Cell refractive index for cell biology and disease diagnosis: past, present and future

Cell refractive index is a key biophysical parameter, which has been extensively studied. It is correlated with other cell biophysical properties including mechanical, electrical and optical properties, and not only represents the intracellular mass and concentration of a cell, but also provides important insight for various biological models. Measurement techniques developed earlier only measure the effective refractive index of a cell or a cell suspension, providing only limited information on cell refractive index and hence hindering its in-depth analysis and correlation. Recently, the emergence of microfluidic, photonic and imaging technologies has enabled the manipulation of a single cell and the 3D refractive index of a single cell down to sub-micron resolution, providing powerful tools to study cells based on refractive index. In this review, we provide an overview of cell refractive index models and measurement techniques including microfluidic chip-based techniques for the last 50 years, present the applications and significance of cell refractive index in cell biology, hematology, and pathology, and discuss future research trends in the field, including 3D imaging methods, integration with microfluidics and potential applications in new and breakthrough research areas.

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam-based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up

OBJECTIVE

To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)-based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

METHODS

A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan- Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child-Pugh classification) were analysed by univariate logistic regression.

RESULTS

HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21-21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83-66.29) during 10 sessions and 68.0% (95% CI, 67.62-88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors.

CONCLUSION

In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE.

ADVANCES IN KNOWLEDGE

In patients who underwent three or more sessions of cisplatin and Gelfoam-based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.

Effect of splenic artery embolization for splenic artery steal syndrome in liver transplant recipients: estimation at computed tomography based on changes in caliber of related arteries

PURPOSE

To estimate the effect of splenic artery embolization (SAE) on blood flow in orthotopic liver transplantation (OLT) recipients with splenic artery steal syndrome (SASS) based on changes in caliber of related arteries upon serial computed tomography (CT) scans.

METHODS

Between 2004 and 2007, nine OLT recipients with SASS underwent SAE. They had CT scans before and after SAE: short-, mid-, and long-term, ie, approximately 1 week, 1 month, and 1 year, respectively. The diameters of the celiac axis (CA), common hepatic artery (CHA), and splenic artery (SA) were measured with arterial phase of each CT scan and the ratios of SA to CHA diameter (SA/CHA) calculated to analyze their changes during the follow-up period.

RESULTS

The diameters of celiac axis, CHA, and SA and SA/CHA changed most rapidly during the short-term period. The CHA diameter significantly increased short-term post-SAE by CT and slightly decreased thereafter. However, the mid-term and long-term post-SAE CT values were still significantly greater than those on the pre-SAE CT. The SA diameter steadily decreased throughout the follow-up. The SA/CHA decreased until the mid-term. The SA diameter and SA/CHA were significantly smaller upon mid-term and long-term post-SAE CT compared with those at pre-SAE CT.

CONCLUSIONS

The effect of SAE to improve hepatic arterial flow in OLT recipients with SASS might be expected for at least approximately one year. The effect maximally occurred during the short-term after SAE on the basis of changes in the caliber of related arteries upon CT.

Transcatheter arterial chemoembolization vs. chemoinfusion for unresectable hepatocellular carcinoma in patients with major portal vein thrombosis

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has been limited in palliative treatment of unresectable hepatocellular carcinoma (HCC) with major portal vein (PV) invasion due to the possibility of liver failure following embolization. Transcatheter arterial chemoinfusion (TACI) has been an option in such cases.

AIM

To compare clinical outcomes after TACE vs. TACI in HCC patients with major PV occlusion.

METHODS

We compared clinical outcomes after TACE vs. TACI in HCC patients with major PV occlusion. From 2005 to 2007, 110 HCC patients with major PV thrombosis were treated with TACE (n = 49) or TACI (n = 61).

RESULTS

The morbidity rate was similar for both TACE (6.1%) and TACI (6.5%) patients, and complications were adequately managed using medical treatment. The Kaplan-Meier survival analysis showed that the survival period was significantly longer for the TACE group (median: 14.9 months) than for the TACI (median: 4.4 months) group (P < 0.001). There was a higher probability of death in the TACI group than in the TACE group in both our multivariate Cox-proportional hazards (OR 3.09, P < 0.001) and the propensity score-matched (27 pairs) cohort analyses (OR 2.27, P = 0.024).

CONCLUSIONS

Transcatheter arterial chemoembolization can be safely performed in HCC patients with main PV occlusion. Compared with TACI, TACE may result in longer survival of HCC patients with major PV occlusion.

A case of successful embolotherapy for gastric ulcer bleeding from the intercostal artery after oesophagectomy and gastric reconstruction

We report a successful treatment with coil embolisation of an intercostal artery for ulcer bleeding in a gastric tube in a 70-year-old man who underwent a total oesophagectomy and gastric tube reconstruction for oesophageal cancer. This case teaches us to search aberrant feeding vessels when active bleeding is suspected in reconstructed gastric tube in the patient with oesophagectomy and oesophagogastrostomy.

Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.

Near real time in vivo fibre optic confocal microscopy: sub-cellular structure resolved

We have built a fibre optic confocal reflectance microscope capable of imaging biological tissue in near real time. The measured lateral resolution is 3 micro m and axial resolution is 6 micro m. Images of epithelial cells, excised tissue biopsies, and the human lip in vivo have been obtained at 15 frames s-1. Both cell morphology and tissue architecture can be appreciated from images obtained with this microscope. This device has the potential to enable reflected light confocal imaging of internal organs for in situ detection of pathology.

Fiber confocal reflectance microscope (FCRM) for in-vivo imaging

In-vivo imaging can be achieved with a coherent-fiber-bundle based confocal reflectance microscope. Such a microscope could provide the means to detect pre-cancerous lesions in the cervix by characterizing cells' nuclear-to-cytoplasmic ratio. In this paper we present the design of such a fiber confocal reflectance microscope, with an emphasis on its optical sub-systems. The optical sub-systems consist of a commercially available microscope objective and custom designed telescope, scan lens, and coupling lens systems. The performance of the fiber confocal reflectance microscope was evaluated by imaging a resolution bar target and human cervical biopsy tissues. The results presented in this paper demonstrate a lateral resolution of 2 microm and axial resolution of 6 microm. The sensitivity of the system defined by the smallest refractive-index mismatch that can be detected is approximately Delta n 0.05.

Aortic dissection: percutaneous management with a separating stent-graft--preliminary results

The authors used a separating stent-graft to treat Stanford type B aortic dissection. The separating stent-graft consists of two stents: a stent-graft and an inner bare stent. The separating stent-graft has three parts: a proximal stent, a graft made of synthetic polyester textile fiber, and a distal stent. A 12-F introducing sheath was used. After the separating stent-graft was placed, false-lumen thrombosis was evident in all six patients during a follow-up period of 206 days. The major advantages of this technique are that a cutdown and blood pressure control are not required.

Association between insulin-like growth factor-2 and metastases after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma: a prospective study

BACKGROUND

Hypoxia up-regulates insulin-like growth factor-2 (IGF-2) and thus stimulates the growth of hepatocellular carcinoma (HCC) cells. In the current study, the authors prospectively evaluated changes in plasma IGF-2 levels in HCC patients after transcatheter arterial chemoembolization (TACE), which usually results in hypoxic insult to liver tissue. The authors also examined the association between changes in plasma IGF-2 levels after TACE and HCC progression, especially in relation to metastasis.

METHODS

Plasma IGF-2 levels were measured before and 4 weeks after TACE in 46 patients with HCC. Three months after TACE, the patients were evaluated for the occurrence of metastatic HCC.

RESULTS

In 13 of the 46 patients, post-TACE plasma IGF-2 levels decreased by > 20% (Group 1) compared with their basal levels; in 18 patients, the IGF-2 levels changed within 20% (Group 2) and in 15 patients the IGF-2 levels increased by > 20% (Group 3). Plasma IGF-2 levels had a tendency to increase in patients with large-sized tumors, high serum alpha-fetoprotein (AFP) levels, and the heterogeneous uptake of iodized oil. Metastatic foci were found in 9 patients in Group 3 (60%), in contrast to only 3 patients in Group 2 (17%) and in none of the patients in Group 1 (P = 0.001). On multivariate analysis, higher Child-Pugh scores and increased plasma IGF-2 levels (Group 3) were found to be independent risk factors for metastasis.

CONCLUSIONS

Increased plasma IGF-2 levels after TACE, which are common in patients with large-sized tumors and high serum AFP levels, appear to be associated with the occurrence of metastatic HCC after TACE.

Ischemic bile duct injury as a serious complication after transarterial chemoembolization in patients with hepatocellular carcinoma

BACKGROUND

Bile duct injuries after transarterial chemoembolization (TACE) have been reported; however, the exact pathogenic mechanisms and clinical implications of the injuries remain to be clarified.

STUDY

A total of 950 consecutive patients with hepatocellular carcinoma (HCC) were studied. Among them, 807 were treated with TACE and the remaining 143 were treated with transarterial chemoinfusion (TACI) of cisplatin.

RESULTS

None of 143 patients with HCC treated with TACI were found to have any radiographic evidence of biliary injury. In contrast, of the 807 patients treated with TACE, 17 (2%) developed biliary complications. Of all complications, 12 (71%) were subcapsular bilomas; 3 (17%), focal strictures of the common hepatic duct or common bile duct; and 2 (12%), diffuse mild dilatation of the intrahepatic bile ducts. Interestingly, 2 of the 12 bilomas were found in the lobe that was not embolized with gelatin sponge particles. The median numbers of TACE tended to be greater in the patients with focal stricture than in those with bilomas (6.0 vs. 2.5; p = 0.08). All 3 patients with focal strictures and 4 of the 12 patients with bilomas had associated serious bacterial infections at presentation.

CONCLUSIONS

Bilomas seem to be caused by iodized oil rather than gelatin sponge particles; focal strictures of large bile ducts seem to be caused by gelatin sponge particles. We suggest that adjustments in the amounts of iodized oil or gelatin sponge particles and in the sites of embolization may reduce ischemic biliary injuries after TACE.

Balloon dacryocystoplasty: results and factors influencing outcome in 350 patients

PURPOSE

To evaluate the initial and long-term results of balloon dacryocystoplasty in the treatment of epiphora caused by obstruction of the lacrimal system with analysis of the procedure's favorable effects.

MATERIALS AND METHODS

Four hundred thirty eyes of 350 patients with obstructions of the lacrimal system were enrolled. Dacryocystoplasty was performed with use of a balloon catheter and a ball-tipped guide wire. The lesions were categorized according to cause, severity, site of the obstruction, and diameter and inflation time of the balloon. The technical success, initial success (improvement of symptoms after 1 week), and long-term patency rates were calculated. These rates in each group were compared with the chi(2) test and the Kaplan-Meier method.

RESULTS

The overall technical success rate was 95.3%. The overall initial success rate was 57.4%. There was no significant complication except for mild epistaxis in 12%. The 2-month, 1-year, and 5-year patency rates were 48.2%, 39.4%, and 36.9%, respectively. Initial success was influenced by the severity (P =.014) and the site (P <.001) of the obstruction, and the diameter of the balloon (P =.047). Long-term patency was affected by the site of the obstruction (P <.001) and the balloon inflation time (P <.001). Among the 183 initially ineffective and 88 recurrent cases, 62 underwent repeat balloon dacryocystoplasty, and the initial success rate was 38.7%.

CONCLUSIONS

The initial success rate of balloon dacryocystoplasty is relatively low. However, long-term patency can be expected in cases with initial success. Some additional factors also should be considered for better results.

Congenital lacrimal system obstruction: treatment with balloon dilation

PURPOSE

To evaluate the safety and effectiveness of balloon dilation for the treatment of congenital lacrimal system obstruction.

MATERIALS AND METHODS

Fluoroscopically guided balloon dilation was attempted in 20 eyes of 16 patients with an age range of 12-78 months (mean, 33 mo) for congenital lacrimal system obstruction. Fifteen eyes had complete obstruction at the valve of Hasner, three eyes had completely obstruction at the junction between the lacrimal sac and the nasolacrimal duct, and two eyes had partial obstruction at the nasolacrimal duct. Under general anesthesia, a ball-tipped guide wire was introduced through the superior punctum into the inferior meatus of the nasal cavity and pulled out through the naris with use of a hook. A deflated 3-mm-diameter balloon catheter was then advanced in a retrograde direction and the balloon was dilated. Every patient underwent an ophthalmic evaluation before the procedure and was scheduled to be followed with office examination at 1, 3, and 6 months after the procedure.

RESULTS

There were no major complications. "Technical success" was defined as free passage of contrast medium through the entire lacrimal system to the nasal cavity. The procedure failed in one eye. After balloon dilation, all 19 eyes in which technical success was achieved showed improvement of epiphora. During the follow-up period of 2-33 months (mean, 16 mo), all eyes maintained improvement of epiphora and needed no further treatment.

CONCLUSION

Balloon dilation is a safe and effective therapeutic technique for the treatment of congenital lacrimal system obstruction.

Combined therapy consisting of intraarterial cisplatin infusion and systemic interferon-alpha for hepatocellular carcinoma patients with major portal vein thrombosis or distant metastasis

BACKGROUND

Hepatocellular carcinoma (HCC) patients with major vascular involvement or extrahepatic metastasis are not good candidates for surgery or transarterial chemoembolization (TACE). In this study, the authors evaluated the efficacy of combined therapy with intraarterial cisplatin infusion and systemic administration of interferon-alpha (IFN-alpha) as a palliative treatment for these patients.

METHODS

Sixty-eight HCC patients with major portal vein thrombosis (n = 47) or distant metastasis (n = 27) were randomly allocated to 1 of 3 groups. Group I (n = 19) received combined therapy consisting of intraarterial cisplatin infusion and systemic IFN-alpha, Group II (n = 23) received intraarterial cisplatin infusion, and Group III (n = 26) was managed with only supportive care. Cisplatin 2 mg/kg was infused through the proper hepatic artery every 8 weeks, and IFN-alpha 3 million IU/m2 was administered subcutaneously 3 times a week.

RESULTS

The partial response (defined as a 50% or greater reduction in the product of the 2 longest perpendicular tumor measurements) rate of Group I was significantly higher than that of Group II (33% vs. 14%; P < 0.05). Also, the 1-year survival rate of Group I (27%) was higher than that of Group II (9%) or Group III (0%) (P < 0.05 and P < 0.01, respectively). The median survival period of Group I was 19 weeks, which was significantly longer than that of Group II (11 weeks) or Group III (5 weeks) (P < 0.05 and P < 0.01, respectively).

CONCLUSIONS

These results suggest that combined therapy consisting of intraarterial cisplatin infusion and systemic IFN-alpha may be useful as a palliative treatment for HCC patients with major vascular involvement or extrahepatic metastasis.

Use of a lacrimal stent retrieval hook in the removal of occluded plastic and expandable metallic lacrimal stents

PURPOSE

To evaluate the clinical usefulness of a stent retrieval hook in the removal of occluded lacrimal stents.

MATERIALS AND METHODS

The hook consisted of an inner hook part and an outer pusher part. Under administration of local anesthetic, the retrieval hook was introduced into the nasal cavity and aimed laterally toward the inferior meatus to grasp the distal end of the stent. After grasping the end of the stent, the sheath was pushed to fully grasp it. After that, the hook was pulled out of the external naris. The retrieval hook was used to remove 267 occluded lacrimal plastic or metallic stents.

RESULTS

Technical success rate was 97% in the removal of plastic stents and 96% in the removal of metallic stents. The causes of technical failure were entrenchment of granulation tissue into the stent in six plastic stents and one metallic stent, and inaccessibility of the hook to the distal tip of the stent in one plastic stent. These eight stents were removed by an otorhinolaryngologist or an ophthalmologist. Epistaxis occurred in six patients, which was controlled by a nasal pack.

CONCLUSIONS

The lacrimal stent retrieval hook seems useful for the removal of occluded stents.

Radiologic findings of abdominal polyarteritis nodosa

OBJECTIVE

The purpose of this study was to evaluate the radiographic and imaging findings of seven patients with polyarteritis nodosa involving the abdomen.

CONCLUSION

Vasculitis should be considered when multiple abdominal organs have abnormal radiologic findings; however, angiography is necessary to specifically diagnose polyarteritis nodosa.

Pleural and pulmonary staining at inferior phrenic arteriography mimicking a tumor staining of hepatocellular carcinoma

PURPOSE

To describe the findings of pleural and pulmonary staining of the inferior phrenic artery, which can be confused with tumor staining during transarterial chemoembolization (TACE) of hepatoma.

METHODS

Fifteen patients who showed pleural and pulmonary staining without relationship to hepatic masses at inferior phrenic arteriography were enrolled. The staining was noted at initial TACE (n = 8), at successive TACE (n = 5), and after hepatic surgery (n = 2). The angiographic pattern, the presence of pleural change on computed tomography (CT), and clinical history were evaluated.

RESULTS

Draining pulmonary veins were seen in all cases. The lower margin of the staining corresponded to the lower margin of the pleura in 10 patients. CT showed pleural and/or pulmonary abnormalities in all cases. After embolization of the inferior phrenic artery, the accumulation of iodized oil in the lung was noted.

CONCLUSION

Understanding the CT and angiographic findings of pleural and pulmonary staining during TACE may help differentiate benign staining from tumor staining.

Balloon catheter dilation in common canalicular obstruction of the lacrimal system: safety and long-term effectiveness

PURPOSE

To evaluate the safety and long-term effectiveness of balloon catheter dilation in the treatment of common canalicular obstruction of the lacrimal system.

MATERIALS AND METHODS

Fluoroscopically guided dilation with a 3-mm-diameter balloon catheter was attempted in 195 eyes of 148 patients (26 men, 122 women; mean age, 57 years; age range, 33-78 years) with epiphora due to common canalicular obstruction. Eighty-four of 195 eyes had complete obstruction, and 111 had partial obstruction.

RESULTS

Complications were self-limited nasal bleeding (n = 8), false passage (n = 7), and extravasation of contrast material (n = 6). Initial technical success was achieved in 76 (90%) of 84 eyes with complete obstruction and in 104 (94%) of 111 eyes with partial obstruction. In the 180 eyes with technical success, immediate clinical improvement was achieved in 76 eyes with complete obstruction and in 100 eyes with partial obstruction. The mean follow-up period was 36 weeks (range, 4-168 weeks). The cumulative patency rates were 51% at 6-month, 43% at 12-month, and 40% at 24-month follow-up.

CONCLUSION

Although the long-term recurrence rate is relatively high, balloon catheter dilation is a safe and effective therapeutic technique to be used initially in common canalicular obstruction.

Near real time confocal microscopy of amelanotic tissue: dynamics of aceto-whitening enable nuclear segmentation

High resolution, in vivo confocal imaging of amelanotic epithelial tissue may offer a clinically useful adjunct to standard histopathologic techniques. Application of acetic acid has been shown to enhance contrast in confocal images of these tissues. In this study, we record the time course of aceto-whitening at the cellular level and determine whether the contrast provided enables quantitative feature analysis. Confocal images and videos of cervical specimens were obtained throughout the epithelium before, during and post-acetic acid after the application of 6% acetic acid. Aceto-whitening occurs within seconds after the application. The confocal imaging system resolved sub-cellular detail throughout the entire epithelial thickness and provided sufficient contrast to enable quantitative feature analysis.

Hepatic falciform artery: is prophylactic embolization needed before short-term hepatic arterial chemoinfusion?

OBJECTIVE

The purpose of this study was to assess the need for prophylactic embolization of the hepatic falciform artery (HFA) to prevent supraumbilical skin rash before short-term hepatic arterial chemoinfusion with or without subsequent embolization.

MATERIALS AND METHODS

Transcatheter arterial chemoinfusions or chemoembolizations were performed on 127 consecutive patients with hepatocellular carcinoma between August 1997 and September 1997. Hepatic angiography findings regarding the anatomic variations of the hepatic artery and the presence and origin of the HFA were analyzed. The patients were followed up for 35-143 days (mean, 78 days). The incidence of supraumbilical skin rash was assessed for two groups of patients, those with an HFA and those without. We also evaluated other factors that seemed closely related to the presence of an HFA.

RESULTS

An HFA was identified in 16 (13%) of 127 patients. Each HFA originated either in the left hepatic artery (n = 14) or the middle hepatic artery (n = 2). In the 16 patients with an HFA, serum bilirubin levels were significantly higher than in patients without one (p < .05), whereas serum albumin levels and prothrombin times were significantly lower (p < .05) and more prolonged (p = .02) than in patients without one. Portal venous collateral vessels were more frequently seen in patients with an HFA (50%) than in those without one (31%), but the frequency was not significant (p = .157). However, supraumbilical skin rash was not seen in any patient.

CONCLUSION

We found no need for prophylactic embolization of the HFA to prevent supraumbilical skin rash before short-term hepatic arterial chemoinfusion with or without subsequent embolization.

Transluminal angioplasty for middle cerebral artery stenosis in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Precutaneous transluminal angioplasty (PTA) is currently performed to treat supraaortic atherosclerotic lesions. Our purpose was to evaluate the safety and efficacy of PTA for middle cerebral artery (MCA) stenosis in patients with acute ischemic stroke.

METHODS

We performed PTA with the use of a microballoon (2-2.5 mm in diameter and 10-13 mm in length) in 10 consecutive patients (mean age, 48 years) who met the following criteria: high-grade M1 stenosis (> 70%) and mild neurologic deficits (NIH stroke scale < 4) and/or recurrent transient ischemic attacks (TIAs) resistant to anticoagulation, or a large area of hypoperfusion in the MCA territory on brain perfusion SPECT scans. During follow-up, we administered antiplatelet agents and evaluated the status of restenosis by angiography (n = 2), brain perfusion SPECT (n = 4), and/or transcranial Doppler sonography (TCD) (n = 7).

RESULTS

Stenotic arteries were successfully dilated in nine of 10 patients. Angioplasty failed in one patient because the balloon could not pass through the tortuous cavernous internal carotid artery. None of the patients experienced either peri- or postangioplasty complications. Residual stenosis was less than 50%, and clinical improvement, including elimination of TIAs in four patients who had suffered resistant TIAs, was observed in all patients; improvement of the cerebral perfusion was also noted in two patients with a large hypoperfusion area in the MCA territory. The average follow-up period was 11 months (range, 2 to 36 months). None experienced recurrent stroke during the follow-up period. TCD revealed decreased flow velocity of the MCA after angioplasty in seven patients.

CONCLUSION

PTA of the proximal portion of the MCA seems to be a safe and effective therapeutic technique for the prevention of secondary ischemic stroke.

Percutaneous hot saline injection therapy: effectiveness in large hepatocellular carcinoma

PURPOSE

To report on the efficacy of percutaneous hot saline injection therapy (PSIT) in the treatment of large hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Twenty-nine patients with 31 HCCs underwent PSIT. Physiologic saline was mixed with contrast medium and Lipiodol; this mixture was boiled and injected into the tumor. Mean tumor diameter was 7.0 cm. Initial regression rates were evaluated at 3-month interval with computed tomography (CT) and alpha-fetoprotein level measurement. Cumulative survival rates were calculated with the Kaplan-Meier method. Multivariate analysis using Cox's proportional hazard regression model was performed to determine the significant prognostic factors.

RESULTS

Initial regression rate for all tumors at a 3-month interval was 42% (13 of 31 tumors) and the median survival was 10.0 months (range, 3.0-36.0 months). The significant prognostic factors were encapsulated tumors, tumors less than 10 cm in diameter, tumors with even saline dispersion, tumors with initial regression at 3-month follow-up, and TNM stage II or III rather than IV.

CONCLUSION

PSIT is a feasible alternative treatment for a large HCC when transcatheter arterial chemoembolization is not feasible or has failed.

Portal vein embolization with use of a new liquid embolic material: an experimental study

PURPOSE

To evaluate the efficacy and safety of a new liquid embolic material in portal vein embolization (PVE).

MATERIALS AND METHODS

A new embolic material (Embol) was percutaneously injected into the left portal vein of 13 swine, using a balloon catheter to prevent reflux. The swine were killed immediately (n = 6), 2 weeks (n = 4), and 4 weeks (n = 3) after the PVE, and the volumes of the right and left lobes were measured. The changes in body temperature, aspartate aminotransferase (AST) (formerly SGOT), alanine aminotrasferase (ALT) (formerly SGPT), and bilirubin levels after the PVE were studied, and the histopathologic changes in the embolized and nonembolized lobes were examined with light microscopy.

RESULTS

The average volume ratio of the right:left lobe immediately after the PVE was 55(+/-2):45(+/-1), and changed to 71(+/-3):29(+/-3) at 2 weeks and 82(+/-3):18(+/-3) at 4 weeks after embolization. There were only mild changes in AST, ALT, and bilirubin levels, and only one pig showed a significant elevation in body temperature after PVE. Microscopically, the embolized lobe showed contraction of hepatocyte without any sign of necrosis and the nonembolized lobe expansion of hepatocyte.

CONCLUSIONS

The new embolic material seems effective and safe for PVE.

Esophageal rupture during balloon dilation of strictures of benign or malignant causes: prevalence and clinical importance

PURPOSE

To review the prevalence and clinical importance of esophageal rupture during balloon dilation for treatment of esophageal stricture.

MATERIALS AND METHODS

Fluoroscopically guided esophageal balloon dilation was performed within 9 years in 96 consecutive patients with esophageal strictures. Esophageal rupture was classified into three types: type 1 was intramural; type 2, transmural; and type 3, transmural with mediastinal leakage.

RESULTS

Each patient underwent one to seven procedures, for a total of 191 procedures. Esophageal rupture occurred in 20 patients (21%). Type 1 esophageal rupture occurred in eight patients, type 2 in 11, and type 3 in one. All esophageal ruptures were detected immediately after the procedure. Sixteen patients were treated with fasting, parenteral alimentation, and antibiotics; two were treated surgically; and two were treated with stent placement. No treatment-related deaths occurred.

CONCLUSION

The overall prevalence of esophageal rupture was 21%. A substantial number of patients who developed type 1 rupture had associated clinical symptoms, such as pain and fever, but responded to conservative management and are thus included as having complications of esophageal balloon dilation.

Lacrimal system obstruction treated with lacrimal polyurethane stents: outcome of removal of occluded stents

PURPOSE

To describe the short- and long-term outcomes of the removal of occluded stents.

MATERIALS AND METHODS

With fluoroscopic guidance, 571 lacrimal polyurethane stents were placed in 502 patients with epiphora due to obstruction of the lacrimal system. Of the 571 stents, 142 were removed 2 weeks to 42 months (mean, 7 months) after placement because of recurrent epiphora, and the lacrimal system was irrigated with saline solution through the lacrimal point.

RESULTS

Stent removal was well tolerated. Mild epistaxis occurred in one patient and was controlled with a nasal pack. Recurrent epiphora was due to obstruction of the stent with mucoid material in 49 (35%) of 142 systems and granulation tissue in 93 (65%) systems. After stent removal, 73 (51%) of the 142 lacrimal systems showed improvement of epiphora, with a patent lacrimal system at 7-day follow-up dacryocystography. During the follow-up of 2 weeks to 49 months (mean, 22 months) after stent removal, patency was maintained in 24 (33%) of the 73 lacrimal systems.

CONCLUSION

Removal of an occluded lacrimal plastic stent was easy and safe. Recurrent epiphora after placement of lacrimal plastic stents can be treated with removal of the occluded stents an irrigation with saline solution through the lacrimal point, which resulted in a patent lacrimal system in 33% of cases in this study.

Vasculature in hepatocellular carcinoma after transcatheter arterial chemoembolization: comparison of power and color Doppler sonography

The purpose of this study was to compare power Doppler sonography with conventional color Doppler sonography for the detection of the vascularity of hepatocellular carcinomas after transcatheter arterial chemoembolization. Of the 93 embolized hepatocellular carcinomas, hypervascularity was demonstrated in 36 on angiography; power Doppler sonography correctly identified pulsatile flow signals in 33 (92%) of these 36, whereas color Doppler sonography identified flow signals in 24 (67%). A statistically significant difference was noted when the sizes of the nodules were 30 mm or less. Despite technical difficulties, such as flash artifact, power Doppler sonography is superior to color Doppler sonography for detection of hypervascularity, especially in small embolized nodules of hepatocellular carcinoma (30 mm or less in diameter).

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

OBJECTIVE

The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed.

SUBJECTS AND METHODS

During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents.

RESULTS

The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents.

CONCLUSION

We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.

Small arterial-portal venous shunts: a cause of pseudolesions at hepatic imaging

PURPOSE

To compare hepatic angiographic findings of small arterial-portal venous shunts with those of other imaging modalities, and to determine whether these shunts are related to hepatocellular carcinoma.

MATERIALS AND METHODS

At hepatic angiography in 223 patients, small arterial-portal venous shunts not directly related to hepatocellular carcinoma and focal areas of parenchymal contrast material enhancement more than 1 cm in diameter were found in 28 patients. These 28 patients were prospectively evaluated with computed tomography (CT) during arterial portography (CTAP) (n = 12), CT after iodized oil administration (n = 23), intraoperative ultrasonography (n = 5), or follow-up hepatic angiography (n = 13). Magnetic resonance (MR) images (n = 10) and dynamic CT scans (n = 4) in these patients were retrospectively reviewed.

RESULTS

Arterial-portal venous shunts noted at angiography manifested as perfusion defects at CTAP in 10 patients and as an area of arterial contrast enhancement at dynamic CT in three patients. No lesion was seen at MR imaging, and no persistent iodized oil uptake was seen at CT. There was no evidence of hepatocellular carcinoma tumor growth around the shunts at follow-up angiography, and no tumor was present at surgery.

CONCLUSION

Understanding of the hemodynamic changes caused by these small shunts can aid in the interpretation of vascular imaging findings.

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

PURPOSE

To evaluate the clinical effectiveness of a polyurethane-covered, retrievable, self-expandable metallic stent and hook catheter in the treatment of esophageal strictures.

MATERIALS AND METHODS

Stents were constructed of 0.4-mm stainless steel wire in a cylindric zig-zag configuration of six to nine bends. Four to eight stents were connected in tandem by dipping in a polyurethane solution. A nylon loop was hooked inside to each bend of the proximal portion of the stent and strung with a thread. Under fluoroscopic guidance, 22 stents were placed in 16 patients with a malignant stricture and five patients with a benign stricture. The stent was removed with a hook catheter 2 months after placement in patients with a benign stricture and when complications occurred in patients with a malignant stricture. All patients had dysphagia with ingestion of soft foods or liquids.

RESULTS

Stent placement was technically successful and well tolerated in 20 patients. In one patient, the stent was misplaced but relocated successfully. After stent placement, all patients were able to ingest solid and/or soft foods without dysphagia. After stent removal, strictures showed improvement but recurred in two patients.

CONCLUSION

Use of polyurethane-covered, retrievable expandable stents seems to be a feasible and effective method of treatment of benign and malignant esophageal strictures.

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

PURPOSE

To evaluate the long-term effectiveness of expandable esophageal metallic stents in benign esophageal strictures.

MATERIALS AND METHODS

The authors performed long-term follow-up of 14 expandable metallic stents in 12 patients (aged 16-72 years) with benign esophageal strictures. All 12 patients had initially undergone placement of one stent; two patients received an additional stent because of recurrent dysphagia.

RESULTS

No procedural complications occurred. Delayed complications occurred in all patients. New strictures formed in six stents (five patients), migration occurred in seven stents (six patients), and both migration and formation of new strictures occurred in one stent (one patient). New stricture formation caused recurrence of dysphagia and necessitated further treatment. Three of four stents that migrated within 2 months after placement but none of the four stents that migrated more than 2 months after placement caused recurrence of dysphagia. Six patients died of unrelated causes 6-20 months after stent placement. The remaining six patients are still alive 24-48 (mean, 35) months after stent placement.

CONCLUSION

The long-term effectiveness of expandable metallic stents in benign esophageal strictures is not encouraging because of the high delayed-complication rate. That the patients with migration showed improvement of dysphagia, however, may warrant further investigation of temporary placement of a retrievable covered stent.

Lacrimal canalicular obstructions: safety and effectiveness of balloon dilation

PURPOSE

Balloon dilation of the lacrimal canaliculi has been considered contraindicated because of possible damage to the canaliculi. The purpose of this study was to assess the safety and effectiveness of balloon dilation in treatment of obstruction of the lacrimal canaliculus.

MATERIALS AND METHODS

Fluoroscopically guided balloon dilation was performed in 26 eyes of 21 consecutive patients with epiphora due to lacrimal canalicular obstruction confirmed at dacryocystography. Nine of 26 eyes had complete obstruction and 17 eyes had incomplete obstruction.

RESULTS

Technical failure occurred in one eye. Only one acute complication (punctal slitting) and no late complications occurred. At 7 days after balloon dilation, 14 of 17 eyes (82%) with incomplete obstruction and five of nine eyes (56%) with complete obstruction showed complete or partial resolution of epiphora with patency of the lacrimal drainage system. At 6-month follow-up, that improvement was maintained in seven of 17 eyes (41%) with incomplete obstruction and three of nine eyes (33%) with complete obstruction.

CONCLUSIONS

Although the 6-month recurrence rate is rather high, balloon dilation seems to be safe and valuable as an initial therapy for patients with obstruction of the lacrimal canaliculus.

Nonsurgical placement of a nasolacrimal polyurethane stent: long-term effectiveness

PURPOSE

To evaluate the long-term effectiveness of a polyurethane stent in the treatment of obstruction of the lacrimal sac and the nasolacrimal duct.

MATERIALS AND METHODS

Fluoroscopically guided placement of a polyurethane nasolacrimal stent was evaluated in 283 obstructed lacrimal systems of 236 patients, with a follow-up period of more than 1 year (range, 52-134 weeks). The obstruction was at the junction between the lacrimal sac and the nasolacrimal duct in 192 systems, at the lacrimal sac in 52, and at the nasolacrimal duct in 39. The causes of obstruction were traumatic in 34 and idiopathic in 249 systems.

RESULTS

Stent placement was technically successful in 270 systems (95%). At 7 days after stent placement, 235 (87%) of the 270 systems with successful placement demonstrated complete resolution of epiphora, 27 (10%) had partial resolution, and the remaining eight (3%) had no resolution. There was recurrence in 81 systems due to obstruction of the stent (n = 77) or obstruction of the common canaliculus (n = 4). The recurrence rate was much higher in the systems with obstruction at the lacrimal sac (64%) than in the systems with obstruction at the junction (26%) between the lacrimal sac and nasolacrimal duct or at the nasolacrimal duct (15%).

CONCLUSION

Stent placement in the obstructed lacrimal system below the junction between the lacrimal sac and the nasolacrimal duct is valuable as an initial therapy.

Lacrimal canaliculus obstruction: nonsurgical treatment with a newly designed polyurethane stent

A newly designed polyurethane stent was used to successfully treat 30 eyes (in 28 patients) with epiphora resulting from obstruction of the lacrimal canaliculus. After stent placement, epiphora resolved in all eyes. During follow-up, epiphora recurred in 20 eyes, but epiphora did not recur and the lacrimal canaliculus was patent in 12 eyes after the stent was removed. The stent appears to be valuable for nonsurgical treatment of obstruction of the lacrimal canaliculus.

Self-expandable metallic stents in high-risk patients with benign prostatic hyperplasia: long-term follow-up

PURPOSE

To evaluate the long-term clinical utility of self-expandable metallic Z stents in benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Under fluoroscopic guidance, 14 multiple-connected Z stents (10 mm in diameter fully expanded, 30-60 mm in length) were placed in 13 patients with bladder obstruction from BPH and high operative risks. The stents were placed in the prostatic urethra with 2-20-mm protrusion into the urinary bladder in six patients (group A) and entirely within the prostatic urethra in seven patients (group B).

RESULTS

Eleven of 13 patients could void immediately, and the other two patients with atonic bladder voided within 8 weeks. Maximum urine flow rates just after stent placement were 8-27 mL/sec. Two patients died of unrelated causes within 2 months. During the follow-up period (mean, 37 months) in the other 11 patients, all patients in group A but none in group B underwent surgery owing to stone formation where the stent protruded into the bladder.

CONCLUSION

Expandable Z stents are effective in patients with BPH but should not protrude into the urinary bladder because of stone formation.

Nonsurgical placement of a nasolacrimal polyurethane stent

PURPOSE

To describe the placement of a nasolacrimal polyurethane stent with a new introducer set and hook.

MATERIALS AND METHODS

The authors designed a soft polyurethane stent, an introducer that does not require balloon dilation, and a hook that can remove a ball-tipped guide wire from the inferior nasal meatus under fluoroscopic guidance. The stent was placed in 51 lacrimal systems in 44 outpatients who had complete obstruction of the lacrimal sac or nasolacrimal duct.

RESULTS

Stent placement was technically successful and well tolerated in 50 of 51 nasolacrimal systems. The procedure lasted an average of 16 minutes (range, 10-33 minutes). After stent placement, 47 of 50 eyes showed complete resolution of epiphora, and the other three showed partial resolution. During follow-up, no stents migrated, and one stent became blocked. The stent was reopened by means of forceful irrigation of saline solution through the superior punctum.

CONCLUSION

Placing a polyurethane nasolacrimal stent by use of the new introducer and hook simplifies the technique, shortens operating time, reduces cost, and makes the procedure well tolerated by patients.

Covered, expandable esophageal metallic stent tubes: experiences in 119 patients

PURPOSE

To study fluoroscopic placement of covered expandable stent tubes in patients with esophagogastric strictures.

MATERIALS AND METHODS

Under fluoroscopic guidance, 132 stent tubes were placed in 116 patients with malignant neoplasm; four, in three patients with benign lesions. All patients had aphagia or dysphagia to soft food or liquid.

RESULTS

After placement (successful in 100% of cases), 93 (78%) of the patients could ingest solid food; 24 (20%), soft food. Complications in the 119 patients included blockage in 13, stent tube migration in 12, gastroesophageal reflux in nine, severe pain in nine, and delayed massive bleeding in four. Most major complications were managed by means of a balloon catheter, a second stent tube, or analgesics. One hundred four patients died 2-80 weeks after stent placement.

CONCLUSION

Treatment with placement of a covered expandable stent tube is effective in most patients with dysphagia due to malignant esophogastric strictures and is less effective in patients with benign strictures.

Nasolacrimal duct obstruction treated nonsurgically with use of plastic stents

PURPOSE

To evaluate the clinical utility of plastic stents in treatment of complete obstruction of the nasolacrimal duct.

MATERIALS AND METHODS

Nineteen plastic stents were successfully placed under fluoroscopic guidance in 16 consecutive patients with epiphora due to complete obstruction of the nasolacrimal duct. After balloon dilation of the obstructed area, the stents were placed in the lacrimal system with the head portion lying in the dilated lacrimal sac and the body in the nasolacrimal duct and projecting into the inferior meatus of the nasal cavity.

RESULTS

Complete resolution of epiphora was accomplished in 15 (79%) of 19 eyes and partial resolution in the remaining four (21%) eyes.

CONCLUSION

These preliminary results with use of plastic nasolacrimal stents are encouraging.

Therapeutic percutaneous aspiration of hepatic abscesses: effectiveness in 25 patients

OBJECTIVE

The objective of this study was to evaluate the effectiveness of sonographically guided needle aspiration and systemic antibiotic therapy for the treatment of hepatic abscesses.

SUBJECTS AND METHODS

From June 1989 to September 1991, sonographically guided needle aspiration and systemic antibiotics were used to treat 25 consecutive patients with 25 hepatic abscesses. Among 36 patients with hepatic abscesses who were admitted to the hospital during that time, six had antibiotic therapy only; of these, three had microabscesses, two had abscesses less than 3.0 cm in diameter, and one refused needle aspiration. Four patients had surgical external drainage (three had cholelithiasis in addition to hepatic abscesses, and one did not respond to needle aspiration). Two patients treated in 1989 had drainage via an indwelling catheter, which was the preferred method at that time. The remaining 24 patients and one patient who had needle aspiration followed by surgical drainage made up the study group. Seventeen of the hepatic abscesses were caused by pyogenic organisms, six by amoeba, and two by unknown organisms. Eighteen abscesses (72%) were aspirated once, four (16%) were aspirated twice in 8 days, two (8%) were aspirated three times in 14 days, and one (4%) was aspirated four times in 10 days. Persistent fever, pain and tenderness in the right upper quadrant, and leukocytosis were the indications for multiple aspirations. Follow-up sonography was performed to evaluate the outcome of treatment.

RESULTS

In 16 cases (64%), the abscesses disappeared within a mean of 84 days. In eight cases (32%) with only partial follow-up, the patients were asymptomatic at the time of discharge and the abscesses were markedly smaller on the last follow-up sonograms (mean, 43 days). One patient (4%) did not respond to aspiration and had surgical drainage. The length of hospitalization varied from 5 to 42 days (mean, 22 days). In patients who became afebrile during the treatment, the fever had lasted from 0 to 10 days (mean, 3 days). Only one patient had a complication of the procedure, a pleural effusion that was treated conservatively.

CONCLUSION

Our results show that sonographically guided needle aspiration combined with antibiotic therapy is effective as the initial treatment for hepatic abscesses.

Extracorporeal shockwave lithotripsy of primary intrahepatic stones

Extracorporeal shockwave lithothripsy (ESWL) was performed in intrahepatic stone patients (n = 18) by Dornier MPL 9,000 with ultrasound guidance. The patients had T-tube (n = 9) or percutaneous transhepatic biliary drainage tube (n = 9). Average treatment session was four and shock-wave numbers were in the range of 3,064 to 12,000 (average 6,288 shocks). Intrahepatic stones were removed completely in 16 patients over a 3 month period by ESWL and combined stone extraction maneuver such as cholangioscopic or interventional radiologic method. Extracorporeal shockwave lithothripsy was very helpful in facilitating extraction of stones in unfavorable locations or located above the severe stricture. In summary, extracorporeal shockwave lithotripsy, followed by percutaneous stone extraction, will provide an improvement in the success rate and duration of treatment required for complete removal of primary hepatolithiasis.

Herpes zoster ophthalmicus and delayed contralateral hemiparesis

Central nervous system is often involved by herpes zoster but it is very rarely seen that contralateral hemiparesis or hemiplegia developed after herpes zoster ophthalmicus. We report a case of herpes zoster ophthalmicus followed by the delayed contralateral hemiparesis. A 33-year-old man developed acute cerebral infarction and resultant right hemiparesis 44 days after herpes zoster ophthalmicus in the left side. Brain CT disclosed hypodense area in the left basal ganglia. Cerebral angiography revealed segmental narrowing of M1 portion of the right middle cerebral artery.

A case of aneurysm of the vein of Galen

Aneurysm of the vein of Galen is a very rare disease. The authors present a case of secondary aneurysm of the vein of Galen which was confirmed by characteristic clinical symptoms, brain CT and angiographic findings. The patient was a 14-year-old right handed girl with intermittent headache, nausea, vomiting, dysphasia and gait disturbance. Neurologic examination revealed dysarthria, nasal voice, blurring of both margins of optic discs, truncal ataxia and dysdiadochokinesia. Sensory function was normal but right hemiparesis was seen. Roentgenogram of the skull revealed diffuse thinning of the calvarium, widening of sella turcica and erosion of clinoid processes. Computed tomogram of the brain showed dilatation of all ventricles and round hyperdense mass behind the third ventricle in the midline. The lesion was enhanced markedly and homogeneously. Left and right internal carotid angiograms showed arteriovenousmal-formation with drainage to the aneurysm of the vein of Galen.

Percutaneous removal of residual intrahepatic stones

In the Orient there is a high frequency of residual intrahepatic stones after biliary tract surgery. Percutaneous removal of residual intrahepatic stones was attempted in a group of 74 patients. Stones were exclusively intrahepatic in 57 patients, whereas 17 patients also had stones in the common bile duct. Biliary strictures were present in 60 cases (81%). A combination of techniques was used, including preshaped angulated catheters, irrigation-suction, balloon dilation of strictures, and crushing of large stones. In 36 cases all stones were removed and in 14 cases most stones were removed, for a success rate of 67.6%. Biliary stricture was the factor most often responsible for failure.