Benign biliary strictures associated with recurrent pyogenic cholangitis: treatment with expandable metallic stents

OBJECTIVE: The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed. SUBJECTS AND METHODS: During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents. RESULTS: The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents. CONCLUSION: We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.     

Biliary strictures in hepatic transplantation: treatment with self-expanding Z stents

Excellent and good results following different operations for TOS are close to 80%, using simple statistics, where results included many patients followed up for only a few months. Using life-table methods, the success rate is 6% to 9% less, close to 70%, at 5 years. The results were virtually identical for anterior and middle scalenectomy, transaxillary first rib resection, and combined supraclavicular scalenectomy and first rib resection. Secondary success, the results of reoperation on patients in whom the first operation failed, improved the results of the primary operation 15% and 17%, respectively, for transaxillary rib resection and anterior and middle scalenectomy. When the initial operation was combined rib resection and scalenectomy, fewer patients underwent reoperation, as only neurolysis could be performed, and the results improved only 3%. A significant variable in results was etiology: Work-related injuries versus non-work-related accidents, usually auto accidents. Results of three independent studies showed better success rates by 13% to 15%, in patients who had non-work-related auto accidents, as compared with work-related injuries.     

Iliofemoral venous stenoses: effectiveness of treatment with metallic endovascular stents

PURPOSE: To assess effectiveness of metallic endovascular stents in treatment of venous stenoses and occlusions. MATERIALS AND METHODS: Stents were placed intravenously in 56 patients (59 stenoses or occlusions) over a 6-year period. Stent sites included the inferior vena cava (n = 10) and common iliac (n = 31), external iliac (n = 46), common femoral (n = 27), and superficial femoral veins (n = 4). Indications for stent placement included stenoses from pelvic malignancy and its treatment; trauma, surgery, or pregnancy; and idiopathic stenoses. Patients underwent anticoagulation therapy for 3-6 months after stent placement. Follow-up was performed with duplex ultrasound. RESULTS: With use of life-table analysis, overall primary and secondary 1-year patency rates were 50% and 81%, respectively. Primary and secondary 4-year patency rates were and 50% and 75%, respectively. Five patients died of primary disease progression within 6 months after stent placement. Major complications occurred in 6.8% of cases. One-year secondary patency rates were statistically significantly lower (P = .05) for patients with malignant disease, although primary patency rates were comparable. Overall sustained decrease in symptoms (P < .0001) was observed 1 year later. CONCLUSION: Endovascular stent placement is a nonsurgical alternative for reestablishment of venous flow and sustained relief of symptoms in patients with malignant or benign pelvic venous disease.     

Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent

PURPOSE: To evaluate the clinical effectiveness of a polyurethane-covered, retrievable, self-expandable metallic stent and hook catheter in the treatment of esophageal strictures. MATERIALS AND METHODS: Stents were constructed of 0.4-mm stainless steel wire in a cylindric zig-zag configuration of six to nine bends. Four to eight stents were connected in tandem by dipping in a polyurethane solution. A nylon loop was hooked inside to each bend of the proximal portion of the stent and strung with a thread. Under fluoroscopic guidance, 22 stents were placed in 16 patients with a malignant stricture and five patients with a benign stricture. The stent was removed with a hook catheter 2 months after placement in patients with a benign stricture and when complications occurred in patients with a malignant stricture. All patients had dysphagia with ingestion of soft foods or liquids. RESULTS: Stent placement was technically successful and well tolerated in 20 patients. In one patient, the stent was misplaced but relocated successfully. After stent placement, all patients were able to ingest solid and/or soft foods without dysphagia. After stent removal, strictures showed improvement but recurred in two patients. CONCLUSION: Use of polyurethane-covered, retrievable expandable stents seems to be a feasible and effective method of treatment of benign and malignant esophageal strictures.     

Expandable metallic stent placement in patients with benign esophageal strictures: results of long-term follow-up

Prosthetic mandibular advancement (PMA) was applied to nine patients with obstructive sleep apnea syndrome (OSAS) and its therapeutic usefulness, mechanism of action, and clinical indication were discussed based on polysomnographic findings and serial examination of upper airway before and during PMA treatment. Apnea hypopnea index significantly decreased during PMA treatment compared with the value before treatment (P < 0.01) and the rate of the treatment responder counted 78.1%. Cephalometric variables indicated forward and inferior advancement of mandible in our subjects. Magnetic resonance imaging of the upper airway during sleep revealed a marked improvement of velophanryngeal obstruction in most subjects. In addition, intraesophageal negative pressure during sleep decreased significantly. Our results confirmed the high therapeutic efficacy of PMA for OSAS and indicated forward advancement of the mandible and decrease of negative pressure loading on upper airway with PMA might suppress velopharyngeal collapse. Thus, PMA was regarded as one of the treatments of choice for OSAS occurring based on with velopharyngeal narrowing.     

The parent-therapist program: an innovative approach to treating emotionally disturbed children

The authors describe the parent-therapist program, an innovative alternative to residential treatment for emotionally disturbed children. In the program, which is based on the extended family model, couples not only provide a residential milieu for a child placed with them, but also are trained to be therapists who can deal with specific emotional and behavioral problems. The parent-therapists work together in three treatment teams, each consisting of five couples. Education and supervision are ongoing. A total of 27 children have been treated in the program since it got under way in May 1972. Clinical impressions indicate that the children have made substantial gains in developing social and interpersonal skills and in their academic acievement.     

Results of treatment of inferior vena cava syndrome with expandable metallic stents

A 73-year-old male was admitted to our hospital because of detection of Shigella flexneri 2a from his stool. Antimicrobial treatment with levofloxacin (LVFX) was started, but could not eliminate the organism in the stool. In the examination of drug susceptibility, this strain was highly resistant to all new quinolones. The minimal inhibitory concentration of norfloxacin, ofloxacin and ciprofloxacin to this strain was 12.5 micrograms/ml, 6.25 micrograms/ml and 6.25 micrograms/ml, respectively. The dual mutations were detected in the codon 83 and 87 of the gyrA gene by sequencing the quinolone-resistance determining region (QRDR). There was, however, no significant difference between the intracellular uptake of ciprofloxacin in this strain and in the ciprofloxacin-sensitive strain. The amount of ciprofloxacin in this strain unchanged when carbonyl cyanide m-chlorophenyl hydrazone (CCCP) was added. These results suggest that the advanced resistance in Shigella flexneri against new quinolones could be acquired by only this dual mutations without the change of the active efflux mechanism.     

Treatment of malignant esophageal obstructions with covered metallic Z stents: long-term results in 52 patients

PURPOSE: To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-R?sch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS: GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS: Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION: GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.     

Esophageal stents may interfere with the swallowing reflex: an illustrative case history

For the first time, Kluver Bucy syndrome (KBS) is described in young children who had no environmental learning of sex. The syndrome has so far been noted only in adults after bilateral temporal lobe affection. A few of its components, especially the hypersexuality and hypermetamorphosis, are likely to manifest differently in very young children. Seven patients in the pre-pubertal age group, who developed KBS as a post-encephalitic sequelae, are described. The patients, 2.5-6 years old, suffered from acute herpes simplex encephalitis (HSE) at 10 months-5.5 years of age and developed KBS on regaining consciousness and ambulation. Altered emotional behaviour, changes in dietary habits, hyperorality and hypersexuality were present in all, while psychic blindness and hypermetamorphosis were noted in a few of the patients. All showed marked indifference and lack of emotional attachment towards their close relatives. Apathy and easy distractibility were rare. Bulimia and strong urge to put non-food items into the mouth were common. Hypersexuality manifested as frequent holding of genitals, intermittent pelvic thrusting movements and rubbing of genitals to the bed on lying prone. Due to lack of environmental learning of sex and also, due to emotional and physical dependence on parents, the manifestations in young children showed modification over those of adults.     

Transbrachial endovascular exclusion of an axillary artery pseudoaneurysm with PTFE-covered stents

PURPOSE: Endovascular exclusion of arterial injuries associated with arteriovenous fistulas and pseudoaneurysms has only recently been described using various stent-graft prostheses. This report details a transbrachial technique used to exclude an axillary artery pseudoaneurysm developing at the axillary anastomosis of an axillofemoral graft. METHODS AND RESULTS: Thin-walled polytetrafluoroethylene was expanded with an angioplasty balloon catheter and used to cover standard Palmaz stents. Two covered stents were delivered under fluoroscopic guidance via open brachial artery access to the site, resulting in complete exclusion of the pseudoaneurysm. Follow-up duplex scanning confirmed aneurysm exclusion 3 months postprocedure. CONCLUSIONS: This technique can be applied in arteries of different sizes and lengths, using currently available materials. However, the long-term behavior of these devices in the arterial tree must be determined before their widespread use can be recommended for most indications.     

Assessment of anastomotic reliability with pulse oximetry in graded intestinal ischemia: an experimental study in dogs

BACKGROUND/PURPOSE: Pulse oximetry has been proposed as an appropriate and feasible technique in the assessment of intestinal ischemia in recent years. In this study the authors aimed to assess the reliability of anastomoses in the dog small intestine in which there is graded irreversible ischemia as measured by pulse oxymeter. METHODS: In a control group of four dogs, without any devascularization, three small bowel anastomoses were formed in each dog. The study group consisted of 12 dogs. In each animal three intestinal segments with different levels of ischemia were created by ligating the marginal vessels proximally and distally in sequence beginning from the midpoint of the segmental vascular arcade. Preanastomotic pulse oximeter readings between 80% and 90% were assigned to mild ischemia, 70% and 80% to moderate, and 60% and 70% to severe ischemia group. Pulse oximetry measurements were obtained from probes applied to the antimesenteric serosal surfaces at the midpoint of small intestinal segments. A total of 48 intestinal segments (12 nonischemic in the control group and 36 with three different levels of ischemia in the study group) were transected in the midpoint and anastomosed in double layers. Postanastomotic SaO2 values were also noted. The anastomoses were evaluated 48 hours later macroscopically if there was any leakage, and biopsy specimens were obtained for histopathologic ischemic gradings. All results were studied statistically. RESULTS: Histopathologic grades between each group were statistically different (P < .01 for each comparison) except for control and mild ischemia groups (P > .05), worsening as the level of ischemia increased. Pre- and postanastomotic pulse oximetry measurements correlated very well with the histological gradings (r = -0.90, P < .001 and r = -0.93, P < 0.001 respectively). Number of anastomotic leakages were none in control, one in mild, nine in moderate, and 12 (all of the anastomoses) in severe ischemia groups. In the moderate ischemia group with an average preanastomotic pulse reading of 76.75%, each of the leaking anastomoses had a postanastomotic pulse measurement of lower than 70%. The finding that the difference between histopathologic grades of control and mild ischemia groups with average preanastomotic pulse measurements of 96% and 85%, respectively is not statistically significant enables us to suggest that a saturation of at least 85% is necessary for a reliable anastomosis. CONCLUSION: These results suggest clearly that anastomotic reliability can be predicted objectively with pulse oximetry.