Endoscopic techniques have emerged as a viable option for treating complications of chronic pancreatitis. They afford immediate, short-term or medium-term symptom relief prior to other measures or progression of the disease alleviating the underlying causes of symptoms. In patients suffering from recurrent (episodic) pancreatitis, endoscopic treatment may eliminate the origin of symptoms and thus offer cure. Endoscopic treatment aims at alleviating ductal obstruction and at accomplishing subsequent relief of ductal and pancreatic tissue pressures. Thus, the presence of a dominant stricture, and/or intraductal calculus with concomitant dilatation of the duct, has been considered a prerequisite for successful symptom relief. Accordingly, endoscopic procedures will drain the main or accessory pancreatic ducts with or without harboured calculi (transpapillary via the major or accessory papilla), peripancreatic fluid collections or pseudocysts (transmurally or transpapillary), the bile ducts (transpapillary via the major papilla) or fistulae draining the pancreatic duct (transpapillary). Symptoms treated in this way include recurrent pancreatitis (pain attacks at monthly or longer intervals, also named pancreatic pain type A) or pain syndrome (pain attacks on a daily or weekly basis or continuous pain, also named pancreatic pain types B and C, respectively), discomfort or pain due to compression of adjacent organs, biliary obstruction with or without cholangitis or collections of pancreatic juice (pancreatic ascites, pleural effusion or cutaneous fistulae). Drainage is obtained by endoprostheses or nasopancreatic catheters with or without endoscopic pancreatic sphincterotomy, and extracorporeal shock wave lithotripsy when appropriate to shatter calculi within or adjacent to the main or accessory pancreatic ducts. In expert hands, endoscopic techniques are associated with high success rates and a few, usually mild, complications. There are few data from clinical randomized controlled trials to support the efficacy of endoscopic techniques and to define their role and cost-effectiveness compared to other treatment modalities in the short or long term. However, although results of endoscopic therapy derived from empirical data are discrepant, they suggest that a great proportion of patients may benefit by significant symptom relief immediately and in the short or medium term. Some complications/ symptoms seem to respond better than others, indicating that appropriate patient selection is an important but not yet clearly defined issue. The aim of this article is to provide guidance when endoscopic therapy is being considered in patients with benign pancreatic disease. To that end, a systematic review of studies rated according to strength of evidence was done in order to compile data for a comprehensive overall assessment of initial success, complications and outcome of endoscopic management.

The aim of this retrospective study was to investigate the accuracy of using preoperative data for the prediction of conversion from laparoscopic to open cholecystectomy in patients operated on for acute calculous cholecystitis. Laparoscopic cholecystectomy was scheduled in eighty-nine of 184 consecutive patients with acute calculous cholecystitis who underwent urgent or early cholecystectomy without bile duct exploration in our department between 1991 and 1998. The correlation between 11 preoperative clinical, laboratory and ultrasonographic variables, and the rate of conversion to open cholecystectomy was studied. Among the 11 variables tested, age and leukocyte count were independent factors of predictive significance. These two factors were used for constructing an additive prognostic index for conversion to open cholecystectomy. Thus, three groups of patients could be identified having a 10%, 30-70% or over 88% risk of conversion. Logistic regression analysis permits accurate preoperative identification of unsuccessful laparoscopic cholecystectomy in patients with acute calculous cholecystitis.

Bile-duct cysts or congenital bile-duct dilatation are rare but important abnormalities often mimicking calculous biliary tract disease. Bile-duct cysts are most often classified according to Todani. In a retrospective study of percutaneous, peroperative or endoscopic cholangiograms from 25 patients, diagnosed and treated during a 20-year period, images of different types of bile-duct cysts are presented and classified. The disease usually presents with vague symptoms and has a female preponderance. Current opinion on aetiology and complications is discussed. Cholangiography is a necessary prerequisite to surgical therapy.

Background: Common bile duct stones (CBDS) are a frequent problem (10–15%) in patients with symptomatic cholecystolithiasis. Over the last decade, new diagnostic and surgical techniques have expanded the options for their management. This report of the Consensus Development Conference is intended to summarize the current state of the art, including principal guidelines and an extensive review of the literature. Methods: An international panel of 12 experts met under the auspices of the European Association of Endoscopic Surgery (EAES) to investigate the diagnostic and therapeutic alternatives for gallstone disease. Prior to the conference, all the experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The preconsensus document compiled out of this correspondence was altered following a discussion of the external evidence made available by the panel members and presented at the public conference session. The personal experiences of the participants and other aspects of individualized therapy were also considered. Results: Our panel of experts agreed that the presence of common bile duct stones should be investigated in all patients with symptomatic cholecystolithiasis. Based on preoperative noninvasive diagnostics, either endoscopic retrograde cholangiopancreaticography (ERCP) or intraoperative cholangiography should be employed for detecting CBDS. Eight of the 12 panelists recommended treating any diagnosed CBDS. For patients with no other extenuating circumstances, several treatment options exist. Stones can be extracted during ERCP, or either before or (in exceptional cases) after laparoscopic or open surgery. Bile duct clearance should always be combined with cholecystectomy. Evidence for further special aspects of CBDS treatment is equivocal and drawn from nonrandomized trials only. Conclusions: The management of common bile duct stones is currently undergoing some major changes. Many diagnostic and therapeutic strategies need further study.

The development of non-surgical techniques for the relief of malignant low bileduct obstruction has cast doubt on the best way of relieving jaundice, particularly in patients fit for surgery whose life expectancy is more than a few weeks. We did a randomised prospective controlled trial comparing endoscopic stent insertion and surgical biliary bypass in patients with malignant low bileduct obstruction. 204 patients were randomised (surgery 103, stent 101); 3 subsequently proved to have benign disease and were excluded, leaving 101 surgical and 100 stented patients for assessment. Technical success was achieved in 94 surgical and 95 stent patients, with functional biliary decompression obtained in 92 patients in both groups. In stented patients, there was a lower procedure-related mortality (3% vs 14%, p =0.01), major complication rate (11% vs 29%, p =0.02), and median total hospital stay (20 vs 26 days, p =0.001). Recurrent jaundice occurred in 36 stented patients and 2 surgical patients. Late gastric outlet obstruction occurred in 17% of stented patients and 7% of the surgical group. Despite the early benefits of stenting there was no significant difference in overall survival between the two groups (median survival: surgical 26 weeks; stented 21 weeks; p =0.065). Endoscopic stenting and surgery are effective palliative treatments with the former having fewer early treatment-related complications and the latter fewer late complications.

OBJECTIVE:To elucidate further the role of endoscopy in the treatment of benign pancreatic disease.DESIGN:Retrospective study.SETTING:University hospital, Sweden.SUBJECTS:136 of 319 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for known or suspected pancreatic disease had abnormal findings at duodenoscopy or ductography, or both. In 28 patients endoscopic treatment was considered because of recurrent acute pancreatitis (n = 6), chronic pancreatitis (n = 5), pancreatic pain syndrome (n = 5), pancreatic fistula with ascites (n = 1), and pseudocyst (n = 1), or appreciable biliary obstruction from chronic pancreatitis (n = 10).INTERVENTIONS:Pancreatic duct drainage was attempted in 18 patients and successful in 13 (72%). Endoscopic sphincterotomy (EST) alone was done in 7/13 patients and an endoprosthesis (stent) was placed in 6/13. Bile duct drainage was attempted and successful in 10 patients by EST together with dilatation with (n = 6) or without (n = 4) simultaneous placement of a stent.MAIN OUTCOME MEASURES:Relief of pain and cholestasis.RESULTS:Immediate (1-30 days after initial treatment) and medium term (median 48 months after initial treatment) outcome after pancreatic duct drainage was excellent (no pain) or good (occasional mild pain) in 62% (8/13) and 67% (8/12) of the patients, respectively. Complications of the endoscopic procedure were encountered in four patients (31%) and comprised infection with abscess formation (n = 1), repeated stent clogging (n = 1) or stent migration (n = 2). Surgery was subsequently required in three patients (23%) because of intraabdominal abscess (n = 1), recurrent pain (n = 1), or no pain relief (n = 1). At medium term follow-up (median 68 months) after biliary drainage 7/10 patients had liver function tests within the reference ranges. Only two patients required subsequent biliodigestive shunts 7 and 13 months after EST, respectively.CONCLUSION:Our findings favour endoscopic drainage as a safe and effective method for temporary and medium term relief of pain and biliary obstruction in selected patients with benign pancreatic disease.

Contractile responses were studied in isolated tubal segments of branches of the rat portal vein (luminal diameter approximately 300 microns) and hepatic artery (luminal diameter approximately 200 microns). Portal veins were approximately three times more sensitive to noradrenaline (NA) than hepatic arteries. 5-hydroxytryptamine contracted hepatic arteries concentration-dependently, whereas it produced only weak and inconsistent contractions in portal veins. Vasopressin effectively contracted hepatic arteries, whereas it had no effect on portal veins. Both vessel types responded to prostaglandin F2 alpha with contractions, although the drug potency was relatively low (EC50 greater than 10(-5) mol l-1). Histamine and carbachol failed to induce (hepatic arteries) or caused only weak (portal veins) contractions. Microsurgical hepatic hilar denervation reduced the catecholamine content of the parenchyma to less than or equal to 25% of controls. In both portal veins and hepatic arteries, the denervation procedure increased the NA sensitivity by factors of 3.1 and 2.0, respectively. In non-denervated livers, cocaine produced a similar increase of the NA sensitivity, whereas the drug had no significant effect in vessels from denervated animals. Thus, there was a marked difference between rat portal veins and hepatic arteries in their responsiveness to several contractile agents. Furthermore, the results of the present study indicate that the adrenergic nerves in both vessel types can be adequately removed by the microsurgical denervation procedure used.

BACKGROUND:Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy.METHODS:To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing.RESULTS:Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months).CONCLUSIONS:These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.

Fibrotic stenosing anastomoses of the common bile duct were surgically created in pigs in order to investigate the effects of percutaneous transhepatic balloon catheter dilatation. In a group of 6 animals, not treated with balloon dilatation, percutaneous transhepatic cholangiography and microscopic examination of the stricture were performed 5 to 25 weeks postoperatively. A persistent stenosis and slight to moderate fibrosis of the bile duct wall and peribiliary tissue were observed. In 5 animals the stenotic anastomosis was dilated.4 to 10 weeks postoperatively and this resulted in widening of the stricture and necrosis of the mucosa at the stricture site. Rupture of the fibrotic tissue in the bile duct wall and thrombus formation in the peribiliary veins also occurred in one of these 5 animals. Short-term follow-up in 3 animals 4 to 6 weeks after balloon dilatation showed almost complete fibrotic healing and partial re-stenosis of the anastomoses.

The in vivo effect of formaldehyde on pulp tissue in short-term studies cannot be established by using routine histologic techniques because the tissue is exposed to a fixative in vivo as well as during the histologic preparation. The pulps of permanent premolars were amputated and zinc oxide with 4% formaldehyde or formocresol was used as wound dressing. The observation periods varied from 1 to 16 d. After extraction the teeth were freeze-sectioned, freeze-dried and then incubated for histochemical demonstration of some oxidative and hydrolytic enzymes. A demarcated border between apically stained and cervically nonstained pulp tissue was found in sections incubated for oxidative enzymes. When formocresol, which has a high concentration of formaldehyde, was used, the border was situated closer to the apex. This was also the case when the observation period was increased. The incubation for lactate dehydrogenase gave a high staining intensity. Thus the use of frozen sections in combination with the histochemical method for the demonstration of lactate dehydrogenase appears to be suitable for the study of the penetration of formaldehyde in pulp tissue in short-term studies.

Proton activation analysis, using the reactions 19F(p, alpha gamma)16O and 15N(p, alpha gamma)12C, was employed to study the fluorine and nitrogen content of developing rat molar enamel at various stages of maturation. Four groups of rats were utilized: Group I -- injected intraperitoneally at 6 days of age with 20 mg F/kg b.w. as sodium fluoride solution and terminated at 30 minutes and 1, 5 and 9 days postinjection; Group II -- injected in a similar way at 7 days of age and terminated 30 minutes and 1, 4 and 8 days postinjection; Group III -- injected with 10 mg F/kg, at 6, 15 and 19 days of age and terminated 30 minutes later; Group IV -- control animals injected with distilled water at 6 and 15 days of age respectively and terminated 30 minutes later. Analysis reflected decreasing nitrogen content in the enamel as maturation proceeded. However, fluorine concentrations were highest in all groups at the earlier stages of enamel development.

Naphthylamidase activity was studied in rat molar and incisor teeth at different stages of development. L-leucyl-4-methoxy-2-naphthylamide, L-alanyl-4-methoxy-2-naphthylamide, L-leucyl-2-naphthylamide and DL-alanyl-2-naphthylamide were used as substrates and Fast blue B and Fast Garnet GBC as diazonium salts. Naphthylamidase was not demonstrable in the teeth during enamel matrix formation. After the termination of this stage, naphthylamidase was present in the ameloblasts in their distal ends close to the enamel surface. The enzyme activity retained this localization until the dental epithelium fused with the oral epithelium at the time of tooth eruption into the oral cavity.