The problems encountered in draining the bile ducts endoscopically in 148 patients with malignant obstruction of the mid or distal common bile duct and/or the papilla were assessed. Endoscopically visible extrinsic invasion of the papilla by a malignancy in the pancreatic head, with or without duodenal stenosis, appeared to be the major reason for the failure to insert a stent. The larger a tumor in the pancreatic head the greater the chance of invasion of the papillary region. This appeared to be evident for tumors restricted to the non-uncinate region of the pancreatic head. We would recommend primary percutaneous biliary drainage or surgery when the size of a proven malignancy restricted to the non-uncinate region of the pancreatic head is 5 cm or more, or when diagnostic duodenoscopy reveals extrinsic invasion of the papilla of Vater, or severe duodenal involvement with stenosis.

During the period 1974–1983, 320 patients with pancreas carcinoma, papilla of Vater carcinoma, bile duct bifurcation carcinoma, or duodenal carcinoma were examined by ERCP. Using 30 ERCP criteria, a radiological diagnosis was made. A valid pathological diagnosis was available in 200 patients (62.5%). In 183 of the 200 patients (91.5%), the ERCP diagnosis and the pathological diagnosis were identical. We then performed an analysis using 52 ERCP criteria. In 192 of the 200 patients (96.0%), the ERCP diagnosis based on this reanalysis and the pathological diagnosis were identical. By discriminant analysis, 13 ERCP criteria with a maximal discriminatory value were selected in patients in whom all diagnostic structures (bile ducts, pancreatic duct, and duodenum) were visible. Using these 13 criteria selected by discriminant analysis, the diagnostic score was 98.9%. A computer program based on these 13 ERCP criteria was designed for use in practice. The diagnostic accuracy of this computer program was 98.4%. Finally we tested this computer program on 171 new patients who were seen in the period 1983– 1986. In 143 of the 171 patients, a valid pathological diagnosis was available (83.6%). Comparing the ERCP diagnosis in all patients (even if not all structures were visible) with a valid pathological diagnosis, the prospective score of the computer program was 91.6%. Using this program it was possible to evaluate examinations in which not all structures were visible. When the ERCP diagnosis was uncertain, the doubt could be quantified.

During a 10-yr period starting January 1973, 123 patients with a carcinoma at the head of the pancreas underwent endoscopic retrograde cholangiopancreatography at our hospital.Analysis of their case histories revealed that the early complaints of pancreatic head carcinoma are rather nonspecificsudden onset of diabetes mellitus (33.3%), weight loss [80.5%], tiredness and malaise (42.3%], change in bowel habits (41.5%), and upper abdominal discomfort (22.0%)-and that jaundice (88.6%) and classic pain (70.7%) are late symptoms.The diagnostic accuracy of endoscopic retrograde cholangiopancreatography (92.7%) was much higher than that of computed tomography (58.5%) and echography (54.4%).The patients were divided according to the maximal tumor diameter into three groups: group 1, tumor diameter ranging between 2.5 and 4.0 cm; group 2, tumor diameter ranging between 4.5 and 6.0 cm; and group 3, tumor diameter ranging between 7.0 and 15.0 cm.The tumor diameter did not correlate with the degree of difierentiation.Extension of the tumor, vascular involvement, and metastases were evaluated for the several tumor diameters.The tumor was, in principle, operable in 77% of group 3 patients; in 24% of group 2 patients; and in 9% of group 3 patients.Tumors <3 cm in diameter were always resectable; tumors >8 cm in diameter were

Changes in the shape of the common bile duct (CBD) can be expressed mathematically by measuring the C.B.D.-diameter at five points and expressing these measurements as a percentage of the mean diameter. Variations in magnification are compensated for by relating the mean diameter to the length of the C.B.D. By comparing the shape of the C.B.D. in patients with various diseases with the shape of the normal common bile duct it was possible to define pathognomonic signs of various diseases of the extrahepatic biliary system. Indirect signs of pathology of the extrahepatic bile ducts are discussed.