Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study

The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnoses at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed. Use of biliary drainage was liberal. A completion cholangiogram was obtained for all patients. Laparoscopic treatment of CBD stones was successful in 96 patients: after TC-CBDE in 63 and after D-CBDE in 33. Four operations were converted to open surgery (4%). Retained stones, observed in five patients, were treated by ES in two cases and by percutaneous endoscopic/fluoroscopic lithotripsy in three. Minor morbidity included biloma (n = 2), port site infection (n = 2), and subumbilical hematoma (n = 1). Major morbidity was bile leakage from the cystic duct stump in two cases due to clips or transcystic duct drainage displacement, respectively. One elderly, high risk patient died after being referred for several failed attempts of endoscopic clearance; she died from cardiogenic shock 3 days after successful laparoscopic treatment. Laparoscopic CBD exploration is feasible and safe in most patients, with short-term results that compare favorably with the results of sequential ES/LC reported in the literature.     

Metal stents for benign and malignant bile duct strictures stents for benign and malignant bile duct strictures

Self-expanding metal stents provide a much larger diameter--up to 30 Fr--in comparison with plastic stents, which have a maximum diameter of 12 Fr. Although they have consequently been found to be far superior to plastic prostheses, they are not removable, and in benign strictures metal stents should therefore be used only in exceptional situations. Metal stents are the preferred mode of treatment for malignant strictures, provided the patient has a sufficient life expectancy although this is hard to predict in individual cases. Metal stents also seem to be superior in hilar malignancy, but the data here are limited. Future developments may include the use of covered metal stents and self-expanding stents (made of plastic or other materials) that are removable or self-dissolving.     

Single-specimen bile cytology: a prospective study of 80 patients with obstructive jaundice

The interaction between drugs (tolbutamide (1), 1-butyl-3-(methylsulfonyl)urea (2)) and human serum albumin (3) was investigated by equilibrium dialysis and NMR spectroscopy. The binding of 1 and 2 to 3 was concluded to be hydrophobic and hydrophilic, respectively, on the basis of the dependence of the binding constants on temperature, ionic strength, and chain length of fatty acid added. In 1H-NMR spectra of 1, there were no significant shifts with change in concentration or addition of 3. The spin-lattice relaxation time (T1) and spin-spin relaxation rate (1/T2) of the respective protons of 1 were independent of concentration, but depended on the concentration of 3 added. The binding position was determined from the ratio of 1/T2 of 1 bound to 3 and free 1. 1 and 2 were found to bind to 3 through the tolyl group and sulfonylurea group, respectively. The binding property of 1 was considered to be governed by the competition between the hydrophobic effect of the tolyl group and the hydrophilic effect of the sulfonylurea group in the molecule.     

Value of dacryocystography in localization diagnosis of lacrimal duct stenosis

SETTING: Department of internal medicine in a general hospital in Rio de Janeiro, Brazil, which provides secondary care to the poor population. OBJECTIVE: The aim of this study was to evaluate the prevalence of human immunodeficiency virus (HIV) infection in patients with pleural tuberculosis (TB) and to compare its manifestations in HIV-negative and HIV-infected patients. DESIGN: Cross-sectional study. METHODS: Forty-three patients with a final diagnosis of pleural TB were submitted to HIV testing (ELISA), chest X-ray, and thoracentesis for biochemical, cytological and bacteriological analysis. Pleural tissue was obtained in 36 patients for histopathological examination. PPD testing was performed in 29 patients. Whenever productive cough was present, sputum acid-fast smears and culture for Mycobacterium tuberculosis were performed. RESULTS: The HIV prevalence was high (30%). TB symptoms were similar in both groups. Atypical radiological aspects were observed in HIV-infected patients with concurrent pulmonary TB (P = 0.03). Pleural fluid, tissue aspects and PPD testing were comparable in both groups. CONCLUSION: Only atypical radiographic patterns in patients with concurrent pulmonary TB were indicative of HIV infection. Therefore, a high index of suspicion is necessary for the early recognition of HIV/TB co-infection. We suggest that all patients presenting with pleural TB should be screened for anti-HIV antibodies.     

Value of bronchoscopic pneumonia diagnosis: prospective study

The frequent detection of benign liver lesions during ultrasound routine examination and a possible curative therapy of early detected malignant tumors require a reliable method of differentiation. Conventional gray-scale ultrasound, according to this problem, has been extended by the Duplex technique and color Doppler ultrasound. Measurement of blood flow velocity by Doppler in the center and at the periphery of liver lesions is not reliable enough to distinguish between benign and malignant lesions. Color Doppler ultrasound possesses some reliable criteria for differentiation. A central spot could be detected in 2 out of 12 hemangiomas, a giant spot in 1 out of 3 giant cavernous hemangiomas. The halo sign without detectable blood flow is considered to be specific for malignancy. We found this sign in 26 out of 81 malignant liver lesions and only in one benign lesion (sensitivity 32%, specificity 97%). The vascularization of focal liver lesions is excellently demonstrated with color Doppler ultrasound. This is very helpful for the diagnosis (e.g. "chaotic blood vessel architecture' in malignant tumors) and for the therapy of focal liver lesions (e.g. follow-up examinations after chemotherapy or chemoembolization). Therefore, application of Duplex and color Doppler ultrasound is highly recommended as a noninvasive diagnostic method of first choice for unknown liver lesions.     

Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush

A cigarette which heats rather than burns tobacco (Premier) was introduced in 1988, but was unacceptable due to unpleasant taste and low nicotine intake. We examined availability of nicotine from a new version (Eclipse), in the same four subjects as our earlier Premier study. Average blood nicotine boosts of 23.7 and 17.8 ng/ml were obtained from smoking a first and second Eclipse. This substantially exceeds intake from Premier (boost 13 ng/ml) and that obtained by heavy smokers from conventional brands (boost 12-15 ng/ml). Eclipse (or similar product) may be the best option for averting Peto's dire warnings of rising millions of annual smoking deaths in the 2020s, and its potential for large-scale, long-term switching warrants further study.     

Retained stones in the common bile duct: results of management

Seventeen patients underwent treatment for retained common bile duct stones. In 7 patients the stones were removed via a T-tube tract using steerable catheters while 5 patients underwent ERCP and sphincterotomy and 5 underwent surgical re-exploration. Considering morbidity, mortality, success rate and patients' stay in the hospital, non-operative modalities should be the treatment of choice for retained common bile duct stones.     

Current results of endoscopic sphincterotomy for lithiasis of the common bile duct

Between January 1989 and June 1990, endoscopic sphincterotomy was performed in 308 consecutive patients with common bile duct stones (mean age: 74 years). Complete clearance of common bile duct was achieved at the first attempt in 65% of cases. This rate was significantly related to the size and the number of biliary stones. The success rate reached 97 percent after repeated endoscopic sessions (127 patients), mechanical lithotripsy (20 patients), extracorporeal or intracorporeal lithotripsy (18 and 11 patients, respectively). During the month following the endoscopic sphincterotomy, 39 patients (13%) developed one or more complications and 11 patients (3.7%) died. The complication rate was related to the time elapsed between biliary opacification and endoscopic sphincterotomy (P = 0.04) and between endoscopic sphincterotomy and total common bile duct clearance (P = 0.0007). No patient younger than 75 years died, but death occurred in 4.5% of the patients older than 75 years. Thirty patients (10%) developed endoscopic sphincterotomy-related complications. Cholangitis and bleeding were the most frequent complications (4 and 2%, respectively). Cholangitis occurred more frequently among the patients older than 75 (P < 0.05) or when transhepatic guided endoscopic sphincterotomy or intracorporeal lithotripsy was used (P < 0.005). Cholangitis led to death in 2 patients, 86 and 87 years old (0.7%). Endoscopic sphincterotomy related complications developed within 48 hours in all but 4 patients (2 patients with pancreatitis and 2 patients with cholecystitis).     

Diffuse bile duct papillomatosis: high rate of recurrence and risk of malignant transformation

Magnesium (Mg2+) is an important cofactor in many intracellular biochemical reactions; however, its role in the signal transduction pathways of pulmonary vascular smooth muscle is poorly defined. The purpose of this study was to examine the following mechanisms of pulmonary vascular smooth relaxation in the presence and in the absence of Mg2+: (1) Endothelium-dependent cGMP-mediated relaxation (response to acetylcholine, ACh), (2) Endothelium-independent cGMP-mediated relaxation (response to sodium nitroprusside, SNP), and (3) beta2-adrenergic cAMP-mediated relaxation (response to isoproterenol, ISO). Dose response curves were generated in isolated rat pulmonary artery rings preconstricted with phenylephrine. With Mg2+, ACh 10(-6) M produced complete ring relaxation but in the absence of Mg2+, only 66% relaxation was produced in response to ACh 10(-6) M (P < 0.05). On the other hand, endothelium-independent cGMP-mediated relaxation (response SNP) was not impaired without Mg2+. Beta2-adrenergic cAMP-mediated relaxation was also impaired in the absence of Mg2+. In the presence of Mg2+, ISO 10(-6) M produced complete relaxation but without Mg2+, only 30% relaxation was produced (P < 0.05). We conclude that Mg2+ is essential for cGMP- and cAMP-mediated mechanisms of pulmonary vasorelaxation. Hypomagnesemia should be avoided to prevent pulmonary vasomotor dysfunction.     

No treatment for low-risk thrombocythaemia: results from a prospective study

Essential thrombocythaemia (ET) is a chronic myeloproliferative disorder characterized by the occurrence of thromboembolic episodes, particularly in patients aged > 60 years or with a previous history of thrombosis, and/or by haemorrhages in patients with an exceedingly high platelet count. In these subgroups of patients the use of cytoreductive therapy is beneficial in terms of risk/benefit ratio. Only limited anecdotal data are available on the thrombotic or haemorrhagic risk and survival in young asymptomatic ET patients with a platelet count < 1500 x 10(9)/l. Therefore the optimal management of these patients is unknown. To assess the incidence of thrombosis and haemorrhages in this group of patients we carried out a prospective observational study in a cohort of 65 patients with ET, aged < 60 years, with no history of thrombosis or haemorrhage and platelet count < 1500 x 10(9)/l, and in 65 age- and sex-matched controls. Patients were not treated with cytoreductive therapy until the occurrence of thrombosis or haemorrhage. Arterial or venous thrombotic events were objectively documented both in cases and in controls. The median follow-up was 4.1 years, with an incidence of thrombosis in patients and controls of 1.91 and 1.50 cases/100 patient-years, respectively. The age- and sex-adjusted risk rate ratio was 1.43 (95% CI 0.37-5.4). Only three minor haemorrhagic episodes occurred in patients, with an incidence of 1.12 cases/100 patient-years. Pregnancy and surgery were not associated with thrombosis in these patients. We conclude that the thrombotic risk in young ET patients, with no thrombotic history and a platelet count < 1500 x 10(9)/l, is not increased compared to the normal population and that a conservative therapeutic approach should therefore be considered in these patients.     

Intraductal ultrasonography for the diagnosis of proximal invasion in extrahepatic bile duct cancer

Intraductal ultrasonography (IDUS) was performed on 22 patients with extrahepatic bile duct cancer, using the percutaneous transhepatic approach. Intraductal ultrasonography images of the proximal invasion of the bile duct cancer were defined. In addition, three patients were examined through the peroral approach, to try to diagnose whether or not the cancer invaded to the bifurcation of the hepatic duct. Intraductal ultrasonography images obtained through the percutaneous approach could be classified into three patterns, types 1, 2 and 3, according to the features of the interior surface of the bile duct and the thickness of the bile duct wall. Type 1 images, which did not show protrusions into the bile duct lumen and had a bile duct wall of even thickness, were not likely to show bile duct cancer. Type 2 images showed protrusions of the tumour into the bile duct lumen and the surfaces of the protrusions were irregular. Type 3 images showed single or multiple low echoic papillary masses in the bile duct. Using the peroral technique, we considered all three cases to be type 1 and could diagnose that cancer had not invaded to the bifurcation of the hepatic ducts. From the results of this study, we suggest that proximal invasion of extrahepatic bile duct cancer can be diagnosed using IDUS.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Use of bile cytology for early diagnosis of complications in orthotopic liver transplantation

The purpose of this project was to develop rapport with a Chinese Community Association and then establish preventive diabetic and hypertension programs with the Chinese in Chinatown, Hawaii. Subjects were recruited from this Chinese Community Association. Two hundred Chinese responded to the invitation. Among these, 75 individuals had either Type 2 diabetes, hypertension or both. Thirty-six males and 39 females ranging in age from 51 years old to 96 years old (Mean = 71.76, SD = 9.58) participated. Surveys and educational programs were carried out in Chinese. Results were described in terms of quantitative measures (family support and health outcomes) and qualitative experiences (case studies). Eighty percent of participants had decreased their diastolic blood pressure from above 95 mmHg to below 90 mmHg and systolic blood pressure from above 155 mmHg to below 140 mmHg. Ninety-five (n = 71) percent of participants had maintained their glucose level within the 90 mg/dL to 150 mg/dL range with a mean reduction of 57.86 mg/dL in one year. The hardest thing for families was the glucose self-monitoring. Case studies suggested that open-minded active listening and persistence formed the basis for developing a culturally sensitive community-based self management program for chronic diseases. Collaboration among the community, public health nurses, and diabetes nurse educators facilitated the process of community education and health promotion.     

The AutoPap system for primary screening in cervical cytology. Comparing the results of a prospective, intended-use study with routine manual practice

OBJECTIVE: To evaluate the effectiveness of the AutoPap System in detecting abnormal and normal cervical smears when used in a primary screening/quality control mode, as compared with currently established laboratory practices. STUDY DESIGN: Slides were obtained prospectively and were initially processed in the routine fashion with cytotechnologist screening followed by 10% random quality control rescreening. Slides were then processed on the AutoPap System and allocated into the following groups: (1) approximately 25% of the lowest-ranking slides were placed in the laboratory's archives as within normal limits; (2) the remaining approximately 75% of slides were subjected to manual screening. Approximately 15% of the highest-ranking slides in this group underwent quality control rescreening. For each slide needing manual screening, the cytotechnologist was supplied with a report giving the ranking score of that slide. All discrepant slides for either adequacy or diagnosis were subjected to a truth-determination process. The results obtained from the two arms of the protocol were then compared. RESULTS: The AutoPap System-assisted arm of the study was superior to the current practice arm for the identification of abnormal slides at the level of atypical squamous cells of undetermined significance and above (ASCUS+), low grade squamous intraepithelial lesion (LSIL) and higher LSIL+. AutoPap System-assisted practice was equivalent to current practice for the identification of unsatisfactory and satisfactory but limited by slides. All results showed statistical significance. In addition, AutoPap System-assisted practice in the study indicated improved specificity of diagnosis. CONCLUSION: AutoPap System-assisted practice shows superior sensitivity and specificity when compared to current practice. Its clinical use as a primary screening device should improve the overall practice of cervical cytology as well as provide potential enhancement in overall laboratory productivity.     

Pathological study on the metastatic routes of bile duct carcinoma

Multiple staining was performed on resected tumors. Samples after curative surgery in 40 cases of bile duct carcinoma for observation of tumor blood vessel density (TVD), and perineural invasion index (PNI). Lymphatic invasion was found in 29 cases (72.5%), blood vessel invasion in 31 (77.5%), and PNI in 33 (82.5%). TVD and PNI were positively correlated with metastasis. Three years after operation, the recurrent rate was 100%, with an averaging recurrent time of 9.6 months in the metastatic group in contrast to 64.3% and 17.5 months in those without metastasis.     

Usefulness of simple endoscopic aspiration cytology of pancreatic juice for diagnosis of early pancreatic neoplasm. A prospective study

For detection of early cancer of the pancreas, endoscopic aspiration cytology of pancreatic juice without endoscopic retrograde pancreatography was performed in 64 consecutive outpatients who had symptoms or findings that suggested pancreatic disease. Patients with positive or suspicious cytologic results or abnormal US findings were admitted and underwent detailed examinations. Positive and suspicious cytologic results were obtained in 2 and 10 patients, respectively. Of those with positive and suspicious cytologic results, two, and one patient, respectively, were ultimately found to have pancreatic neoplasms. Of these three resected specimens, one was in situ carcinoma and two presented marked atypia. All patients were alive with no evidence of recurrence. No further cases of pancreatic neoplasm were found. Complications from the procedure did not develop in any patient. This technique is useful in the diagnosis of early neoplasms of the pancreas, because it is simple and safe to perform for outpatients.