A New Technique for Reconstruction of the Common Bile Duct by an Autologous Vein Graft and a Biodegradable Endoluminal Stent

The incidence of severe bile duct injuries has significantly increased since the introduction of laparoscopic cholecystectomy. The ideal reconstruction procedure for traumatic defects of the bile duct should be technically simple and should preserve both the physiological passage of bile and the sphincter of Oddi. In this article we describe a new technique for bile duct reconstruction in a pig model by means of an autologous vein graft that is splinted by a endoluminal biodegradable polylactate acid stent. In 12 pigs the external jugular vein was removed and used as an autologous vein graft. After performing a median laparotomy a 2-cm segment was resected from the bile duct. The common bile duct was reconstructed by a venous interponate that had been endoluminally stented by a biodegradable polylactate acid stent. For the examination of stent degradation, 2 pigs were sacrificed at 3, 4, and 5 months (stent degradation group) and the remaining 6 pigs at 6 months (survival group). All the pigs in the survival group survived for 6 months before being sacrificed. After 4 months the stent material had been completely broken down and the vein graft had been relined with bile duct epithelium. Thus, this new technique for bile duct reconstruction using an autologous vein graft with an endoluminal stent is simple to perform and reliable, and constitutes an interesting alternative to bilodigestive anastomosis due to the preservation of the papilla of Vateri.     

A new technique for reconstruction of the common bile duct by an autologous vein graft and a biodegradable endoluminal stent.

The incidence of severe bile duct injuries has significantly increased since the introduction of laparoscopic cholecystectomy. The ideal reconstruction procedure for traumatic defects of the bile duct should be technically simple and should preserve both the physiological passage of bile and the sphincter of Oddi. In this article we describe a new technique for bile duct reconstruction in a pig model by means of an autologous vein graft that is splinted by a endoluminal biodegradable polylactate acid stent. In 12 pigs the external jugular vein was removed and used as an autologous vein graft. After performing a median laparotomy a 2-cm segment was resected from the bile duct. The common bile duct was reconstructed by a venous interponate that had been endoluminally stented by a biodegradable polylactate acid stent. For the examination of stent degradation, 2 pigs were sacrificed at 3, 4, and 5 months (stent degradation group) and the remaining 6 pigs at 6 months (survival group). All the pigs in the survival group survived for 6 months before being sacrificed. After 4 months the stent material had been completely broken down and the vein graft had been relined with bile duct epithelium. Thus, this new technique for bile duct reconstruction using an autologous vein graft with an endoluminal stent is simple to perform and reliable, and constitutes an interesting alternative to bilodigestive anastomosis due to the preservation of the papilla of Vateri.     

Reconstruction of a Common Bile Duct Injury by Venous Bypass

Hepaticojejunostomy is the standard technique for the reconstruction of severe iatrogenic lesions of the common bile duct (CBD), although the technique itself is major surgery with a complication rate up to 30%. We report a case of a male patient with a iatrogenic complete transsection of the CBD. Due to multiple previous operations and the present inflammation a standard reconstruction technique was not possible to perform. A neo-bile duct was created using a segment of the Great Saphenous Vein (GSV) synchronously with an external biliary drainage by PTCA and biliary stenting (after 4 weeks). The stent was removed 8 months later. Cholangiography showed normal bile flow without occlusion. Blood tests normalised. We believe that using an autologous vein graft in combination with a removable or biodegradable stent is the right track for the reconstruction of the CBD in the future.     

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Background : The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Methods : Over the three‐year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio‐pancreatography. Results : Transcystic stenting was the ‘intention‐to‐treat’ basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1–15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio‐pancreatography, was 98%. A second endoscopic retrograde cholangio‐pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. Conclusion : A treatment option open to all surgeons for non‐jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.     

A Tissue-Engineered Artificial Bile Duct Grown to Resemble The Native Bile Duct

The aim of this study was to fabricate an artificial bile duct for the development of a new treatment for biliary diseases. Eighteen hybrid pigs were implanted with a bile duct organoid unit (BDOU) made of a bioabsorbable polymer. Twelve of the transplanted BDOUs had been seeded with autologous bone marrow cells (BMCs) in advance. Six animals, the controls, were grafted with the scaffold alone with no BMCs seeded. The common bile duct was cut, the hepatic cut end of the native common bile duct was anastomosed to the BDOU and the other end was anastomosed to the duodenum. The controls underwent a similar operation. The neo-bile duct was removed at pre-determined time points and investigated histologically. All 18 recipient pigs survived until their sacrifice at 6 weeks, 10 weeks or 6 months. Histological examination revealed incomplete epithelialization of the neo-bile duct at 6 weeks and 10 weeks after transplantation. At 6 months, the organoid exhibited a morphology almost identical to that of the native common bile duct. No differences were found between the controls and BMC-seeded pigs. These results show that the artificial bile duct thus fabricated can serve as a substitute for the native bile duct.     

Biliary-Venous Fistula Complicating Transjugular Intrahepatic Portosystemic Shunt Presenting With Recurrent Bacteremia, Jaundice, Anemia and Fever

A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices. Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia. Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia. Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded. Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure. The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant. Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein. Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension. Infection is rarely reported in a totally occluded TIPS. Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement. Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.     

Reconstruction of bile duct lesions by an autologous vein graft and a bio-degradable endoluminal stent in an animal model: technique and clinical impact

INTRODUCTION: In this study a new treatment of bile duct lesions was investigated. A segment of the bile duct was replaced by an autologous venous interponate which had been endoluminally stented with a braided bio-degradable stent. METHODS: A total of 18 pigs (20-28 kg) was divided into three equal groups (I-III). In each group a 2 cm segment of the jugular vein was harvested. The animals in Group I (vein group, n = 6) underwent resection of a 2 cm long segment of the common bile duct which was replaced solely by the venous interponate, in Group II (stent group, n = 6) the venous interponate had been endoluminally stented by a braided bio-degradable stent. Group III (control group, n = 6) underwent only a circular mobilization of the common bile duct. Postoperatively survival rate, general condition as well as the weight were observed and checked for 6 months. During surgery and finally after sacrifice after 6 months blood and tissue samples were taken and semiquantitatively scored concerning grade of inflammation and fibrosis. RESULTS: In the stent and control group all animals survived in good condition. 3 pigs of the vein group died within 3 weeks showing signs of biliary peritonitis, another one died due to a high grade stenosis of the common bile duct with secondary biliary cirrhosis after 4 months. In the stent group all animals survived until sacrifice after 6 months. On examination the venous interponate was laminated with bile duct epithelium showing the diameter of the implanted stent. CONCLUSION: The reconstruction of bile duct lesions by a venous interponate in combination with a bio-degradable stent is easy to perform and represents a clinically interesting alternative to the biliodigestive anastomosis because of the preservation of the sphincter oddi. After 6 months the stent is completely absorbed and the venous interponate is laminated with bile duct epithelium.     

Pathophysiology of acute obstructive cholangitis

Because acute obstructive cholangitis is life-threatening, understanding of the pathophysiology of this disease is required to establish a medical treatment. Experimental results indicate that obstruction of the bile duct itself does not induce acute cholangitis, but infection of gut-derived bacteria such asEscherichia coli into the bile triggers fatal septicemia, which leads to liver injury and renal failure. In obstructive cholangitis, functional changes in sinusoidal lining cells are often seen. Mediators produced by Kupffer cells, endothelial cells, and stellate cells may modulate inflammatory reactions especially in the periportal area of bile duct ligated animals. In addition, proliferation of bile duct epithelial cells is induced by bile duct ligation. Recently, nitric oxide has been recognized as an important mediator of multiple organ failure. Actually, when bile duct ligated animals are treated with endotoxin, metabolites of nitric oxide in blood and plasma increase, indicating that nitric oxide may take part in the pathophysiology of acute obstructive cholangitis.     

A Novel Biodegradable Biliary Stent in the Normal Duct Hepaticojejunal Anastomosis: an 18-month Follow-up in a Large Animal Model

Creating a well-functioning hepaticojejunostomy (HJ) anastomosis with nondilated bile ducts remains a challenge. Our aim was to study the use in a large animal model of a novel, braided polylactide barium sulfate biodegradable biliary stent (BDBS) without external connection and with no need for later removal. Fifty swine were randomly operated on for Roux-Y HJ with or without BDBS in the anastomosis, and followed up (dynamic biligraphy, x-ray, serum determinations, anastomosis inner diameter, and histology) for 1.5, 3, 6, 12, and 18 months. During the follow-up, one nonstented animal died because of anastomotic leakage. In x-ray BDBS was seen in place until 1.5 months in all of the stented animals. In the nonstented animals HJ anastomosis inner diameter was decreased at 18 months [6.3 (5.0–7.0) mm vs 7.4 (7.0–9.0) mm, p = 0.05] and liver clearance reduced at 12 and 18 months compared to stented animals. Serum liver values and liver and bile duct histology did not differ between the groups. We conclude that this novel BDBS is easy to insert into the HJ anastomosis with nondilated ducts. It is nontoxic, dissolves safely, and may be associated with a larger and better draining anastomosis at 18-month follow-up. These results encourage us to proceed to clinical studies.     

Liver transplantation for “mass-forming” sclerosing cholangitis after laparoscopic cholecystectomy

INTRODUCTIONChronic biliary obstruction consequence of a bile duct injury may require liver transplantation (LT) in case of secondary biliary cirrhosis, intractable pruritus or reiterate episodes of cholangitis. “Mass-forming” sclerosing cholangitis leading to secondary portal vein thrombosis and pre-sinusoidal portal hypertension has not been reported so far.PRESENTATION OF CASEWe present the case of a patient who underwent laparoscopic cholecystectomy for Mirizzi syndrome. The persistent bile duct obstruction due to a residual gallstone fragment was treated by a prolonged biliary stenting. Following repeated bouts of cholangitis, a fibrous centrohepatic scar developed, conglobating and obstructing the main branches of the portal vein and of the biliary tree. The patient developed secondary portal vein thrombosis and portal hypertension. After an extensive diagnostic work-up, including surgical exploration to rule out malignancy, the case was successfully managed by liver transplantation.DISCUSSIONMass-forming sclerosis of the bile duct and biliary bifurcation may develop as a consequence of chronic biliary obstruction and prolonged stenting. Secondary portal vein thrombosis and pre-sinusoidal portal hypertension represents an unusual complication, mimicking Klatskin tumor.CONCLUSIONA timely and proper management of post-cholecystectomy complications is of mainstay importance. Early referral to a specialized hepato-biliary center is strongly advised.     

A prospective randomised trial of bile duct reconstruction at liver transplantation: T tube or no T tube?

A prospective randomised study of end-to-end bile duct reconstruction with or without T-tube drainage during orthotopic liver transplantation (OLT) was undertaken in 60 patients well matched for age, sex, aetiology of liver disease, operative blood loss, cold ischaemic time, preoperative serum bilirubin level and Child-Pugh score. Significant biliary complications in the T tube group occurred in five patients and included bile duct stricture (n=2), bile leak/peritonitis (n=1) and cholangitis (n=2). Bile duct strictures occurred in six patients in the no T tube group (P>0.05, NS). Hepatic artery stenosis was identified in one patient from each group in association with a biliary stricture. Biliary complications in both groups were associated with a prolonged graft cold ischaemic time (P<0.01). As no significant difference was noted in the number of early and late biliary complications between the two groups, the routine use of a T tube has been discontinued.     

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

Background Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. Methods In this study, 47 patients (median age, 73 years, range, 56–86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. Results The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). Conclusions Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.     

A novel technique for hepaticojejunostomy for nondilated bile ducts: a purse-string anastomosis with an intra-anastomotic biodegradable biliary stent

In non-dilated bile ducts, performing a well-functioning hepaticojejunal anastomosis (HJ) may be challenging. We investigated a novel technique for small-caliber HJ: a purse-string anastomosis with an intra-anastomotic biodegradable stent. HJ was performed randomly either conventionally with interrupted sutures without any stent (n = 5; conventional) or using the novel purse-string technique with a 4-mm caliber polylactide-barium sulfate biodegradable biliary stent (n = 4; pursestring + stent) in minipigs with bile ducts 3.5-4.0 mm in caliber. The anastomosis creation time was not different in the groups. In the conventional group 2 complications occurred: 1 early anastomotic leakage, and 1 late anastomotic stricture. The remaining animals (3/5 in conventional, and 4/4 in purse-string + stent group) had normal liver histology and function, and developed no signs of complications during the 6-month follow-up. All biodegradable stents disappeared by 3 months. At 6 months, the HJ caliber was smaller in the conventional (5 [1-9] mm) than in the purse-string + stent group (12 [4-15] mm; P < .05). We conclude that this novel HJ technique is easy and safe to perform, and ensures a well-functioning anastomosis in nondilated bile ducts.     

Biliary complications in orthotopic liver transplantation: experience with a modified technique of duct-to-duct reconstruction

Biliary complications are described as frequent causes of morbidity during the postoperative course of orthotopic liver transplantation (OLTx), even in recent papers. The authors report here on their experience with duct-to-duct anastomosis as their method of choice for biliary reconstruction in a consecutive series of 100 OLTx in adult patients. The original technique, as described by Starzl, was modified by the authors by performing a wide, longitudinal plasty of both the donor and recipient bile ducts, joined together with two polidioxanone running sutures, producing the effect of a side-to-side anastomosis. This technique was used in all procedures, even when a significant discrepancy was evident between the ducts (n=10). Follow-up was completed in 100% of the patients for a period of 2–40 months (mean 13.1 months). Four major complications (4%) occurred including hepatic abscesses due to ascending cholangitis, T-tube dislocation, partial occlusion by a branch of the T-tube at the anastomotic site, and disruption of the bile duct after T-tube removal. In four other patients, transient abdominal pain followed removal of the stent. Neither strictures nor fistulas were observed. Choledochocholedochostomy on a T-tube stent represents, in our experience, the technique of choice for biliary reconstruction in OLTx. The procedure, as described in the present study, proved to be safe in preventing strictures and leakages and appears to be feasible in nearly 100% of all adult patients undergoing OLTx.     

Laparoscopic exploration of common bile duct in difficult choledocholithiasis

Background This review investigated the role played by laparoscopic exploration of the common bile duct (LECBD) in the management of difficult choledocholithiasis.Methods This retrospective study reviewed a prospective database of LECBD for difficult choledocholithiasis during the period 1995 to 2003.Results Of the 97 LECBDs performed in the authors center from 1995 to 2003, 25 were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as failure of endoscopic stone retrieval for the following reasons: access and cannulation difficulty, the difficult nature of common bile duct (CBD) stones, and the presence of endoscopic retrograde cholangiopancreatography (ERCP)-related complications. There were seven unsuccessful cannulations because of previous gastrectomy (n = 5) and periampullary diverticulum (n = 2). Among the 18 patients with failed endoscopic extraction, there were 10 impacted stones, 2 incomplete stone clearances after multiple attempts, 2 type 2 Mirizzi syndromes, 1 proximal stent migration, 1 repeated post-ERCP pancreatitis, 1 situs inversus, and 1 stricture at the distal common bile duct. There were 14 male and 11 female patients with a mean age of 67.8 ± 15 years. Initial presentations included cholangitis (n = 14, 56%), biliary colic (n = 3, 12%), jaundice/deranged liver function (n = 5, 20%), cholecystitis (n = 2, 8%), and pancreatitis (n = 1, 4%). Regarding the approach for LECBD, there were 2 transcystic duct explorations and 23 choledochotomies. The mean operative time was 149.4 ± 49.3 min, and there were three conversions (12%). The stone clearance rate was 100%, and no recurrence was detected during a mean follow-up period of 16.8 months. Five complications were encountered, which included bile leak (3 patients) and wound infection (2 patients). When the results were compared with the remaining 72 LECBDs for nondifficult stones during the same period, the complication rate, conversion rate, and rate of residual stones were similar despite a longer operation time (149.4 ± 49.4 min vs 121.6 ± 50.5 min).Conclusion When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones.     

Management of Electrothermal Injury of Common Bile Duct with a Degradable Biliary Stent: an Experimental Study in a Porcine Model

Background

Electrothermal injury of common bile duct is a frequent type of biliary injury. A long-term postoperative course and biliary leakage after removing T-tube are associated with external drainage. A method was developed to repair the injury with a degradable biliary stent instead of T-tube insertion.

Methods

Pigs were divided into a stent repair (SR) group (n?=?18), a T-tube repair (TR) group (n?=?4), and a suturing repair (SUR) group (n?=?4). An electrothermal injury model was made by electric coagulation. Pigs in the SR group were further divided into five subgroups according to the observation time (2 weeks and 1, 3, 6, and 18 months). Pigs in the TR group and SUR group were observed for 6 months. Cholangiography was repeated and bilirubin level was monitored. Pigs were reoperated for further evaluation at the end of observation.

Results

No biliary stricture, bile leakage, or bile duct necrosis occurred in the SR group. The stent could be detected in the first 2 months. No stent migration or stent-related obstruction was observed. Three pigs in the SUR group had biliary stricture with elevated bilirubin levels.

Conclusions

These results suggested that the developed method for repairing electrothermal injury of common bile duct is feasible and safe.     

Interventional radiologic procedures in liver transplantation

Postoperative biliary and vascular complications contribute significantly to morbidity and mortality in liver transplantation. Interventional radiologists are an integral part of the multidisciplinary team necessary for optimizing the management of these complications. During a 15-year period, 39 cadaveric and 25 living related liver transplantations were performed at the Chang Gung Memorial hospital, Taiwan. Of 64 liver transplant recipients, 9 (3 adult and 6 pediatric) underwent 13 interventional radiological procedures for the treatment of biliary sludge-casts (n = 2), bile duct occlusion or stenosis (n = 2), hepatic veins thrombosis (n = 1), hepatic veins stenosis (n = 1), portal vein stenosis with splenorenal shunting (n = 1), biloma (n = 1), and infected fluid collection or ascites (n = 4). Antegrade or retrograde interventional approach was used to successfully treat all biliary complications, and all percutaneous drainage procedures were effective in the control of intra-abdominal fluid collections. Portal vein stenosis was treated by balloon dilatation, and the associated splenorenal shunt was closed by metallic coil embolization via transhepatic catheterization of the portal vein. Hepatic vein stenosis was effectively treated by balloon dilatation and expandable metallic stent deployment via transfemoral and jugular venous approaches, respectively. Hepatic vein thrombosis was only partially lysed by transvenous streptokinase administration, and surgical thrombectomy was needed to achieve complete recanalization. The total success rate of the interventional procedures was 92 % with no procedure-related complications. The overall survival rate in this series is 89 %, and all patients who underwent living related liver transplantation maintain to date a 100 % survival rate. We can conclude that interventional radiological procedures are very useful for managing biliary and vascular complications after liver transplantation. These techniques provide a cure in most situations, thus obviating the need for further surgical intervention or re-transplantation. Received: 6 March 2000 Accepted: 5 May 2001     

Single-Stitch Telescopic Bilioenterostomy in an Animal Model

ABSTRACT

Background/Aims: An end-to-side biliodigestive anastomosis is the most common procedure performed in hepato-pancreato-biliary surgery, and this procedure may become technically demanding. A telescopic ureterovesical anastomosis is frequently used in transplant surgery. The aim of this study was to investigate the feasibility of constructing a telescopic biliodigestive anastomosis. Methodology: The technique-standardization (n = 8) and main study (n = 3) groups were formed from 11 pigs. A single-stitch telescopic anastomosis with a self-disposable internal stent was performed in the main study group. The animals were sacrificed at the end of the 4-week follow-up period, and cholangiograms and tissue samples were obtained. Repeated biological, hematological, and biochemical data were recorded. Results: No bilomas or functional biliary strictures were identified in any of the main study group animals. Light microscopy revealed intestinal metaplasia of the biliary epithelium in the portion of the bile duct telescoped inside the intestinal lumen. Conclusions: Telescopic bilioenterostomy with a single pull-through stitch and a self-disposable stent is quick and reproducible in animal models, and it appears to be free of complications. Further experiments with longer follow-up periods are required to confirm that this anastomotic technique does not lead to episodes of delayed cholangitis or development of adenocarcinoma.     

Development of a bent-type tube stent for simultaneous drainage of bile and pancreatic juice

Background/Purpose: Endoscopic lithotomy is a useful medical procedure for treating choledocholithiasis. Although this procedure is commonly performed, complications such as pancreatitis and cholangitis are recognized as major and serious problems. The obstruction of bile and pancreatic juice flow caused by papillary edema or spasm is thought to be responsible for such complications. We have developed a new bent-type tube stent that can drain bile and pancreatic juice simultaneously. Methods: From June to November 2001, temporary implantation of the new bent-type tube stent was performed in four patients (two women, two men; mean age, 73.3 years) with choledocholithiasis, for the drainage of bile and pancreatic juice simultaneously after endoscopic lithotomy by endoscopic sphincterotomy or endoscopic balloon sphincter dilatation. Results: Immediately after the implantation of the new type of tube stent, bile and pancreatic juice flow from the respective ducts was recognized under endoscopic observation. Neither pancreatitis nor cholangitis occurred after these procedures. Conclusions: This procedure may be a helpful means to prevent pancreatitis and cholangitis after endoscopic lithotomy. Received: March 1, 2002 / Accepted: May 21, 2002 Offprint requests to: R. Abe     

Penetrating chest gunshot wounds

Common bile duct stones and tumors constitute the leading cause of acute biliary tract obstruction and cholangitis. Septic complications after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) are very unusual in unobstructed bile ducts. There are only three reported cases of patients without evidence of biliary tract disease who developed cholangitis and liver abscesses due to Pseudomonas aeruginosa. Biliary endoscopists believe that the inadvertent submucosal injection of contrast into the papilla of Vater is an innocent accident that has no serious consequences other than increasing the percentage of unsuccessful catheterizations of the common bile duct. Herein we describe a patient with drug-induced cholestatic hepatitis who developed pyogenic cholangitis after the inadvertent injection of submucosal contrast in the papilla of Vater.