Background To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. Methods Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. Results Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02). Conclusions Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.

INTRODUCTION: A step-up endoscopic or percutaneous approach improves outcomes in necrotizing pancreatitis (NP). However, these require multiple radiographic studies and fluoroscopic procedures, which use low-dose ionizing radiation. The cumulative radiation exposure for treatment of NP has not been well defined. METHODS: We conducted a retrospective study of consecutive patients with NP admitted to University of California San Francisco Medical Center from January 2011 to June 2019. We calculated effective doses for fluoroscopic procedures using the dose area product and used the National Cancer Institute tool for computed tomography studies. The primary outcome was the cumulative effective dose (CED). Multivariable logistic regression was used to evaluate risk factors of high exposure (CED > 500 mSv). RESULTS: One hundred seventy-one patients with NP (mean follow-up 40 ± 18 months) underwent a median of 7 (interquartile range [IQR] 5–11) computed tomography scans and 7 (IQR 5–12) fluoroscopic procedures. The median CED was 274 mSv (IQR 177–245) and 30% (51) of patients received high exposure. Risk factors of high exposure include multiorgan failure (aOR 3.47, 95%-CI: 1.53–9.88, P = 0.003), infected necrosis (adjusted odds ratio [aOR] 3.89 95%-CI:1.53–9.88, P = 0.005), and step-up endoscopic approach (aOR 1.86, 95%-CI: 1.41–1.84, P = 0.001) when compared with step-up percutaneous approach. DISCUSSION: Patients with NP were exposed to a substantial amount of ionizing radiation (257 mSv) as a part of their treatment, and 30% received more than 500 mSv, which corresponds with a 5% increase in lifetime cancer risk. Severity of NP and a step-up endoscopic approach were associated with CED > 500 mSv. Further studies are needed to help develop low-radiation treatment protocols for NP, particularly in patients receiving endoscopic therapy.

Dominant strictures occur in roughly 50% of patients with primary sclerosing cholangitis (PSC.) Endoscopic retrograde cholangiopancreatography (ERCP) with either balloon dilation or stent placement are used for first line management of these strictures. An increased rate of serious adverse events following endoscopic stent placement for dominant strictures was recently reported. We aimed to determine the rates of post-procedural bacterial cholangitis in a large cohort of patients with PSC and a dominant stricture undergoing endoscopic intervention with either balloon dilation or stent placement.

INTRODUCTION: Situs inversus is a congenital condition that causes left-right reversal of all organs. This results in unique challenges for the endoscopist when patients with situs inversus require ERCP. Several methods have been described in the literature to optimize the chances of successful cannulation in these unique patients. We describe the case of a 75 year old woman with situs inversus who developed choledocholithiasis requiring ERCP for stone extraction. We review the clinical features of situs inversus, as well as the methods needed to obtain successful cannulation. CASE DESCRIPTION/METHODS: A 75 year old woman with complete situs inversus was transferred to our facility. Eight days prior to this presentation, she developed epigastric pain and emesis. She had new liver test abnormalities with ALT 277, AST 110, alkaline phosphatase 221, and total bilirubin 5.5. A CT scan showed dilation of the common bile duct to 7 mm with a 6 mm stone noted in the distal duct. Upon arrival at our facility, ERCP was performed in the left lateral position. The procedure was notable for distortion of the stomach and duodenal bulb consistent with situs inversus. A precut sphincterotomy was necessary to achieve biliary cannulation. The bile duct was noted to come off the ampulla at 1 o’clock, in mirror image from normal anatomy. A 9 mm stone was identified and removed with a basket. DISCUSSION: Situs inversus is an autosomal recessive congenital condition with an incidence rate of approximately 1 in 5,000 to 10,000 live births. There is no evidence that situs inversus contributes to increased gallstone formation. Currently, there are 15 cases of ERCP performed for choledocholithiasis in situs inversus patients described in the literature. Besides the obvious differences in the orientation of the stomach and duodenum, the bile duct is often noted to come off the ampulla at “1 o’clock” instead of the typical “11 o’clock.” A variety of methods have been described to address these anatomical differences, including placing the patient in the prone position, changing the side of the bed that the endoscopist stands on, setting up the ERCP suite in mirror image, and rotating the duodenoscope 180 degrees clockwise in the stomach, and then either rotating an additional 180 degrees in the second portion of the duodenum or using a rotating sphincterotome. Endoscopists should be aware of the various techniques to optimize cannulation in patients with situs inversus to maximize chances of a successful intervention.

Question: A 61-year-old man was referred for endoscopic retrograde cholangiopancreatography for new-onset relapsing pancreatitis over the past year. A computed tomography scan at an outside hospital reportedly showed a cystic lesion in the head of the pancreas and a dilated pancreatic duct to 7 mm. A representative image from examination of the ampulla with a side-viewing endoscope is shown in Figure A. Pancreatogram is shown in Figure B. Cytologic brushings were obtained. What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Examination of the ampulla reveals a bulging, prominent, patulous ampulla of Vater as shown in Figure A, which is consistent with the fish-mouth sign, a pathognomonic finding for an intraductal papillary mucinous neoplasm.1McNabb-Baltar J. Swanson R. Tumors of the pancreas.in: Greenberger N.J. Blumberg R.S. Burakoff R. Current diagnosis & treatment: gastroenterology, hepatology, & endoscopy, 3rd ed. McGraw-Hill, New York2018Google Scholar This classic fish-mouth appearance of the ampulla may be seen in 25% of cases, and when present is diagnostic.2Fernandez-del Castillo C. Adsay N.V. Intraductal papillary mucinous neoplasms of the pancreas.Gastroenterology. 2010; 139: 708-713Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar This diagnosis is confirmed on the pancreatogram (Figure B), which shows a large, partially obstructing mass at the head of the pancreas with upstream dilation of the pancreatic duct to 10 mm. Cytologic brushings obtained during endoscopic retrograde cholangiopancreatography were consistent with a mucinous neoplasm without high grade dysplasia. The patient underwent a pylorus-sparing pancreaticoduodenectomy resection and the surgical pathology (Figure C; stain: hematoxylin and eosin stain; original magnification ×20) revealed the classic findings of intraductal papillary proliferation, confirming the diagnosis of intraductal papillary mucinous neoplasm with high-grade dysplasia. Trilokesh D. Kidambi's current affiliation is the Division of Gastroenterology, City of Hope National Medical Center, Duarte, California.

AIM To determine the prevalence of gastrointestinal neoplasia among dermatomyositis patients who underwent an esophagogastroduodenoscopy and/or colonoscopy. METHODS A cross-sectional study examining the results of upper endoscopy and colonoscopy in adults with dermatomyositis at an urban, university hospital over a ten year period was performed. Chart review was performed to confirm the diagnosis of dermatomyositis. Findings on endoscopy were collected and statistical analyses stratified by age and presence of symptoms were performed. RESULTS Among 373 adult patients identified through a code based search strategy, only 163 patients had dermatomyositis confirmed by chart review. Of the 47 patients who underwent upper endoscopy, two cases of Barrett’s esophagus without dysplasia were identified and there were no cases of malignancy. Of the 67 patients who underwent colonoscopy, no cases of malignancy were identified and an adenoma was identified in 15% of cases. No significant differences were identified in the yield of endoscopy when stratified by age or presence of symptoms. CONCLUSION The yield of endoscopy is low in patients with dermatomyositis and is likely similar to the general population; we identified no cases of malignancy. A code based search strategy is inaccurate for the diagnosis of dermatomyositis, calling into question the results of prior population-based studies. Larger studies with rigorously validated search strategies are necessary to understand the risk of gastrointestinal malignancy in patients with dermatomyositis.

We read with interest the report by Usatin et al.1Usatin D. Fernandes M. Allen I.E. Perito E.R. Ostroff J. Heyman M.B. Complications of endoscopic retrograde cholangiopancreatography in pediatric patients; a systematic literature review and meta-analysis.J Pediatr. 2016; 179: 160-165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Although experience with endoscopic retrograde cholangiopancreatography (ERCP) in children is growing, there is a lack of well-documented ERCP safety information in children with chronic pancreatitis.1Usatin D. Fernandes M. Allen I.E. Perito E.R. Ostroff J. Heyman M.B. Complications of endoscopic retrograde cholangiopancreatography in pediatric patients; a systematic literature review and meta-analysis.J Pediatr. 2016; 179: 160-165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Kolodziejczyk E. Jurkiewicz E. Pertkiewicz J. Wejnarska K. Dadalski M. Kierkus J. et al.MRCP versus ERCP in the evaluation of chronic pancreatitis in children: which is the better choice?.Pancreas. 2016; 45: 1115-1119Crossref PubMed Scopus (17) Google Scholar, 3Oracz G. Pertkiewicz J. Kierkus J. Dadalski M. Socha J. Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis.Gastrointest Endosc. 2014; 80: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 4Wejnarska K. Kolodziejczyk E. Wertheim-Tysarowska K. Dadalski M. Sobczynska-Tomaszewska A. Kierkus J. et al.The etiology and clinical course of chronic pancreatitis in children with early onset of the disease.J Pediatr Gastroenterol Nutr. 2016; 63: 665-670Crossref PubMed Scopus (16) Google Scholar The authors reviewed most of the known studies concerning ERCP and its safety in children. However, the authors did not cite our recent study.3Oracz G. Pertkiewicz J. Kierkus J. Dadalski M. Socha J. Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis.Gastrointest Endosc. 2014; 80: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar We reviewed our database of children with chronic pancreatitis with particular attention to complication rate of ERCP. Between 1988 and 2016, a total of 641 ERCP procedures were performed in 223 patients. Overall, 626 of 641 ERCP examinations (97.6%) resulted in successful cannulation of the pancreatic duct, with a complication rate of 3.1% (20 in 641 procedures). Post-ERCP pancreatitis was the most common complication, documented in 14 patients. Hemorrhage after papillotomy was observed in 3 patients. Perforation of the duodenal wall was observed in 1 patient. One examination was discontinued owing to sudden decrease in saturation. Furthermore, a lithotripter basket was broken in 1 patient and had to be evacuated with a salvage lithotripter. The successful completion of 98% of ERCP procedures in our group is comparable with the success seen in the adult population, and is similar to that found in other pediatric studies.1Usatin D. Fernandes M. Allen I.E. Perito E.R. Ostroff J. Heyman M.B. Complications of endoscopic retrograde cholangiopancreatography in pediatric patients; a systematic literature review and meta-analysis.J Pediatr. 2016; 179: 160-165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Kolodziejczyk E. Jurkiewicz E. Pertkiewicz J. Wejnarska K. Dadalski M. Kierkus J. et al.MRCP versus ERCP in the evaluation of chronic pancreatitis in children: which is the better choice?.Pancreas. 2016; 45: 1115-1119Crossref PubMed Scopus (17) Google Scholar, 3Oracz G. Pertkiewicz J. Kierkus J. Dadalski M. Socha J. Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis.Gastrointest Endosc. 2014; 80: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 4Wejnarska K. Kolodziejczyk E. Wertheim-Tysarowska K. Dadalski M. Sobczynska-Tomaszewska A. Kierkus J. et al.The etiology and clinical course of chronic pancreatitis in children with early onset of the disease.J Pediatr Gastroenterol Nutr. 2016; 63: 665-670Crossref PubMed Scopus (16) Google Scholar Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-AnalysisThe Journal of PediatricsVol. 179PreviewTo systematically review risks and summarize reported complication rates associated with the performance of endoscopic retrograde cholangiopancreatography (ERCP) in children during the past 2 decades. Full-Text PDF ReplyThe Journal of PediatricsVol. 186PreviewWe appreciate Dr Oracz's interest and for bringing these articles to our attention. We performed a comprehensive literature search of MEDLINE/PubMed, Ovid Embase, and Web of Science, which yielded 1642 unique articles. From this result, articles were screened and assessed for eligibility. Additionally, citations for included articles were hand searched to identify additionally resources. Full-Text PDF

Objectives To systematically review risks and summarize reported complication rates associated with the performance of endoscopic retrograde cholangiopancreatography (ERCP) in children during the past 2 decades.Study design A systematic literature search of MEDLINE, Embase, and Web of Science from January 1995 to January 2016 was conducted for observational studies published in English. Studies reporting ERCP complications in patients <21 years without history of liver transplant or cholecystectomy were included. A summary estimate of the proportion of children who experienced complications following ERCP was derived via a random effects meta-analysis.Results Thirty-two studies involving 2612 children and 3566 procedures were included. Subjects' ages ranged from 3 days to 21 years. Procedures were performed for biliary (54%), pancreatic (38%), and other (8%) indications; 56% of ERCPs were interventional. The pooled complication rate was 6% (95% CI 4%-8%). Procedural complications included post-ERCP pancreatitis (166, 4.7%), bleeding (22, 0.6%), and infections (27, 0.8%). The pooled estimate of post-ERCP pancreatitis was 3% (95% CI 0.02-0.05), and other complications were 1% (95% CI 0.02-0.05). In the subgroup with neonatal cholestasis, the pooled complication rate was 3% (95% CI 0.01-0.07). Adult and pediatric gastroenterologists and surgeons performed the ERCPs. Available data limited the ability to report differences between pediatric-trained and other endoscopists.Conclusions Complications associated with pediatric ERCP range widely in severity and are reported inconsistently. Our review suggests 6% of pediatric ERCPs have complications. Further studies that use systematic and standardized methodologies are needed to determine the frequency and risk factors for ERCP-related complications.

Background: Primary recurrent pyogenic cholangitis (RPC) is characterized by relentless suppurative cholangitis in those with a suspected parasitic injury of the biliary tree. Prior work has demonstrated that the infections recur following "definitive" biliary surgery and long-term percutaneous biliary catheters are poorly tolerated. The aim of this study was to assess whether scheduled surveillance endoscopic retrograde cholangiopancreatography (ERCP) prevents cholangitis in those with RPC. Materials and Methods: Following initial biliary decompression and stone clearance, patients with RPC were offered serial ERCP every 3-6 months to remove accumulating stony debris and to dilate incipient strictures. Review of a large series managed using this approach at the University of California, San Francisco Medical Center was performed. The principle outcome was the development of acute cholangitis requiring hospitalization and whether the episode occurred, while the RPC patient was in compliance with endoscopic surveillance recommendations. Results: Over a period of 10 years, 66 patients with primary RPC were managed for RPC at the University of California, San Francisco. The patients were comprised primarily of first-generation immigrants from Asia though one-quarter had migrated from Latin America and Russia. Episodes of cholangitis were significantly less likely to occur in those undergoing surveillance biliary endoscopy than in those who were not (odds ratio 5.3; P = 0.005) . The mean follow-up was 36.1 months. Conclusions: Serial endoscopic treatment of RPC may be used to systematically clear biliary debris and decreases the risk of cholangitis requiring hospitalization. It represents a reasonable initial management strategy for these patients. Surgery and percutaneous management may also be required, but are best performed as part of a multidisciplinary approach.

One well recognized and potentially serious complication of chronic immunosuppression in organ transplant recipients is post-transplantation lymphoproliferative disorders (PTLD). This accounts for 20% of all malignancies in transplant recipients, which is four times higher than the general population1,2. The diagnosis of PTLD is often difficult, due to various manifestations resulting in late diagnosis. We report an unusual presentation of PTLD in a pediatric patient where the diagnosis was achieved only after extensive investigation.

acid substitutions in the NS5A region among patients with HCV genotype 1a, 1b, 2a, 2b, and 3a affect the response to pegylated-interferon-alpha 2b and ribavirin combination therapy.METHODS: Six hundred sixty-five patients with chronic hepatitis C were enrolled.There were 375 men and 290 women (mean age, 57.7 ± 13.5 years).HCV genotypes 1a (N = 18), 1b (N = 428), 2a (N = 137), 2b (N = 71), and 3a (N = 11) were detected.The NS5A region (IFN sensitivity-determining region (ISDR)) in each genotype was examined by direct sequencing.The proto-type for each genotype were defined and the counting the number of mutations to the sequence of proto-type in the ISDR and the strains which have more than two mutations were defined as mutant-type.Detection of the SNP of IL28B (rs8099917) was done by a real-time PCR system with specific probes.Patients received pegylated-IFNalpha 2b once each week plus oral ribavirin daily for 24 -72weeks.RESULTS: Of the 665 patients, 365 (54.9%) showed sustained virologic response (SVR).SVR rates according genotype 1a, 1b, 2a, 2b, and 3a were 44.4,43.6, 72.9, 70.4, and 80.1%, respectively.Factors related to SVR in genotype 1a were IL28B TT allele (p=0.0359) and ISDR mutanttype (p=0.0229).The IL28B and mutation in the ISDR were the factors related to SVR on multivariate analysis in patients with genotype1b.The best SVR was achieved in patients with mutant-type ISDR and IL28B T allele (70.5%), and the worst was achieved in patients with wild-type ISDR and IL28B G allele (11.1%) in genotype 1a and 1b.Of the 137 patients, 100 (72.9%) achieved SVR in patients with genotype 2a.SVR was achieved in 65.5% of patients with wild-type ISDR and 86% of patients with mutant-type (p = 0.0097).Achievement of SVR occurred in patients with T allele (66.7%) and those with G allele (74.8%).There were no significant differences in SVR according to IL28B in genotype 2a.Similar results were found in genotype 2b.Both ISDR and IL28B in patients with genotype 3a were not associated with SVR.CONCLUSIONS: Both ISDR and IL28B were significantly associated with SVR in genotype 1a and 1b.Only ISDR was useful for predicting the IFN response in genotype 2a and 2b.The impact of ISDR and IL28B on SVR was different in each genotype and these concepts should consider in choosing optimal therapy.

One well recognized and potentially serious complication of chronic immunosuppression in organ transplant recipients is post-transplantation lymphoproliferative disorders (PTLD). This accounts for 20% of all malignancies in transplant recipients, which is four times higher than the general population (1,2). The diagnosis of PTLD is often difficult, due to various manifestations resulting in late diagnosis. We report an unusual presentation of PTLD in a pediatric patient where the diagnosis was achieved only after extensive investigation.

pancreatitis Active cathepsins B, L, and S in murine and human You might find this additional info useful... abnormal function of the gastrointestinal tract, hepatobiliary system, and pancreas. It is published 12 times a year (monthly) by the publishes original articles pertaining to all aspects of research involving normal or AJP-Gastrointestinal and Liver Physiology

Removable plastic double-pigtail stents are commonly used to treat biliary obstruction. A new stent was recently developed by Cook Medical® to improve upon their current design. The Compass® BDS stent is a polyethylene, dual tapered-tip design. The polyethylene material is softer and more malleable than current Cook® stents with less memory at body temperature. The addition of two visual and radio-opaque markers identifies the pigtail locations via both video endoscopy and fluoroscopy. Each pigtail is 5cm long and contains 17 drainage holes, compared to 4-6 on conventional double pigtail stents. These innovations are intended to increase the ease and accuracy of placement and allow for improved biliary and pancreatic drainage and stent durability.

Cathepsins regulate premature trypsinogen activation within acinar cells, a key initial step in pancreatitis. The identity, origin, and causative roles of activated cathepsins in pancreatic inflammation and pain are not defined. By using a near infrared-labeled activity-based probe (GB123) that covalently modifies active cathepsins, we localized and identified activated cathepsins in mice with cerulein-induced pancreatitis and in pancreatic juice from patients with chronic pancreatitis. We used inhibitors of activated cathepsins to define their causative role in pancreatic inflammation and pain. After GB123 administration to mice with pancreatitis, reflectance and confocal imaging showed significant accumulation of the probe in inflamed pancreas compared with controls, particularly in acinar cells and macrophages, and in spinal cord microglia and neurons. Biochemical analysis of pancreatic extracts identified them as cathepsins B, L, and S (Cat-B, Cat-L, and Cat-S, respectively). These active cathepsins were also identified in pancreatic juice from patients with chronic pancreatitis undergoing an endoscopic procedure for the treatment of pain, indicating cathepsin secretion. The cathepsin inhibitor K11777 suppressed cerulein-induced activation of Cat-B, Cat-L, and Cat-S in the pancreas and ameliorated pancreatic inflammation, nocifensive behavior, and activation of spinal nociceptive neurons. Thus pancreatitis is associated with an increase in the active forms of the proteases Cat-B, Cat-L, and Cat-S in pancreatic acinar cells and macrophages, and in spinal neurons and microglial cells. Inhibition of cathepsin activation ameliorated pancreatic inflammation and pain. Activity-based probes permit identification of proteases that are predictive biomarkers of disease progression and response to therapy and may be useful noninvasive tools for the detection of pancreatic inflammation.

Background: Biliary tract problems are the most common complications after liver transplantation. ERCP is increasingly being used to address posttransplantation biliary problems.Objective: To identify predictors of endoscopic treatment outcomes in the management of post liver transplantation complications.Setting and Patients: All adult patients who underwent liver transplantation at the University of California, San Francisco between January 1999 and December 2008 were reviewed.Design: A multivariate regression analysis.Main Outcome Measurements: Identification of donor and recipient factors as well as technical considerations that predicted success or failure in the endoscopic management of posttransplantation biliary complications.Results: In 1062 patients who underwent liver transplantation, there were 224 biliary complications. FRCP was the primary treatment modality and was successful in the majority of patients treated. Patients with biliary complications who had take-back surgery for a nonbiliary indication during the first month after liver transplantation (odds ratio [OR], 0.32; P = .03), particularly for bleeding (OR, 0.18; P = .02), were less likely to respond to endoscopic therapy. Those who received a graft from a donor after cardiac death (OR, 0.15; P = .02) or a living donor (OR, 0.11; P < .01) were also less likely to respond to endoscopic therapy. Take-back surgery for a nonbiliary indication in the first month after liver transplantation was also identified as a novel risk factor for the development of biliary complications (OR, 1.80; P = .02).Limitations: Retrospective design.Conclusions: ERCP can be used to treat the majority of posttransplantation biliary problems. However, endoscopic therapy is less efficacious in the treatment of complications associated with ischemia. (Gastrointest Enclose 2011;73:37-44.)

CONTEXT:Endoscopically placed metal stents, which are patent for 4-9 months, have been the favored decompressive strategy for biliary obstruction due to inoperable pancreatic cancer in order to minimize interventions. However, in the past decade chemotherapeutic options have improved survival. This raises the question of whether metal stents will continue to be the optimal method of decompression.OBJECTIVE:We performed a study to determine the outcome of patients with non-operatively managed pancreatic adenocarcinoma with regards to the development of cholangitis.DESIGN:We reviewed all ERCP performed for malignant distal biliary obstruction in between December 1999 and December 2005 at University of California, San Francisco (UCSF).PATIENTS:Only patients who received chemotherapy for pancreatic adenocarcinoma were included. Patients who underwent surgical biliary diversion procedures were excluded. PRIMARY OUTCOME MEASUREMENT: The primary outcome was the development of cholangitis requiring hospitalization.RESULTS:Among 200 patients with malignant distal biliary obstruction who underwent endoscopic biliary decompression procedures, 54 met study criterion. Metal stents were employed in 90.7% of these cases. The median survival of this population was 12.7 months (range: 2.6-34.6 months). Only 3 of 26 patients (11.5%) surviving one year or less developed cholangitis compared to 13 of 28 (46.5%) who survived more than one year. Thus patients surviving greater than one year had a five fold increase in the odds of developing cholangitis (odds ratio: 4.92; P=0.017).CONCLUSIONS:This cohort of inoperable pancreatic cancer patients undergoing chemotherapy survived longer than the expected patent period of metal stents employed for biliary decompression. The occurrence of cholangitis requiring hospitalization does increase markedly among long term survivors.