Utility and limitations of intraductal ultrasonography in distinguishing longitudinal cancer extension along the bile duct from inflammatory wall thickening

BACKGROUND

We wanted to distinguish wall thickening caused by cancer extension from that caused by inflammation after placing a biliary catheter on intraductal ultrasonography (IDUS).

METHODS

We studied 51 patients with biliary tract malignancies who had undergone placement of biliary drainage catheters before IDUS. IDUS was performed from a transhepatic (n = 34) or transpapillary (n = 17) route with a thin-caliber ultrasonic probe (2.0 mm in diameter, 20-MHz frequency). At the hepatic side of the tumor, the thickness, asymmetry, outer margin, inner margin, and internal echoes of the bile duct wall were reviewed prospectively and correlated with the histologic findings of the surgically resected specimens in all cases.

RESULTS

When IDUS showed wall thickening in a semicircular fashion, notched outer margin, rigid inner margin, papillary inner margin, and heterogeneous internal echoes, each finding had a positive predictive value for diagnosing cancer extension (100%, 100%, 83%, 100%, and 90%, respectively). When these factors were used as the diagnostic criteria of cancer extension, IDUS accurately demonstrated suitable surgical margins in 76% of all patients and 71% of patients with bile duct carcinoma.

CONCLUSION

Wall thickening in a semicircular fashion, notched outer margin, rigid or papillary inner margin, and heterogeneous internal echoes are specific for cancer extension. However, surgical margins can be inaccurately assessed in some patients.

Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up

BACKGROUND

Recurrent small bowel obstruction caused by postoperative adhesions has traditionally been treated by conventional laparotomy, but laparoscopic management of acute small bowel obstruction has been reported. The aim of this study was to assess the long-term efficacy and clinical outcome of laparoscopic adhesiolysis for recurrent small bowel obstruction.

METHODS

After conservative treatment, elective laparoscopic treatment was attempted in 17 patients hospitalized for recurrent small bowel obstruction after abdominal or pelvic surgery.

RESULTS

Postoperative adhesions were identified laparoscopically in all patients. Laparoscopic treatment was possible in 14 patients (82.4%). Conversion to laparotomy was required for 3 patients (17.6%) because of intestinal perforation (n = 1) or a convoluted mass of adherent bowel (n = 2). Long-term follow-up was possible in 16 patients. Two recurrences of small bowel obstructions were noted over a mean follow-up period of 61.7 months.

CONCLUSIONS

Laparoscopic adhesiolysis is a safe and effective treatment for recurrent small bowel obstruction. Conversion to laparotomy should be considered in patients with dense adhesions.

Intraductal ultrasonography for hepatocellular carcinoma with tumor thrombi in the bile duct: comparison with polypoid cholangiocarcinoma

BACKGROUND AND AIM

Tumor thrombi in the bile duct caused by hepatocellular carcinoma (HCC), and cholangiocarcinoma show polypoid lesions on cholangiographic findings. This study prospectively compared the images of intraductal ultrasonography between HCC and polypoid cholangiocarcinoma.

METHODS

In five patients with tumor thrombi in the bile duct caused by HCC, a 2.0 mm diameter ultrasonic probe with a frequency of 20 MHz was inserted into the bile duct via the transpapillary route (n = 4) or the transhepatic route (n = 1). The images were compared to that of 65 patients with cholangiocarcinoma.

RESULTS

In all patients with HCC, intraductal ultrasonography showed a 'polypoid tumor with a narrow base'. In 16 of 65 patients with cholangiocarcinoma, it showed a 'polypoid tumor with a narrow base'. When intraductal ultrasonography showed a 'polypoid tumor with a narrow base', the findings of a positive 'nodule within a nodule' (40 vs 0%; P < 0.05), and the absence of a 'papillary-surface pattern' (80 vs 13%; P < 0.05) were more highly associated with tumor thrombi caused by HCC than to polypoid-type cholangiocarcinoma.

CONCLUSIONS

Intraductal ultrasonography was useful to distinguish between tumor thrombi caused by HCC and polypoid-type cholangiocarcinoma.

Looping technique for transpapillary selective biopsy of the left hepatic duct

PURPOSE

Because biopsy forceps tend to turn towards the right hepatic duct during endoscopic retrograde cholangiopancreatography (ERCP), selective access to the left hepatic duct is difficult.

METHODS

In this study, we managed to insert biopsy forceps selectively into the left hepatic duct, by using a looping technique, in three patients. Biopsy forceps were inserted into the right hepatic duct by the conventional method. The elevator of the endoscope was kept down, and the shaft of the biopsy forceps was then advanced to the duodenal cavity until it formed a loop between the endoscope and the papilla. During the procedure, the tip of the forceps was kept at the hepatic hilus.

RESULTS

In this condition, we were able to slowly rotate the tip of the forceps and direct the forceps towards the left. Sufficient material from the left hepatic duct was obtained in all patients.

CONCLUSIONS

The looping technique was useful for selective access to the left hepatic duct.

Use of an autologous cortical bone graft sandwiched between two intervertebral spacers in posterior lumbar interbody fusion

Various intervertebral spacers with or without posterior instrumentation use pedicle screw fixation in posterior lumbar interbody fusion (PLIF). Recently we harvested an autologous cortical bone graft from a spinous process by en bloc resection and inserted it between two intervertebral spacers during PLIF surgery. Due to better balance, this procedure provides greater mechanical strength, larger contact area, and better bilateral restoration of disc height than PLIF using intervertebral spacers only, and there is no need to take a bone graft from the iliac crest. This technique appears to result in effective spinal fusion in PLIF surgery.

Acyclic neutral carrier-based polymer membrane electrode for a stimulant, phentermine

Groups of dioxadicarboxylic diamides, which were developed as potential ionophores for inorganic cations, were found to act as ionophores for a stimulant, phentermine. Especially, N,N-dioctadecyl-N',N'-dipropyl-3,6-dioxaoctanediamide, which was originally developed as a lead ionophore and is commercially available from Fluka as lead ionophore I, was suitable for making a phentermine-selective electrode. The electrode constructed using this ionophore and bis(2-ethylhexyl) sebacate as a solvent mediator in a poly(vinyl chloride) membrane matrix discriminated between phentermine and analogous compounds more effectively than an electrode based on dibenzo-18-crown-6, a representative ionophore for organic ammonium ions. Moreover, the present electrode showed remarkably little interference by inorganic cations, such as Na+ and K+, as well as lipophilic quaternary ammonium ions including (C2H5)4N+ and (C3H7)4N+. The electrode exhibited a near-Nernstian response to phentermine in the concentration range of 2 x 10(-6) to 1 x 10(-2) M with a slope of 54.8 mV per concentration decade in 0.1 M MgCl2. The lower limit of detection was 7 x 10(-7) M. This electrode was applied to determine phentermine in a cationic-exchange resin complex of this stimulant, which is the general dosage form in medical use.

Fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica

STUDY DESIGN

Report of seven patients with fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica, whose radiographic findings were negative and who experienced relief from sciatica immediately after the entrapment was released.

OBJECTIVES

To describe a new clinical entity of fibrous adhesive entrapment of lumbosacral nerve roots with negative radiographic findings.

SETTING

Orthopaedic department, Japan.

METHODS

Clinical evaluation and post-operative outcome in seven patients with entrapment of lumbosacral nerve roots because of fibrous adhesion confirmed intraoperatively.

RESULTS

Radiographic examinations by magnetic resonance imaging (MRI), myelography, and computed tomographic (CT) myelography demonstrated neither disc herniations nor spinal stenosis in all seven patients, and differential nerve root block was effective for relieving sciatica and low back pain. We confirmed, intraoperatively, entrapment of the nerve root by fibrous adhesion, and all seven patients were relieved from sciatica and low back pain postoperatively.

CONCLUSION

This study presented seven patients with sciatica caused by fibrous adhesive entrapment of lumbosacral nerve roots who underwent decompression and release of fibrous adhesion. Radiographic examinations, such as MRI, myelography and CT myelography, showed no compressive shadows and also differential nerve root block was effective for its diagnosis. This study seems to be the first report of patients with entrapment of lumbosacral nerve roots caused by fibrous adhesion, whose radiographic findings were negative.

Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty

BACKGROUND AND AIM

Endoscopic balloon sphincteroplasty (EBS) is an alternative to sphincterotomy for the treatment of bile duct stones. The purpose of this study was to determine if epinephrine irrigation of the papilla can prevent the pancreatic damage associated with EBS.

METHODS

A total of 173 patients with bile duct stones were treated by EBS. After conventional endoscopic retrograde cholangiography, EBS was performed by using a biliary dilatation catheter (balloon diameter: 8 mm). The duct was then cleared by using Dormia baskets or retrieval balloon catheters. Mechanical lithotripsy was performed before extraction when the stones were greater than 8 mm in diameter. In 81 patients, the dilated orifice was irrigated with 40-120 mL (50 +/- 37 mL) of 1:1,000,000 epinephrine (epinephrine group). In the remaining 92 patients, epinephrine irrigation was not performed (control group). Acute pancreatitis was defined by a serum amylase concentration fivefold greater than the upper limits of normal in association with abdominal pain.

RESULTS

After EBS, serum amylase concentrations were significantly increased in both groups. However, the degree of hyperamylasemia was less in the epinephrine group than in the control group (617 +/- 611 vs 1037 +/- 1491 IU/L, P < 0.05). The incidence of pancreatitis was lower in the epinephrine group than in the control group (1.2 vs 7.6%, P < 0.05).

CONCLUSIONS

Epinephrine irrigation is a simple and useful method to prevent post-EBS pancreatic damage and pancreatitis.

A new-type titanium intervertebral spacer and its insertion device used in posterior lumbar interbody fusion

We have recently developed a new-type trapezoid mesh cage (TPM cage) together with an insertion device, which for use as a new titanium mesh intervertebral spacer in posterior lumbar interbody fusion (PLIF). The TPM cage has sufficient mechanical strength, a large contact area that gives good long-term stability, and preserves the initial disc height to provide good balance. The insertion device for the TPM cage is useful not only for handling the implant but also for controlling the implant insertion direction. The TPM cage and its insertion device are promising for use in PLIF.

Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties

There have been several attempts to reduce postoperative blood loss in patients undergoing total arthroplasty. Benoni et al. reported the usefulness of tranexamic acid in total knee arthroplasty (TKA). We investigated its effect in TKA and total hip arthroplasty (THA). Blood loss was significantly reduced in patients given tranexamic acid in both the TKA and THA groups, and no severe complications, such as venous or pulmonary thrombosis, were noted in any of the patients who received the agent. Administration of tranexamic acid seems to be useful for reducing postoperative blood loss in TKA and THA.

Multiple bile duct biopsies using a sheath with a side port: usefulness of intraductal sonography

OBJECTIVE

We clarified the number of biopsies required to determine malignancy of the biliary tract on the basis of the type of bile duct tumor.

SUBJECTS AND METHODS

Patients with a biliary tract malignancy (n = 33) and a benign biliary stenosis (n = 3) underwent biopsy via the percutaneous transhepatic route. We performed intraductal sonography using a 20-MHz probe with a 2.0-mm diameter. The sonographic findings were prospectively classified as polypoid, circular, or semicircular. The tip of a long 9-French sheath with a side port was wedged into the stenosis, and six specimens were obtained with a 1.8-mm-diameter forceps with serrated cups.

RESULTS

When cholangiography or intraductal sonography showed a polypoid lesion, the sensitivity of two biopsies was 100% (6/6). When cholangiography showed a stenotic lesion, the sensitivity of nine biopsies (96%, 26/27) was superior to that of two biopsies (74%, 20/27; p < 0.05). When intraductal sonography showed a circular lesion, the sensitivity of three biopsies (100%, 14/14) was superior to that of a single biopsy (64%, 9/14; p < 0.05). When it showed a semicircular lesion, the sensitivity of nine biopsies (92%, 12/13) was superior to that of two biopsies (54%, 7/13; p < 0.05).

CONCLUSION

Bile duct biopsy using a sheath with a side port has a high sensitivity. However, the number of biopsies required depends on the cholangioscopic and intraductal sonographic appearance of the tumor.

Transpapillary intraductal US prior to biliary drainage in the assessment of longitudinal spread of extrahepatic bile duct carcinoma

BACKGROUND

The utility of intraductal US via the transpapillary route prior to biliary drainage in the assessment of longitudinal extension of extrahepatic bile duct carcinoma was investigated.

METHODS

In 19 patients with extrahepatic bile duct carcinoma who underwent surgical resection, an ultrasonic probe (diameter, 2.0 mm; frequency, 20 MHz) was inserted into the bile duct via the transpapillary route prior to biliary drainage. Longitudinal cancer extension along the bile duct was prospectively determined and compared with the histologic findings in the resected specimens.

RESULTS

Results on the hepatic side were as follows: Intraductal US demonstrated more extensive longitudinal cancer spread than cholangiography in 9 of 19 patients with one instance of overdiagnosis. The accuracy of intraductal US in assessing the extent of spread (84%) was superior to that of cholangiography (47%) (p < 0.05). Results on the duodenal side were as follows: In patients with suprapancreatic bile duct cancer (n = 14), intraductal US demonstrated more extensive longitudinal cancer spread than cholangiography in 8 of 14 patients. The accuracy of intraductal US in assessing the extent of the spread (86%) was superior to that of cholangiography (43%) (p < 0.05).

CONCLUSIONS

Transpapillary intraductal US prior to biliary drainage is useful in demonstrating longitudinal extension of bile duct cancer. However, the surgical margins were inaccurate in some patients.

Intraductal ultrasonography for evaluating the patency of biliary metallic stents: correlation with cholangioscopic findings

BACKGROUND

This is the first study to correlate intraductal ultrasonography (IDUS) with cholangioscopy in evaluating the patency of biliary metallic stents.

METHODS

The findings of IDUS (probe 2.0 mm in diameter and 20-MHz frequency) through a percutaneous transhepatic (n = 24) or transpapillary (n = 2) approach were retrospectively reviewed without other information. Criteria for IDUS are as follows: type 1, the inside of the stent is free; type 2, the inner edge is smooth; type 3, the inner edge is irregular; type 4, the inside of the stent is totally occupied; type 5, the solid echo is connected to the outside mass; type 2+D, a hypoechoic line is seen between the bile duct wall and the inside solid component and the inner edge of the bile duct wall is smooth; type 3+D, an irregular hypoechoic line is seen between the bile duct wall and the inside solid component.

RESULTS

In the control group (n = 11), IDUS showed type 1 (n = 9) or type 2 (n = 2). In the occluded group (n = 15), when IDUS showed type 3 or 5, the patients (n = 5) required additional stents (n = 3), microwave coagulation of the tumor (n = 1), or transient external drainage (n = 1). When IDUS showed type 4 (n = 5), after washing, the findings changed to type 2+D (n = 4). When IDUS after washing showed a smooth inner edge (type 2+D), the patients were treated without additional stents more frequently than the other groups (eight of nine vs. two of six), a significant distinction (p < 0.05).

CONCLUSION

IDUS is useful in assessing the patency of metallic stents. When the inside of the stent is totally occupied, however, examination after washing is necessary.

Percutaneous recanalization of the bile duct along an endoscopic naso-biliary catheter

Percutaneous recanalization of the bile duct is essential for placing biliary stents and carrying out other interventions. This prospective study was performed to establish safe approaches for percutaneous recanalization of the bile duct when it had previously resulted in failure. Between July 1995 and July 1999, percutaneous recanalization of the bile duct was attempted in 58 patients with a malignant biliary stenosis. When recanalization failed, an endoscopic naso-biliary drainage (ENBD) catheter was placed across the stenosis. The procedure was again attempted along the ENBD catheter. In the period of the study, four patients underwent successful recanalization after ENBD, although attempts prior to ENBD had been unsuccessful. As a result, the success rate of recanalization in the period was 100% (58/58). When recanalization fails, the use of an ENBD catheter may provide access to the biliary tree, and the biliary stenosis can be recanalized safely.

Pitfalls in endoscope reprocessing: brushing of air and water channels is mandatory for high-level disinfection

BACKGROUND

Endoscopic transmission of pathogens has been reported. Guidelines have been formulated concerning the risk of infection via contaminated suction and accessory channels. Contamination of the other 2 channels for air and water has not been demonstrated. These channels were examined to clarify whether they require cleaning.

METHODS

Endoscopes used for examinations were divided into 2 groups. Group A endoscopes (n = 20) were brushed along the air and water channels. Group B endoscopes (n = 22) were not. After machine reprocessing, specimens were obtained for bacterial culture. The residual protein was measured in the 2 channels by using amido black 10B dye, and results were compared between the 2 groups.

RESULTS

With regard to the air channel, there were no contaminated endoscopes detected in either group. For the water channel, 1 endoscope in group B was positive whereas there were none positive in group A. With regard to quantification of residual protein, brushing diminished the level in both the air and the water channels.

CONCLUSION

The air and water channels can become contaminated. Brushing every channel is mandatory for high-level disinfection. A redesign of the fundamental structure of endoscopes is proposed.

Total enteroscopy with a nonsurgical steerable double-balloon method

BACKGROUND

Deep insertion of an enteroscope by use of a push technique is difficult. A new method of enteroscopy was developed, a double-balloon method, to improve the access to the small intestine.

METHODS

The new method uses 2 balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops in the small intestine. This method was tried with a standard upper endoscope in 3 patients and with a longer enteroscope in 1 patient.

RESULTS

Despite its short length the upper endoscope was successfully inserted as far as 30 to 50 cm beyond the ligament of Treitz in the 3 patients. In the fourth patient the longer enteroscope was successfully inserted beyond the ileo-cecal valve.

CONCLUSIONS

The double-balloon method facilitates endoscopic access to the small intestine.

Comparison of intraductal ultrasonography with percutaneous transhepatic cholangioscopy for the identification of residual bile duct stones during lithotripsy

BACKGROUND

An imaging modality that can be used to identity small stones after a biliary lithotripsy is required. Intraductal ultrasonography was evaluated by using percutaneous transhepatic cholangioscopy as the gold standard.

METHODS

Lithotripsy, under percutaneous transhepatic cholangioscopy guidance, was performed in 20 patients. A thin-caliber ultrasonic probe (2.0 mm in diameter and 20 MHz frequency) was inserted into the bile duct through the percutaneous tract after lithotripsy, and residual stones were identified. This was followed by percutaneous transhepatic cholangioscopy.

RESULTS

In the extrahepatic bile ducts, intraductal ultrasonography provided images of all the stones demonstrated on cholangioscopy (n = 11). The sensitivity was superior to that of cholangiography (P < 0.005). However, in the intrahepatic bile ducts, intraductal ultrasonography only visualized the stones located in the cannulated lobe. Extrahepatic stones smaller than 5.0 mm in diameter or in a common hepatic duct larger than 15.0 mm in diameter were missed by cholangiography, but were visualized by the use of intraductal ultrasonography (P < 0.05).

CONCLUSIONS

Intraductal ultrasonography is equivalent to cholangioscopy in the extrahepatic bile ducts. Cholangiography and intraductal ultrasonography should be used in combination to image intrahepatic and extrahepatic stones.

Ropeway-type bile duct biopsy forceps with a side slit for a guidewire

BACKGROUND

Transpapillary procurement of bile duct biopsy specimens is an effective diagnostic technique in cases of biliary structure. The utility of new ropeway-type bile duct biopsy forceps with a side slit for a guidewire was investigated in this study.

METHODS

The 12 patients in this study had bile duct cancer (n = 3), cancer of the head of the pancreas (n = 4), gallbladder cancer (n = 1), and benign bile duct stenosis (n = 4). After endoscopic retrograde cholangiography, a guidewire was placed in the bile duct across the stenosis. The new forceps (1.8-mm diameter clamshell-type biopsy forceps without needle) was then introduced through the intact papilla along the guidewire.

RESULTS

In all patients, sufficient tissue for histopathologic evaluation was obtained without complication. In one patient, biopsy specimens were selectively obtained of the left hepatic duct, which was impossible with conventional forceps. In another patient, histologic examination of specimens obtained by using this new forceps showed adenocarcinoma, whereas specimens obtained with a conventional forceps did not contain adenocarcinoma. However, in another patient, biopsy specimens obtained with a conventional forceps contained adenocarcinoma that was not evident in specimens obtained with the new forceps. Dislodgement of the guidewire during procurement of biopsy specimens occurred in 1 patient. In the other 11 patients, an endoscopic biliary drain was inserted over the guidewire.

CONCLUSION

The new ropeway-type biopsy forceps is useful for selectively obtaining biopsy specimens of the bile duct. With this system, access for subsequent endoscopic biliary drainage is maintained.

Hyperechoic lines as a sonographic confirmatory sign during percutaneous transhepatic biliary drainage

BACKGROUND

In ultrasonically guided percutaneous transhepatic biliary drainage, we often can recognize hyperechoic lines at the tip of the needle when the duct is penetrated successfully. We evaluated the frequency of this phenomenon and analyzed whether it was a useful sign for confirming successful bile duct puncture.

METHODS

In 65 patients with biliary tract diseases, 84 catheters were placed in the course of 108 attempts at puncture. Results of puncture and the presence of hyperechoic lines were investigated prospectively.

RESULTS

When the ultrasonographic findings showed hyperechoic lines, successful puncture was significantly more frequent than when the findings did not show hyperechoic lines (53/55, 96%, vs. 31/59, 53%; p < 0.0001). When we judged the hyperechoic lines as the sign of successful puncture, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 63%, 93%, 96%, 48%, and 71%, respectively.

CONCLUSION

Hyperechoic lines are a useful confirmatory sign of successful puncture. However, absence of these lines was not invariably associated with unsuccessful puncture.

Limitations of three-dimensional intraductal ultrasonography in the assessment of longitudinal spread of extrahepatic bile duct carcinoma

We investigated the utility and limitations of three-dimensional intraductal ultrasonography (3D-IDUS), for the assessment of the extent of longitudinal cancer spread to the hepatic side by extrahepatic bile duct carcinoma. In eight patients with extrahepatic bile duct carcinoma. 3D-IDUS was used to assess longitudinal cancer extension to the hepatic side prior to resection. When the linear dimension of 3D-IDUS showed bile duct wall thickening that was connected to the tumor and which became thin at a point, it was determined to be the front formation of longitudinal cancer extension. The findings were examined in relation to histologic information from the resected specimen. Although 3D-IDUS showed front formation of wall thickening in two patients, it accurately reflected the histological margin of the longitudinal cancer extension in only one patient. In the other patient, the wall thickening was longer than the histological margin. When 3D-IDUS showed bile duct wall thickening without front formation (n = 2), the wall thickening was longer than the histological margin of the longitudinal cancer extension. Even when 3D-IDUS did not show wall thickening (n = 4), one of these patients showed cancer spread histologically. As a result, the accuracy in assessing longitudinal cancer extension by 3D-IDUS was only 50%. Even if the linear dimension of 3D-IDUS demonstrated front formation of thickening of the bile duct, it reflected not only cancer extension but also inflammatory wall thickening.

Access for percutaneous transhepatic cholangioscopy in patients with nondilated bile ducts using nasobiliary catheter cholangiography and oblique fluoroscopy

BACKGROUND

Percutaneous transhepatic biliary drainage is required for percutaneous transhepatic cholangioscopy. However, puncture of nondilated bile ducts under ultrasonographic guidance is difficult.

METHODS

In 10 patients with no ultrasonographic evidence of intrahepatic bile duct dilatation, percutaneous transhepatic biliary drainage was performed under fluoroscopic guidance using cholangiography obtained via a nasobiliary drainage catheter. Direct puncture was performed by means of a left ventral approach using oblique C-arm fluoroscopy.

RESULTS

Bile duct puncture was successful in all patients. There were no procedure-related complications. Subsequent cholangioscopy was successful in all patients.

CONCLUSIONS

Direct puncture using nasobiliary drainage cholangiography and oblique fluoroscopy is a useful method when cholangioscopy is necessary in patients with nondilated bile ducts.