No abstract

No abstract

SUMMARY Emergency endoscopy on 332 patients with acute upper gastrointestinal bleeding showed that 178 had peptic ulcers; 28 of these were actively bleeding (spurting) and 108 showed stigmata of recent haemorrhage (vessels or spots in the ulcer base) suggesting a risk of rebleeding. These 136 patients were randomly allocated to Argon laser photocoagulation or to no additional therapy (controls) at the time of initial endoscopy. All patients received conventional management, and the controlling clinicians did not know whether or not the laser had been used in any individual patient. The laser system proved both simple and safe in use. Initial haemostasis was achieved by the laser in 10 of 15 'spurting vessels', but four of 13 'control' spurting vessels also stopped bleeding spontaneously. Overall, there were no statistically significant differences between the laser treated and control groups in terms of rebleeding, the need for surgical intervention, or death. These results require amplification in larger trials, and comparison with other studies using different protocols and other haemostatic methods.

Duodenoscopic sphincterotomy is rapidly becoming popular in Britain. Representatives of 14 British centres met in January 1980 to discuss progress and problems with the technique. This report summarizes current experience, with particular reference to hazards. Duodenoscopic sphincterotomy is mainly being used in patients who have previously undergone cholecystectomy and who no longer have a T tube drain in place. Sphincterotomy was achieved in 87 per cent of 679 patients attempted, and the common duct was cleared of stones in 87 per cent of these. Immediate complications followed in 8.5 per cent; 1.6 per cent required urgent surgery and 7 patients (1 per cent) died. Centres with the greatest experience had better results and fewer complications. Those performing duodenoscopic sphincterotomy believe it to be a major advance in the management of high risk patients with common duct stones, after cholecystectomy. Its use remains controversial in high risk patients who still have gallbladders and in low risk patients after cholecystectomy; long term follow-up studies are essential.

A total of 180 patients with malignant obstructive jaundice have been treated by 5 different methods: surgical resection; surgical by-pass; percutaneous prosthesis; endoscopic prosthesis; and endoscopic sphincterotomy (for papillary tumours). The spectrum of patients is unusual, because many elderly and ill patients were referred for nonoperative management. Operative by-pass, percutaneous and endoscopic prostheses gave similar overall results, with a mean survival of about 6 months. Patients with tumours of the papilla of Vater treated by endoscopy or surgery fared well; 11 of 18 were alive at follow-up. Median survival after resection of other tumours was 17 months. These results underline the need for randomized clinical trials, which are now in progress.