Small prophylactic pancreatic duct stents: an assessment of spontaneous passage and stent-induced ductal abnormalities.

BACKGROUND AND STUDY AIMS: Placing small stents in the pancreatic duct at endoscopic retrograde cholangiopancreatography reduces the risk of pancreatitis. However, this practice means that a second procedure might be required to remove the stent, and stents can also damage the duct. The aims of this study were to determine the frequency of spontaneous dislodgment and to assess the incidence of stent-induced ductal irregularities. PATIENTS AND METHODS: We performed a retrospective analysis of consecutive patients seen over a 3-year period (2001 - 2004) who had undergone placement of a 3-Fr pancreatic duct stent and in whom the fate of the stent had been documented. Radiographs were reviewed to determine stent passage at 30 days. If applicable, follow-up pancreatograms were reviewed to assess for stent-induced ductal abnormalities. Statistical analysis was performed using chi-squared and Fisher's exact tests for proportions, and 95 % binomial confidence intervals (CI) were calculated. RESULTS: Records for 125 consecutive patients who had had 3-Fr pancreatic stents placed were reviewed. The stents had passed spontaneously within 30 days in 110/125 patients (88 %). In the remaining 15 patients (12 %, 95 % CI 6.9 % - 19 %), the stents were still present on follow-up radiographs after a median time of 36 days, (range 31 - 116 days). Stent length, pancreatic sphincterotomy, and pancreas divisum had no effect on the likelihood of spontaneous passage. No stent-induced ductal irregularities were observed. CONCLUSIONS: Nearly 90 % of prophylactic 3-Fr pancreatic duct stents pass spontaneously within 30 days, and these stents were not observed to induce changes in the pancreatic duct.

Enhanced skin allograft survival after photodynamic therapy. Association with lymphocyte inactivation and macrophage stimulation.

It has been found previously that peritoneal exposure to hematoporphyrin derivative (HpD) photodynamic therapy (PDT) can induce systemic immunosuppression of contact hypersensitivity. We have now found that HpD-PDT also significantly prolongs survival of murine skin allografts. Normal A/J mice transplanted with BALB/c skin rejected the grafts within 10 +/- 0.9 days. Recipient mice treated 24 hr previously with HpD-PDT rejected skin allografts at 16 +/- 1.2 days. HpD alone or irradiation alone had no effect on skin graft survival, nor did HpD-PDT administered shortly after grafting. Flow cytometric analyses showed a nearly complete depletion of peritoneal lymphocytes 3 days after HpD-PDT. Lymphocyte levels were normal in the spleen, an organ not directly targeted by the PDT treatment, but the cells were totally unresponsive to Con A and LPS mitogens. Conversely, peritoneal HpD-PDT caused a striking enhancement in macrophage function as measured by phagocytosis of antibody-coated sheep erythrocytes. Humoral immunity to hen egg-white lysozyme was not significantly changed by HpD-PDT. These results demonstrate that HpD-PDT causes systemic immunosuppression of cellular immunity which, in turn, allows prolonged survival of allografts. Humoral immunity appears to remain largely unaffected by HpD-PDT and macrophages become activated, suggesting that this therapy might be more effective in specifically targeting T cell-mediated immunity than current immunosuppressive treatments.

The role of transjugular intrahepatic portosystemic shunts in the management of patients with end-stage liver disease.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to successfully treat complications of portal hypertension; however, not all reports have been favorable. METHODS: Forty patients underwent 41 attempts to place a TIPS. All patients but 1 had a Wallstent placed. RESULTS: Thirty-nine procedures (95%) were successful. Thirty-one patients were treated for gastrointestinal bleeding, and 9 for refractory ascites. The average fall in portal pressure was 13.7 +/- 0.9 mm Hg. Major postprocedure complications included 4 deaths. Minor problems included liver capsular perforation, fever, self-limited bleeding, and a pseudoaneurysm. Follow-up evaluation revealed that by 5 months, 50% of the shunts developed a portal-venous-to-right-atrial pressure gradient requiring balloon dilatation or a new stent. The 1-year actuarial patient survival was 72%. Eighteen patients were candidates for orthotopic liver transplantation (OLT) and 5 have been transplanted. CONCLUSIONS: TIPS may be best used for stabilization, prior to OLT or as a temporizing measure prior to elective shunt surgery.

Is the role of transjugular intrahepatic portosystemic shunts limited in the management of patients with end-stage liver disease?

BACKGROUND: Transjugular intrahepatic portosystemic shunts (TIPS) are an established method for the treatment of the complications of portal hypertension. Recent reports have suggested that TIPS require frequent follow-up and may interfere with orthotopic liver transplantation (OLT). METHODS: Retrospective chart review was performed of ultrasound studies, angiographic studies, and complications of the first 100 patients treated consecutively with TIPS from February 1992 through October 1995. RESULTS: Ninety-seven patients had functional TIPS. Thirty-one percent of patients treated emergently survived, significantly less than the 96% survival of elective patients. Fifty percent of the shunts were found to require angioplasty by 5 months. Seventeen patients treated with OLT did well, without intraoperative bleeding problems, and are alive. CONCLUSIONS: The TIPS method treats successfully the complications of portal hypertension but requires careful follow-up. The technique may be used prior to OLT. For non-OLT candidates, the cost effectiveness of TIPS versus surgical shunting remains in question.

The technique of percutaneous endoscopic gastrostomy. A safe and cost-effective alternative to operative gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is an attractive method of providing enteral nutrition to patients who are candidates for operative gastrostomy or nasoenteric tube feeding; it is currently the procedure of choice for selected nutritionally compromised patients. PEG may be considered for patients who need short- or long-term enteral support; those unable to swallow or who cannot maintain adequate oral intake are ideal candidates. Several techniques are used to perform PEG; each involves the placement of a gastrostomy tube at a point where the stomach and abdominal walls are in closest contact. PEG can be done at the bedside without general anesthesia. Feeding can begin within 24 hours of PEG placement. Major complications (peritonitis and pulmonary aspiration) occur infrequently.

Method development in pharmaceutical analysis employing capillary electrochromatography.

Capillary electrochromatography (CEC) has been employed to explore method development for a series of structurally related polar neutral compounds of pharmaceutical relevance. Capillaries with dimensions of 75 microm ID x 25 cm length (34.5 cm total) were packed with Spherisorb ODS-1, Hypersil phenyl, and Hypersil MOS (all 3 microm particles) and were compared in the reversed-phase mode in order to determine which phase provided the best initial performance and thus serve as the phase of choice for additional method development experiments. The various separation parameters examined for their effect on efficiency, k', resolution, and linear velocity included percent and type of organic modifier, buffer concentration, voltage, and temperature. All separations were conducted with an acidic mobile phase (aqueous mobile phase component, pH 3.0). The separation efficiencies obtained were on the order of 200,000-260,000 plates/m, which equates to reduced plate heights of 1.22 for columns packed with Spherisorb ODS-1. Repeatable column-to-column separation performance was demonstrated.

Relationship between biochemical and virological responses to interferon therapy in chronic hepatitis C infection. Consensus Interferon Study Group.

We have investigated the relationship between serum alanine aminotransferase (ALT) and hepatitis C virus (HCV) RNA in the assessment of responses to interferon (IFN) therapy in chronic HCV infection. Data from 704 patients with HCV infection who were randomized to receive consensus IFN-alpha (CIFN) 3 micrograms (n = 232 patients) or 9 micrograms (n = 232 patients), or IFN-alpha 2b 3 million units (MU) (n = 240 patients), were used for these analyses. All patients were treated three times weekly. Hepatitis C viral RNA (HCV RNA) was determined by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) with a lower limit of detection of 100 copies ml-1. Of patients with normal serum ALT concentrations, 53% (120/225) had undetectable HCV RNA at the end-of-treatment period and 47% (51/109) had undetectable HCV RNA at the end of the post-treatment observation period. In contrast, of the patients with undetectable HCV RNA, 75% (120/161) and 84% (51/61) had normal serum ALT activities at the end-of-treatment and post-treatment observations periods, respectively. The majority of patients with undetectable HCV RNA had normal ALT values. In contrast, only half of the patients with normal ALT values were negative for HCV. End-of-treatment HCV RNA response also better predicted sustained virological response than did end-of-treatment ALT response.