Ca(2+)-permeable, outwardly-rectifying K+ channels in mesophyll cells of Arabidopsis thaliana

Advances in cannulation techniques and instruments have helped in difficult bile duct cannulation and thus stone extraction. For small common bile duct (CBD) stones, endoscopic papillary balloon dilatation has been proposed as an alternative to endoscopic papillotomy (EPT). The technique must undergo further evaluation before recommending its routine use. For most patients with bile duct stones, EPT remains the method of choice. Out of 8204 patients treated in three surgical endoscopy centers (Chile, Germany, and India), 86% to 91% of all CBD stones could be extracted subsequently after EPT using a Dormia basket; 4% to 7% required mechanical lithotripsy (ML) before removal and 3% to 10% of the patients needed other sophisticated techniques, such as electrohydraulic lithotripsy (EHL), laser-induced shock-wave lithotripsy (LISL), or extracorporeal shock-wave lithotripsy (ESWL). The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Permanent stenting can be offered to poor risk patients instead of extensive procedures to clear the bile duct. Using currently available nonsurgical techniques, fewer than 1% of all patients with bile duct stones still require surgical intervention.     

Outcome of mechanical lithotripsy of bile duct stones in an unselected series of 704 patients

BACKGROUND/AIMS: This paper evaluates the potential benefit of non mechanical bile duct stone lithotripsy techniques. The efficacy, limitations and risks of mechanical lithotripsy as first choice procedure were studied. MATERIAL AND METHODS: Endoscopic sphincterotomy was performed by Erlangen-type papillotomes, stone extraction by Olympus baskets and mechanical lithotripsy by the Wurbs-system. In an unselected series of 704 patients, everyone with common bile and hepatic duct stones (independent of size, number, location and stone consistency) was included in the study. RESULTS: Complete stone clearance by endoscopic sphincterotomy and basket extraction was possible in 87.6%. Additional mechanical lithotripsy led to a success rate of 98.4% and in combination with ESWL of 98.5%. In 11 patients without possibility of endoscopic stone removal (1.6%), 4 had no access transpapillary (B-II-situs or duodenal diverticulum), 5 anatomical problems (S-shaped common bile duct, intrahepatic stones or impacted stones in cystic duct orifice), and 2 refused further endoscopic interventions. Complication rate was 1.4% (thereof 1.1% successful treatment by endoscopic or surgical means), lethality rate 0.3%. CONCLUSIONS: A very high rate of stone clearance by standard endoscopic procedures is possible. In those patients where mechanical lithotripsy is not successful, other non-surgical lithotriptic procedures either cannot be applied because of anatomical reasons or if performed, the improvement in success rate is marginal.     

Long-term results of extracorporeal peizoelectric shock wave lithotripsy of parotid stones

OBJECTIVE: To evaluate prospectively the recently developed method of extracorporeal shock-wave treatment of stones of the parotid gland. PATIENTS AND METHODS: 76 patients with symptomatic, sonographically proven, solitary stones of the parotid gland (36 females, 40 males; aged 2-80 years) were treated with extracorporeal piezoelectric shock-wave lithotripsy (ESWL) after failed conservative management (sialagogues, gland massage, duct bougie dilation). RESULTS: Parotid stones were no longer demonstrable after a mean follow-up time of 48 (6-71) months in 38 of the 76 patients; they were symptom-free and no new stones had formed. A residual, but symptom-free, stone was found in another 20 patients (26%) of whom 13 (17%) reported marked improvement after ESWL. No change from pretreatment symptoms occurred in five patients (7%) so that operative removal had to be performed. The success rate of the lithotripsy was independent of size and site of the stone. CONCLUSION: ESWL is the method of first choice in the treatment of parotid gland stones after unsuccessful conservative treatment and obviates operative gland removal in most cases.     

Similar fragmentation and dissolution after extracorporeal shock wave lithotripsy in eutrophic and overweight patients with gallstones

The aim of this study was to assess the relative importance of overweight and adjuvant treatment with bile acids to obtain fragment dissolution and clearance after biliary extracorporeal shock wave lithotripsy (BESWL), in eutrophic and overweight patients with gallbladder stones. During a 3-year period 103 patients were treated with BESWL. Patients were strictly selected in terms of the number and type of stones. Of the total of 103 patients, 53 were women and 50 men. Mean age was 50.8 +/- 14.3 (range 17 to 86) years. Body mass index was calculated for each patient. All patients underwent BESWL with an electromagnetic device. Medical therapy for stone dissolution included the combination of chenodeoxycholic acid plus ursodeoxycholic acid (50% + 50%), at a total dose of 10-15 mg/day. Of the 103 patients, 45 were eutrophic and 58 were considered overweight. Age was similar in both groups. Number of lithotripsy sessions in eutrophic patients was 1.96 +/- 1.07 and 1.88 +/- 0.84 in overweight patients, but no statistical differences were found. Complete clearance of calculi was observed in more than 50% of the cases after 6 months, and reached 98% after 22 months of therapy in both groups. Total clearance of calculi was similar in patients with single and multiple stones. In conclusion, our results suggest that the time required to obtain complete gallstone clearance after BESWL is similar in eutrophic and overweight patients with gallbladder stones, and also that adjuvant therapy with bile acids plays an important role in gallstone fragment dissolution in these patients.     

Osseointegrated implants in a patient with osteoporosis: a case report

OBJECTIVE: To evaluate the performance of in situ piezolectric extracorporeal shock-wave lithotripsy (ESWL) in the middle part of the ureter. MATERIAL AND METHODS: 36 consecutive patients presenting with stones of the middle part of the ureter were treated by in situ piezoelectric ESWL (EDAP LT 02). The maximal dimensions of the stones ranged from 5 to 14 mm (m = 7.8). Moderate or severe ureterohydronephrosis was present in 19 cases (53%) and a double J stent had been previously implanted in 6 cases (17%). The ESWL sessions were performed in the ventral supine position without any anaesthesia or systematic premedication, but an IM injection of 100 mg of pethidine was administered during poorly tolerated treatments. RESULTS: The stone was located easily in 23 cases (64%) and with greater difficulty in 13 cases (36%), as an intraoperative intravenous injection of contrast agent was performed in 6 cases (17%). The number of sessions per patient ranged from 1 to 2 (m = 1.16). The complete sucess rate was 75%, with a 64% success rate after a single ESWL session. The performances were statistically independent of stone dimensions and the degree of obstruction of the urinary tract. The complication rate was 5.5%, but no ancillary endoscopic or percutaneous treatment was required. CONCLUSION: In situ piezoelectric ESWL allows effective management of most stones of the middle part of the ureter. However, the treatment of stones with a maximal diameter < 5 mm, especially poorly radiopaque stones, can raise problems of localization. Very large or impacted stones, especially when complicated by urinary tract infection, should be preferably treated by first-line ureteroscopy.     

Extracorporeal shockwave lithotripsy in the treatment of common bile duct calculi

Fifteen patients with stones in the common bile duct, in whom treatment with endoscopic papillotomy and stone-extraction had been unsuccessful were treated with extracorporeal shockwave lithotripsy. Nine patients were stone-free after one or two sessions, and two patients after further endoscopic treatment. One patient achieved partial clearance and palliation. One patient had a choledochoduodenostomy performed due to ineffectiveness of the shockwave lithotripsy. Two patients, who were thought to have a stone, turned out to have neoplasma in the common bile duct. Complications were frequent but temporary and needed no treatment. We conclude that extracorporeal shockwave lithotripsy is a valuable and safe alternative in those cases where conventional endoscopic treatment has failed, and should be considered before operation, especially to old for high-risk patients.     

Control of the mutagenicity of arylamines by protein kinases and phosphatases: II. Lack of response of rat liver N-acetyl transferases to phosphorylation modulators

OBJECTIVES: Endoscopic sphincterotomy has become a generally accepted method for extracting common bile duct stones in high risk or cholecystectomized patients. However, stone extraction is impossible by the usual methods in 5 to 10% of cases. The purpose of this study was to evaluate the effect of a recently developed solvent system in patients with large bile duct stones. METHODS: Forty four patients (15 men and 29 women, median age of years) underwent contact dissolution after unsuccessful Dormia extraction. Solvents were administered via a nasobiliary catheter in 41 patients following papillotomy and through a T-tube in 3 patients. Solvent mixtures (26 mM ethylene diamine tetraacetic acid, 40 mM sodium deoxycholate and 30% dimethyl sulfoxide in an alkaline aqueous solution; and a 70/30 dimethyl sulfoxide/methyl tert-butyl ether mixture) were infused continuously and alternatively for 2 hours. RESULTS: Bile duct stones disappeared in 13-24 hours of infusion in 11 patients. In 29 patients, a clear reduction in stone volume occurred, allowing complete endoscopic extraction of the fragments. In 4 patients, the size of the stone did not change. Only mild and transient side-effects including abdominal pain (68%), nausea (72%), vomiting (52%), diarrhea and sleepiness (50%) were observed. CONCLUSION: Direct dissolution therapy could be an effective method for the non-surgical management of large bile duct stones in selected patients when intra- or extracorporeal lithotripsy is unsuccessful.     

Intra-corporeal shockwave lithotripsy in the treatment of complex lithiasis of the bile ducts. Comparison of endoscopic techniques and long-term results

OBJECTIVES: About 2% of common bile duct stones and most intra-hepatic stones cannot be removed by conventional endoscopy. Intra-corporeal lithotripsy is an alternative technique for these patients. Contact lithotripsy can be obtained by a pulsed dye laser or by electro-hydraulic shockwaves. We compared and assessed the results of these two methods. METHODS: Thirty-seven patients (79 +/- 9.8 years, 25 women and 12 men) underwent laser lithotripsy (n = 21), electro-hydraulic lithotripsy (n = 9) or both methods consecutively (n = 7) for common bile duct stones (n = 31), intra-hepatic stones (n = 3) or diffuse lithiasis (n = 3). The mean diameter of the largest stone was 23 +/- 12 mm. Lithotripsy was performed by a retrograde approach in 35 cases and a combined, retrograde and transhepatic approach in 2 cases. RESULTS: The mean number of lithotripsy sessions was 1.5 +/- 0.65. The overall success rate (free bile ducts with patent drainage) was 95%. In 2 patients, stones were not fully extracted: one underwent surgery, the other one was treated conservatively with antibiotics. The duration of the hospital stay was 9.3 +/- 4.5 days. Morbidity at 30 days was 27% and only one case of major morbidity (hemorrhage after sphincterotomy, 2.7%) was observed. There were no procedure-related mortality. Electro-hydraulic and laser groups did not differ significantly for success rate, morbidity and time spent at hospital. Follow-up information was obtained in 34 patients (91.8%) a median of 17 months after lithotripsy (range: 4.52 months). Ten patients died of non-biliary diseases. Two patients (5.8%) developed biliary symptoms 24 and 34 months after lithotripsy, one after unsuccessful lithotripsy. CONCLUSION: Intra-corporeal lithotripsy is a valuable tool for the most complex cases of duct stones, and with an acceptable morbidity. The results of the two techniques are similar. Late biliary complications after intra-corporeal lithotripsy appear to be rare.     

Effect of simultaneous exercise and noise exposure (music) on hearing

BACKGROUND: Bile duct stone is a common biliary tract disease in Taiwan. Surgery and choledochoscopy are the current methods of treatment. This is a retrospective review of 65 cases who were admitted with postoperative biliary residual stones, or cholangitis secondary to the biliary stones. Percutaneous biliary stone removals under fluoroscopy were attempted. METHODS: Either a T-tube tract or percutaneous transhepatic cholangial drainage tract or both were used for stone removal. Angiographic superselective catheterization technique was applied for superselective cholangiography to identify the location of stones and to deliver basket and electrohydraulic lithotripsy probe to the site of the stones. Balloon dilation was applied for biliary stricture. RESULTS: Most of the cases needed multiple sessions (four, on an average) to remove all stones. There were 52% of the cases who needed balloon dilation for associated biliary strictures, and 7.7% of the cases had residual stones at the end of the procedure, because of technical difficulties. Chills and fever, pancreatitis, hepatic arterial injury and perforation of the common bile duct were procedure-related complications. In follow-up studies, 15% of the cases had recurrent biliary stones and 4.6% of the patients expired from malignant biliary tumors. CONCLUSIONS: Percutaneous biliary stone removal under fluoroscopy is beneficial for direct visualization of the location and number of the stones, and the architectural changes of the bile ducts. Superselective catheterization and balloon dilation were responsible for the high success rate (92.5%) here.     

Endoscopic treatment of symptomatic choledocholithiasis

BACKGROUND/AIMS: Today, different endoscopic techniques are available to treat choledocholithiasis. These techniques include mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), laserlithotripsy (LL), and extracorporal shock-wave lithotripsy (ESWL). These techniques have to compete with laparoscopic stone removal which is performed with increasing frequency at some centers. METHODOLOGY: We report the results of treatment of choledocholithiasis and compare the results with a meta-analysis of studies in whom endoscopic and laparoscopic techniques were applied. From 1994-1995, 217 patients with symptomatic choledocholithiasis were treated using endoscopic retrograde cholangiography (ERC). RESULTS: Overall, complete stone removal was successful in 98% of all patients and only 5 patients had to undergo surgery. Complete endoscopic removal of stones was achieved in 70% during the first ERC session. In 47 patients consecutive ERC sessions with application of EML, EHL, or ESWL were necessary to completely remove the stones. Complication rate was 5% and included pancreatitis and bleeding from papillotomy. There was no procedure-related mortality. CONCLUSION: The study suggests that today ERC remains the treatment of choice in most patients with symptomatic choledocholithiasis.     

Endoscopic sphincterotomy for lithotripsy (EST-L) of bile duct stones

We performed EST-L for 555 patients with choledocholithiasis between 1981 and 1992. With the aid of conventional occlusion balloons and dormia-type baskets, calculi < or = 1.5 cm was extracted with relative ease. In patients with larger stone (> 1.5 cm), the mechanical lithotripter, extracorporeal shock wave lithotripsy (ESWL) and electrohydrolic lithotripsy were used for the lithotripsy. The overall success rate was 95%. Important early and late complications from these procedures occurred in 6.9% and 9.1% of all cases respectively. This result reveal that EST-L is safe and effective therapeutic procedures for choledocholithiasis. We would recommend EST-L is adopted as an initial measure to remove common bile duct stones.     

Lithostar Multiline. A multi-function lithotripter for ESWL and endourology: initial clinical experiences

After > 10,000 treatments-our HM3/4 and MPL 9000 have been replaced by the Siemens Lithostar multiline. As a ESWL center with ESWL as the primary treatment indication for all types of stones in kidney and ureter we report our initial experience with this new multifunctional lithotripter. The system consists of an electromagnetic shock-wave emitter (Focus 80 x 5 mm) and a digital fluoroscopy unit. Stone localization is achieved in a - 10 degrees and + 30 degrees position without movement of the patient. The treatment table itself allows most endourologic and percutaneous auxiliary procedures. Additionally, an intergrated inline ultrasound is available. From 10/94 to 08/95, 204 male and 96 female patients with a mean age of 50.7 (4-92) years underwent ESWL with the Lithostar multiline. The mean stone diameter was 10.3 (2-20) mm with 53% ureteral and 47% renal stones. 300 patients underwent 480 treatments (average shocks 3673, range 793-8000; mean energy level 5.5, range 1-9). Stone localization was achieved after 5 (1-39) min (mean fluoroscopy time 3.1 (0.5-16.2) min). In 92.7% no analgesic premedication was done, 56% of the patients needed no analgesics at all during ESWL. 44% received 8.1 (2-15) mg Piritramid intravenously. Epidural anesthesia was performed in only 2.3% for a second treatment. 95% of the patients had complete stone disintegration. In 68% disintegration was achieved in one session. ESWL was repeated for further disintegration in 18.5%, because of an unsuccessful treatment in 11.5% and because of technical interruption of the previous session in 2.5%. We saw subkapsular haematomas in 2%. Auxiliary procedures following ESWL were necessary in only 9.2% of the patients. In situ ESWL with the new Lithostar Multiline seems to be effective as the Domler HM3/4. Analgesia-free treatment was performed in more than 50% of the patients. Auxiliary procedures were less frequently necessary as compared to our previous experience with in situ ESWL.     

Genetic analysis of mutations in seven Japanese families with type I antithrombin deficiency

Recently, a new device (Combilith) for electrokinetic lithotripsy (EKL) has become available which is very similar to the well-known device for pneumatic (ballistic) lithotripsy (Swiss Lithoclast). The Lithoclast uses air pressure to push a projectile within the handpiece against the end of a metal probe, which is thereby accelerated and thrown like a jackhammer against the stone. In principle, the same stroking movement of a small metal probe is provided by EKL; the difference is that instead of a projectile, a magnetic core within the handpiece is accelerated by the electromagnetic principle. This paper compares the clinical efficacy and the features of the two devices. Testing the devices on a stone model, taking into account stone propulsion, the systems turned out to equally effective regarding stone disintegration. However, stone displacement was more pronounced with the Lithoclast applied on easily breaking stones. In a second experiment, an optoelectronic movement-measuring apparatus (Zimmer camera) was employed to measure the range and velocity of the movement of the probe tip without any contact. The linear acceleration velocity ranged from 5 to a maximum of 12.5 m/sec with both systems, but the maximum height of the stroke was 2.5 mm with the Lithoclast and 1 mm with EKL. After the initial break-up of soft stones, further impact of the probe tip against the stone resulted merely in propulsion; thus, the greater probe stroke height is the cause of the stone displacement. In a clinical trial, 22 ureteral stones were treated with the Lithoclast and 35 with the EKL. The two devices were equally effective in terms of stone disintegration and safety margin. Fixation using a Dormia basket was necessary in 12 cases (8 Lithoclast, 4 EKL). Although a difference in probe stroke height was noted when comparing pneumatic and electrokinetic lithotripsy, there were no clinically significant differences in the efficacy of stone fragmentation or stone-free rates. At the current time, EKL is less costly.     

Management of traction wire fracture complicating mechanical basket lithotripsy

BACKGROUND AND STUDY AIMS: The application of basket catheters has become the main method of removing calculi from the biliary and pancreatic duct. However, larger or impacted stones have to be crushed and fragmented by mechanical lithotriptors before removal is possible. Sometimes, fracture of the traction wire occurs as a severe and fraught complication. We describe a precautionary measure which helps to manage this complication. PATIENTS AND METHODS: In a series of 569 consecutive patients suffering from bile or pancreatic duct stones we found 60 (10.5%) who required mechanical lithotripsy for oversized or impacted calculi. Mechanical lithotripsy was always performed initially with a long metal sheath (80 cm) in combination with a standard traction wire. If the traction wire fractured we replaced the long metal sheath stepwise by shorter ones (70cm, 60cm and 50 cm, respectively), allowing immediate continuation of the lithotriptic procedure using the same traction wire. RESULTS: During the lithotriptic procedure three of our patients (5%) were afflicted by traction wire fracture. Two patients could be relieved directly by changing the initial metal sheath to shorter ones. Because of the exceptional hardness of a pancreatic duct stone the third patient needed stone fragmentation by extracorporeal shock wave lithrotripsy (ESWL) before complete mechanical clearance of the duct could be accomplished. CONCLUSION: We advocate the initial use of a long metal sheath (80cm) to perform mechanical lithotripsy. In case of traction wire fracture the use of a shorter metal sheath allows immediate successful continuation of the procedure, thereby frequently avoiding procedures such as ESWL or surgery.     

Echographic characteristics of retinal arterial macroaneurysm

BACKGROUND AND STUDY AIMS: Caroli's disease causes relapsing episodes of cholangitis due to the presence of intrahepatic lithiasis. Strategies for cholangitis prevention are still widely debated. Ursodeoxycholic acid, hepaticojejunostomy, partial hepatectomy, or transplantation, have all been proposed as therapeutic options. The aim of this study was to evaluate the role of therapeutic endoscopy, and especially endoscopic sphincterotomy (ES), in the management of Caroli's disease. PATIENTS AND METHODS: Between 1983 and 1995, six patients with Caroli's disease (mean age 52, range 17-75) underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. Sphincterotomy was performed if common bile duct stones were present. Extracorporeal shock-wave lithotripsy, (ESWL) or intraductal electrohydraulic lithotripsy (IEL) were performed if necessary. RESULTS: The mean number of endoscopic sessions per patient was four (range three to seven). Sphincterotomy was performed in five patients and cholangioscopy in three. ESWL was performed twice in each of four patients. A Strecker expandable metal stent was placed in one patient to maintain sphincterotomy patency. In one patient, two sessions of IEL and pulsed laser were carried out. Complete clearance of intrahepatic stones was achieved in four of the six subjects (66.6%) and partial clearance in two patients. No morbidity or mortality was observed. During the follow-up (mean 6.2 years; range: 2.1-16.3), only two patients had acute cholangitis at nine months and three years, respectively, after the endoscopic treatment. Both had residual intrahepatic stones left after the initial endoscopic attempt at clearance. CONCLUSION: ERCP is a necessary diagnostic procedure which should always be carried out in patients with Caroli's disease. Our experience shows that ES does not result in an increased incidence of cholangitis and that therapeutic endoscopy allows complete clearance of intrahepatic stones in the majority of patients with unresectable symptomatic Caroli's disease. Nevertheless, the oncological risk in these patients remains unchanged, and they still have an increased risk of cholangiocarcinoma.     

Extracorporeal shock wave lithotripsy on patients with spinal cord injury with special reference to autonomic hyperreflexia

We performed treatment of urolithiasis on 7 patients with spinal cord injury (6 males and one female, with a mean age of 41 years old) by extracorporeal shock wave lithotripsy (ESWL) using a Lithostar (Siemens). The level of injury was cervical in 3 patients and lower thoracic in 4. The treated stones were renal in 6 patients, including one staghorn caliculus, ureteral in 2, and bladder stones in 2 patients. ESWL was performed under general anesthesia in 2 patients, and in another patient, epidural anaesthesia was employed in the first several sessions, but thereafter treatment was safely continued with no anesthesia. The other 4 patients were treated without anesthesia. In most patients, the stones (9 stones in 6 cases) were easily disintegrated after treatment of from one to 14 sessions, except one case of staghorn caliculus, and the clearance of fragments was also satisfactory. In one patient, hypertension and bradycardia due to autonomic hyperreflexia were observed during ESWL, and the treatment was discontinued, but the stone was successfully disintegrated and the fragments were voided. In another patient, autonomic hyperreflexia was observed while the fragments passed through the ureter, although no signs of this reflexia were seen during the ESWL procedure.     

Percutaneous extraction of upper urinary calculi under fluoroscopic control--still a valuable complement to ESWL

Percutaneous extraction of 372 renal and proximal ureteral calculi was performed under fluoroscopic control in 202 consecutive patients. In 193 kidneys (90%) removal of stones was performed under fluoroscopic control only and in 10% initial ultrasonic disintegration was used. A completely stone free kidney was achieved in 74%. If successful outcome is defined as no stones or residual fragments less than 5 mm, the success rate was 91%. With a mean size of 10.3 mm 259 intact stones were extracted under fluoroscopic control. Open surgery was performed in 13 of 202 patients, in 10 of these cases due to unsuccessful removal of an impacted ureteral stone. Complications occurred in 16%, none of them were serious. Open intervention became necessary in 2 patients. Bleeding which required blood transfusion occurred once. Percutaneous renal stone extraction under fluoroscopy is safe and useful in selected patients when ESWL can be expected to produce less favourable results. The ability to perform this technique should therefore be well maintained.     

The treatment of staghorn calculi

Between May 1989 and November 1991, 19 staghorn calculi were treated by extracorporeal shock-wave lithotripsy (ESWL) with a Dornier MFL 5000 or Northgate SD-3. The 19 calculi were evaluated. Treatment was with monotherapy by ESWL in 9, combination percutaneous nephrolithotomy (PNL)-ESWL in 9, and nephrostomy in 1. Of the patients, 14 had a cross stent catheter pre-ESWL treatment to improve fragment evacuation. Radiologic follow up in 19 kidneys revealed that 57.9% were stone free. We arbitrarily separated our cases into 3 groups: struvite renal calculi, calcium carbonate calculi and others. Result of stone-free rate was 100% for stones consisting of struvite, and 14. 3% for stones consisting of calcium carbonate. In our opinion, the best indication of monotherapy by ESWL is for staghorn calculi, which consists of struvite, without marked dilation of pelvis and calyces.     

Emergency laparoscopy for abdominal stab wounds

BACKGROUND: The roles of endoscopy and surgery in the management of Ascaris lumbricoides affecting the hepatobiliary and pancreatic system in adults were determined. METHODS: All patients undergoing endoscopic retrograde pancreatography for ascariasis of the biliary or pancreatic system unresponsive to standard medical therapy were analysed. Worms were extracted using snare, Dormia basket or biopsy forceps. Success was defined as clearance of worms and eradication of symptoms. RESULTS: Endoscopic extraction was performed in 25 patients with success in 19. Failures occurred in one patient with Ascaris in the gallbladder, and in five with associated strictures or stones. All six patients were treated successfully by surgery. CONCLUSION: Endoscopy was successful in the treatment of Ascaris infestation resistant to medical therapy in 19 of 25 patients. Surgery remains important in the management of infestations complicated by biliary or pancreatic strictures and stones, or worms in the gallbladder.     

Endoscopic lithotomy of common bile duct stones with sublingual nitroglycerin and guidewire

OBJECTIVE: In 21 patients, our objective was the endoscopic removal of common bile duct stones by sphincter dilation with the application of sublingual nitroglycerin. METHODS: Nitroglycerin 0.3-0.6 mg was needed for proper dilation of the orifice and for successful cannulation of the Dormia basket into the bile duct. Cannulation of the Dormia basket was simplified by placing the guidewire in the common bile duct beforehand. Because of possible stone impaction, a mechanical lithotriptor was applied smoothly in two patients. RESULTS: Complete stone removal was successful in 18 of the 21 (86%) patients. One patient who developed a mild form of acute pancreatitis recovered in a few days by conservative management with drip infusion of protease inhibitor. Blood pressure dropped transiently in a patient receiving nitroglycerin, but the general condition of the patient was stable. CONCLUSIONS: This procedure was found to be safe, easy, and effective in extracting common bile duct stones.