Acute biliary pancreatitis: Diagnosis and management

Acute biliary pancreatitis is a serious complication of biliary calculous disease and is associated with significant morbidity and mortality. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute biliary pancreatitis has been the focus of discussion in recent years. In addition, the exact role of laparoscopic cholecystectomy (LC) in the management of acute biliary pancreatitis has not yet been fully defined. In this report, we evaluated a protocol of emergency ERCP (within 24 hours) for predicted severe attacks, early ERCP (within 72 hours) for predicted mild attacks, and interval LC for management of acute biliary pancreatitis. Between January 1992 and June 1995 a total of 75 patients with acute biliary pancreatitis were managed according to the protocol. Bedside ultrasonography at admission diagnosed 94% of all 64 patients with gallbladder stones, but the sensitivity of visualizing choledocholithiasis was low (19%). Forty-five (60%) of them were predicted to have a severe attack by either Ranson or glucose/urea criteria. Emergency ERCP and endoscopic sphincterotomy (ES) for identifiable common bile duct (CBD) or ampullary stones were performed on all patients predicted to have a severe attack within 24 hours from presentation. An early endoscopic procedure was performed on all patients predicted to have a mild attack within 72 hours from presentation. ERCP was successful in 95% of all patients, and CBD stones were detected in 52 (69%) of them. ES and stone clearance were successful in all of these 52 patients. The morbidity associated with the endoscopic procedure was 3%, and there were no deaths. All except one patient survived the attack of acute pancreatitis, resulting in an overall mortality of 1%. Interval LC was performed on 46 patients with a conversion rate of 4%. The median postoperative hospital stay after LC was 2 days, and there was no major intraoperative or postoperative morbidity or mortality. Our experience suggests that the policy of emergency ERCP for patients with predicted severe disease, early ERCP for patients with predicted mild disease, and interval LC are associated with favorable outcomes in patients with acute biliary pancreatitis. Acute biliary pancreatitis can be managed safely and effectively by a combined endoscopic and laparoscopic approach.     

Influence of age on the mortality from acute pancreatitis

The influence of age on the mortality rate of 268 patients with acute pancreatitis was studied. The hospital mortality rate for patients aged below 50 years was 5.9 per cent. The figure increased to 21.3 per cent in patients aged over 75; the high mortality was accounted for by a higher incidence of deaths related to concomitant medical or surgical diseases in the same hospital admission rather than to complications resulting directly from the pathological process of acute pancreatitis. When only deaths due to complications of acute pancreatitis were analysed, the mortality rate was not significantly different between the young and elderly groups. Moreover, the complication rate and the proportion of patients having severe disease (judged by the number of prognostic signs) were not higher in the elderly. Thus acute pancreatitis was intrinsically not more serious were it not for the presence of concomitant diseases with advanced age.     

Acute pancreatitis in Algeria. Report of 221 Cases

A review of 221 patients operated on for acute pancreatitis during a 16 year period showed that women predominated 2:1. This is explained by the common occurrence of biliary stones in Algerian women. In more than half the patients, primary symptoms were biliary. Only 56 percent of diagnoses were established preoperatively. Acute edematous pancreatitis predominated, occurring in 58 percent, with necrotic pancreatitis occurring in 42 percent. Edematous pancreatitis was most often treated by biliary procedures and infiltration and draining of the pancreatic area. Necrotic forms were treated by necrotectomy, whereas segmental pancreatectomy was performed in seven patients. Postoperative mortality was 9.4 percent in the whole group but 37 percent in those with necrotic hemorrhagic pancreatitis. It is noteworthy that alcoholism, which is rare in Algeria, was the cause of pancreatitis in only six patients (3 percent). The main cause was biliary disease.     

The biliary tract in patients with acute gallstone pancreatitis

The biliary tract has been prospectively studied in a consecutive series of 769 patients undergoing surgery for gallstones to determine whether differences exist between subjects with and without a history of acute pancreatitis. The incidence of acute gallstone pancreatitis (AGP) was 7.7 per cent and men with gallstones were significantly more likely to develop pancreatic inflammation. Operations on patients with AGP were accompanied by a higher mortality rate which was almost entirely due to the severity of the disease at the time of surgery. The earlier operations were performed after the onset of pancreatitis the more often stones were found in the common bile duct and at the ampulla. Patients with AGP had smaller and more numerous gallbladder stones in association with a wider cystic duct that controls. The common bile duct diameter in patients with AGP was independent of the presence of choledochal calculi implying either previous temporary obstruction to the biliary tree or a dilated duct ab initio. Pancreatic duct reflux was far more commonly observed on the cholangiograms of patients with AGP and in these patients reflux occurred into a wider pancreatic duct, at a greater angle and was associated with a longer functioning common channel. No patient developed recurrent pancreatitis following biliary surgery. These features strongly support the concept of gallstone migration and suggest that patients with gallstones who develop acute pancreatitis have essential differences in their biliary tree which mechanically facilitate migration of calculi.     

腹腔镜联合十二指肠镜早期治疗轻型急性胆源性胰腺炎57例报告

目的 探讨运用腹腔镜联合十二指肠镜早期治疗胆囊结石继发细径胆总管结石和轻型急性胆源性胰腺炎的手术方法及疗效.方法 分析在发病7 d内(早期手术组)同期行腹腔镜胆囊切除术(LC)联合十二指肠镜下乳头切开术(EST)40例患者资料,并与在胰腺炎治疗2周后(延期手术组)同期行LC联合EST 17例患者资料,观察两组的疗效.结果 同期行LC联合EST手术成功率早期手术组为92.5%,延期手术组为94.1%,两组差异无统计学意义(P>0.05).两组术后均无胆管残留结石、胰腺炎加重.无胃肠穿孔、胆管穿孔、胆漏、大出血等手术并发症,无死亡.但延期手术组的住院时间和住院费用明显高于早期手术组.(P<0.05).结论 只要选择合适的轻型急性胆源性急性胰腺炎病例,于发病7 d内同期行腹腔镜胆囊切除术及十二指肠镜下乳头切开术是安全、有效的.     

Treatment of acute biliary pancreatitis: our experience

The results of endoscopic and surgical treatment in 21 patients affected by acute biliary pancreatitis are reported. All patients were managed according to the same protocol. Once the diagnosis was formulated (pain, serum amylase, ultrasonography, cholestasis and/or cholangitis) and the severity evaluated (Ranson's criteria, glucose and urea levels), the 21 patients underwent endoscopic retrograde cholangiopanctratography--within 24 hours in 8 patients (predicted severe disease) or within 72 hours in 13 patients (predicted mild disease). Endoscopic sphincterotomy was performed in 18 patients with stones in the common bile duct and was successful in 94.5% (17 patients: 3 patients underwent more than one session to confirm or achieve clearance of the duct). The morbidity rate associated with endoscopic sphincterotomy was 16% (3 patients: 2 haemorrhages, 1 perforation). There were no deaths. Cholecystectomy was performed in 16 patients within 2-9 weeks of the initial attack of acute biliary pancreatitis. There were 3 minor complications (respiratory, laparotomy, urinary infection), no major intraoperative or postoperative morbidity, and no mortality. Acute biliary pancreatitis is still associated with significant morbidity and mortality, but can be managed safely with combined medical, endoscopic and surgical treatment.     

Gallstone disease among black South Africans. A review of the Baragwanath Hospital experience

It has been suggested that gallstone disease is rare in Africa. The 118 cholecystectomies for this condition performed at Baragwanath Hospital over the 3-year period 1983-1985 were reviewed; 100 records were available. The male: female ratio was 1:4, the mean age 51 years. Fifty-one per cent of patients presented with acute cholecystitis, 18% with obstructive jaundice, 9% with pancreatitis and only 22% with biliary colic. The incidence of complicated presentation was higher in the over 60-year-old age group (P less than 0.05). The correct diagnosis was made on admission in only 41% of cases. The mean delay in diagnosis was 5 days; however, the delay was 8 days for patients admitted to the medical wards compared with 2 days in the surgical wards (P less than 0.001). Elective operations were performed on 82% of patients and 18% had urgent surgery. The incidence of common bile duct stones was 22%. The overall mortality rate was 10%; however, the mortality rate was 3.2% for the under-60-year-old group compared with 21% for patients 60 years and older (P = 0.006). This series, which is probably the largest reported in black patients, suggests that greater awareness of acute cholecystitis is necessary in the black patient since there is a rising in-hospital incidence.     

Acute pancreatitis in elderly patients. Pathogenesis and outcome

Forty patients over 70 years of age with acute pancreatitis were studied. The most common cause of pancreatitis was biliary tract disease (14 patients, 35 percent). Twelve patients (30 percent) were discharged with a diagnosis of idiopathic pancreatitis, but tests such as endoscopic retrograde cholangiopancreatography that might have established the cause of disease were frequently not employed. Eight of the 40 patients died, for a mortality rate of 20 percent. Significant morbidity occurred in an additional seven (17.5 percent). Multisystem failure was the cause of death in all eight patients, and only two patients with multisystem failure survived. The mortality rate was significantly higher in those patients with postoperative pancreatitis. Acute pancreatitis in the elderly carries a grave prognosis. All patients should undergo thorough evaluation, as biliary tract disease is the most common cause. Cholecystectomy should be performed in those with biliary disease to prevent recurrent attacks.     

Early operation for acute biliary tract stone disease

A prospective study to evaluate the accuracy of early diagnosis and the efficacy of early operation for biliary tract stone disease was performed. One hundred fifty-two consecutive patients with signs and symptoms compatible with biliary colic or acute cholecystitis were admitted to the hospital and promptly evaluated with ultrasonography and hepatobiliary (Pipida) scanning. Patients with demonstrable stones or a nonvisualized gallbladder underwent operation within 48 hours of admission. Of 75 patients who underwent operation, 64 had acute and/or severe chronic cholecystitis. Associated biliary pancreatitis was present in 14 of 75 patients. Cholecystectomy with intraoperative cholangiography was performed for 73 of the 75 patients. One patient underwent cholecystectomy only and one patient underwent cholecystostomy. There were 18 common duct explorations. No transfusions were required and there were no deaths. The average duration of hospital stay for all patients who underwent operation was 6.5 days. The results indicate that an accurate diagnosis of acute biliary tract stone disease can be made rapidly with use of sonography and hepatobiliary scanning, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary can be performed safely (including cases of biliary pancreatitis) in the acute setting, and that with early operation the duration of stay is decreased and morbidity and mortality rates compare favorably with those of elective cholecystectomy. It is concluded that operation performed within at least 48 hours of admission is the treatment of choice for acute biliary tract stone disease.     

急诊ERCP在急性胆源性胰腺炎治疗中的应用

目的探讨急诊ERCP在急性胆源性胰腺炎(ABP)急性反应期中的作用与地位。方法回顾分析92例ABP患者,根据是否早期接受急诊ERCP分为ERCP组(ERCP组,52例)和非ERCP组(N-ERCP组,40例)。观察ERCP组中胆总管微小结石或胆泥发生率;比较两组重症胰腺炎发生率、腹痛缓解时间、血清淀粉酶及肝功能变化。结果 ERCP组中49例急诊ERCP治疗成功,成功率达94.2%。ERCP组中,胆总管微小结石及胆泥共6例,占胰腺炎病因11.5%(6/52);ERCP组重症胰腺炎发生率[5.8%(3/52)]明显低于N-ERCP组[20%(8/40)](P<0.05)。ERCP组腹痛缓解时间(3.5±1.1 d vs 5.0±1.5 d)、血清淀粉酶下降速度(50±135 U/L vs 201±120 U/L)、肝功能(TBIL:125±114μmol/L vs 250±140μmol/L;ALT:210±183 U/L vs 452±215 U/L;GGT:241±198 U/L vs 450±285 U/L)改善情况均优于N-ERCP组(P<0.05)。结论急诊治疗性ERCP可显著缓解临床症状和降低重症胰腺炎发生率。     

The role of clinical and biochemical criteria and endoscopic retrograde cholangiopancreatography in the urgent diagnosis of common bile duct stones in acute pancreatitis

The role of clinical and biochemical criteria in predicting common bile duct (CBD) stones was analyzed in 76 patients with acute pancreatitis undergoing endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Forty patients had ERCP within 72 hours; cholangiography was successful in 92%. Fifty patients had biliary pancreatitis; 25 patients had CBD stones and all were successfully removed by endoscopic sphincterotomy (ES). Twenty-six patients had nonbiliary pancreatitis. Two patients had complications from ERCP and/or ES; two patients died (no CBD stones) but ERCP was noncontributory. Significant differences were found between the biliary and nonbiliary disease groups with respect to age, and bilirubin. gamma-glutamyl transpeptidase, alkaline phosphatase, alanine transaminase, and amylase levels. The first four factors also discriminated between those patients with and without CBD stones. Logistic discriminant functions were estimated providing probabilities for the presence of CBD stones for each patient but were too cumbersome for clinical use. A simple scoring system was devised on the basis of cut-off levels: bilirubin greater than or equal to 40 mumol/L, gamma-glutamyl transpeptidase greater than or equal to 250 IU/L, alkaline phosphatase greater than or equal to 225 IU/L, and age greater than or equal to 70 years, indicating CBD stones. Bilirubin alone had a sensitivity and specificity of 80%; the specificity increased to 93% with all four factors. These results suggest that clinical and biochemical criteria and ERCP and/or ES may have important roles in the management of patients with suspected biliary pancreatitis.     

老年人胆源性急性胰腺炎的早期外科治疗体会

目的总结老年人胆源性急性胰腺炎早期外科治疗的经验。方法对1997年1月至2007年1月10年间,收治的39例老年人胆源性急性胰腺炎患者早期外科治疗的临床资料进行回顾性分析。结果39例老年人胆源性急性胰腺炎,术中均见胆总管有不同程度的扩张,其中33例胆总管内有大小不等的结石,12例有脓性胆汁。36例治愈出院。手术后死亡率为7.69%（3/39）,死亡原因为呼吸功能衰竭或多器官功能衰竭5例发生手术后胆漏,发生率为12.8%（5/39）。结论早期积极的胆道取石和/或胆道置管引流、减压等处理,是成功治疗老年人胆源性急性胰腺炎的有效手段。但由于老年人多有重要器官功能不全等,手术风险大,术后并发症多,应遵循“个体化方案”的治疗原则,重视维持水电解质酸碱平衡和血液循环的稳定,加强围手术期处理。     

Outcome analysis of laparoscopic cholecystectomy in patients aged 80 years and older with complicated gallstone disease

BACKGROUND: The aim of this study was to evaluate the outcome of laparoscopic cholecystectomy (LC) in octogenarians with complicated gallstone disease. MATERIALS AND METHODS: This study was a retrospective analysis of prospectively collected data of 51 patients aged 80 years or older who underwent an LC for complicated gallstone disease between 2001 and 2006. This group was compared with 41 octogenarian patients with uncomplicated gallstone disease. RESULTS: There were 51 patients (26 men) with a median (range) age of 87 years (range, 80-93) who underwent an LC for complicated biliary disease, including acute cholecystitis in 29 (57%), gallstone pancreatitis in 14 (27%), cholangitis in 4 (7.8%), and obstructive jaundice in 4 (7.8%). Significantly more patients in the complicated disease group underwent preoperative endoscopic retrograde cholangiopancreatography (33.3% vs. 12.1%; P = 0.026) The median operative time was 110 minutes (range, 55-165) and this was significantly longer, compared to the uncomplicated disease group (P = 0.031). Postoperative morbidity was 27.3%, a significantly higher rate, compared to the uncomplicated group (27.4% vs. 7.3%; P = 0.015) with zero mortality. The conversion rate was 7.8% and this was not significantly different from the uncomplicated disease group. The median length of hospital stay was 6 days, which was significantly longer than the uncomplicated disease group (P = 0.021). CONCLUSIONS: The LC can be performed with acceptable morbidity in octogenarians with complicated gallstone disease. Early treatment of gallstone disease in this age group could further improve outcomes.     

The surgical management of impacted common bile duct stones without sphincter ablation

Thirty-two consecutive patients with impacted ampullary or distal common bile duct stones were managed prospectively. Preoperative indications for surgery were obstructive jaundice in 13 patients (40.6%), acute cholangitis in 7 patients (21.9%), biliary pancreatitis in 6 patients (18.8%), acute cholecystitis in 5 patients (15.6%), and chronic cholecystitis in 1 patient (3.1%). No patient had a prior cholecystectomy, and all stones were removed retrograde during cholecystectomy and open-duct exploration. There were no deaths, one retained stone in the biliary radicals, two episodes of mild pancreatitis, one superficial wound infection, and one minor bile leak. All patients have done well on follow-up. This study demonstrated that impacted biliary stones can be consistently and successfully extracted by the supraduodenal approach with minimal morbidity and no mortality, without resorting to duodenotomy and sphincter ablation.     

The Timing of Biliary Surgery in Acute Pancreatitis

The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed nonoperatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 "mild" episodes (1.8% mortality) and 23 "severe" episodes (17% mortality). Early (day 0-7) definitive biliary surgery was undertaken in 11 patients with "mild" pancreatitis, with one death (9%), and in six patients with "severe" pancreatitis, with four deaths (67%). In three recent patients with "severe" pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with "mild" acute pancreatitis, early definitive surgery is hazardous in "severe" pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.     

Single-stage definitive laparoscopic management in mild acute biliary pancreatitis

BACKGROUND: Population-based studies have shown that nearly one third of patients with acute biliary pancreatitis undergo endoscopic retrograde cholangiopancreatography (ERCP) before undergoing laparoscopic cholecystectomy (LC) (two-stage approach). The present study was designed to evaluate the safety of single-stage laparoscopic management to avoid preoperative ERCP. MATERIALS AND METHODS: Between June 1998 and June 2002, 35 female patients and 10 male patients (median age, 59 years) with uncomplicated mild acute biliary pancreatitis were studied prospectively and reviewed retrospectively. LC with fluoroscopic intraoperative cholangiography (IOC) or with fluoroscopic IOC and laparoscopic CBD exploration in cases of concomitant choledocholithiasis was performed as the definitive treatment (single-stage approach). Patients underwent surgery electively when symptoms had subsided and laboratory parameters had improved. RESULTS: LC alone was performed in 39 patients, and an additional laparoscopic CBD exploration was performed in the remaining six. In one patient, IOC yielded a false-positive result. CBD stones were detected in four cases, and debris in the CBD in one case, for an 11% incidence of concomitant choledocholithiasis. The conversion rate was zero, and single-stage laparoscopic treatment was successful in all cases. The overall morbidity rate was 4%. The 30-day postoperative mortality rate was zero. CONCLUSION: Although preoperative ERCP and sphincterotomy still have a role in complicated cases of mild acute biliary pancreatitis, laparoscopic single-stage definitive treatment is feasible and safe in uncomplicated cases of disease when local experience is available.     

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.     

急性胆源性胰腺炎的微创治疗

目的探讨应用十二指肠镜及腹腔镜治疗急性胆源性胰腺炎(ABP)的有效性。方法回顾性分析5年间对94例ABP患者进行微创治疗的临床资料。ABP合并胆囊结石的59例行行单纯腹腔镜胆囊切除术(LC);胆总管结石14例内镜下乳头括约肌切开取石术(EST),同时置入鼻胆管引流(ENBD),其中3例联合LC;对胆囊结石合并胆总管结石21例行ERCP EST,联合LC治疗。结果全组术后再次发作胰腺炎1例,胆道出血1例,均为ERCP EST患者;另肺部感染2例,切口感染1例,5例均经非手术治疗痊愈。全组有效率100%。结论十二指肠镜及腹腔镜联合应用于治疗ABP效果好。微创技术是目前ABP理想的治疗方法。     

Laparoscopic Cholecystectomy for Biliary Tract Emergencies: State of the Art

Although laparoscopic cholecystectomy is unusually safe and well tolerated in patients with routine symptomatic cholelithiasis, it can become a formidable procedure when used to manage biliary tract emergencies. Optimally, a reasoned and cautious approach and a low threshold for conversion can avoid major complications. One such emergency, acute cholecystitis, may be particularly hazardous because of the relatively common finding of severe inflammation with dense adhesions to adjacent viscera and gallbladder necrosis. Special modifications of technique may be required. Overall, urgent operation (within 72 hours) results in an acceptably low mortality (0.3%) but a somewhat higher conversion rate (16%) and longer hospital stay (3 days). Unnecessary delays may result in more adhesions and an increased level of operative difficulty. In patients who are at an especially high risk because of co-morbid disease, percutaneous cholecystostomy is an appropriate alternative strategy. Biliary pancreatitis may be associated with high mortality (9%) and has an unpredictable course. Accordingly, a multidisciplinary approach that may include both gastroenterologists and radiologists is generally advisable. Because common bile duct (CBD) stones are present in more than 20% of patients who present with biliary pancreatitis, endoscopic retrograde cholangiopancreatography (ERCP) can be used effectively on a selective basis during the preoperative or postoperative period; the preferred timing continues to be somewhat controversial. As an alternative approach, laparoscopic CBD exploration is gradually gaining wider acceptance. In eight reported series using a variety of techniques for stone extraction, major complications were infrequent (10%), and the conversion rate was low (5%). Acute suppurative cholangitis is a more fulminant problem that is best managed by expeditious ERCP with removal of all intraductal stones. Resuscitation should be continued until complete; laparoscopic cholecystectomy can follow at an appropriate interval.     

Large bile duct stones treated by endoscopic biliary drainage

One hundred five patients with obstructive jaundice and cholangitis (49 patients), referred for diagnostic endoscopy, were found to have inextractable bile duct stones. Median age was 76 years and three quarters were more than 72 years of age. Insertion of an endoprosthesis with or without a sphincterotomy relieved jaundice in 94% and settled cholangitis in 90%. Antibiotic cover during the procedure seems essential inasmuch as pyrexia and septicemia occurred in 6 of 57 cases where it was not given. One case was lethal. Another patient died of acute pancreatitis. The patients were old. One quarter died before the follow-up, 1 to 5 years after the initial intervention. The results indicate that the combination of endoscopic sphincterotomy, insertion of an endoprosthesis, and, if feasible, stone extraction on a later occasion when the acute phase of the illness had subsided brought the disease sufficiently under control among three quarters of the patients with large common duct stones or stenoses in the biliary tract. One quarter of the patients were treated surgically. This was accomplished without mortality, but morbidity was not negligible. A policy with a surgical approach restricted to selected cases with persistent symptoms in spite of sufficient endoscopic drainage is recommended.