group. During follow-up, one patient in each group underwent reoperation for anastomotic stricture. Recovery of the gastrointestinal tract was similar in the two groups regarding duration of nasogastric drainage, intravenous fluid therapy and ileus. There was no difference between the groups in duration of hospital stay. The BAR seems to be a safe and reliable alternative to conventional suture anastomosis in colonic surgery.