No abstract

One hundred and twenty patients with known common bile duct stones were entered into a prospective randomised study of preoperative endoscopic sphincterotomy and stone clearance (group 1) versus surgery alone (group 2). Five patients were incorrectly entered; the 55 patients randomised to group 1 and the 60 randomised to group 2 were well matched with respect to clinical features and biochemical and medical risk factors. In group 1 endoscopic stone clearance was successful in 50 patients (91%); five of these patients refused elective surgery, though this was subsequently necessary in one. In'group 2 common bile duct stones were cleared surgically in 54 of 59 patients (91-5%); one patient was treated by endoscopic sphincterotomy alone because of a myocardial infarct. The overall major complication rate in group 1 was 16-4% and included two deaths; in group 2 this was 8*5% and included one death. The minor complication rate in group 1 was 16*4% and that in group 2 13-6%. These differences in outcome were not significant.Despite a significant reduction in total hospital stay ofpatients in group 1, these results do not support the routine use of preoperative endoscopic sphincterotomy in patients having biliary surgery for stones in the common bile duct.

No abstract

The results of treatment and outcome in 52 consecutive patients presenting to Leicester from 1972 to 1984 are presented. The number of patients diagnosed increased from two per year before the introduction of duodenoscopy to nearly five per year afterwards. Endoscopic drainage (ED) was attempted in 21 patients with a success rate of 81 per cent. In eight cases ED was used pre-operatively and in the remainder as definitive treatment. Twenty-four patients had a Whipple's resection (12.5 per cent mortality), four patients had a local resection (no deaths), ten patients had surgical bypass (60 per cent mortality) and thirteen patients had ED alone (23 per cent mortality). The major risk factor score was significantly greater in patients undergoing surgical bypass compared with Whipple's resection. Age and risk factor scores were significantly greater in patients who had ED drainage alone than in surgical patients. The 5 year survival rate for resection was 56 per cent versus 13 per cent for drainage procedures (P less than 0.001). Survival in resection cases was directly related to the degree of tumour differentiation and a new staging system. It is proposed that all patients with ampullary tumours should have endoscopic biopsy followed by ED; Whipple's resection remains the surgical treatment of choice.

Ultrasonography (US), radionuclide biliary scanning (RBS), and biochemical tests were performed within 72 h of admission in 83 patients with acute pancreatitis in an attempt to define those with gallstones as an aetiological factor. US was 92 per cent accurate in the 80 per cent of patients in whom the gallbladder was demonstrated. There were no false positives. Sixty-seven per cent of patients with gallstones were diagnosed although this improved to 78 per cent when US was repeated following the patients' clinical improvement. The pattern of RBS was completely normal in 46.5 per cent of patients with biliary pancreatitis and 64 per cent of patients with non-biliary pancreatitis. Biochemical tests completely separated 47 per cent of patients with gallstones from those without. Used in combination with US these two methods accurately identified 81 per cent of patients in the biliary group. In conclusion US was found to be a rapid and accurate method of gallstone detection but used alone it has limited usefulness. RBS can be time consuming and was found to be of doubtful value. Biochemical tests were helpful in indicating a proportion of patients who had gallstones which were not detected by US, and therefore have a practical application. Current methods of gallstone detection in patients with acute pancreatitis are far from ideal and further studies are indicated.