Balloon catheter-assisted placement of large percutaneous biliary drainage catheters

Gastric cancer is the world's second most common malignancy. In the U.S., patients present with advanced disease, and surgery with curative intent accounts for only 30% of gastric malignancies. Palliative surgery has significant morbidity and mortality. Recently, there have been encouraging reports of self-expanding endoprostheses in obstructing gastrointestinal neoplasms. We report a case of a 70-yr-old woman with inoperable outlet stenosis secondary to a mucinous infiltrating adenocarcinoma involving nearly the entire stomach, except the anterior wall, which provided a percutaneous access site for gastrostomy and subsequently successful management of outlet obstruction with metallic stents.     

A prospective randomized trial of Teflon versus polyethylene stents for distal malignant biliary obstruction

BACKGROUND AND STUDY AIMS: Clogging of biliary stents continues to be a major clinical problem. Different polymer materials may have different effects on clogging. In vitro studies have shown a direct relation between the frictional coefficient of a polymer and the amount of encrusted material. Teflon appeared to be the best polymer for biliary stents. Two different types of stents made of Teflon have been tested in clinical practice and showed favourable patency rates. However, a randomized trial has never been performed. We compared the patency of an Amsterdam-type polyethylene stent with a Teflon stent in a prospective randomized trial. PATIENTS AND METHODS: Between September 1995 and November 1996, 42 patients received a Teflon stent and 42 patients a polyethylene stent. All patients had a distal malignant biliary stricture without a previous drainage procedure. Diagnoses included carcinoma of the pancreas (n = 76), papilla (n = 1), bile duct (n = 5) and metastases (n = 2). The internal and external diameter (10 Fr), length (9 cm) and stent design (a straight stent with two side flaps and one side hole at each end) were similar for both stents. RESULTS: A reduction in bilirubin of more than 20% within one week was seen in 91% of the patients. Early complication rates were similar in both groups (10%). The median follow-up was 142 days. Stent dysfunction occurred in 28 Teflon and 29 polyethylene stents. The thirty-day mortality was 14% in both groups. Patient survival did not differ significantly between the groups (median survival: Teflon 165 days, polyethylene 140 days). The median stent patency was 83 days for Teflon and 80 days for polyethylene stents, and was not significantly different either. CONCLUSION: Teflon material did not improve patency in biliary stents with an Amsterdam-type design.     

A simplified technique for radionuclide hysterosalpingography

The nutrient intakes and circulating vitamin levels of 32 patients with rheumatoid arthritis who were treated with methotrexate were evaluated over a 6-month period. Dietary data were obtained and blood was drawn prior to the initiation of and following 12 and 24 weeks of methotrexate therapy. More than 50% of the patients had food intakes providing less than 67% of the recommended dietary allowance for zinc, vitamin E, folic acid, pyridoxine, and magnesium. Patients 51 years or older had better nutrient intakes than patients less than 51 years. Of the patients, 22% consumed vitamin supplements at the time they were recruited for the study. Mean circulating vitamin levels measured over the 6-month period were within normal limits. Our findings agree with previously published reports that patients with rheumatoid arthritis, particularly the subpopulation taking methotrexate, consume diets that are marginal in some nutrients. Additional research needs to be done to identify more sensitive nutrient assays and to establish more definitively the nutrient needs of patients with rheumatoid arthritis taking several therapeutic agents.     

A simplified technique for casting anatomical models

For anyone desiring to cast anatomical models, a simplified technique for external casting has been developed using dental impression materials readily available in dental supply houses. These impressions yield life-like permanent models retaining topographical features of normal as well as pathological skin and nails.     

Metallic stents in malignant biliary obstruction: prospective long-term clinical results

OBJECTIVE: The purpose of this prospective study was to evaluate the long-term clinical efficacy of metallic stents when used as the initial palliative treatment of patients with inoperable malignant biliary obstruction. SUBJECTS AND METHODS: From August 1991 through May 1995, 100 consecutive patients with malignant biliary obstruction were treated with percutaneous placement of metallic stents. The causes of obstruction were bile duct carcinoma (n = 50), pancreatic carcinoma (n = 17), gallbladder carcinoma (n = 6), hepatocellular carcinoma (n = 2), and metastatic lymphadenopathy in the hepatoduodenal ligament (n = 25). We used 123 stents: 64 Gianturco Z stents, 39 Hanaro spiral stents, 16 Wallstents, two tantalum Strecker stents, one Endocoil stent, and one Memotherm nitinol stent. Every 3 months we followed up all patients except those who died. The average length of follow-up was 220 days (range, 4-1125 days). Patient survival and stent patency rates were estimated by life-table analysis. RESULTS: The median length of survival for the entire patient group was 246 days: 25-week and 50-week survival rates were 62% and 25%, respectively. We found no statistically significant difference in the median length of survival between patients with hilar obstruction (256 days) and patients with common bile duct (CBD) obstruction (227 days). Patients with bile duct carcinoma had longer median survival (269 days) than did patients with other conditions (197 days). The overall median length of patency for all stents was 360 days; the 25-week and 50-week patency rates were 81% and 53%, respectively. The stent patency rate at the median length of survival was 71%. The median length of stent patency in patients with hilar obstruction (617 days) was nearly double that of patients with CBD obstruction (324 days). However, the median length of stent patency in patients with bile duct carcinoma showed no statistically significant difference from the median length in patients with other disease. Four patients (4%) died within 1 month after stent placement. Twenty-one patients (21%) developed recurrent jaundice or cholangitis. In order of frequency, the causes of recurrent jaundice were tumor overgrowth, incrustation of bile sludge, duodenal obstruction due to tumor invasion, stent impaction into the bile duct wall, stent malposition, and tumor ingrowth. CONCLUSION: Metallic stents showed a favorable patency rate with regard to patient survival. In patients with hilar obstruction, the clinical efficacy of metallic stents was superior to that in patients with CBD obstruction. We believe that placement of metallic stents is the procedure of choice for palliation of malignant biliary obstruction.     

Clinical factors associated with positive bile cultures during primary percutaneous biliary drainage

PURPOSE: To evaluate the utility of routine bile cultures and to determine the risk factors for bacterial colonization of the bile as well as the biliary flora in patients with biliary obstruction undergoing primary percutaneous biliary drainage. MATERIALS AND METHODS: Between October 1995 and January 1997, bile cultures were prospectively obtained in all patients undergoing percutaneous biliary drainage. Seventy-six patients underwent 86 procedures. Culture results were correlated with clinical, laboratory, and demographic variables. The antibiotic sensitivities of cultured organisms were examined. RESULTS: Fever, previous endoscopic or percutaneous biliary instrumentation, and bilioenteric anastomosis were significant predictors of a positive bile culture. In the absence of any of these indicators, bile cultures were unlikely to be positive. Enterococcus species was the organism isolated most commonly. Yeast, gram-negative aerobic bacilli, and Streptococcus viridans followed in frequency. CONCLUSION: Bile cultures provide valuable information that was useful for planning antibiotic prophylaxis and treatment. The likelihood of positive bile cultures can be predicted based on certain clinical variables. Continued investigation is needed to better predict bacterial flora in individual patients. Given the association between previous instrumentation and biliary colonization, noninvasive imaging modalities should be exhausted before invasive procedures are performed for solely diagnostic purposes in patients with biliary obstruction.     

A simplified technique for selective and superselective abdominal angiography

A simplified technique for selective abdominal angiography utilizing the Simmons Femoral-Cerebral catheter is described. The technique affords a rapid simple approach to selective and superselective catheterization of the celiac, superior mesenteric and inferior mesenteric arteries.     

Feasibility of stent placement above the sphincter of Oddi ("inside-stent") for patients with malignant biliary obstruction

In three cases of primary pulmonary amyloidosis the chief complaint was hemosputum. The diagnosis of amyloidosis was made using histochemical analysis of bronchial wall biopsy in all cases; multiple nodular lesions were observed in trachea and bronchi on flexible fiberoptic bronchoscopy. The surface of the tracheobronchial mucosa was smooth but bled easily. In one patient, chest X-ray film showed a solitary nodular shadow in the left lower lung field. These three cases were tracheobronchial amyloidosis, and one case was combined with nodular parenchymal type amyloidosis.     

Left hepaticogastrostomy for biliary obstruction: long-term results

PURPOSE: To evaluate the long-term results of peripheral biliary diversion by means of anastomoses of the left lobe of the liver to the stomach. MATERIALS AND METHODS: Transhepatic perforation of the left lobe of the liver into the lesser curvature of the stomach was performed in 35 patients with a presumed diagnosis of malignant obstructive jaundice. Jaundice was found to be caused by a malignant stricture in 32 patients and a benign stricture in three. Perforation was performed under fluoroscopic, endoscopic, and laparoscopic guidance in 33 patients and without laparoscopy in the other two. The hepaticogastric anastomosis was secured with a gastrostomy tube; patency of the tract was maintained with placement of a metallic stent. Kaplan-Meier analysis was used to evaluate survival, anastomosis patency rate, and jaundice recurrence. RESULTS: Technical success was achieved in all patients. Two (6%) patients had anastomotic obstruction. The actuarial survival rate was 91%, 80%, 59%, and 26% at 1, 3, 6, and 12 months. The mean patency was 234 days +/- 252. The jaundice-free rate among surviving patients was 100%, 96%, 93%, and 80% at 1, 3, 6, and 12 months. The reintervention rate was 14%. Late cholangitis occurred in seven (20%) patients. CONCLUSION: This peripheral diversion procedure appears to be safe and shows good long-term patency.     

Shape-memory nitinol alloy endoprosthesis for malignant biliary strictures

A new design of endoprosthesis, made of shape-memory nitinol alloy, was used to replace the currently used one, which was soon clogged with bile mud. After nitinol wire coil stent was slenderized in ice water, it was inserted into the strictured bile duct by endoscopy or operation. When nitinol wire coil was positioned in a narrowed biliary segment, normal saline heated to 39 degrees C was rapidly hand-injected into the lumen of the inner transport catheter to make the alloy coil to resume its original shape with a length of 3 to 10cm, and a diameter of 5 to 10mm. Since June 1991, 13 patients with malignant biliary strictures were treated with nitinol endoprosthesis. The follow-up period ranged from 1 to 16 months (average 6 months). Biliary sludge was not found in the endoprosthesis during the period. The results suggested that shape-memory nitinol alloy endoprosthesis could maintain long term patency without severe infection or obstruction due to biliary sludge.     

A quantitative measurement of peritoneal drainage in malignant ascites

With a two-compartment model, a method is described for quantitative determination of peritoneal drainage rates in malignant ascites. Data on twenty-four patients are presented and comparison is made with the qualitative assessment of the integrity of diaphragmatic and mediastinal lymphatics on the basis of lymphoscintigrams. It is concluded that flow rates less than 50 ml/hour are usually associated with abnormalities of the diaphragmatic and mediastinal lymphatics, indicating that tumor permeation of these structures is a significant contributing factor to persistent, intractable ascites in patients with malignant diseases.     

Subcutaneous implantation metastasis of a cholangiocarcinoma of the bile duct after percutaneous transhepatic biliary drainage (PTBD)

The differential diagnosis of herpes simplex and zoster may require virological confirmation, yet virus typing is not regarded as necessary in routine dermatological assessment. In an attempt to evaluate the clinical benefits of the routine detection of herpes simplex virus (HSV) and varicella zoster virus (VZV), we analysed skin swabs from 110 patients who were diagnosed at the first clinical visit as having herpes simplex (n = 45) or zoster (n = 65). Viruses were typed using the polymerase chain reaction (PCR) with the general primer pair GPHV-RU. PCR analysis showed that at the initial clinical presentation, herpes simplex in these patients was not mistaken for zoster but that zoster was incorrectly diagnosed as herpes simplex in nine cases. Thus these results suggest that initial zoster often mimics herpes simplex, hence routine PCR diagnosis of HSV and VZV or alternative rapid diagnostic approaches may be beneficial in these cases.     

The Glidewire technique for overcoming urethral obstruction

PURPOSE: Using the hydrophilic Terumo Glidewire we developed a less traumatic, yet effective alternative method to filiforms and followers for cases of urethral obstruction. MATERIALS AND METHODS: The initial step and cornerstone of our method is the passage of the Glidewire per urethra in a manner similar to a filiform. After the appropriate intravesical location of the Glidewire is confirmed using a ureteral catheter, it is exchanged for a standard polytetrafluoroethylene (Teflon) coated guide wire. Urethral dilation and/or catheter placement is then performed. RESULTS: This technique was successful in 19 of 20 attempts, several of which followed unsuccessful passage of filliform catheters. Urethral obstruction due to strictures, bladder neck contractures and benign prostatic hyperplasia in our group was treated effectively. Furthermore, no complications occurred due to the technique. CONCLUSIONS: The Glidewire method is safe and effective for treating most cases of urethral obstruction. Therefore, we recommend this technique over standard filiforms and followers when flexible or rigid cystourethroscopy is not immediately available.