This report describes the initial clinical implementation of a new laser lithotripter system capable of effective fragmentation of common bile duct stones with a high degree of safety provided by an integrated stone-tissue detection system. This system automatically terminates laser pulse transmission if tissue contact is sensed. Eighteen patients with giant or impacted common bile duct stones refractory to standard treatment techniques were treated via the endoscopic retrograde route using a rhodamine-6G dye laser with an integrated stone-tissue detection system. In the event of tissue contact, the stone-tissue detection system cuts off the laser pulse after 190 ns (after transmission of 5% to 8% of the total pulse energy). Nine patients were treated under cholangioscopic control, and nine patients were treated blindly under fluoroscopic control using only standard duodenoscopes with either a 6F standard endoscopic retrograde cholangiopancreatography catheter (4 patients), a 6.8F balloon catheter (3 patients), or a laser lithotriptor basket (2 patients). Laser-induced fragmentation was achieved in all 18 patients (100%). Sixteen of 18 patients (89%) became completely stone-free after completion of the treatment, including additional intracorporeal shock wave lithotripsy in five patients. The only major complications occurred in one fully anticoagulated patient with a prosthetic heart valve who developed significant hemobilia and transient cholangitis but recovered after conservative treatment. Laser lithotripsy using the rhodamine-6G dye laser plus stone-tissue detection system appears safe and effective and allows "blind" fragmentation of difficult common bile duct stones to be performed under radiologic control.

Adult↗

PubMedDate not supplied

Role of activation-dependent platelet membrane glycoproteins in development of subacute occlusive coronary stent thrombosis.

BACKGROUND: Platelets have an important role in coronary thrombosis. METHODS: We studied 151 consecutive patients undergoing implantation of Palmaz-Schatz stents because of suboptimal results after coronary balloon angioplasty treated by intense anticoagulation. Surface exposure of the constitutively expressed glycoprotein complex IIb-IIIa (CD41), P-selectin (CD62P) and of the GPIIb-IIIa complex activated exposure (of ligand-induced binding site-1) were determined, in addition to platelet count and plasma fibrinogen, before and daily for 12 days after stenting in peripheral venous blood samples. RESULTS: Six of 151 patients (3.9%) developed subacute stent thrombosis within the first week after stenting. The relative risk of stent thrombosis was 18.5-fold for patients with enhanced GPIIb-IIIa surface expression (P < 0.003; 95% confidence interval 2.1 to 163.1) before stent placement. In the period after stenting, platelet activation occurred, with an increase in fibrinogen receptor activity and P-selectin degranulation above pre-stent values (P < 0.01). In logistic regression analysis, GPIIb-IIIa before stenting emerged as a risk factor for stent thrombosis, independent of the activational status of platelets, platelet count or fibrinogen levels (P < 0.02). However, after stenting, P-selectin surface expression acquired prognostic importance for stent thrombosis (P < 0.05). CONCLUSION: We conclude that changes in platelet membrane glycoproteins are of prognostic value in predicting subacute stent thrombosis.

Acute Disease↗

PubMedDate not supplied

Indication and technique of transnasal microscopic orbital decompression for endocrine ophthalmopathy.

If endocrine ophthalmopathy progresses despite conservative treatment then indications for surgical decompression are: loss of visual acuity, increasing strabism, and severe keratopathy. Endonasal microsurgery ensures a binocular view onto the intranasal landmarks of the orbital walls and allows simultaneous decompression of the medial and inferior wall as well as a good relief of pressure at the orbital apex. Surgical decompressions were performed on 29 orbits in 19 patients, 16 by using the endonasal microsurgical, 3 via external approach. The microscopic approach was entirely comparable with regard to the reduction of proptosis with a mean improvement of 4.2 mm against a mean of 4.7 mm by external approach and a mean 0.2 of better visual acuity in both procedures. The microsurgical technique is considered superior to an external approach avoiding external scars, neural pain, and reportedly less diplopia. The healing phase and the hospitalization time are shorter.

Adult↗

PubMedDate not supplied

Endoillumination-guided intranasal microscopic dacryocystorhinostomy for difficult cases.

PURPOSE: This prospective study explores the efficacy of a combined approach by intranasal microsurgical dacryocystorhinostomy and fiberglass endoillumination of the tear passage for difficult cases of lacrimal sac or nasolacrimal duct obstruction. METHODS: Microscopic dacryocystorhinostomy was performed in 67 patients with lacrimal obstruction and for revision of external dacryocystorhinostomy. Improved endonasal visualization by microscope and combination with endoillumination of the tear passage allows instant identification and opening of the lacrimal nasal sac without skin incision. Silicon tubes were used for bicanalicular intubation. The patients were prospectively observed for at least 1 year. RESULTS: The operation was well tolerated by all patients. In 95%, a persistently open tear passage was successfully established. No serious complications were observed. CONCLUSION: Endoillumination of the lacrimal sac is useful for locating the sac precisely and refining the endonasal operation technique.

Adolescent↗

PubMedDate not supplied

Ancillary procedures in microscopic endonasal orbital decompression for thyroid-associated ophthalmopathy.

In 35 patients with thyroid-associated orbitopathy, nonresponsive to conservative treatment, an endonasal microscopic approach with bimural osteotomy was performed for decompression in two ways. While in group A the periorbita was resected, and fat septa were cut, in group B periorbital strips were left, and fat septa were respected. In accordance with other authors, resection of the periorbital and cutting fat septa will improve vision and proptosis, but in up to 30% of the patients de novo diplopia occurs. Our data favor the assumption that a more conservative endonasal microscopic decompression of the orbita leaving periorbital strips and fat septa achieves similar good results for reduction of proptosis and visual gain but creates less often de novo diplopia in primary gaze. Based on our experience, rehabilitation for thyroid-associated arbitopathy comprises as a first step orbital endonasal decompression with cooperation of the ophthalmologist, then if necessary as a second step strabismus surgery, and thirdly eyelid repair for scleral show.

Adult↗

PubMedDate not supplied

[Neonatal hyperinsulinism, congenital corporeal hemihypertrophy, tumor of the breast in adolescence].

The authors report the association of neonatal hyperinsulinism (nesidioblastosis) and congenital hemihypertrophy in an infant. At the age of 13 6/12 years fibro-adenomas of the breast occurred. The diagnosis of Beckwith-Wiedemann syndrome is discussed.

Adenofibroma↗