Comparison of different pseudotumor grading systems in a single cohort of metal-on-metal hip arthroplasty patients.

OBJECTIVE: Follow-up of pseudotumors observed with metal-artefact reducing sequence (MARS)-magnetic resonance imaging (MRI) following metal-on-metal total hip arthroplasty (MoMTHA) depends on how severe these pseudotumors are graded. Several pseudotumor grading systems for MARS-MRI have emerged but little is known of their validity. We studied the intra- and interobserver reliability of three different pseudotumor grading systems in a single cohort of MoMTHA. PATIENTS AND METHODS: Two experienced musculoskeletal radiologists independently used three different pseudotumor grading systems for classifying MARS-MRI results of the same cohort of 42 MoMTHA patients (49 hips, mean follow-up 5.2 years). Intraobserver and interobserver reliability for each grading system was measured using Cohen's kappa (κ). Variance in pseudotumor severity grading between systems was analyzed. RESULTS: Intraobserver reliability on grading pseudotumor severity with the Anderson, Matthies, and Hauptfleisch grading system scored 0.47, 0.10, and 0.35 (observer 1), and 0.75, 0.38, and 0.42 (observer 2), respectively. Interobserver reliability scores for pseudotumor severity were 0.58, 0.23, and 0.34, respectively. CONCLUSIONS: Intraobserver reliability for grading pseudotumor severity on MARS-MRI ranged from poor to good, dependent on observer and grading system used. Interobserver reliability scored best with the Anderson system. A more succinct pseudotumor severity grading system is needed for clinical use.

Asymptomatic pseudotumours after metal-on-metal hip resurfacing show little change within one year.

The aim of this study was to establish the natural course of unrevised asymptomatic pseudotumours after metal-on-metal (MoM) hip resurfacing during a six- to 12-month follow-up period. We used repeated metal artefact reduction sequence (MARS)-magnetic resonance imaging (MRI), serum metal ion analysis and clinical examination to study 14 unrevised hips (mean patient age 52.7 years, 46 to 68, 5 female, 7 male) with a pseudotumour and 23 hips (mean patient age 52.8 years, 38 to 69, 7 female, 16 male) without a pseudotumour. The mean post-operative time to the first MARS-MRI scan was 4.3 years (2.2 to 8.3), and mean time between the first and second MARS-MRI scan was eight months (6 to 12). At the second MRI scan, the grade of severity of the pseudotumour had not changed in 35 hips. One new pseudotumour (Anderson C2 score, moderate) was observed, and one pseudotumour was downgraded from C2 (moderate) to C1 (mild). In general, the characteristics of the pseudotumours hardly changed. Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after MoM hip resurfacing showed little or no variation. In 23 patients without pseudotumour, one new asymptomatic pseudotumour was detected. This is the first longitudinal study on the natural history of pseudotumours using MARS-MRI scans in hip resurfacing, and mirrors recent results for 28 mm diameter MoM total hip replacement.

Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures.

BACKGROUND: The preferred treatment for stones in the bile duct is endoscopic sphincterotomy followed by stone extraction. When this fails, percutaneous treatment is an alternative to surgery. The purpose of this study was to evaluate the success and complication rate of percutaneous treatment. METHODS: Between April 1990 and April 1997, a total of 31 consecutive patients (20 men, 11 women, mean age 70.1 years) underwent percutaneous treatment of bile duct stones (average of 2.2 per patient, range 1 to 10). The percutaneous treatment was considered successful if all stones could be removed. Time and number of sessions needed for imaging, percutaneous treatment, and complications were scored. RESULTS: Twenty-seven patients (87%) were free of stones after 2 to 15 sessions (mean 5.6). The median time for treatment was 16 days (3 to 299). Complications occurred in 3 of the 31 patients: one myocardial infarction during extracorporeal shockwave lithotripsy, one pancreatitis, and one bacteremia. None of these complications were life threatening. Four patients (13%) underwent surgery after failed percutaneous treatment. CONCLUSION: Percutaneous treatment of bile duct stones is an alternative with a high success rate when endoscopic stone removal fails. Surgery can be avoided in nearly 90% of cases.

Can sonographic signs predict long-term results of laparoscopic cholecystectomy?

BACKGROUND/AIMS: To determine whether sonographic signs of the gallbladder can predict the long-term outcome of laparoscopic cholecystectomy (LC). METHODOLOGY: All 346 patients, who underwent LC at our institution between January 1, 1993 and March 1, 1996, were interviewed using a structured questionnaire on the persistence of pre-operative abdominal symptoms. Patients without a sonographic examination 6 months prior to surgery were excluded. Sonographic parameters, scored on the pre-operative examination, were evaluated by univariate analysis using the relief of abdominal symptoms as a dependent variable. RESULTS: The response rate of correctly returned questionnaires was 68%. The follow-up ranged from 14-53 months. Fourteen percent (18/133) of all patients reported persistence of abdominal complaints after cholecystectomy. Grit in the gallbladder on the pre-operative ultrasound examination was significantly associated with a higher relative risk (RR) for persistence of pre-operative abdominal symptoms (RR 4.5, 95% confidence intervals (CI) 2.0-10.1). The presence of echogenic bile (RR 1.9, 95% CI 0.8-4.9), gallbladder distention (RR 1.9, 95% CI 0.6-5.7), and gallbladder wall thickening (RR 1.5, 95% CI 0.5-4.1) were associated with the persistence of symptoms. A contracted gallbladder (RR 0.6, 95% CI 0.4-1.1) and stone impaction (RR 0.44, 95% CI 0.1-1.8) were associated with the relief of abdominal symptoms. None of these sonographic signs reached significance. There was no difference in the post-operative symptoms rate between patients with a laparoscopic cholecystectomy and those who were converted to an open cholecystectomy. CONCLUSIONS: This retrospective study showed that the sonographic sign of grit in the gallbladder is associated with a high relative risk for persistent abdominal symptoms after cholecystectomy. These findings will be re-evaluated in a prospective study to estimate the definitive clinical importance.

Can sonographic signs predict conversion of laparoscopic to open cholecystectomy?

BACKGROUND: The aim of this study was to determine whether sonographic signs can predict the risk for conversion of laparoscopic (LC) to open cholecystectomy (OC). METHODS: All 346 patients who underwent LC at our institution between January 1, 1993, and March 1, 1996, were studied retrospectively. Patients who had no sonographic examination during 6 months prior to surgery and patients treated by inexperienced surgeons were excluded from the study. Patient characteristics and sonographic parameters were evaluated by univariate and multivariate analysis, using conversion to OC as a dependent variable. RESULTS: In 23 of 134 patients (17.2%), LC was converted to OC. In the univariate analysis, gallbladder distention (>4.5 cm; relative risk [RR] 3.5; 95% confidence intervals [CI] 1.7-5.3), stone impaction (RR 2.4; 95% CI 1.1-5.1), thickened gallbladder wall (RR 2.4; 95% CI 1.2-5.1), and acute cholecystitis (RR 2.6; 95% CI 1.1-6.7) were able to predict the need for conversion. Logistic regression defined only the sonographic sign of distention of the gallbladder as a predictor of conversion. CONCLUSIONS: Gallbladder distention as a sonographic sign is associated with a high relative risk for conversion. The predictive value of sonographic signs for conversion requires further assessment in a prospective study.

Methyl tert-butyl ether improves the efficacy of extracorporeal shock wave lithotripsy of human gallstones implanted in pigs.

OBJECTIVE: To investigate the contribution of contact dissolution with methyl tert-butyl ether (MTBE) to the success of extracorporeal shock wave lithotripsy (ESWL) of human gallstones implanted in pigs. DESIGN: Experimental study of matched pairs. SETTING: Laboratory for experimental surgery, The Netherlands. MATERIAL: 30 pigs. INTERVENTIONS: Couples of similar human gallstones were surgically implanted into the gallbladders of 30 pigs. All pigs underwent ESWL with an electromagnetic lithotriptor. Half the animals were given adjuvant treatment with MTBE for 2 hours immediately after the ESWL. All pigs were killed a week after treatment. RESULTS: Adjuvant MTBE dissolution led to superimposed damage of the gallbladder. One pig died of biliary leakage and peritonitis. For all kinds of stones, adjuvant MTBE treatment increased the median (range) percentage of stone dissolved by ESWL from 31 (0-58) to 60 (11-81) (p < 0.01), whereas for pure cholesterol stones the increase was from 23 (0-58) to 61 (11-81) (p < 0.01). CONCLUSIONS: These data warrant clinical evaluation of the applicability of combined ESWL and MTBE dissolution of symptomatic gallstones in selected patients.

Radiographic features of oral cholecystograms of 448 symptomatic gallstone patients: implications for nonsurgical therapy.

Since radiographic findings on oral cholecystography (OCG) have implications for the eligibility for nonsurgical therapy of elderly patients, we investigated the OCGs of 448 symptomatic gallstone patients (109 male, 339 female; mean age, 49.8 +/- 14 (range, 21-88)). Opacification of the gallbladder was found in 323 cases (72.1%). Calcifications of gallstones were found in 85 opacified gallbladders (26.3%). Solitary and multiple stones were calcified in 35.3% and 18.2%, respectively (P < 0.0005). When divided into two groups (< or = 40 years and > 40 years), there was a significant increase in calcifications (P < 0.02) and a non-significant increase in opacification with increasing age. It is concluded that age is a determinant for calcification of gallstones and not opacification of the gallbladder. Since multiple stones are proportionately observed more in clinical studies than in epidemiologic studies, it is suggested that multiplicity of stones predisposes to biliary complaints. That solitary stones are more likely to be calcified than multiple stones, adds to the hypothesis that solitary and multiple stones have a different pathogenesis. Elderly patients, in whom non-surgical therapy is most likely to be indicated and cost-effective, are less likely to be suitable for this form of treatment, since age is a determinant for stone calcification.

Biliary extracorporeal shockwave lithotripsy: short-term and long-term observations in an animal model.

The short- and long-term effects of biliary extracorporeal shockwave lithotripsy (ESWL) using an electromagnetic lithotriptor were investigated in 26 pigs. After implantation of single human gallstones into their gallbladders, all but 4 control pigs were subjected to 4,000 or 8,000 shock waves and killed one day (n = 9), one week (n = 7), or one year (n = 6) thereafter. Post-ESWL, no abnormalities of chest radiographs or laboratory tests were detected. Apart from focal injury of the gallbladder and liver, in 4 out of 9 pigs subpleural pulmonary hemorrhages were found one day post-ESWL. However, tissue damage was largely reversed within one week and after one year only small hepatic scars persisted as permanent damage. Stone fragmentation occurred in 19 (86%) out of 22 pigs, and was adequate (fragments < or = 5 mm) in 9 (41%) pigs. Tissue damage and stone fragmentation after 4,000 as compared with 8,000 shock waves were not significantly different. These data warrant further evaluation of this lithotriptor in human studies.

The value of ultrasound in the follow-up of patients treated with biliary lithotripsy. Implications for monitoring patients after nonsurgical therapy of gallbladder stones.

To establish the value of ultrasound (US) in the follow-up of patients treated with extracorporeal shockwave lithotripsy (ESWL), the results of 484 US examinations of 87 patients were analyzed and related to the results of ESWL. Reliability of US in assessing efficacy was investigated by comparing consecutive US examinations. Unreliable US results were found in 36 patients (41%); in 7 patients US failed to demonstrate fragments. In nine patients (10%) unreliable US findings contributed to delayed retreatment with ESWL. To prevent errors in treatment regimen, verification of US findings is advised in case no fragments or fragments < 5 mm are found. In 22 patients (25%) US findings appeared indicative of hampered stone migration. Only 2 of these 22 patients (9.1%) became free of stones, compared with 32 of the remaining 65 patients (49.3%) (p < 0.01), even though both groups had similar initial stone characteristics and similar time of follow-up. US findings such as a contracted gallbladder or a common bile duct > 7 mm therefore indicate poor efficacy of ESWL.

Electromagnetic shock wave lithotripsy of gallbladder stones in vitro: the role of different stone characteristics and treatment variables.

From 40 sets of five human gallstones obtained at cholecystectomy, four stones were subjected to either 125/250 (maximum generator output) or 250/500 (half maximum generator output) electromagnetic shock waves (treatments I/II and III/IV, respectively); the fifth stone was used for computed tomography (CT) and chemical analysis. Overall, 130 (81%) of 160 stones fragmented, including 72 (45%) adequately (fragments less than or equal to 5 mm). For the treatments I, II, III, and IV the overall fragmentation rates were 80%, 95%, 70%, and 80%, respectively. The corresponding percentages of adequate fragmentation ( less than or equal to 5 mm) were 38%, 70%, 30%, and 42%, respectively. The best results were thus obtained after application of 250 shock waves (maximum generator output; treatment II). Pure cholesterol stones (p less than 0.01), stones with a mean CT density less than or equal to 110 HU (p less than 0.001), and stones with a calcified rim (p < 0.05) fragmented significantly better, but adequate fragmentation ( less than or equal to 5 mm) was significantly determined by stone weight and diameter (p less than 0.001), bilirubin content (p less than 0.02), and calcium content (p less than 0.05). A weight greater than 500 mg and a diameter > 10 mm could be defined as stone characteristics with significant negative predictors of adequate fragmentation. However, because the experimental conditions in this in vitro study did not completely simulate clinical settings for various reasons, these observations must be interpreted accordingly.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of ultrasound and oral cholecystography in assessing the number and size of gallstones: implications for non-surgical therapy.

Prior to non-surgical therapy of gallstones it is important to assess their number and size. In order to evaluate the accuracy of ultrasound (US) and oral cholecystography (OCG) in counting and measuring gallstones, a prospective blind study was conducted to compare the results of US (n = 99) and OCG (n = 36), either alone or in combination (n = 34), with the number and size of gallstones retrieved after cholecystectomy. The number of gallstones was accurately estimated by US and OCG in 74% and 69% of the cases, respectively. In assessing the presence of up to three, five or 10 gallstones both US and OCG proved reliable. In measuring the size of gallstones, there was 19% accuracy with US compared with only 3% with OCG. With an accepted measurement error of 3 mm these values increased to 80% for US and 44% for OCG. US proved more reliable than OCG in discriminating gallstones smaller or larger than 10 mm and smaller or larger than 20 mm, but with US, detection of gallstones larger than 30 mm was problematic. Both US and OCG underestimated gallstone size. The combination of both techniques did not significantly improve the assessment of either number or size of gallstones compared with the results obtained with US or OCG alone. It is concluded that (1) both US and OCG have some limitations in assessing the number and size of gallstones, (2) the combination of both examinations does not improve accuracy, and (3) patient selection for non-surgical treatment of gallstones can be started by US alone.

Electromagnetic shock wave lithotripsy of gallbladder stones: a wide range of inclusion criteria.

From April 1988 until November 1990, 83 patients with symptomatic gallbladder stones were treated in the University Hospital "Dijkzigt" Rotterdam with extracorporeal shock wave lithotripsy (ESWL) followed by oral administration of bile acids (urso- and chenodeoxycholic acid). According to our inclusion criteria, patients with up to 10 stones without any limit to the size of the stone(s) were accepted for treatment. On average, these patients underwent two sessions of ESWL with an electromagnetic lithotriptor (Lithostar and Lithostar Plus, Siemens AG, Erlangen, Germany). Fragmentation of stones was achieved in 70/83 (84% patients). The best results were achieved in patients with a solitary gallstone (50% of these patients were stone-free 12 months after ESWL). Four percent of the patients with two to three stones, and 12% of the patients with four to 10 stones were free of stones 12 months after ESWL. Twenty-eight (34%) patients suffered from biliary colics after ESWL, and three patients (3.5%) developed pancreatitis. The administration of oral bile acids was complicated by transient diarrhoea in 15 (18%) patients. ESWL followed by oral bile acid therapy is a relatively effective and safe therapy for a highly select population of patients with gallbladder stones, which can be performed on an outpatient basis. Although the results for multiple stones were poor, the usage of wide inclusion criteria (up to 10 stones of any size) did not affect the success rate of ESWL for multiple stones.

Sclerotherapy of the gallbladder in pigs. Development of a balloon catheter for a single-step procedure.

Gallbladder sclerotherapy after permanent cystic duct occlusion, to prevent gallstone recurrence in nonsurgical gallstone therapy, is at least a two-stage procedure. A balloon catheter was developed to perform gallbladder sclerotherapy with only temporary occlusion of the cystic duct, and the efficacy and safety of this method was subsequently investigated. Twenty pigs underwent cholecystostomy for positioning of a 7-Fr triple-lumen balloon catheter with proximal side holes. Sclerotherapy with 96% ethanol and 3% sodium tetradecyl sulfate for 20 minutes was performed. The animals were killed 24 hours, two, six, and 12 weeks after the procedure. The balloon catheter functioned well and seems suitable for procedures in which a temporary occlusion of the cystic duct is required. Although gallbladders after six and 12 weeks were shrunken and fibrotic, a single treatment of gallbladder sclerotherapy with subsequent catheter removal and no permanent cystic duct occlusion, as performed in this experiment, did not produce complete gallbladder ablation. In this study, sclerotherapy proved safe in the short term, but long-term effects remain to be assessed.

The value of ultrasound in predicting non-visualization of the gall-bladder on OCG: implications for imaging strategies in patient selection for non-surgical therapy of gallstones.

Gall-bladder visualization on oral cholecystography (OCG) is required for most non-surgical therapies of gallstones. In this study we attempted to establish sonographic criteria which will predict non-visualization of the gall-bladder on OCG. For this purpose we compared the results of ultrasound (US) and OCG in 171 patients with gallstones being assessed for non-surgical therapy. Sonographic criteria for non-visualization were a contracted gall-bladder and stone impaction in the gall-bladder neck or cystic duct. In detecting findings which predict non-visualization on OCG, US had a sensitivity of 78.3% and a specificity of 97.6%. The predictive values were: positive findings 92.3% and negative findings 92.4%. The overall accuracy was 92.4%. We conclude that US can be used as a first step in selecting patients for non-surgical therapy and if US indicates a contracted gall-bladder, 11% of the patients can be excluded from further diagnostic imaging.

Interleukin-1 and interleukin-6 in psoriasis.

We report on the levels of expression of IL-1 and IL-6 in skin from psoriasis patients. Different approaches were pursued. Initially, the levels of IL-1 beta and IL-6 were measured in suction blister fluid from lesional and uninvolved skin from psoriasis patients, using a sensitive enzyme-linked immunoabsorbent assay (ELISA) and bio-assay. Skin sections were also examined for the presence of IL-1 and IL-6 using IL-1 beta- and IL-6-specific antibodies. Finally, the expression of IL-1 and IL-6 mRNA was determined in cultured keratinocytes (KC) and fibroblasts from psoriasis skin. Suction blister fluid from lesional and uninvolved psoriasis skin and from skin of healthy individuals did not contain detectable levels (greater than 100 pg/ml) of IL-1 beta. Blister fluid from psoriasis lesions contained low but significant levels of IL-6, whereas the serum levels of IL-6 in these patients was undetectable. Using cryostat skin sections and an IL-1 beta-specific monoclonal antibody (MoAb) in an indirect immunoperoxidase technique, a diffuse staining in the entire epidermis was observed in sections of uninvolved skin from psoriasis patients. In cryostat sections of psoriasis lesions, a faint diffuse staining of the epidermis and a pronounced "dot-like" intracellular staining pattern was observed. On the other hand, the same IL-1 beta-specific MoAb showed, in a indirect immunofluorescence technique using unfixed epidermal cells, bright membrane staining in epidermal cell suspensions from psoriasis lesions. Slightly elevated levels of IL-1 beta and IL-1 alpha mRNA were observed in cultured KC from psoriasis lesions as compared to those in normal KC and in the HEp-2 cell line. Very low levels of IL-6 mRNA were expressed in KC from psoriasis lesions and healthy individuals. Fibroblasts from psoriasis lesions expressed extremely low levels of IL-1 alpha and IL-1 beta, but high levels of IL-6 mRNA. The results point to a paradoxical situation in psoriatic skin: blister fluid from psoriasis lesions contains no IL-1 beta, whereas IL-1 beta is overexpressed on the plasma membrane and in the intracellular compartment of epidermal cells. This finding may help in explaining the observed absence of IL-1 in aqueous extracts of psoriatic scales. Because cultured KC from psoriasis lesions express minimal levels of IL-6 mRNA. dermal fibroblasts, probably together with the inflammatory infiltrate, may represent a major source of IL-6 in psoriasis lesions in vivo.

[Shock wave lithotripsy of gallbladder stones: the initial 54 patients treated in Rotterdam-Dijkzigt]. / Schokgolfvergruizing van stenen in de galblaas; de eerste 54 in Rotterdam-Dijkzigt behandelde patiënten.

From April 1988 till May 1990 54 patients with symptomatic gallbladder stones were treated in the University Hospital Rotterdam-Dijkzigt with extracorporeal shock wave lithotripsy (ESWL) followed by oral administration of bile acids (urso- and chenodeoxycholic acid). These patients on average underwent 2 sessions of ESWL with an electromagnetic lithotriptor (Lithostar and Lithostar Plus, Siemens AG, Erlangen, FRG). Ultimate disintegration of stones was achieved in 50/54 (93%) patients. The best results were achieved in patients with a solitary gallstone (56% of these patients were stone-free 12 months after ESWL). Four per cent of the patients with 2-10 stones were free of stones 12 months after ESWL). Thirty-seven per cent of the patients suffered from biliary colics after ESWL and three patients developed pancreatitis. The administration of oral bile acids were complicated by transient diarrhoea in 20% of the patients. ESWL followed by oral bile acid therapy is a relatively effective and safe therapy for a highly selected population of patients with gallbladder stones.

Predicting gallstone composition with CT: in vivo and in vitro analysis.

Chemical composition of gallstones is of major importance in selecting patients for nonsurgical therapy. In a combined in vivo and in vitro study of predictive potential, 50 patients undergoing cholecystectomy were evaluated with computed tomography (CT) and either plain abdominal radiography or oral cholecystography (OCG). The largest stone surgically removed from each patient was subjected to in vitro CT and chemical analysis. The authors found an inverse relationship between CT attenuation numbers and cholesterol content and a good positive correlation between CT attenuation numbers and calcium content. In vivo CT analysis improved sensitivity, specificity, accuracy, and positive and negative predictive values compared to plain abdominal radiography and OCG in detection of cholesterol stones. Using their prediction rule (a CT number smaller than 140 HU indicates a pure cholesterol gallstone), the authors correctly classified gallstones in 17 (84%) of another 20 patients. In vivo CT analysis can enable reliable prediction of gallstone composition and should play an important role in the selection of patients for nonsurgical treatment.

Extracorporeal shockwave lithotripsy of gallstones. Possibilities and limitations.

Recently extracorporeal shockwave lithotripsy (ESWL) has been introduced as a nonoperative treatment for gallstone disease. Except for lung damage, no significant adverse effects of ESWL of gallbladder stones have been observed in animals. In clinical use ESWL of gallbladder stones is now confined to 15% to 30% of symptomatic patients. To achieve complete stone clearance, ESWL of gallbladder stones must be supplemented by an adjuvant therapy. ESWL of bile duct stones is highly effective and can be considered in patients in whom primary endoscopic or surgical stone removal fails. Second generation lithotriptors allow anesthesia-free (outpatient) treatments, but the clinical experience with most of these ESWL devices is still limited. The likelihood of gallbladder stone recurrence is a major disadvantage of ESWL treatment, which raises the issue of cost-effectiveness. ESWL for cholelithiasis is a promising treatment modality with good short-term and unknown long-term results.