Endoscopic suprapapillary blunt dissection of the distal common bile duct in cases of difficult cannulation: a pilot series.

BACKGROUND AND STUDY AIMS: There is no consensus about the optimal alternative procedure in cases of failed cannulation of the common bile duct (CBD). The alternatives are usually considered to be high-risk procedures. This study describes endoscopic dissection of the distal biliary tract (EDBT) as a new technique in cases of difficult cannulation of the CBD. PATIENTS AND METHODS: Out of a total of 1057 patients in whom cannulation was attempted, deep cannulation failed in 49 patients, and 48 of those underwent EDBT. The procedure consists of cutting the mucosa, and the partial isolation of the distal part of the biliary tract using catheters, a needle-knife papillotome, and thin forceps. Access to the biliary tract was achieved with an endoscopic needle or forceps with or without electrocoagulation. RESULTS: EDBT was successful in all cases. In 46 patients EDBT was followed by standard sphincterotomy. Four patients developed clinical pancreatitis and hyperamylasemia occurred in 11 cases. Perforation, uncontrolled bleeding, and other complications did not occur in this series. CONCLUSIONS: EDBT is feasible, safe and constitutes a potential alternative for cannulation of the CBD. The endoscopic visualization of the wall structure and duodenal layers during the maneuvers at the papilla probably accounts for the absence of major complications.

Endoscopic treatment of Zenker's diverticulum.

BACKGROUND: The most important aspect of the surgical management of Zenker's diverticulum is probably the cricopharyngeal myotomy. Endoscopic diverticulotomy can be performed with a needle-knife papillotome, which allows simultaneous myotomy of the upper esophageal sphincter. METHODS: Since 1978, 47 patients (28 men and 19 women 51 to 81 years of age) underwent endoscopic diverticulotomy. Most patients underwent more than one treatment session (mean value 2.2). The procedure was performed with sedation. Tubes were not used, and oral intake of food was begun the first day after the operation. RESULTS: Forty-five (95.74%) patients had no dysphagia or only occasional, mild dysphagia during the postoperative course. No fistula, no recurrent laryngeal paralysis, and no deaths occurred. CONCLUSION: Endoscopic diverticulotomy seems to be a good choice of therapy at least for patients with associated diseases that increase surgical risk.

Endoscopic percutaneous gastrostomy without laparotomy.

Observation and manipulation through the endofiberscope, have resulted in a new method of establishing gastrostomy without laparotomy. Subsequent to experimental studies with dogs, the new method was employed to substitute nasogastric tube in patients. In this new procedure, endoscopic application permits the placing of stitches in close contact with the abdominal and gastric walls. The fact that no complications were observed in the patients submitted to operative treatment, is largely attributed to this type of suture. From the results obtained it would seem that this procedure can be routinely employed instead of gastrostomy with laparotomy, since it offers the advantage of being a simpler method and is more likely to be associated with a lower rate of complications.