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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. 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. 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). 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.

Adenomas of the duodenal papilla are rare. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection techniques, transduodenal local excision, and pancreaticoduodenectomy. The aim of this retrospective study was to evaluate the safety and outcome of endoscopic snare resection of papillary adenomas in a Greek cohort of patients. Fourteen patients (six women and eight men; age range, 42-76 years) were referred for endoscopic management of ampullary adenomas. A questionnaire was completed for each patient, which included preoperative and postoperative data points. Presenting symptoms were jaundice (n = 4), cholangitis (n = 1), and pain (n = 2). Seven patients were asymptomatic. If there was no common bile and main pancreatic duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy onto normal duodenal tissue was performed. The adenomas were resected via a diathermy snare, along with the major papilla, after elevation of the lesion by epinephrine plus dextrose 50% (1:10,000) solution. At the discretion of the endoscopist, a biliary or pancreatic stent was inserted as a prophylactic procedure immediately after excision. Histopathologically, resected tissue included 11 adenomas and three adenomas with focal malignancy, referred for pancreaticoduodenectomy. Immediate complications were moderate bleeding (n = 1) and mild pancreatitis (n = 1). No procedure-related death occurred. Follow-up was available for 11 patients (mean, 28.36 months; range, 6-72). Pancreatic and biliary stents were placed in four and nine patients, respectively. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in two patients (18%), which was resected endoscopically. Endoscopic snare resection of adenomas of the major duodenal papilla is a safe, well-tolerated alternative to surgical therapy. In expert hands, complications are mild and may be avoided by pre-resection biductal sphincterotomy, stent placement, and elevation of the lesion by epinephrine plus dextrose 50% solution injection.

The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps. This study aimed to assess the safety and efficacy of colonoscopic ligation of the stalk of large pedunculated polyps by means of an endoloop technique, and to focus particular attention on the instances in which the use of this device was unsuccessful. This study retrospectively evaluated attempted endoloop endoscopic polypectomy in 33 patients (19 men and 14 women; mean age, 62.5 years) with large pedunculated polyps. Application of the endoloop was impossible in four patients, and the snare became entangled with the loop in one patient. The remaining 28 patients underwent endoloop-assisted polypectomy. Bleeding occurred in four patients, either because the loop slipped of the stalk after polypectomy (2 patients) or because a thin stalk (< or = 4 mm) was transected by the loop before polypectomy (2 patients). Colonoscopic polypectomy with an endoloop may be safer than conventional polypectomy. The reasons for technical failure of this technique include a narrow left colon lumen, a thin stalk (< or = 4 mm), and close cutting in relation to the site of encirclement by the loop.

Endoscopic retrograde cholangiopancreatography with biliary drainage is an effective therapeutic tool in the management of bile duct injuries associated with laparoscopic cholecystectomy. Placement of a stent or a nasobiliary drain in the common bile duct, or biliary sphincterotomy, is an effective treatment for bile leaks and obviates the need for otherwise complex biliary tract surgery. Although there are no controlled comparative trials, placement of a 7-, 8.5-, or 10-Fr biliary stent without sphincterotomy may cause the least morbidity and be the most comfortable nonoperative management option. We report a child who presented with a bile leak that occurred after laparoscopic cholecystectomy and was successfully treated with the placement of a biliary stent without sphincterotomy. To our knowledge, this is the second pediatric case of a bile leak successfully treated by endoprosthesis placement without sphincterotomy.

We report the cases of three patients who fulfilled the criteria for sphincter of Oddi dysfunction of biliary type II and underwent needle-knife suprapapillary sphincterotomy. These patients presented with episodes of biliary-type pain after cholecystectomy and significant elevation of liver enzymes. Ultrasonography and MRI cholangiography revealed dilatation of the common bile duct, without visible stones. The patients all underwent needle-knife suprapapillary sphincterotomy because free cannulation of the common bile duct could not be achieved. Needle-knife suprapapillary sphincterotomy enabled catheterization of the common bile duct. After clearing of the common bile duct with a balloon catheter, no stones, fragments of stones, or sludge were observed to exit from the sphincterotomy. None of our patients developed postprocedure pancreatitis. When needle-knife suprapillary sphincterotomy is performed by an experienced biliary endoscopist, it is a safe and effective procedure for patients with sphincter of Oddi dysfunction of biliary type II, who otherwise constitute a high-risk group for the development of postsphincterotomy pancreatitis.

Background The aim of this retrospective study was to evaluate the success rate and complications of three precut techniques of sphincterotomy after failure of conventional techniques of cannulation of common bile duct (CBD). Patients and Methods Between January 2003 and October 2011, 2,903 consecutive ERCPs were performed in patients with naïve major papilla. In 283 patients in whom biliary cannulation was not achieved, precut technique was performed and these patients were included in the study. Results A total of 274 patients were included in the final analysis. Needle-knife papillotomy (NKP) was performed in 129 cases (47.1 %), suprapapillary fistulotomy (SPF) in 78 patients (28.5 %), and transpancreatic sphincterotomy (TPS) in 67 cases (24.5 %). No significant difference was observed in the initial and eventual success rate of biliary cannulation between the three groups. Overall, complications occurred in 54 patients (19.7 %), of which 33 (25.6 %) were with NKP, 6 (7.7 %) with SPF and 15 (22.4 %) with TPS, respectively, a difference statistically significant favoring the SPF group ( p  = 0.006). Post-procedure acute pancreatitis was developed in 27 cases (20.9 %) with NKP, compared to two cases (2.6 %) with SPF and 15 cases (22.4 %) with TPS, a difference statistically significant favoring the SPF group. No difference was observed between the groups with regard to the occurrence of post-procedure hemorrhage and perforation. Conclusions The three types of precut sphincterotomy have no different overall CBD cannulation rates; SPF reduces post-ERCP pancreatitis risk.

Public Utilities Commission officials are still trying to find the cause of the fire, which occurred yesterday morning in an underground vault next to the Coles bookstore on Wellington Street, just north of Princess. At Hardy Har Har, clerk Joan Maika wasn't laughing when she opened the store at 9 a.m. and found the store in darkness. Color Photo: Michael Lea, The Whig-Standard / PUC workers and firefighters surround the Wellington Street manhole as it spews smoke. ; Color Photo: Michael Lea, The Whig-Standard / Camera Kingston employee Jock Devonshire works inside the blacked-out store, using a flashlight to illuminate the inside of a film cooler. ;

Objectives: We evaluated the association between pathological acidic laryngopharyngeal reflux (LPR) events and chronic pharyngitis in patients with Reinke's edema. Methods: We performed a prospective controlled study in 20 consecutive patients with Reinke's edema without pathological acidic LPR events (group A) and 40 consecutive patients with Reinke's edema with both clinical symptoms and 24-hour pH-metry suggesting acidic LPR (group B). The severity of acidic LPR was assessed by use of the Reflux Finding Score (RFS), the Reflux Symptom Index (RSI), and dual antimony probe 24-hour pH-metry. The patients were evaluated for the presence of chronic pharyngitis by clinical examination and biopsy specimens taken from the posterior pharyngeal wall. The χ2 test was used to compare the groups for the presence of pharyngitis. In group B, the RSI, the RFS, and the total duration and number of acidic LPR events on 24-hour pH-metry were compared between patients with and without concomitant pharyngitis by use of the Mann-Whitney test. Results: Five patients of group A and 20 patients of group B had chronic pharyngitis. Therefore, more patients with Reinke's edema and clinical signs of LPR tended to have chronic pharyngitis than did those with Reinke's edema and no clinical signs of LPR, but the difference was not statistically significant (p = 0.064; odds ratio, 3.0; 95% confidence interval, 0.9 to 9.8). Among group B patients, those with pharyngitis had significantly more acidic LPR events (p < 0.001) and a greater exposure time to gastric fluid (p = 0.008) than did those without pharyngitis. Their RFS and RSI did not differ significantly (p = 0.692 and p = 0.914, respectively). Conclusions: Only in the subgroup of patients with Reinke's edema and LPR was there a statistically significant correlation between the pH probe results and the incidence of clinical pharyngitis. Awareness should increase among physicians about addressing chronic pharyngitis in therapy for acidic LPR and/or Reinke's edema.

Mesenteric panniculitis (MP) is a rare inflammatory and fibrotic disease of the mesentery of unknown etiology. It has various clinical and radiological manifestations, posing a diagnostic challenge for clinicians. Its diagnosis is indicated via radiologic imaging and is usually confirmed via peritoneal biopsies. We describe a case of a patient with histopathologically proven MP, in which steroid dependence was successfully managed with colchicine.

Seniors' groups are concerned that a new Tory workfare proposal will slash the benefits of seniors on welfare almost in half and lump them in with general welfare recipients, leading to serious consequences. Sharon Lee, a lawyer at the Kingston Community Legal Clinic, said most seniors will probably fit into the \"community participation\" aspect of workfare, which means getting welfare recipients to do \"volunteer\" work for social agencies in return for their benefits. She said that each case depends on the \"good graces of the case worker.\" Lee also said she's not sure exactly how seniors will be affected because nothing has been finalized. \"So far it seems that you must do what you're told regardless of what you want, or your benefits will be cut,\" Lee said.