Endoscopic diagnosis and management of biliary and pancreatic disease

The diagnosis and management of pancreatic and biliary tract disease require the closely coordinated efforts of the surgeon, radiologist, gastroenterologist, endoscopist and pathologist. Modern surgery needs a precise data base to meet the demands for speed, accuracy and a successful outcome. The sequential approach to the differential diagnosis of jaundice, with its emphasis on “noninvasive” diagnostic tests⁶² and lengthy evaluation⁶³ has been preempted by precise positive diagnostic studies. Our approach to the patient suspected of pancreatic or biliary tract disease has been revolutionized by developments in fiberoptic endoscopy and radiology, culminating in the techniques of ERCP, endoscopic biliary surgery, PTC and the removal of common duct stones through the T-tube tract. The therapeutic value of endoscopic biliary surgery and T-tube tract extraction of retained common duct stones as alternatives to secondary biliary tract surgery is clearly established. We are aware of the potential for dissolving cholesterol gallstones with oral medication or direct injection of solvents into the biliary tree. These advances will be clinically available shortly.Preoperative diagnosis of periampullary cancer permits the patient's referral to a specialized center that promises a lower operative mortality and the best chance for cure.⁶⁴ The frustrations and disappointments of operations for pancreatic cancer can be reduced by accurate preoperative diagnosis and palliative bypass surgery.^{[65.] and [66.]}The influence on surgical options of endoscopic biliary surgery and extraction or dissolution of stones through the T-tube tract is not yet clear. The pressure on the surgeon to clear the biliary tree at operation is lessened, since the mortality increase caused by adding common duct exploration (2.4%)⁶⁷ to elective cholecystectomy (0.6%) in the difficult case is greater than the hazard of endoscopic biliary surgery for choledocholithiasis (1.1%).⁶⁶ In patients with acute cholecystitis, preoperative definition of cystic duct patency and anatomy may reduce the hazard of cholecystectomy alone (2.4%) and allow the surgeon to exercise options that reduce the risk of the added common duct exploration (8%).⁶⁷ Cholangiographic studies performed by PTC or ERCP techniques may obviate the need for some common duct explorations. Initial endoscopic surgery can be used to control cholangitis by removing common duct stones and establishing biliary drainage or to facilitate clearing the biliary tree at operation. Alternatively, in the difficult operation, biliary drainage may be established by placing a T-tube in the common bile duct and extraction or dissolution techniques may be used postoperatively, when the patient is stable.^{[68.] and [69.]}These new concepts, therapies and techniques force us to reevaluate the indications for “exploratory laparotomy”, particularly in the elderly.^{[68.] and [72.]} More important, they herald a new era in surgery of the biliary tract and pancreas, when preoperative appreciation of pathologic anatomy and normal variants, with use of endoscopic and radiologic techniques, will produce the consistent yield of excellence desired by all.