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Endoscopic stent placement for biliary leak from an accessory duct of Luschka after laparoscopic cholecystectomy
Endoscopic stent placement for biliary leak from an accessory duct of Luschka after laparoscopic cholecystectomy James T. Frakes, MD Stephen J. Bradley, MD
Approximately 800,000 cholecystectomies are performed each year in the United States.! In recent years, the laparoscopic method of gallbladder removal has become increasingly popular; it is now estimated that nearly half of the 33,000 general surgeons delivering patient care in the United States have been trained in the technique. 2 With the increased use of laparoscopic cholecystectomy have come biliary tract complications such as retained common bile duct (CBD) stones and CBD or cystic duct leaks amenable to treatment with therapeutic ERCP. As experience grows, additional complications will be recognized that may lend themselves to management with interventional ERCP techniques, as shown by the following case.
Figure 1. Ascites (large arrows) around the liver and spleen 9 days after laparoscopic cholecystectomy. Note cystic duct clips (small arrow) and subcutaneous air (white open arrow).
CASE REPORT
A 69-year-old woman with cholelithiasis and recurrent biliary colic underwent uneventful laparoscopic cholecystectomy with normal intralaparoscopic cholangiogram. She was discharged 2 days later and felt well, with the exception of commonly reported mild right shoulder pain. Seven days later, however, she experienced nausea, mild diarrhea, and moderately severe left lower quadrant abdominal pain. Abdominal examination revealed healed trocar puncture sites, mild distention, and diffuse abdominal tenderness with mild guarding most prominent in the left lower quadrant. Laboratory values included a normal WBC count, total bilirubin level of 3.3 mgldl (normal <1.5 mg/dl), alkaline phosphatase level of 477 lUlL (normal <137 lUlL), AST level of 111 lUlL (normal <46 lUlL), and a normal amylase level. All of these serum chemistry values had been normal at the time of recent laparoscopic cholecystectomy. Abdominal CT showed the expected cystic duct clips and subcutaneous air from recent laparoscopic cholecystectomy but also demonstrated ascites in the abdomen and pelvis (Fig. 1). Retrograde cholangiography demonstrated extravasation of radiographic contrast agent from an accessory bile duct connecting the right hepatic duct and the gallbladder fossa (Fig. 2). The two cystic duct clips were in proper position, and we saw no leak from the cystic duct. An 11.5F Amsterdam-type straight stent with side flaps was placed after a small endoscopic sphincterotomy. Symptoms resolved within 12 hours, and serum liver chemistries improved rapidly. Bilirubin returned to normal before the patient's discharge 3 days after stent From the Departments of Medicine and Surgery, University of Illinois College of Medicine at Rockford, Rockford, Illinois. Reprint requests:J.T. Frakes, MD, Rockford Gastroenterology Associates, Ltd., 401 Roxbury Road, Rockford, IL 61107. 0016-5107/93/3901-0090$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright @ 1993 by the American Society for Gastrointestinal Endoscopy
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Figure 2. Leak into previous gallbladder bed (large open arrow) from accessory bile duct of Luschka (solid arrow). Note cystic duct clips (small open arrow).
placement. She returned as an outpatient 6 weeks later for follow-up ERCP. Liver function was normal at that time, and she was asymptomatic. The stent was cannulated with a deflated balloon catheter (l-cm maximum inflated diameter), which was threaded up through the stent and out the GASTROINTESTINAL ENDOSCOPY
Figure 3. Balloon catheter (large arrow) occluding CBO
above stent (small arrow) with contrast material in biliary tract.
proximal end into the common hepatic duct. The balloon was inflated to occlude the duct above the stent, and contrast material was injected to fill out the biliary tract above the balloon (Fig. 3). The leak was no longer present. The inflated balloon catheter was then used to extract the stent from the common bile duct. The patient returned home the same day and was symptomatic when last seen (4 months later). Follow-up ultrasound exam of the abdomen and pelvis confirmed the clinical impression of resolution of the ascites and absence of any localized fluid collections.
DISCUSSION
Since its introduction in 1987, laparoscopic cholecystectomy has gained rapid acceptance as a valuable technique for removing the gallbladder. Today almost any patient considered for elective cholecystectomy is considered a candidate for the laparoscopic approach. As skill and experience with the technique increases, an increasing number of patients with acute cholecystitis are also being treated laparoscopically. Advantages of laparoscopic cholecystectomy as compared with the standard incisional approach include reduced recovery time, less pain, shorter hospitalization, a better cosmetic result, and lower cost. Complications ocVOLUME 39, NO.1, 1993
cur in roughly the same frequency as with open cholecystectomy.2 Both known choledocholithiasis and unsuspected CBD stones discovered at laparoscopic cholangiography have limited the use of laparoscopic cholecystectomy because of surgeons' reluctance to attempt laparoscopic removal of these stones or their hesitance to leave calculi in the CBD for later endoscopic removal. Recently, ERCP has complemented the laparoscopic technique, before and after surgery, for the discovery or removal of CBD stones by endoscopic sphincterotomy and stone extraction. 3 This combined approach preserves the benefits oflaparoscopic cholecystectomy in patients who might otherwise require open surgery. In addition to biliary duct stones, CBD injuries and cystic duct leaks from malpositioned or displaced clips have also complicated laparoscopic cholecystectomy. Several reports of successful endoscopic treatment of postoperative bile duct injuries have been published. 4-7 In addition, a recent report has described the effective placement of an endoscopic stent for a cystic duct leak after laparoscopic cholecystectomy.s It has been suggested that the stent decompresses the bile duct by eliminating the choledochal-duodenal pressure gradient, thus allowing the leak to seal. 7 This report describes a new indication for endoscopic stent placement to close a bile leak after laparoscopic cholecystectomy, namely, a disrupted accessory bile duct of Luschka. This slender bile duct, first described by Luschka in 1863, passes from the right hepatic lobe in the gallbladder fossa to join the right hepatic or common hepatic duct. 9 The surgical significance of the duct lies in its vulnerable position during cholecystectomy. Its location places it at risk for inadvertent disruption, subsequent bile leak, and the possibility of biliary ascites, biliary peritonitis, subphrenic collection or abscess, biliary fistula, or bile duct stricture. lO The reported prevalence of this duct has varied markedly, from 1 % 11, 12 to 50 % .1 3, 14 Twenty postmortem dissections in subjects without previous biliary tract disease yielded six such accessory ducts, for a prevalence of 30 % .10 None of these ducts was visible before careful dissection of the gallbladder from its bed, suggesting that surgical identification could be difficult. This identification might be even more difficult with the laparoscopic technique. With the increasing use of laparoscopic cholecystectomy, more frequent instances of disrupted ducts of Luschka can be anticipated. Our patient had symptoms and findings of such a leak 7 days after laparoscopic cholecystectomy. Her leak was demonstrated at ERCP. She was treated with endoscopic placement of a temporary biliary stent and recovered uneventfully without surgical intervention or percutaneous drainage. A follow-up ultrasound exam was obtained to assure resolution of the process without a resultant localized collection (i.e., fluid or abscess). Awareness of 91
this potential complication and additional series analyzing the incidence of complications will clarify the true clinical significance of this accessory bile duct in the setting of laparoscopic cholecystectomy. REFERENCES 1. Mack E. Role of surgery in the management of gallstones. Semin Liver Dis 1990;10:222-31.
2. White JV. Laparoscopic cholecystectomy: the evolution of general surgery [Editorial]. Ann Intern Med 1991;115:651-3. 3. Aliperti G, Edmundowicz SA, Soper NJ, Ashley SW. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy in patients with choledocholithiasis and cholecystolithiasis. Ann Intern Med 1991;115:783-5. 4. Sauerbruch T, Weinzierl M, Holl J, Pratschke E. Treatment of postoperative bile fistulas by endoscopic biliary drainage. Gastroenterology 1988;90:1998-2003. 5. Smith AC, Schapiro RH, Kelsey PB. Successful treatment of non-healing biliary fistulae with biliary stents. Gastroenterology 1986;90:764-9.
Anomalous pancreaticobiliary communication in a neurofibromatosis patient Thomas M. Sturgis, MD, David B. Thomas, MD Hagop S. Mekhjian, MD, John J. Fromkes, MD
Anomalous pancreaticobiliary ductal union (PBDU) typically has been classified as a single communication of the pancreatic duct with the common bile duct (or vice versa) that forms a long common channel before entering the ampulla. Anomalous PBDU usually is seen in association with congenital cystic dilation of the common bile duct. 1, 2 We report on a patient with neurofibromatosis who exhibited an anomalous PBDU far different from previous classifications that ultimately resulted in chronic pancreatitis. To our knowledge no known association exists between neurofibromatosis and anomalous PBDU. CASE REPORT
A 37-year-old woman was admitted to our hospital after a 3-week history of sharp epigastric pain radiating to her back that was associated with nausea and vomiting. The patient did not have any history of pancreatitis, cholelithiasis, alcohol use, or biliary surgery. Her past medical history was sigFrom the Ohio State University Hospitals, Columbus, Ohio. Reprint requests: Thomas M. Sturgis, MD, Ohio State University Hospitals, N-214 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210-1228. 0016-5107/93/3901-0092$1.00 + .10 GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
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6. Ponchon T, Gallelz J -F, Valette P-J, et al. Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 1989;35:490-8. 7. Golden E, Katz E, Wengrower D, et al. Treatment of fistulas of the biliary tract by endoscopic insertion of endoprostheses. Surg Gynecol Obstet 1990;170:418-23. 8. Kozarek RA, Traverso LW. Endoscopic stent placement for cystic duct leak after laparoscopic cholecystectomy. Gastrointest Endosc 1991;37:71-3. 9. Luschka H. Die anatomie des menschlichen bauches. Tubingen: H. Lauppschen, Buchhandlung, 1863;255. 10. McQuillan T, Manolas SG, Hayman JA, Kune GA. Surgical significance of the bile duct of Luschka. Br J Surg 1989;76:696-8. 11. Goor DA, Ebert PA. Anomalies of the biliary tree. Arch Surg 1972;104:302-9. 12. Benson EA, Page RE. A practical reappraisal of the anatomy of the extrahepatic bile ducts and arteries. Br J Surg 1976;63:85360. 13. Kune GA. External biliary fistula. In: Blumgart LH, ed. Surgery
of the liver and biliary tract. Edinburgh: Churchill-Livingstone, 1987:765-75. 14. Hobsley M. Intra-hepatic anatomy. Br J Surg 1958;45:635-44.
nificant for neurofibromatosis involving the spine, skin, and bowel. Two separate exploratory laparotomies were performed for abdominal pain of undetermined cause. On admission, physical examination revealed a thinappearing woman in mild distress, with a temperature of 99° F, a blood pressure of 122/70 mm Hg, and a pulse of 90 beats/min. The skin showed multiple neurofibroma and a cafe au lait spot on her posterior trunk and neck. Her sclera were anicteric. The abdominal exam showed a well-healed midline scar, and bowel sounds were present but diminished. Mild mid-epigastric tenderness to palpation occurred, but no palpable masses, organomegaly, rebound, or guarding were seen. On rectal exam the stool was negative for occult blood. Routine laboratory examination revealed a hemoglobin level of 12.2 gm/dl and a hematocrit percentage of 35.4 %. The WBC count was 9400/mm3 with a normal differential. The total serum bilirubin level was 0.8 mg/dl, the alkaline phosphatase level was 40 lUlL, the ALT level was 71 lUlL, the AST level was 21 lUlL, the amylase level was 47 lUlL, and the lipase level was 46 lUlL. A hepatobiliary ultrasound revealed cholesterolosis and a normal-appearing pancreas. CT of the abdomen demonstrated an atrophic-appearing pancreatic head without other abnormalities. Esophagogastroduodenoscopy demonstrated a diminutive antral ulcer. Colonoscopy was normal. ERCP disclosed several abnormalities. The proximal pancreatic duct appeared bulbous and demonstrated a 0.75-cm intraluminal filling defect. This dilated segment communicated with the distal common bile in two distinct areas, whereas the middle and distal pancreatic duct appeared normal. The distal common bile duct was slightly narrowed without proximal cystic dilation (Figs. 1 and 2). The patient's hospital course was marked by persistent abdominal pain despite empiric trials of pancreatic enzymes and somatostatin. Because of this lack of response to medical therapy, surgical intervention was undertaken. GASTROINTESTINAL ENDOSCOPY
Approximately 800,000 cholecystectomies are performed each year in the United States.! In recent years, the laparoscopic method of gallbladder removal has become increasingly popular; it is now estimated that nearly half of the 33,000 general surgeons delivering patient care in the United States have been trained in the technique. 2 With the increased use of laparoscopic cholecystectomy have come biliary tract complications such as retained common bile duct (CBD) stones and CBD or cystic duct leaks amenable to treatment with therapeutic ERCP. As experience grows, additional complications will be recognized that may lend themselves to management with interventional ERCP techniques, as shown by the following case.
Figure 1. Ascites (large arrows) around the liver and spleen 9 days after laparoscopic cholecystectomy. Note cystic duct clips (small arrow) and subcutaneous air (white open arrow).
CASE REPORT
A 69-year-old woman with cholelithiasis and recurrent biliary colic underwent uneventful laparoscopic cholecystectomy with normal intralaparoscopic cholangiogram. She was discharged 2 days later and felt well, with the exception of commonly reported mild right shoulder pain. Seven days later, however, she experienced nausea, mild diarrhea, and moderately severe left lower quadrant abdominal pain. Abdominal examination revealed healed trocar puncture sites, mild distention, and diffuse abdominal tenderness with mild guarding most prominent in the left lower quadrant. Laboratory values included a normal WBC count, total bilirubin level of 3.3 mgldl (normal <1.5 mg/dl), alkaline phosphatase level of 477 lUlL (normal <137 lUlL), AST level of 111 lUlL (normal <46 lUlL), and a normal amylase level. All of these serum chemistry values had been normal at the time of recent laparoscopic cholecystectomy. Abdominal CT showed the expected cystic duct clips and subcutaneous air from recent laparoscopic cholecystectomy but also demonstrated ascites in the abdomen and pelvis (Fig. 1). Retrograde cholangiography demonstrated extravasation of radiographic contrast agent from an accessory bile duct connecting the right hepatic duct and the gallbladder fossa (Fig. 2). The two cystic duct clips were in proper position, and we saw no leak from the cystic duct. An 11.5F Amsterdam-type straight stent with side flaps was placed after a small endoscopic sphincterotomy. Symptoms resolved within 12 hours, and serum liver chemistries improved rapidly. Bilirubin returned to normal before the patient's discharge 3 days after stent From the Departments of Medicine and Surgery, University of Illinois College of Medicine at Rockford, Rockford, Illinois. Reprint requests:J.T. Frakes, MD, Rockford Gastroenterology Associates, Ltd., 401 Roxbury Road, Rockford, IL 61107. 0016-5107/93/3901-0090$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright @ 1993 by the American Society for Gastrointestinal Endoscopy
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Figure 2. Leak into previous gallbladder bed (large open arrow) from accessory bile duct of Luschka (solid arrow). Note cystic duct clips (small open arrow).
placement. She returned as an outpatient 6 weeks later for follow-up ERCP. Liver function was normal at that time, and she was asymptomatic. The stent was cannulated with a deflated balloon catheter (l-cm maximum inflated diameter), which was threaded up through the stent and out the GASTROINTESTINAL ENDOSCOPY
Figure 3. Balloon catheter (large arrow) occluding CBO
above stent (small arrow) with contrast material in biliary tract.
proximal end into the common hepatic duct. The balloon was inflated to occlude the duct above the stent, and contrast material was injected to fill out the biliary tract above the balloon (Fig. 3). The leak was no longer present. The inflated balloon catheter was then used to extract the stent from the common bile duct. The patient returned home the same day and was symptomatic when last seen (4 months later). Follow-up ultrasound exam of the abdomen and pelvis confirmed the clinical impression of resolution of the ascites and absence of any localized fluid collections.
DISCUSSION
Since its introduction in 1987, laparoscopic cholecystectomy has gained rapid acceptance as a valuable technique for removing the gallbladder. Today almost any patient considered for elective cholecystectomy is considered a candidate for the laparoscopic approach. As skill and experience with the technique increases, an increasing number of patients with acute cholecystitis are also being treated laparoscopically. Advantages of laparoscopic cholecystectomy as compared with the standard incisional approach include reduced recovery time, less pain, shorter hospitalization, a better cosmetic result, and lower cost. Complications ocVOLUME 39, NO.1, 1993
cur in roughly the same frequency as with open cholecystectomy.2 Both known choledocholithiasis and unsuspected CBD stones discovered at laparoscopic cholangiography have limited the use of laparoscopic cholecystectomy because of surgeons' reluctance to attempt laparoscopic removal of these stones or their hesitance to leave calculi in the CBD for later endoscopic removal. Recently, ERCP has complemented the laparoscopic technique, before and after surgery, for the discovery or removal of CBD stones by endoscopic sphincterotomy and stone extraction. 3 This combined approach preserves the benefits oflaparoscopic cholecystectomy in patients who might otherwise require open surgery. In addition to biliary duct stones, CBD injuries and cystic duct leaks from malpositioned or displaced clips have also complicated laparoscopic cholecystectomy. Several reports of successful endoscopic treatment of postoperative bile duct injuries have been published. 4-7 In addition, a recent report has described the effective placement of an endoscopic stent for a cystic duct leak after laparoscopic cholecystectomy.s It has been suggested that the stent decompresses the bile duct by eliminating the choledochal-duodenal pressure gradient, thus allowing the leak to seal. 7 This report describes a new indication for endoscopic stent placement to close a bile leak after laparoscopic cholecystectomy, namely, a disrupted accessory bile duct of Luschka. This slender bile duct, first described by Luschka in 1863, passes from the right hepatic lobe in the gallbladder fossa to join the right hepatic or common hepatic duct. 9 The surgical significance of the duct lies in its vulnerable position during cholecystectomy. Its location places it at risk for inadvertent disruption, subsequent bile leak, and the possibility of biliary ascites, biliary peritonitis, subphrenic collection or abscess, biliary fistula, or bile duct stricture. lO The reported prevalence of this duct has varied markedly, from 1 % 11, 12 to 50 % .1 3, 14 Twenty postmortem dissections in subjects without previous biliary tract disease yielded six such accessory ducts, for a prevalence of 30 % .10 None of these ducts was visible before careful dissection of the gallbladder from its bed, suggesting that surgical identification could be difficult. This identification might be even more difficult with the laparoscopic technique. With the increasing use of laparoscopic cholecystectomy, more frequent instances of disrupted ducts of Luschka can be anticipated. Our patient had symptoms and findings of such a leak 7 days after laparoscopic cholecystectomy. Her leak was demonstrated at ERCP. She was treated with endoscopic placement of a temporary biliary stent and recovered uneventfully without surgical intervention or percutaneous drainage. A follow-up ultrasound exam was obtained to assure resolution of the process without a resultant localized collection (i.e., fluid or abscess). Awareness of 91
this potential complication and additional series analyzing the incidence of complications will clarify the true clinical significance of this accessory bile duct in the setting of laparoscopic cholecystectomy. REFERENCES 1. Mack E. Role of surgery in the management of gallstones. Semin Liver Dis 1990;10:222-31.
2. White JV. Laparoscopic cholecystectomy: the evolution of general surgery [Editorial]. Ann Intern Med 1991;115:651-3. 3. Aliperti G, Edmundowicz SA, Soper NJ, Ashley SW. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy in patients with choledocholithiasis and cholecystolithiasis. Ann Intern Med 1991;115:783-5. 4. Sauerbruch T, Weinzierl M, Holl J, Pratschke E. Treatment of postoperative bile fistulas by endoscopic biliary drainage. Gastroenterology 1988;90:1998-2003. 5. Smith AC, Schapiro RH, Kelsey PB. Successful treatment of non-healing biliary fistulae with biliary stents. Gastroenterology 1986;90:764-9.
Anomalous pancreaticobiliary communication in a neurofibromatosis patient Thomas M. Sturgis, MD, David B. Thomas, MD Hagop S. Mekhjian, MD, John J. Fromkes, MD
Anomalous pancreaticobiliary ductal union (PBDU) typically has been classified as a single communication of the pancreatic duct with the common bile duct (or vice versa) that forms a long common channel before entering the ampulla. Anomalous PBDU usually is seen in association with congenital cystic dilation of the common bile duct. 1, 2 We report on a patient with neurofibromatosis who exhibited an anomalous PBDU far different from previous classifications that ultimately resulted in chronic pancreatitis. To our knowledge no known association exists between neurofibromatosis and anomalous PBDU. CASE REPORT
A 37-year-old woman was admitted to our hospital after a 3-week history of sharp epigastric pain radiating to her back that was associated with nausea and vomiting. The patient did not have any history of pancreatitis, cholelithiasis, alcohol use, or biliary surgery. Her past medical history was sigFrom the Ohio State University Hospitals, Columbus, Ohio. Reprint requests: Thomas M. Sturgis, MD, Ohio State University Hospitals, N-214 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210-1228. 0016-5107/93/3901-0092$1.00 + .10 GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
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6. Ponchon T, Gallelz J -F, Valette P-J, et al. Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 1989;35:490-8. 7. Golden E, Katz E, Wengrower D, et al. Treatment of fistulas of the biliary tract by endoscopic insertion of endoprostheses. Surg Gynecol Obstet 1990;170:418-23. 8. Kozarek RA, Traverso LW. Endoscopic stent placement for cystic duct leak after laparoscopic cholecystectomy. Gastrointest Endosc 1991;37:71-3. 9. Luschka H. Die anatomie des menschlichen bauches. Tubingen: H. Lauppschen, Buchhandlung, 1863;255. 10. McQuillan T, Manolas SG, Hayman JA, Kune GA. Surgical significance of the bile duct of Luschka. Br J Surg 1989;76:696-8. 11. Goor DA, Ebert PA. Anomalies of the biliary tree. Arch Surg 1972;104:302-9. 12. Benson EA, Page RE. A practical reappraisal of the anatomy of the extrahepatic bile ducts and arteries. Br J Surg 1976;63:85360. 13. Kune GA. External biliary fistula. In: Blumgart LH, ed. Surgery
of the liver and biliary tract. Edinburgh: Churchill-Livingstone, 1987:765-75. 14. Hobsley M. Intra-hepatic anatomy. Br J Surg 1958;45:635-44.
nificant for neurofibromatosis involving the spine, skin, and bowel. Two separate exploratory laparotomies were performed for abdominal pain of undetermined cause. On admission, physical examination revealed a thinappearing woman in mild distress, with a temperature of 99° F, a blood pressure of 122/70 mm Hg, and a pulse of 90 beats/min. The skin showed multiple neurofibroma and a cafe au lait spot on her posterior trunk and neck. Her sclera were anicteric. The abdominal exam showed a well-healed midline scar, and bowel sounds were present but diminished. Mild mid-epigastric tenderness to palpation occurred, but no palpable masses, organomegaly, rebound, or guarding were seen. On rectal exam the stool was negative for occult blood. Routine laboratory examination revealed a hemoglobin level of 12.2 gm/dl and a hematocrit percentage of 35.4 %. The WBC count was 9400/mm3 with a normal differential. The total serum bilirubin level was 0.8 mg/dl, the alkaline phosphatase level was 40 lUlL, the ALT level was 71 lUlL, the AST level was 21 lUlL, the amylase level was 47 lUlL, and the lipase level was 46 lUlL. A hepatobiliary ultrasound revealed cholesterolosis and a normal-appearing pancreas. CT of the abdomen demonstrated an atrophic-appearing pancreatic head without other abnormalities. Esophagogastroduodenoscopy demonstrated a diminutive antral ulcer. Colonoscopy was normal. ERCP disclosed several abnormalities. The proximal pancreatic duct appeared bulbous and demonstrated a 0.75-cm intraluminal filling defect. This dilated segment communicated with the distal common bile in two distinct areas, whereas the middle and distal pancreatic duct appeared normal. The distal common bile duct was slightly narrowed without proximal cystic dilation (Figs. 1 and 2). The patient's hospital course was marked by persistent abdominal pain despite empiric trials of pancreatic enzymes and somatostatin. Because of this lack of response to medical therapy, surgical intervention was undertaken. GASTROINTESTINAL ENDOSCOPY