Jerome H. Siegel

Complications of diagnostic and therapeutic ERCP.

SummaryComplications associated with ERCP have been well defined, clinically recognized, and effectively managed conservatively. Few patients require surgery or prolonged hospitalization. The morbidity and mortality associated with ERCP and sphincterotomy have remained low, and, although the outcome of endoscopy is equivalent to or better than surgical or radiologic techniques, the complications are less. Despite the general acceptance of ERCP, its therapeutic applications, its more universal performance, and the morbidity and mortality rates have remained the same or lower since its introduction a quarter of a century ago.

LONG-TERM FOLLOW-UP OF TWENTY PATIENTS WITH ADENOCARCINOMA OF THE PANCREAS : Resection Following Combined Modality Therapy

Long-term follow-up of 5 or more years in 20 patients with initially unresectable cancer of the pancreas that responded to chemoradiation therapy is detailed in this article. All patients underwent resection. Seven or 18 surgical survivors are alive 50 or more months.

Endotherapy for pancreatic fistulae: inside out or outside in?

How therapeutic endoscopy has changed! As participants and observers of the evolution of endotherapy, one has to marvel at the progress we have made in this field. We have withstood mild outrage of our description of precut sphincterotomy, to questions regarding the efficacy of balloon dilators for the bile and pancreatic duct sphincters, to outspoken objections at national meetings of our presentations describing the use of pancreatic stents for the treatment of various forms of pancreatitis, to the expectation of greater progress and advancement in the field. We routinely drain pseudocysts, stent disrupted pancreatic ducts, but, now, we commend the innovators from Erasme Hospital in Brussels for their newly described technique of completing an endoscopic rendezvous procedure performed through an external pancreatic fistula (EPF). In this new technique, an endoscopist, who is observing the progress of a percutaneous puncture through an EPF, positions an endoscope in the stomach or small bowel lumen while assisting another endoscopist (not a radiologist) who is advancing catheters and guide wires through the fistulous tract (a virtual cyst demonstrated by EUS) so that the assistant can guide the operators puncture through the gut wall into the bowel lumen in order to deploy an internal stent to allow the normal flow or egress of pancreatic juices into the gut facilitating the closure of the fistula. Although the procedure is time-consuming and probably not cost-effective for the free enterprise reimbursement system in the United States, the results of this procedure, in a small number of patients over a long time period, were as effective as surgery. Our hats are off to those who continue to explore the outer limits of endotherapy, and we look forward to more exciting, unquestioned developments in the field. This is progress.