Biliary cystadenoma: rare variant of intrahepatic cystic disease.

Intrahepatic nonparasitic cystic disease is rare and may be of congenital or neoplastic origin. The most frequent symptoms and signs are nonspecific and include pain, nausea, fullness, increased girth, and palpable mass. Interventional therapy is reserved for symptomatic patients, which usually corresponds to cysts >5 cm in diameter. Retrospective analysis revealed 26 cases of intrahepatic cystic disease over 15 years at our institution. We discuss the case of a patient who had bilobular biliary cystadenomatous disease, a rare, benign variant of intrahepatic nonparasitic cystic disease.

Nonsurgical management of primary cholangiocarcinoma. Retrospective analysis of 40 cases.

Forty patients with cholangiocarcinoma (23 men, 17 women) underwent nonsurgical palliative biliary drainage over a period of 12 years. All were surgically unfit or had unresectable disease. All were jaundiced at presentation with a mean serum bilirubin of 11.5 +/- 1.9 mg/dl. Thirty patients (75%) had hilar obstruction. Twenty-eight were drained percutaneously, three endoscopically and nine by a combined endoscopic and percutaneous procedure. Technical success was 97.5%. Final mean bilirubin was 1.5 +/- 0.4 mg/dl. Minor complications occurred in 10 (25%) patients, and major complications in four (10%). Procedure-related mortality was 2.5% with a 30-day mortality of 7.5%. Mean survival was 8.2 +/- 0.5 months. Stent changes were required in eight patients. In patients with inoperable or unresectable cholangiocarcinoma, percutaneous or endoscopic biliary drainage offers effective palliation.

Percutaneous transcholecystic approach to the rendezvous procedure when transhepatic access fails.

PURPOSE: Extrahepatic biliary obstruction can be managed endoscopically or percutaneously. When endoscopic therapy fails, percutaneous drainage with or without endoscopic assistance may be performed. However, transhepatic drainage may itself be unsuccessful. In such patients, a transcholecystic approach combined with endoscopic therapy was used to achieve biliary drainage. MATERIALS AND METHODS: After attempts at transhepatic biliary drainage failed, a percutaneous cholecystostomy was performed in four patients, with subsequent cannulation of the common bile duct, endoprosthesis insertion, or papillotomy. RESULTS: The success rate was 100%, with no major complication or procedure-related mortality. Slight bleeding from a sphincterotomy was the only minor complication. CONCLUSION: When percutaneous transhepatic access to the bile duct fails, the transcholecystic route can be safely used with care to successfully achieve biliary drainage.

Effects of gallstone solvents on commonly used catheters.

PURPOSE: To determine what interaction and effect different cholesterol gallstone solvents have on catheters used for gallstone chemolysis. MATERIALS AND METHODS: Five types of catheters used for biliary procedures were chosen: polyethylene, Percuflex, silicon, Silitek, and polyurethane. The solvents chosen were methyl tert-butyl ether, ethyl propionate, isopropyl acetate, and N-propyl acetate. After incubation of the catheters in the solvents for 72 hours, they were air dried. Weight and area changes were determined for each catheter. Additionally, carbon-13 nuclear magnetic resonance (NMR) spectroscopy was performed for analysis of composition changes. RESULTS: Three catheters--silicone, Silitek, and polyurethane--showed changes in their physical characteristics that would make them less desirable for stone chemolysis. The silicone catheter showed changes in elastic texture as well as marked weight reduction. The Silitek and polyurethane catheters had similar, but less dramatic changes. C-13 NMR analysis of collected solvents showed that commonly used plasticizers were leached out of some catheters. CONCLUSION: These results suggest that all catheters are not suitable for use with all solvents. The choice of catheter should be made based on the solvent in use. The polyethylene catheter performed best under the conditions and endpoints used in this study.

Pain control during interventional biliary procedures: epidural anesthesia vs i.v. sedation.

OBJECTIVE: We performed a study designed to compare epidural anesthesia with IV sedation for the control of pain during interventional biliary procedures. MATERIALS AND METHODS: Two hundred sixty-three biliary procedures were performed in 126 patients during a 3-year period. The transhepatic approach was used for all the procedures. Epidural anesthesia was used in 140 procedures and IV sedation was used in 123. Both epidural anesthesia and IV sedation were used in 31 patients who required multiple procedures. The efficacy of each method for control of pain was determined by a subjective rating of the patients' pain during the procedure: from 0 (no pain) to +3 (severe). The ratings were compiled and compared for each of the methods to ascertain which technique best achieved the desired effect. The pain control used depended on the urgency of the procedures and the availability of an anesthesiologist to administer epidural anesthetic. When an anesthesiologist was unavailable, IV sedation was used. The type and amount of drug administered depended on the patient's preference and history. RESULTS: Of the 140 procedures done with epidural anesthesia, patients had no pain to mild pain in 127 (91%) and moderate to severe pain in 13 (9%). All instances of moderate to severe pain were the result of unsuccessful attempts to establish or maintain anesthesia. Of the 123 procedures done with IV sedation, patients had no pain to mild pain in 62 (50%) and moderate to severe pain in 61 (50%). Complications were more frequent when IV sedation was used. Six (5%) occurred, and all were related to hypotension. The hypotensive episodes occurred early in the study, before monitoring of patients was improved; now, continuous updates on vital signs are provided throughout the interventional procedure. With epidural anesthesia, hypotension developed in only one patient (< 1%) and the patient responded to fluid administration. CONCLUSION: When it is successful, epidural anesthesia can completely eliminate moderate to severe pain in patients undergoing biliary procedures. IV sedation is only 50% effective in this regard. The greater efficacy of epidural anesthesia, coupled with the significantly lower prevalence of hypotension, justifies the additional cost and time associated with epidural anesthesia for pain management in biliary procedures.

Gallbladder ablation with gallstones in situ in an animal model.

RATIONALE AND OBJECTIVES: The authors evaluated a method of gallbladder sclerosis in the presence of cholelithiasis. METHODS: The study was performed in 20 pigs. The gallbladders of 16 pigs contained surgically placed human gallstones. Control groups included animals that had their gallbladders sclerosed in the absence of stones, as well as a surgical sham control. Sclerosis followed cystic duct ligation to prevent extravasation of the sclerosing agent (95% Ethanol with 2 mole% trifluoroacetic acid) into the biliary tree. After sclerosis, a pigtail catheter was placed in the gallbladder to drain any post-procedure fluid accumulations. Catheters were removed after all drainage had ceased. Animals were killed at either 8 weeks (n = 6) or 6 months (n = 14). RESULTS: Stones were enveloped within the sclerosed and fibrotic gallbladder remnant in 13 of 15 test animals (87%). CONCLUSIONS: Sclerosis of gallbladders with stones in situ was achievable. Total mucosal obliteration did not appear to be required to produce a dysfunctional gallbladder in the time frame of this study.

Accelerated destruction of large, calcified gallstone burdens by performing lithotripsy in the presence of methyl t-butyl ether: an in vitro study.

Numerous, large, or calcified gallstones hinder successful extracorporeal fragmentation. The purpose of this study was to investigate an in vitro method that could accelerate the destruction of these types of gallstone burdens. Matched sets of partially calcified gallstones, each set having a combined stone diameter greater than 3 cm, underwent lithotripsy while immersed in either 15 cc of bile, methyl t-butyl ether (MTBE), or dimethyl sulfoxide (DMSO), with a fourth set serving as a control. Results showed a 20% reduction in the relative weight of all fragments, an eightfold reduction of the relative weight of fragments greater than 3 mm, and a 50% reduction of the number of large fragments when the stones were immersed and shocked in MTBE rather than when shocked in bile. Dimethyl sulfoxide hindered gallstone destruction. These results indicate that large, partially calcified gallstone burdens can be more successfully destroyed if lithotripsy is performed in the presence of a small quantity of MTBE rather than in bile alone or in the presence of DMSO. If proven safe in vivo, this technique could expand the applicability of lithotripsy to those with larger, partially calcified stone burdens.

The acceleration of gallstone destruction with synchronous biliary lithotripsy and contact dissolution in vitro using three cholesterol-solubilizing solvent.

In the first-known application of its kind, shockwave lithotripsy and contact-solvent dissolution of large, calcified gallstone burdens were performed simultaneously with three chemical solvents, each tested separately in an in vitro model, with the combined effects on gallstone eradication examined. Two solvents, ethyl propionate and isopropyl acetate, were chosen for their solubilizing ability and potentially high level of patient safety. The third solvent, a 70%:30% mixture of methyl tert-butyl ether (MTBE) and dimethyl sulfoxide (DMSO), was chosen for its known ability to accelerate the dissolution of calcium-containing gallstones. All stones were matched for size, weight, and number. Gallstone lithotripsy performed in ethyl propionate was significantly more effective (P less than .02) in the production of fragments less than 2 mm when compared with bile; lithotripsy with isopropyl acetate and the MTBE/DMSO mixture showed no statistically significant effect. Biliary lithotripsy performed in an ethyl propionate medium may enhance gallstone dissolution and the production of small fragments (diameter less than 2 mm).

The radiologic diagnosis of Barrett esophagus: importance of mucosal surface abnormalities on air-contrast barium studies.

Patients with Barrett esophagus are predisposed to the development of esophageal adenocarcinoma. Identification of these patients before this complication develops is essential. We prospectively made the diagnosis of Barrett esophagus on routine biphasic upper gastrointestinal series in nine patients in whom a mucosal surface pattern alteration was the only radiologic abnormality on the esophagogram. The diagnosis was confirmed by biopsy in eight patients and during surgery in one patient. Only a third of the patients had symptoms related to the esophagus. Two types of surface changes were noted. A reticular pattern was present in six cases and a villous pattern in five cases. Both patterns were noted in two patients. This series was obtained in a 5-year interval during which there were 15 additional patients with Barrett esophagus and corresponding esophagograms. None of these patients had normal results on esophagograms. Recognition of these subtle surface patterns, particularly in the absence of other reflux-induced abnormalities, may improve detection of Barrett esophagus and aid in the selection of patients for subsequent surveillance.

Development of non-Hodgkin's lymphoma of the colon after radiation therapy for Hodgkin's disease.

Developments in the therapeutic approach to Hodgkin's disease have resulted in excellent long-term survival statistics. However, these patients are at risk for second malignancies, most commonly acute myelogenous leukemia and non-Hodgkin's lymphoma. We present a patient who developed non-Hodgkin's lymphoma of the colon simulating adenocarcinoma 14 years after successful radiation therapy for Hodgkin's disease.

Laparoscopic cholecystectomy: evolution, early results, and impact on nonsurgical gallstone therapies.

Laparoscopic cholecystectomy, a surgical technique first performed in France, has gained widespread acceptance among surgeons in the United States. The abdominal cavity is inflated by carbon dioxide, a video monitor is inserted via a laparoscope placed periumbilically, and the gallbladder is freed and removed from the liver bed by using small subcostal ports for access and dissection. Intraoperative cholangiography is routinely performed, but uncertainty exists about how best to manage choledocholithiasis. Compared with traditional cholecystectomy, initial reports describing laparoscopic cholecystectomy cite shorter recovery times because no large incisions are made, thus potentially reducing the cost and morbidity of cholecystectomy. A survey of 614 early cases supports these claims, with a reported complication rate of 1.5% and quick resumption of normal activities by patients. Because of its promise for reduced morbidity, laparoscopic cholecystectomy is challenging open cholecystectomy as the therapeutic gold standard for symptomatic cholelithiasis. Thus, the standard to which the nonsurgical gallstone therapies, such as lithotripsy and contact dissolution, will be compared may shift to laparoscopic cholecystectomy. As the laparoscopic complications are similar to those of traditional cholecystectomy, such as abscesses and bile leaks, their percutaneous treatment should not change.

In vitro cholesterol gallstone dissolution: comparison of methyl tert-butyl ether with three new ester solvents.

The in vitro effectiveness of three new cholesterol gallstone solvents that have a potential for clinical use--ethyl propionate, isopropyl acetate, and n-propyl acetate--was compared with that of the well-known cholesterol solvent methyl tert-butyl ether (MTBE). Ten sets of matched gallstones were initially weighed, imaged with radiography and computed tomography (CT), and analyzed for content. One stone from each set was incubated in one of the four solvents at 37 degrees C. Solvents were changed at 30-minute intervals. The study was stopped either when the stones were completely dissolved or at the end of 7 hours. Any residual fragments were weighed, reimaged, and reanalyzed for content. There were no statistical differences between dissolution times of the stones in MTBE compared with those in the three new solvents. Ethyl propionate and n-propyl acetate appear to be as efficacious as MTBE in dissolving cholesterol stones and could be attractive alternatives for gallstone chemolysis.