Percutaneous transhepatic sphincterotomy--a report on 3 cases

The technique of percutaneous transhepatic sphincterotomy is described. This procedure was employed in 3 patients with common bile duct (CBD) stones in whom a previous attempted endoscopic procedure had failed for anatomical reasons (a Billroth II gastric resection or a partial gastric resection with Braun anastomosis). Complete immediate success was obtained in all 3 patients. Furthermore, no major complications occurred during transhepatic treatment. The authors suggest that PTS be employed electively in patients with diseases of the biliary tree in whom the endoscopic approach fails.

[Percutaneous transhepatic sphincterotomy]

The authors describe the technique employed for percutaneous transhepatic sphincterotomy as performed on 3 patients with common bile duct (CBD) stones. In all patients, previous endoscopic attempt had failed for anatomical reasons (Billroth II gastric resection or partial gastric resection with Brown anastomosis), and the ampulla could not be correctly incannulated with the sphincterotome. In all patients endoscopy was useful to check the position of the diathermic loop inserted percutaneously. Complete and immediate success was obtained in all 3 cases. No major complications occurred during transhepatic treatment. To date, 1 recurrence has been observed, and the patient has been retreated with bilioplasty. All patients were followed after 5-6 months with US, plain X-rays of the abdomen and blood tests (gamma Gt, alkaline phosphatase, and bilirubinemia). The authors suggest that percutaneous transhepatic sphincterotomy be employed electively in patients with biliary tree diseases in case the endoscopic approach failes.

[CT of the operated liver]

The Authors examine retrospectively 93 CT exams performed on 60 patients submitted to hepatic surgery both for malignant and benign lesions. It is concluded that CT, if performed correctly, is helpful in recognizing both complications and recurrences.

[Percutaneous transhepatic bilioplasty: long-term results]

We report the results of a long-term follow-up of 40/101 patients with benign biliary strictures treated with percutaneous balloon dilatation (PBD) at the Radiology Department of the University of Turin, from March 1983 to March 1990. We excluded all the patients who were not followed or treated after June 1988, being their follow-up shorter than 18 months. All patients underwent accurate clinical, biological (AST, ALT, gammaGT, alcaline phosphatase) and US controls. Mean follow-up was 33.5 months. Mean success rate was 75% in strictures of bilioenteric anastomosis, 86% in iatrogenic strictures of the common bile duct, 65% in sclerosing cholangitis, 80% in papillary strictures in which endoscopic treatment had not been possible for anatomical reasons. Our results, compared to the most important radiological and surgical series, show PBD to have lower morbidity than surgery and no mortality during the so-called peroperative period (30 days). Moreover, in case of recurrences, PBD can be repeated without further complications and does not affect eventual surgery.

Percutaneous removal of biliary stones

Since 1983 we have performed percutaneous treatment of biliary lithiasis in 97 patients. Previous retrograde endoscopic procedures were incomplete or infeasible in all patients. Immediate results were excellent resulting in complete resolution of lithiasis in 89 of 97 patients (92%). In 4 patients (4%) partial success was obtained (symptoms subsided although there were nonobstructing residual stones). Percutaneous treatment failed in 1 patient (1%). Three patients died. Complications occurred in 14 of 97 patients (14%) and mortality at 30 days was 3%. Long-term results were evaluated in 71 patients who had a least a 6-month follow-up (mean 31 months and range 6-78 months). Eight of 71 patients (11%) had recurrence of stones and 7 of these were successfully retreated transhepatically. Percutaneous removal of biliary stones is efficacious because it has a high cure rate, a low complication rate, and a mortality rate that compares favorably to that of surgery even though the patients are usually older and in poorer general condition.

[The results of the percutaneous treatment of obstructed ureteral diversions. The technic and personal experience in 46 cases]

The ureteral diversions performed in the treatment of mainly malignant lesions of the pelvis with ureteral or bladder involvement may be complicated by strictures and cause hydronephrosis, pyelonephritis and lithiasis. Personal experience and technique are described as applied in the percutaneous antegrade drainage of different urinary diversions (cutaneous ureterostomy, ileal conduit, colon conduit, ureterosigmoidostomy, ureterocolostomy) in 46 patients. The good results obtained (70% success rate), the absence of major complications, the low cost and the little patient discomfort confirm the leading role of percutaneous treatment versus surgery in obstructed urinary diversions.

Percutaneous treatment (including pseudocystogastrostomy) of 74 pancreatic pseudocysts

Percutaneous treatment of 74 pancreatic pseudocysts was performed in 70 patients. Initially, single-step fine-needle aspiration was used and had a 71% (15 of 21 patients) recurrence rate. Better results were obtained with prolonged extragastric or transgastric external drainage, performed in 43 patients (46 pseudocysts). Two patients in this series (4.7%) required urgent surgery: one for gastric wall hematoma and the other for intracystic hemorrhage. Three patients (7.0%) were lost to follow-up. The recurrence rate in the remaining 38 patients (41 pseudocysts) was 23.7% (nine of 38 patients). Since 1986, seven patients have been treated with percutaneous pseudocystogastrostomy (one also underwent external drainage and is thus included in the previous series, too) after placement of a transgastric drainage catheter, with no recurrence (follow-up, 2-26 months). It is concluded that transgastric drainage should be performed whenever the anatomic situation is favorable and that a pseudocystogastric stent should be placed in these patients whenever secretions are still abundant after 7-10 days.

[Use of an electrohydraulic lithotripter in the percutaneous treatment of biliary tract calculi. The preliminary clinical experience in 4 cases]

The results are reported of percutaneous transhepatic treatment with an electrohydraulic lithotripter in 4 cases of bile duct lithiasis. An electric discharge, generated by a bipolar electrode, gives origin to high-amplitude and low-frequency shock waves in the fluid medium which cause the stone to fragment. Complete resolution of lithiasis was obtained in 2 patients with intrahepatic calculosis. In the other 2 cases of massive lithiasis of intra and extrahepatic bile ducts the treatment, however incomplete, proved to be useful, as the biliary flux was rehabilitated and clinical symptoms disappeared. No relevant immediate side-effects were observed, except for well-tolerated pain during the discharges, and transitory hemobilia which solved spontaneously. No complications were observed in this series of patients. Electrohydraulic lithotripsy proves thus to be useful for supporting standard interventional radiology techniques in very complex cases of intra- and extrahepatic bile duct stones.

[Use of a high-frequency pulsed hydro jet in the percutaneous treatment of biliary tract calculi]

A new system (Broxo Jet) is described for bile duct washing to complete mechanical maneuvers during nonsurgical treatment of intra- and extrahepatic calculi. The device is connected either to a percutaneous biliary drainage catheter or to a fibroscope, and provides a high-frequency pulsating water jet. Seven patients with intra- and extrahepatic bile duct stones were treated with this new technique. Complete resolution was observed in 4/7 cases. The water jet allows the mobilization of even the biggest stones and the elimination of stone debris, as well as the removing of fibrin and necrotic tissue fragments tightly attached to bile duct walls in subacute cholangitis.

Arteriovenous anastomoses' function and Raynaud's phenomenon

By intrabrachial artery injections of a bolus of human albumin microspheres labeled with 99mTc in patients with primary or secondary Raynaud's phenomenon (RP) and in a group of healthy volunteers, the authors developed a method of detecting the patency rate of arteriovenous anastomoses (AVA) in the hand, after local heat and cold stimulation, by quantifying the radioactivity of the lungs expressed as a percentage of an intravenously injected radionuclide dose. With strain gauge plethysmography, simultaneous changes in the digital total (DTF) flow were also measured. After exposure of fingers to cold, 25 of 26 subjects had a clear reduction in both DTF and the AVA patency rate (APR) in comparison with the corresponding heat values. The RP patients, in particular, showed a statistically significant reduction in DTF (P less than 0.001) and in APR (P less than 0.001). These results appear to be consistent with the onset of critically reduced patency of the AVA of the hand during the ischemic phase of RP.

[Percutaneous transhepatic cholangioscopy with an 8.5 French endoscopic catheter. Technic and preliminary results]

The authors describe their preliminary personal experience in bile duct endoscopy with a very small diameter catheter (8.5 F) much less traumatic than traditional choledochoscope (15 F). The CE can be reutilized after sterilization; an angiographic guide wire up to 0.042" can be introduced in the operating channel. The CE was used in 3 patients with uncertain cholangiographic diagnosis. Instrument introduction is facilitated when simple technical manoeuvres are followed; there were no difficulties in report interpretation. An experienced interventional radiologist and an endoscopist are needed to handle the instrument. Cytologic sample, biopsy and gallstone lithotomy instruments will increase diagnostic and therapeutic possibilities of the system: for this a wider CE use in the immediate future to complete interventional radiology manoeuvres can be expected.

[Percutaneous treatment of ureteral obstructions with an internal double-J prosthesis. Initial long-term results]

Percutaneous insertion of ureteral stents is a widely accepted method for ureteral obstructions treatment. From 1981 to february 1986, we introduced 78 endoprostheses in 60 patients. Fifty-six with malignant tumours and 4 with benign stenoses. In 48 of those 60 patients follow-up is complete. In the patients with malignant obstructions the mean time of survival was 198 days. Twelve patients were still alive in february 1986, with a mean time of survival over 300 days. In 12 patients (25%) the stent became obstructed in a mean time of 96.8 days. The placement of ureteral stents offers an alternative treatment to the palliative urologic surgery.

[Percutaneous pancreato-gastrostomy in the treatment of pancreatic pseudocysts. Presentation of 2 cases]

The authors describe a new method for the treatment of pancreatic pseudocysts using a personal technique: the percutaneous pseudocystogastrostomy. Under US and fluoroscopy guidance at first a percutaneous drainage is introduced in the pseudocyst using a transgastric approach. For seven days the drainage catheter is flushed with antibiotic solution (Rifocin), then under fluoroscopy and endoscopy guidance doubled pig-tail catheter is placed with its curlend ends in the lumen of the stomach and pseudocyst respectively. After 60 days the double pig-tail catheter is removed endoscopically. Two patients with pancreatic pseudocysts were treated successful by this method. No complications or recurrences were observed.

[Transhepatic percutaneous drainage of the bile with anterior entry in the ducts of the left lobe. Personal experience in 28 cases]

In 28 selected cases (right hepatic lobe lobectomy or atrophy; prevalent dilatation of the left bile ducts; necessary double drainage in the obstruction of the right and left hepatic ducts confluence; etc.) the percutaneous transhepatic cholangiography and the biliary drainage were performed by a left-lobe subxiphoid approach, rather than the currently popular right-lobe approach. By means of this technique some treatments (biliary endoprosthesis insertion, gallstones removal or dissolution, bilioplasty) were executed; these treatments were impossible or very hard to realize by the right-lobe approach. No failures or complications occurred.

Methyl-TER-butyl ether (MTBE) and endoscopic sphincterotomy. A possible solution for dissolving gallstones

MTBE was instilled in 6 cases of lithiasis (1 intrahepatic, 5 giant common bile duct stones following EPT). The nasobiliary route (3 cases) and a percutaneous biliary drain (3 cases) were used for this purpose. Complete stone dissolution was achieved in four cases. In the other two, volume reduction was sufficient to allow spontaneous elimination after EPT. A full clinical recovery was obtained in all cases. Further investigation is required in cases of intrahepatic and common bile duct stones when their removal by EPT is not enough to lead to clinical resolution. Follow-up is indispensable.

[Percutaneous transhepatic treatment of massive intrahepatic calculosis secondary to stenosis of a biliary-digestive anastomosis]

The authors describe a successful technique for the percutaneous treatment of intrahepatic gallstones from a stenotic Rouxen-Y hepaticojejunostomy. A bilioplasty of the anastomosis with wash-out of the biliary tract has been achieved through two percutaneous external biliary drainage catheters, one inserted in the right biliary ducts and the other placed in the left biliary ducts by means of an anterior approach.

[Use of the one-stick introducer system set in the pyelostomy as a 1st stage of pyelo-uretero-lithotripsy (PUL)]

In the last few years there has been an increasing diffusion of endoscopic percutaneous trans-lumbar lithotripsy as a treatment for kidney stones. This technique requires an adequate pyelostomic approach. The authors at this purpose suggest the utilisation of the "One Stick Introducer System Set", that has been created for the biliary tree catheterism as this set is easy to use and rarely traumatic for the patient.

[Percutaneous drainage of abscess cavities. Technic of insertion of 2 small-caliber catheters with a single puncture]

The authors describe their experience in the utilisation of vessel dilators provided with coaxial sheath to insert, with a single puncture two drainage catheters of stated caliber in abscessual cavities.

[Percutaneous correction of benign stenosis of the bile ducts and biliary-digestive anastomosis. Percutaneous transhepatic biliplasty]

The authors describe their experience in nine cases of transhepatic percutaneous dilatation of bile ducts benign stenosis by a Gruntzig catheter inflated at the stenotic level in order to stretch the sclerotic lesion. Despite the brief follow-up, the first results are satisfying; for this reason percutaneous dilatation of bile ducts benign stenosis could be a new procedure in the treatment of these lesions in selected cases.

A study of the semeiological reliability of dorsalis pedis artery and posterior tibial artery in the diagnosis of lower limb arterial occlusive disease

Routine diagnosis of suspected occlusive arterial disease of the lower limbs are often based on the pulse absence at the dorsalis pedis artery. However many of these diagnoses are not confirmed after more thorough tests, and this fact arises the problem of the semeiological reliability of the above mentioned artery. Researches carried out by several authors in normal individuals on the dorsalis pedis artery yielded controversial results. Three hundred-sixty subjects free of occlusive arterial disease were then examined by means of clinical and Doppler investigation in order to assess the semeiological reliability of the dorsalis pedis artery in the diagnosis of occlusive arteriopathy of lower limbs, when compared to the posterior tibial one. The conclusion is drawn that a greater semeiological reliability must be attributed to the latter, due to its lesser "absence" incidence.

Sensitization of mice to methylphenidate

Mice that received five daily injection of methylphenidate HCl, 10-75 mg/kg, showed an increased running response to methylphenidate, cocaine, and amphetamine. Sensitization to methylphenidate persisted for at least 50 days. Repeated IP injections of methylphenidate into mice with unilateral striatal lesions increased ipsilateral turning in response to methylphenidate, but decreased contralateral turning after apomorphine. The climbing response to apomorphine in intact, methylphenidate-sensitized mice was also decreased. There was no change in either basal or dopamine-stimulated adenyl cyclase activity in the striata of sensitized mice, but there was a 36% increase in the specific binding of haloperidol. The rate of turnover of striatal dopamine was increased in sensitized mice. These results suggest that pretreatment with methylphenidate may alter the sensitivity of presynaptic dopamine receptors.