Abstracts Timing of Laparoscopic Cholecystectomy After Biliary Pancreatitis* Gary C. Vitale, MD Endoscopic treatment of distal bile duct stricture from chronic pancreatitis. BACKGROUND: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for > or =12 months. This study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with this protocol. METHODS: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene stent (7-11.5 F). Stents were exchanged at 3-4-month intervals to avoid the complications of clogging and cholangitis. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent. RESULTS: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths. Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3-28). To date, there has been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required operation--one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head of the pancreas that was thought to be cancer. CONCLUSIONS: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered a viable alternative to standard surgical bypass. From: Vitale GC; Reed DN; Nguyen CT; Lawhon JC; Larson GM. Endoscopic treatment of distal bile duct stricture from chronic pancreatitis. Surg Endosc 2000 Mar; 14(3):227-231. (MedLine record accessed 3/21) Management of malignant biliary stricture with self-expanding metallic stent BACKGROUND: Self-expanding metallic mesh stents are designed to remain patent longer than polyethylene (PE) stents, which generally clog in 3 to 4 months. Though more expensive, metal stents may therefore be a better choice for malignant strictures. METHODS: From January 1991 to October 1995, we performed ERCP in 212 patients with malignant or benign strictures, and 34 ultimately had insertion of a metallic stent. These stents were placed by the percutaneous transhepatic route in 17 patients and endoscopically in 17. RESULTS: Metallic stent insertion was successful in each case and relieved the preoperative jaundice and cholangitis. There were no procedure-related deaths; complications were pancreatitis (one) and hemorrhage (one). Overall stent patency was 6.2 months. Three of 34 stents occluded due to tumor ingrowth at 3, 4.5, and 8 months and were treated by placing a new PE stent through the blocked metal stent. The remaining 31 stents remained patent until patient death (n = 15, mean survival = 4.9 months) or are still open (n = 16, mean patency = 12.2 months). CONCLUSIONS: Self-expanding metal stents provide effective palliation of malignant biliary strictures and should be considered an alternative to open surgery. Metal stents remain patent much longer than PE stents and usually a single session of metal stenting can palliate biliary obstruction for life. From: Vitale GC; Larson GM; George M; Tatum C. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc 1996 Oct; 10(10): 970-973. Abstracts "Dome Down" Laparoscopic Cholecystectomy Glenn L. Sandler, MD Endoscopic Drainage of Pancreatic Pseudocyst Gary C. Vitale, MD Thoracoscopic Splanchnicectomy for Pancreatic Pain Henry L. Laws, MD CT Guided Percutaneous Drainage of Infected Acute Necrotizing Pancreatitis Patrick C. Freeny, MD Management of Metastatic Carcinoma T. S. Ravikumar, MD Management of Liver Trauma Juan C. Asensio, MD Management of Benign Liver Tumors Leslie H. Blumgart, MD, FRCS Role and Techniques of "Dome-Down" Laparoscopic Cholecystectomy Glenn L. Sandler, MD Thoracoscopic Splanchnicectomy for Pancreatic Pain Henry L. Laws, MD Current ConceptsæAdequate Pain Management Young K. Choi, MD Prevention and Management of Infection Complicating Acute Pancreatitis Henry L. Laws, MD Indication for and Timing of ERCP in Biliary Pancreatitis John Baillie, MB, ChB, FRCP Timing of Laparoscopic Cholecystectomy After Biliary Pancreatitis Gary C. Vitale Magnetic Resonance Angiography Martin R. Prince, MD, PhD Pancreatic Imaging Patrick C. Freeny, MD Endoscopic Ultrasonography Charles Noyer, MD Limited Gastric Resection Jo Buyske, MD Current ConceptsæManagement of Pancreatic Carcinoma Henry A. Pitt, MD Watchful Waiting in the Management of Inguinal Hernia Robert J. Fitzgibbons, MD Treatment of Incisional (Ventral) Hernias: Open Repair Maximo Deysine, MD, FACP Treatment of Incisional (Ventral) Hernias: Laparoscopic Repair Adrian E. Park, MD Indications for Converting to Open Operation John G. Hunter, MD Medicolegal Implications of Common Bile Duct Injury During Laparoscopic Cholecystectomy Kenneth A. Kern, MD, FACS Role and Technique of Pylorus Preserving Pacreatectomy Henry A. Pitt, MD