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Die endoskopisch retrograde Cholangiopankreatikographie (ERCP) hat sich seit ihrer Etablierung Anfang der 1970er Jahre von einer primar diagnostischen Prozedur zu einem uberwiegend therapeutischen Verfahren entwickelt. Diagnostisch werden heutzutage von wenigen Ausnahmen abgesehen komplikationsarmere Alternativen wie Endosonographie (EUS) und Magnetresonanz-Cholangiopankreatikographie (MRCP) eingesetzt. Die therapeutische ERCP ist eine der invasivsten endoskopischen Untersuchungstechniken mit einem Komplikationsrisiko von bis zu 10 %. Es dominiert die Post-ERCP-Pankreatitis, gefolgt von Cholangitis, Cholezystitis, Blutung und Perforation. Risikofaktoren fur Komplikationen und prophylaktische Masnahmen werden in diesem Artikel erortert.

In einer mehrjahrigen prospektiven klinischen Beobachtungsstudie sollten Risikofaktoren fur das Auftreten von Infektionen nach ERCP ermittelt werden. Methoden: Es wurden 2349 ERCP-Untersuchungen in 1805 Behandlungsfallen von 1544 Patienten eingeschlossen. Infektionen traten in 2,0 % (n = 46) auf. Fur das Auftreten dieses Ereignisses wurden geeignete statistische Methoden, wie die logistische Regressionsanalyse und die GEE-Analyse, angewandt, um Risikofaktoren zu ermitteln. Ergebnisse: In der abschliesenden Analyse war die Verabreichung einer antibiotischen Dauertherapie ein signifikanter protektiver Faktor, der die Haufigkeit von Infektionen auf signifikant senken konnte (OR 0,41; p = 0,0234). Die einmalige Antibiotikagabe dagegen konnte das Infektionsrisiko nicht senken. In der vorliegenden Arbeit konnten mehrere Risikofaktoren ermittelt werden. Bei einem Zustand nach Cholezystektomie sind vor allem Index-ERCP-Untersuchungen mit einem erhohten Infektionsrisiko behaftet (OR 5,2; p = 0,004). Alle anderen Risikofaktoren gelten auch oder speziell bei repetitiven ERCP-Untersuchungen und wurden mithilfe der GEE-Analyse ermittelt. Die Diagnose einer malignen Gallengangsstenose (OR 3,3; p = 0,013) und eines schlechten biliaren Kontrastmittelabflusses (OR 3,5; p = 0,009) waren mit einem besonders hohen Infektionsrisiko behaftet. Aber auch bei Leberzirrhose (OR 2,8; p = 0,034) und bei rezidivierender akuter Pankreatitis (OR 2,5; p = 0,029) war das Infektionsrisiko noch signifikant erhoht. Endoskopiker mit einer geringen ERCP-Frequenz ( Schlussfolgerungen: Die ERCP ist und bleibt eine komplexe technisch anspruchsvolle und mit einem nennenswerten Komplikationsrisiko behaftete Untersuchung, die nur von geubten Endoskopikern bzw. in Zentren mit hohen Untersuchungsaufkommen durchgefuhrt werden sollte. Bei Vorliegen der oben genannten Risikofaktoren empfiehlt sich die periinterventionelle Antibiotikagabe uber mehrere Tage.

Bei Patienten mit erhohten Leberwerten, die anamnestisch katecholaminpflichtig waren und invasiv beatmet wurden, sollte auch an eine sekundar sklerosierende Cholangitis „bei kritisch Kranken“ gedacht werden. Im hier besprochenen Fall gelang es, die ublicherweise rasche Progression dieser SSC-Sonderform durch biliare Sphinkterotomien mit Castextraktion und Antibiotikabehandlung deutlich zu verlangsamen.

Background and study aims Gastric cancer diagnosed from routine gastric biopsies without any evidence of a visible lesion and negative repeated biopsies is an infrequent but serious clinical problem for which gastrectomy has usually been recommended, even if operative specimens do not show cancer either. We report on a series of 22 such patients undergoing long-term follow-up after attempted treatment with photodynamic therapy (PDT). Patients and methods 22 patients with invisible gastric cancer (IGC) who presented during a 10-year period (10 men, mean age 56 +/- 15 years) were prospectively included. Initial histopathological findings confirmed by second opinion included 10 well-differentiated adenocarcinomas and 12 signet ring cell carcinomas. After two negative state-of-the art endoscopic reassessments, a single session of PDT using 5-delta-aminolevulinic acid (ALA) was performed in the area from which the biopsy was taken, and patients were followed up regularly. Results After a mean follow-up period of 56.2 +/- 27.6 months, three patients had died of causes unrelated to gastric cancer, four had developed mucosal cancer that was successfully treated endoscopically after 4 - 38 months, and the remaining 15 patients remained without evidence of recurrent gastric cancer, lymph-node involvement, or metastases during a follow-up period of 54 +/- 26 months. Conclusions Our results suggest that gastrectomy may not be the only option for IGC, which might follow an uneventful natural course provided careful follow-up is scheduled. The role of PDT in this setting remains unclear and should be studied further.

Die endoskopische Therapie des Magenfruhkarzinoms ist in der westlichen Welt noch nicht vollstandig etabliert. Neuerdings ist die Entdeckung fruher Tumorstadien und die Option der kurativen operativen Therapie, ggf. auch durch endoskopische Operation, das Ziel diagnostischer endoskopischer Masnahmen. Die endoskopische Resektion des mukosalen Magenfruhkarzinoms (EMR) ist in Japan inzwischen die Behandlungsmethode der Wahl. Mittlerweile gibt es erfolgreiche Standardtechniken der endoskopischen Resektion. Eine mit modifizierten Nadelmessern durchgefuhrte direkte „Dissektion“ der Submukosa wurde als endoskopische Submukosadissektion (ESD) klassifiziert. Eine internationale Studiengruppe unter Deutscher Leitung untersuchte die Durchfuhrbarkeit der ESD. Die Ergebnisse zeigen, dass Diagnose und Therapie des Magenfruhkarzinoms auserhalb von Japan zwar moglich sind, aber offensichtlich mit deutlich differenten Ergebnissen. Vor einer breiten Anwendung der EMR oder der ESD beim Magenfruhkarzinom durch in Diagnostik und Therapie von gastrointestinalen Neoplasien unerfahrene Institutionen und auserhalb von prospektiven Studien ist daher abzuraten. Minimal-invasive chirurgische Therapieverfahren und lokale Exzisionstechniken sind individuell zu diskutieren.

Background & Aims: Confocal laser endomicroscopy has been shown to allow direct histologic imaging of gastrointestinal tumors in vivo. This study was designed to assess the potential of endomicroscopy for predicting histology in vivo during routine endoscopy in patients with early squamous cell cancer. Methods: Twenty-one consecutive patients with suspected early squamous cell cancer who had been referred for endoscopic therapy to a tertiary-care academic medical center were included in this prospective study. After staining with 0.5% Lugol's solution and injection of 500 mg fluorescein sodium, unstained mucosal areas were examined using confocal imaging. Images of each scanned lesion were acquired and stored digitally, and in vivo diagnosis was performed during ongoing endoscopy. Biopsy specimens were taken from every lesion. The confocal images were reviewed by 2 endoscopists, who were blinded to the histology and endoscopic appearance. Results: Confocal images were acquired from 43 lesions in 21 patients. Twenty-seven of the 43 lesions (63%) were proven to be squamous cell cancer on histology. All squamous cell cancers were diagnosed correctly by endomicroscopy and 2 lesions were falsely diagnosed as neoplastic. The overall accuracy was 95%, and the sensitivity and specificity were 100% and 87%, respectively. Intraobserver agreement was almost perfect (κ = 0.95) and interobserver agreement was substantial (κ = 0.79). Conclusions: Confocal laser endomicroscopy is able to provide virtual histology of early squamous cell cancers with a high degree of accuracy and can facilitate rapid diagnosis during routine endoscopy.

The macroscopic appearance of early gastric cancers, classified according to the Japanese criteria, has been shown to be an important prognostic factor for local endoscopic therapy. No prospective data about the distribution of macroscopic types and their location in early Barrett's neoplasia are available, however. The present study was conducted to evaluate the clinical applicability of this macroscopic classification and to analyze the relative proportions of the different gross types in early Barrett's neoplasms and the correlation between the macroscopic classification and the stage or grade of differentiation.A total of 344 patients with 380 Barrett's neoplastic lesions who were referred between October 1996 and September 2005 for endoscopic therapy of early Barrett's high-grade intraepithelial neoplasia and carcinoma were prospectively included in the study. Routine endoscopy prior to endoscopic resection in our center included assessment of the macroscopic type (according to the Japanese classification) and documentation of the radial location of the neoplastic lesions. Images were recorded which were later assessed by six independent reviewers; intra- and interobserver agreement for the assessment of the macroscopic type were calculated using kappa statistics.The distribution of the lesions by gross type was as follows: type I, n = 49 (13 %); type IIa, n = 139 (37 %); type IIb, n = 106 (28 %); type IIc, n = 17 (4 %); type IIa + c, n = 62 (16 %); type III, n = 7 (2 %). Type IIb lesions seem to be the most favorable type with regard to differentiation and T category ( P0.05). The mean kappa value for the interobserver agreement was 0.86 and the mean kappa value for the intraobserver agreement was 0.89. Most lesions were found at the 12 o'clock and 3 o'clock positions.Assessment of the macroscopic type may provide important information about the possibility of endoscopic treatment. The harder-to-detect flat lesions are by far the most frequent macroscopic type of neoplastic lesion in Barrett's esophagus.

BACKGROUND AND STUDY AIMS The increasing use of flexible endoscopy to treat symptomatic Zenker's diverticulum is only partially supported by data on safety and benefits. This retrospective study reports the mid-term results of argon plasma coagulation (APC) for flexible endoscopic therapy of Zenker's diverticulum. PATIENTS AND METHODS Between January 2002 and July 2006, 41 patients (27 men, 14 women, mean age +/- standard deviation [SD] 73 +/- 11 years) were treated by means of APC flexible endoscopic Zenker's diverticulotomy. Technical and immediate clinical success (on a 3-month control examination) was assessed for the entire group. Mid-term follow-up data were obtained for patients treated until December 2005 (n = 34) with a mean +/- SD follow-up period of 16 +/- 5 months. RESULTS Technical success was achieved in all 41 patients, with a mean +/- SD of 3 +/- 2 treatment sessions during one or two hospitalizations (1-3 sessions for 78% patients, > 3 sessions for 22% patients). Immediate clinical success was achieved in 95% of cases. Fever occurred in seven patients (17%), lasting less than 24 hours in three patients (7%) and associated with clinical infections in four (10%); one perforation occurred, which was managed conservatively. In the patients for whom we had mid-term follow-up data, 5/34 experienced recurrence and achieved a successful clinical outcome after retreatment with APC. CONCLUSIONS APC treatment of Zenker's diverticulum is safe and effective in the short term, with a mean of three treatment sessions. Recurrence rates of around 15% have to be expected on mid-term follow-up. The relative value of APC vs. needle-knife techniques can only be clarified in a prospective randomized study.

We conducted a study of a newly developed "computed virtual chromoendoscopy" (CVC) system that enhances the contrast of the mucosal surface without the use of dyes. The CVC imaging technique is based on narrowing the bandwidth of the conventional endoscopic image arithmetically, using spectral estimation technology. Preliminary clinical tests comparing CVC-enhanced visualization of neoplastic and non-neoplastic lesions with images obtained by conventional endoscopy show that CVC enhances the vascular network as well as the pit pattern. CVC might therefore complement high-resolution endoscopy by facilitating the assessment of the nature and extent of gastrointestinal mucosal lesions.

Summary Objectives: To evaluate split selection instability in six survival tree algorithms and its relationship with predictive error by means of a bootstrap study. Methods: We study the following algorithms: logrank statistic with multivariate p-value adjustment without pruning (LR), Kaplan-Meier distance of survival curves (KM), martingale residuals (MR), Poisson regression for censored data (PR), within-node impurity (WI), and exponential log-likelihood loss (XL). With the exception of LR, initial trees are pruned by using split-complexity, and final trees are selected by means of cross-validation. We employ a real dataset from a clinical study of patients with gallbladder stones. The predictive error is evaluated using the integrated Brier score for censored data. The relationship between split selection instability and predictive error is evaluated by means of box-percentile plots, covariate and cutpoint selection entropy, and cutpoint selection coefficients of variation, respectively, in the root node. Results: We found a positive association between covariate selection instability and predictive error in the root node. LR yields the lowest predictive error, while KM and MR yield the highest predictive error. Conclusions: The predictive error of survival trees is related to split selection instability. Based on the low predictive error of LR, we recommend the use of this algorithm for the construction of survival trees. Unpruned survival trees with multivariate p-value adjustment can perform equally well compared to pruned trees. The analysis of split selection instability can be used to communicate the results of tree-based analyses to clinicians and to support the application of survival trees.

Die ERCP ist eine der invasivsten endoskopischen Untersuchungstechniken mit einer Komplikationsrate von bis zu 10 %. Es dominiert die Post-ERCP-Pankreatitis. Die Moglichkeiten zur Vermeidung der Post-ERCP-Pankreatitis, insbesondere NSAR und Pankreas-Stents, werden dargestellt.

Endoscopic resection (ER) has gained more and more importance in the treatment of early gastrointestinal neoplasia over the last few years. The choice of the different available techniques depends on the site, the macroscopic type of the tumour and the personal experience of the endoscopist. The 'suck-and-cut' technique with ligation device or cap should be favoured to normal strip biopsy in the oesophagus because of the size of the resected specimen and its technical feasibility. A recently described method of ER in the stomach is the circumferential mucosal incision with a type of needle-knife and subsequent en-bloc resection following prior injection under the lesions. ER of high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus should be considered as the treatment of choice. First mid-term results of endoscopic therapy of early squamous-cell neoplasia in the oesophagus show promising results; however, long-term results are awaited. Studies with large numbers of patients in Japan proved the efficiency and safety of ER in low-risk early gastric carcinoma. Duodenal lesions and adenomas of the major duodenal papilla were also proved to be treated successfully by ER. In the colon, ER is used successfully for resection of adenomas and small well-differentiated or moderately differentiated carcinomas that are restricted to the mucosa. ER of gastrointestinal lesions is a safe and effective method but should be performed only by experienced endoscopists.

Die reale Koloskopie ist als Vorsorgeuntersuchung zur Fruherkennung und Pravention des kolorektalen Karzinoms als Kassenleistung anerkannt. Die Entwicklung der so genannten hochauflosenden Videoendoskope und deren Kombination mit Farbetechniken hat zu einer wesentlichen Verbesserung der Detektion von kleinen und flachen Neoplasien gefuhrt. Andererseits stehen die computertomographische und die magnetresonanztomographische virtuelle Koloskopie an der Schwelle zur klinischen Anwendung. Sie versprechen mehr Komfort und konnten so die Akzeptanz der Vorsorgeuntersuchung Koloskopie steigern. Welche klinische Wertigkeit haben diese radiologischen Verfahren im Vergleich zur realen Koloskopie derzeit? Sind sie als Screeningmethode geeignet, einen vergleichbaren Nutzen und eine hohere Akzeptanz in der Bevolkerung zu erreichen, als die reale Endoskopie?

ENT manifestations of gastroesophageal reflux disease. Gastroesophageal reflux disease (GERD) is the most common esophageal disease. It typically presents with heartburn and regurgitation, but it may also cause atypical symptoms, either alone or in combination. About 20 to 60 percent of patients with GERD have ENT symptoms without any heartburn. The most common ENT symptom is a globus sensation, yet there are many possible clinical signs such as laryngitis, pharyngitis, sinusitis, laryngospasm, laryngeal edema and granuloma that may mislead the initial work-up. In this work the pathophysiology, symptomatology, diagnostic measurements and therapeutic options of GERD are discussed. It is suggested that GERD has to be included into differential diagnostic approaches especially when routine treatment of these ENT diseases failes.

The awereness and the knowledge of endoscopic complications are essential points for their prevention. Treatment should always be made in accordance with the surgical partner. Only early treatment with the fear of legal consequences is beneficial for the patient and the physician.

Background and study aims Endoscopic resection of esophageal squamous-cell neoplasia with curative intent is considered to be a safe and effective alternative treatment to radical surgery in cases where the neoplasia is intraepithelial or limited to the mucosal layer. These patients are at risk for recurrent malignancy in the preserved esophagus, however. We conducted a prospective study to evaluate the efficacy and safety of endoscopic resection and to analyze variables associated with recurrence in patients with mucosal or intraepithelial squamous-cell neoplasia. Patients and methods Between December 1997 and September 2005, 65 patients (mean age +/- standard deviation [SD] 62.9 +/- 9.5 years), 12 with high-grade intraepithelial neoplasia (HGIN) and 53 with mucosal squamous-cell cancer, were included in our study and were treated using endoscopic resection. Details of patient and tumor characteristics were documented prospectively. All patients were included in a staging protocol including high-resolution endoscopy with Lugol staining, endoscopic ultrasound, computed tomography, and abdominal ultrasound. Endoscopic resection was performed using a ligation technique. The data acquired were subjected to univariate and multivariate analysis. Results A total of 179 resections were performed (mean number of resections +/- SD per patient, 2.8 +/- 1.8): 11/12 patients with HGIN (91.7%), and 51/53 patients with mucosal cancer (96.2%) achieved a complete response during a mean follow-up period of 39.3 +/- 22.8 months; three patients were still under therapy at the end of the study period. Recurrence of malignancy after achieving a complete response was observed in 16 patients (26%), but these patients all achieved another complete response after further endoscopic treatment. Independent risk factors for recurrence was multifocal carcinoma (RR 4.1, P = 0.018). Tumor-related deaths occurred in two patients (3%), and eight patients died as a result of co-morbidity. Complications were seen in 15/65 patients (23%, all esophageal stenoses). The 7 year survival rate calculated for all groups was 77%. Conclusions According to the results of long-term follow-up in this study, endosocopic resection appears to be an effective and safe method of curative treatment in patients with HGIN and mucosal squamous-cell carcinomas of the esophagus. Multifocal carcinoma and T1m1 tumors seem to be highly associated with recurrence.

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Background and study aims We present ten patients who developed secondary sclerosing cholangitis following long-term treatment in an intensive care unit (ICU) between 1999 and 2004. Patients and methods Ten consecutive patients who had no evidence suggestive of pre-existing hepatobiliary disease were admitted to an ICU because of trauma (n = 5), intracerebral hemorrhage (n = 3), or nonabdominal postsurgical complications (n = 2). All the patients had required treatment with long-term ventilation, catecholamines, total parenteral nutrition, and several antimicrobial agents. Results Cholestasis was first noted within 11 days after the initial insult. Endoscopic retrograde cholangiopancreatography (ERCP), performed after a median follow-up of 69 days, revealed multifocal stricturing and beading of the intrahepatic bile ducts, and attenuation of the peripheral branches. In all the patients, the bile ducts were partially filled by black-pigmented thrombotic material. All the patients underwent endotherapy, which comprised sphincterotomy and removal of the occluding material, in an attempt to improve biliary drainage; the treatment had to be repeated in seven of the ten patients. After a median follow-up period of 21 months, despite transient clinical improvement following endotherapy, complete recovery has not been achieved in any of the patients and so far one patient has had to undergo orthotopic liver transplantation as a result of end-stage liver disease. Conclusions The development of secondary sclerosing cholangitis in patients who have received long-term treatment in an ICU is a rare event of unknown pathophysiology, but patients demonstrate characteristic findings on ERCP. It is not known whether endotherapy can delay the progress of the condition in the long term.

Tree-based methods can be used to generate rules for prognostic classification of patients that are expressed as logical combinations of covariate values. Several splitting algorithms have been proposed for generating trees from survival data. However, the choice of an appropriate algorithm is difficult and may also depend on clinical considerations. By means of a prognostic study of patients with gallbladder stones and of a simulation study, we compare the following splitting algorithms: log-rank statistic adjusted for measurement scale with (AP) and without (AU) pruning, exponential log-likelihood loss (EP), Kaplan-Meier (KP) distance of survival curves, unadjusted log-rank statistic (LP), martingale residuals (MP), and node impurity (ZP). With the exception of the AU algorithm (based on a Bonferroni-adjusted p-value driven stopping rule), trees are pruned using the measure of split-complexity, and optimally-sized trees are selected using cross-validation. The integrated Brier score is used for the evaluation of predictive models. According to the results of our simulation study and of the clinical example, we conclude that the AU, AP, EP, and LP algorithm may yield superior predictive accuracy. The choice among these four algorithms may be based on the required parsimonity and on medical considerations.

Various split criteria for constructing recursively partitioned trees from censored data have been proposed. However, no uniform superior split criterion is available. Wecompared five different split criteria regarding the explained variation of outcome with application to a clinical data set from a study of extracorpore al shock wave lithotripsy (ESWL) for treatment of gallbladder stones in 408 patients. The main end point was time until detection of complete stone clearance. The covariates patient age, sex, body mass index, relative gallbladder volume reduction after fatty meal, stone density, stone diameter, and stone number were analysed. The split criteria relative risk, log-rank statistic, log-rank statistic adjusted for measurement scale, partial likelihood ratio, and constant hazard likelihood ratio were compared. Model likelihood and Magee’s R 2 were used as measures of information content and explained variation, respectively. In the first step, trees were constructed and validated using separate learning and validation samples, respectively. In the second step, bootstrap confidence intervals of explained variation were estimated using an internal validation procedure. There was no substantial difference between splitting algorithms in terms of explained variation. Simulation studies of pruned trees are necessary to extend our results.

Gastroesophageal reflux disease (GERD) is the most common esophageal disease. It typically presents with heartburn and regurgitation, but it may also cause atypical symptoms, either alone or in combination. About 20 to 60 percent of patients with GERD have ENT symptoms without any heartburn. The most common ENT symptom is a globus sensation, yet there are many possible clinical signs such as laryngitis, pharyngitis, sinusitis, laryngospasm, laryngeal edema and granuloma that may mislead the initial work-up. In this work the pathophysiology, symptomatology, diagnostic measurements and therapeutic options of GERD are discussed. It is suggested that GERD has to be included into differential diagnostic approaches especially when routine treatment of these ENT diseases failes.

Is "pulverization" or "fragmentation" the best endpoint of extracorporeal shock wave application in ESWL of gallbladder stones? Has gallbladder motility a potential for the prevention of stone recurrence?Prospective, monocentric study with randomization between the conventional treatment strategy (endpoint of shock wave application: fragmentsor = 4 mm, concomitant oral chemolitholysis) and an intensified treatment strategy (endpoint of shock wave application: Pulverization, no chemolitholysis). Prevention of stone recurrence: At least once per month for one hour after a meal standardized position (back position, lowered chest).34 patients, age 46 +/- 14 years (27 women, seven men) were included (F-ESWL: n = 18; P-ESWL: n = 16). Gallbladder motility, number, size and CT-measured calcifications of stones were comparable for both groups. P-ESWL patients received more shock wave pulses than F-ESWL patients and more treatment sessions. P-ESWL resulted in a better fragmentation and pulverization of stones was reached significantly more often (p0.05). The time period for stone clearance was significantly depending on the fragmentation result (pulverization: 0.7 months vs. fragmentsor = 4 mm: 6.6 months vs. fragmentsor = 4 mm: 8.0 months; p0.01). The stone free rate after twelve months was 87.5% for P-ESWL and 72.2% for F-ESWL (n.s.) and correlated significantly with the fragmentation result (p0.01). Pain sensations during stone clearance were significantly reduced by P-ESWL. Stonefree patients were followed up for 30 +/- 13 months, the total recurrence rate was 7.1%.Aiming for pulverization of gallbladder stones by means of intensified extracorporeal shock wave application is at least equal or in tendency superior compared to disintegration to fragementsor = 4 mm. Gallbladder motility might be useful to prevent gallstone recurrence after successful ESWL.

If non-surgical methods are to be taken into account in the therapeutic decision-making process in cholecystolithiasis, an expanded diagnostic work-up including not only stone parameters but also gallbladder function, is needed. In 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) with (suspected) "cholecystolithiasis" attending the special gallstone outpatient clinic at a university medical department within a period of 5 years the diagnostic procedures most commonly used in both the doctor's office and hospital were abdominal ultrasonography (52%/78%), laboratory investigations (28%/39%) and plain films of the biliary tract (27%/39%). In the doctor's office gallbladder function testing took the form of an cholecystogram (17% of the patients); in the hospital ultrasonography to determine gallbladder contractility (38%). With decreasing frequency, the following additional procedures were carried out (office/hospital): CT 3%/19%, esophagogastroduodenoscopy 7%/3%, intravenous cholegram 6%/0.6%, abdominal X-ray 1%/0.4%, ERCP 1%/0.4%, chest X-ray 0.8%/1.6%. Duplicated examinations showed a relevant frequency only for ultrasonography (39% of the cases), laboratory investigations (18%) and plain films of the gallbladder (4%). Pathologic secondary findings were established in 22% of the cases.

The treatment of cholecystolithiasis has changed fundamentally in recent years due to the development of non-surgical techniques (extracorporeal shockwave lithotripsy [ESWL], oral litholysis) and the implementation of laparoscopic cholecystectomy.Retrospective analysis of 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) presenting with gallstone disorders in a university medical outpatients department between 1988 and 1992 in order to be instructed as to the most suitable therapy method bear witness to the rapid change in therapeutic procedure. Laparoscopic removal of the gallbladder has virtually supplanted conventional cholecystectomy, and within 5 years the proportionate role of ESWL has declined from 21 to 12%. Over the years, the proportion of patients requiring no therapeutic intervention remained constant (at about 20%). The therapeutic recommendations of the "experts" were implemented in almost 80% of cases. The majority of patients were satisfied with the chosen therapeutic approach (surgery: 93.0%, ESWL: 77.6%), although 44% of ESWL-patients and 36% of surgically managed patients reported complaints which persisted even after completion of therapy. Despite unsuccessful ESWL (residual fragments or recurrent stones) 58/95 (61%) of interviewed patients would again give preference to this non-invasive modality in the event of a renewed therapeutic decision.Only a few years after its introduction, laparoscopic cholecystectomy has asserted itself as the predominant treatment option. But as far as acceptance and preference by the patient are concerned extracorporeal shockwave lithotripsy--as a non-invasive treatment modality--also enjoys high popularity and can be recommended as an alternative to surgery in suitable patients chosen according to the currently established stringent selection criteria.

The contribution of ethanol to the pathogenesis of acute pancreatitis has been questioned for a long time. The authors asked whether acute ingestion of large amounts of alcohol may lead to pancreatic injury, as assessed by serum amylase levels, clinical picture, and abdominal ultrasound. Therefore, all patients (N = 122) admitted to our medical emergency ward with the diagnosis of alcohol intoxication were evaluated prospectively during a 12-mo period. Of these, 78 (56 M, 22 F; mean age 36 +/- 15) could be evaluated. The other 44 were excluded because of incomplete data (n = 18), mixed intoxications (n = 8), repeated admission (n = 9), incorrect diagnosis on admission (n = 7), and chronic pancreatitis (n = 2). Serum ethanol, amylase, and GOT were measured. Serum ethanol was 246 +/- 122 mg/dL (3-500 mg/dL), amylase 83 +/- 44 U/L (27-361 U/L), and GOT 25 +/- 37 U/L (5-271 U/L) without significant differences among the genders. No correlation between serum ethanol and serum amylase levels could be detected.

Following the development and introduction of endoscopic papillotomy (EPT), 2752 procedures were performed at Erlangen University Hospitals between 1973 and 1993. All papillotomies were evaluated with regard to indications, technique, results, complications and mortality. To show the development process clearly, results for the periods 1973-1980 (A), 1981-1987 (B) and 1988-1993 (C) were summarised separately. The proportion of patients with common bile duct stones was 91% in group A, 60% in group B and 41% in group C. By contrast the number of papillotomies for malignant disease rose from 1% (A) to 26% (B) and 29% (C). More recent indications such as chronic pancreatitis (11%), biliary pancreatitis (5%) and others (for example sphincter of Oddi dysfunction) (11%) were first seen in group C. While the Erlangen standard papillotomy was used in almost all cases in group A (96%), the precut technique was used (mostly with needle knife) in one-third of all papillotomies in groups B and C (32%). The success rate for EPT in all three periods was highest for common bile duct stones (from 96% for group A to 98% for groups B and C). For malignancies, the success rate was lower (89% in groups B and C). The complication rate fell significantly with time (P0.05) from 11% (A) to 7.6% (B) and 6.3% (C). Precut techniques did not increase the complication rate. While 71% of all complications were treated surgically in period A, the proportions fell to 28% (B) and then to 7.5% (C). Method-related mortality fell from 1.1% (A) to 0.4% (B) and 0.5% (C).(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of extracorporeal piezoelectric shock wave lithotripsy in patients with obstructing pancreatic duct stones was investigated.Fifty patients suffering from chronic pancreatitis and obstructing pancreatolithiasis were treated by ESWL (Piezolith 2500). Shock wave treatment was administered, inasmuch as the stones were not extractable by initially applied endoscopic measures.A total of 119 (2.4 +/- 1.4, range 1-7) lithotripsy sessions were conducted; only mild sedation/analgesia was used. Optimum targeting of the concrements in the shock wave focus was achieved in 17 (14%) treatment sessions with ultrasonography only; it was achieved in 65 (55%) cases by fluoroscopy and, in further 37 (31%) sessions by using both localization systems. Stone fragmentation was successful in 43 (86%) patients. Nineteen (38%) patients achieved spontaneous stone discharge after shock wave lithotripsy. In 11 (22%) cases, it was possible to remove all fragments endoscopically; residual fragments remained in 20 (40%) patients. Severe complications attributable to shock wave application did not occur. During follow-up, six patients had to be referred to surgery; two male patients died of specific diabetic complications and pleural mesothelioma, respectively. Thirty-five (90%) of 39 patients whose conditions were followed for 2-50 (20 +/- 14) months reported improvement of their pain sensations. Six (15%) patients required endoscopic treatment, including ESWL in five of those patients, to be repeated due to recurrent formation of calculi in the main pancreatic duct, which was again successful in five of the six patients.Piezoelectric shock wave lithotripsy offers a basis for safe and effective fragmentation of pancreatic stones and facilitates endoscopic procedures. Most of the patients with obstructing pancreatic stones became stonefree and showed a significant reduction of pain.

Extracorporeal piezoelectric lithotripsy (PEL) with oral lysis (about 7.5 mg/kg urso- and chenodeoxycholic acid as single dose in the evening) was performed, according to a standardized treatment and follow-up protocol, in 219 patients (177 women, 42 men; aged 47 +/- 14 years) with symptoms of gallbladder stones. The average number of treatment sessions per patient was 2.0 +/- 0.8. Significantly fewer sessions with fewer shockwave charges were required in solitary gallstones of less than or equal to 20 mm diameter than in those of greater than 20 mm diameter and in multiple concrements (P less than 0.01). Fragmentation was successful in 99% of patients. Sedation and/or analgesia during PEL were required in only 2% of patients. There were no marked side effects during the treatment. The stone-free rate 12 months after the start of treatment was 76% in the group with solitary stones less than or equal to 20 mm, 75% with solitary stones greater than 20 mm and 64% for multiple stones. During the follow-up period 36% of patients had biliary colics and 3% had fragments impacted in the common bile duct. Biliary pancreatitis occurred in 1% of patients. PEL is an effective and sparing procedure in the treatment of selected patients with gallbladder stones.