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Biomedical subjects

G Aliperti

Publications and source records attributed to G Aliperti.

At least 19 recordsLinked to original sources
PubMed2000

Sphincter of oddi manometry: is it necessary to measure both biliary and pancreatic sphincter pressures?

BACKGROUND: Data are scant on the miss rate of sphincter of Oddi dysfunction if basal pressure in both biliary and pancreatic sphincter segments is not measured during manometry. METHODS: Motility tracings with basal pressure measurements of both sphincter segments were retrospectively analyzed. Basal sphincter pressure greater than 40 mm Hg was considered abnormal in either sphincter segment. RESULTS: The study population consisted of 73 subjects (64 women, 9 men; age 45.3 +/- 1.6 yr). The basal pressures in the 2 sphincter segments were highly discordant (correlation coefficient = 0.2, p = 0.04). Basal pressures were normal in both segments in 19%, abnormal in both segments in 40%, and abnormal in 1 segment but normal in the other in 41%. The negative predictive value of normal biliary sphincter pressure in excluding sphincter dysfunction was 0. 42; when the pancreatic sphincter pressure was normal, the negative predictive value was 0.58. The incidence of pancreatitis with dual duct manometry was comparable to the institutional experience with all sphincter studies. CONCLUSIONS: Although the clinical relevance of individually elevated sphincter pressures remains uncertain, there is significant discordance of basal pressures between the biliary and pancreatic sphincter segments. If only the biliary sphincter pressure were to be measured, one fourth of abnormal sphincter pressures would be missed. Therefore, if the first sphincter segment has a normal basal pressure, the other segment should also be evaluated.

Adult↗
PubMed1999

Endoscopic hemostasis in acute diverticular bleeding.

BACKGROUND AND STUDY AIMS: Early reports of urgent colonoscopy in acute lower intestinal bleeding suggest a role for endoscopic therapy for bleeding colonic lesions, but scant data exist on bleeding diverticula. We report our experience with endoscopic hemostasis in acute diverticular bleeding. PATIENTS AND METHODS: Bleeding diverticula were identified on urgent diagnostic endoscopy in five patients with acute gastrointestinal bleeding, two in the duodenum, and three in the colon. All patients had co-morbid conditions preventing more conventional therapeutic approaches. The five cases are described, including the technique of endoscopic hemostasis and outcome. RESULTS: Endoscopic therapy using epinephrine injection, thermal cautery and/or laser therapy successfully induced hemostasis in all patients. One patient died of co-morbid illness during the hospital stay, while the remaining four patients had no recurrent bleeding over a mean follow-up period of 20.6 months. CONCLUSION: Endoscopic therapy of bleeding diverticula is technically possible when the culprit diverticulum can be identified. This therapeutic modality may have a place in debilitated patients in whom other more invasive procedures are contraindicated, but further experience is needed to establish its safety.

Acute Disease↗
PubMed1998

Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review.

BACKGROUND: Endoscopic therapy of biliary tract leaks was uncommon before laparoscopic cholecystectomy. Studies have demonstrated the efficacy of endoscopic drainage by endoscopic sphincterotomy or stent placement. Various endoscopic therapeutic modalities and long-term follow-up of this problem were studied. METHODS: Members of the Midwest Pancreaticobiliary Group reviewed all patients referred for endoscopic therapy of biliary leaks after laparoscopic cholecystectomy from 1990 to 1994. Long-term follow-up was by direct patient contact. RESULTS: Fifty patients were referred for endoscopic therapy of biliary leaks. Abdominal pain was present in 94%. The mean time from laparoscopic cholecystectomy to referral was 6.9 days. Therapy consisted of sphincterotomy only in 6 patients, stent only in 13, and sphincterotomy with stent in 31. Biliary leaks were healed in 44 patients at a mean of 5.4 weeks. A second or third endoscopic procedure was necessary to achieve healing in five patients. Two stent-related complications were noted. Percutaneous or surgical drainage of biliary fluid collections was required in 16 patients. The mean hospital stay for treatment of the leak was 11.1 days after endoscopic therapy. On follow-up (mean 17.5 months), all patients were well except two with mild abdominal discomfort. CONCLUSIONS: Endoscopic sphincterotomy, stent placement, or sphincterotomy with stent are effective in healing biliary leaks after laparoscopic cholecystectomy. Despite prolonged treatment for the leak, patients did well on long-term follow-up.

Bile↗
PubMed1998

Recurrent gastrointestinal bleeding: use of thrombolysis with anticoagulation in diagnosis.

PURPOSE: To determine the safety and diagnostic accuracy of a provocative protocol with heparin and urokinase to induce bleeding and determine the source in patients with chronic gastrointestinal hemorrhage. MATERIALS AND METHODS: Nine patients had gastrointestinal bleeding from an indeterminate source and had negative results from esophagogastroduodenoscopy, colonoscopy, small-bowel examination, and angiography. Ten provocative bleeding studies were performed prospectively. Patients had no clinical evidence of bleeding within 2 days before the study. Intravenous administration of heparin and urokinase was performed systemically during a 4-hour period while scintigraphy was performed continuously. Mesenteric angiography was performed immediately in patients in whom substantial gastrointestinal bleeding was detected at scintigraphy. RESULTS: The provocative protocol was successful in inducing scintigraphically detectable hemorrhage in four (40%) studies within 4 hours. In two of these four studies, the source of hemorrhage was determined and treated with embolization or surgery. Three (30%) studies demonstrated scintigraphic evidence of hemorrhage only at delayed imaging (8-24 hours after initiation of the study). The remaining three (30%) studies did not show active bleeding. No complications occurred, including hemodynamic instability or uncontrollable decreases in hematocrit. CONCLUSION: Since this protocol with heparin and urokinase enabled determination of the bleeding source in only two of 10 studies, protocol modifications are necessary before this intervention is used widely.

Adult↗
PubMed1997

Enteroscopy-enteroclysis: experience with a combined endoscopic-radiographic technique.

BACKGROUND: Video enteroscopy provides high-quality diagnostic and therapeutic capabilities in the proximal small bowel. Enteroclysis remains an essential diagnostic technique in the distal small bowel. We report our experience with the combination of these techniques. METHODS: Seventy-one patients with obscure gastrointestinal bleeding (group A, 54 patients) or abnormal radiologic studies (group B, 17 patients) were evaluated with enteroscopy. Enteroclysis via a tube inserted on withdrawal of the enteroscope was performed in all patients with nondiagnostic enteroscopy. RESULTS: Enteroscopy identified bleeding sites in 29 of 54 (54%) group A patients (12 angiodysplasia, 10 ulcers, 7 gastric erosions, 1 vessel, 1 aortoenteric fistula), and lesions in 11 of 17 (65%) group B patients (7 ulcers, 3 benign strictures, 2 radiation enteritis, 1 mass). In group A, 13 (24%) patients had findings detectable by standard esophagogastroduodenoscopy. Enteroclysis identified masses in 2 of 24 (8%) group A patients, and lesions in 5 of 10 (50%) group B patients (3 strictures, 1 mass, 1 large diverticulum). No complications occurred. CONCLUSIONS: The combination of enteroscopy and enteroclysis is safe and offers quality small bowel examinations in more comfortable and convenient single diagnostic sittings. This combination detected bleeding sources in 57% and lesions in 70% of patients. Though enteroclysis identified bleeding sources in only 8% of patients, this study excluded lesions other than angiodysplasia.

Diagnosis, Differential↗
PubMed1996

Complications related to diagnostic and therapeutic endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is examined from a variety of viewpoints in this article, including physician experience with ERCP and the environment in which the procedure is performed, the initial intent to treat, and complications, including their severity. Specific complications discussed include pancreatic hemorrhage, perforation, septic complications, complications related to stents, rare complications, and late complications following sphincterotomy.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1996

Endoscopic management of bile duct leaks after attempted laparoscopic cholecystectomy.

Fourteen patients with symptomatic bile duct leaks following laparoscopic cholecystectomy were treated using endotherapeutic techniques. Patients presented with abdominal pain, liver test abnormalities, jaundice, leukocytosis, and fever. Twelve leaks originated from cystic duct stumps and two from right posterior hepatic ducts. Distal biliary obstruction, which may have promoted leakage, was present in five patients. Treatment methods included stent insertion with endoscopic sphincterotomy (ES), stent insertion without ES, and nasobiliary tube (NBT) placement without ES. Eleven of 14 patients had prompt resolution of their bile leaks following initial endotherapy. Three patients with continued leakage underwent successful repeat endoscopic retrograde cholangiopancreatography 4-5 days after the initial examination. Cholangiographic evidence of leak closure was documented in all patients, and all remained asymptomatic during an average follow-up period of 18.5 months. Endoscopic therapy is safe and effective treatment for clinically significant bile leaks following laparoscopic cholecystectomy. In our small group of patients, NBT alone did not appear to be as effective as endoprostheses with or without ES. The ideal endoscopic treatment method has not yet been established but will likely vary depending on the site and specific nature of the injury and any concomitant biliary ductal pathology.

Adult↗
PubMed1996

Enteroscopy with enteroclysis.

The authors conclude that their experiences support the conclusion that the combination of enteroscopy and enterocysis is safe and offers quality small bowel examinations in a more comfortable and convenient single diagnostic setting. Although enteroclysis has identified bleeding sources in only 8% of patients who underwent this study, other lesions than angiodysplasia were confidently excluded in the remainder of patients. The combined procedure is well tolerated in the outpatient setting, more comfortable, and safer by decreasing radiation exposures than enteroclysis alone. Use of small bowel enteroscopy at an earlier stage in the evaluation of patients with obscure gastrointestinal bleeding increases cost effectiveness without compromising quality.

Barium Sulfate↗
PubMed1995

Washington University experience with extracorporeal shock-wave lithotripsy of pancreatic duct calculi.

OBJECTIVES: To ascertain the effectiveness and safety of extracorporeal shock-wave lithotripsy (ESWL) for pancreatic calculi. METHODS: Fourteen ESWL treatments were performed in 12 patients with chronic pancreatitis. RESULTS: Fragmentation was perceptible after 13 of 14 treatments. Subsequent endoscopic manipulation resulted in complete extraction, partial extraction, and failed extraction of the fragments after 7, 4, and 2 of the ESWL treatments, respectively. No complications occurred and no patient had pancreatitis following ESWL. At a median follow-up of 19 to 22 months, 4 patients have had complete relief of symptoms, 4 have had a decrease in both severity and frequency of pain, and 4 have had no improvement. CONCLUSIONS: ESWL is a safe and useful noninvasive adjunct in the treatment of patients with pancreatic duct calculi.

Adult↗
PubMed1994

Role of laparoscopic cholecystectomy in the management of acute gallstone pancreatitis.

Laparoscopic cholecystectomy has rapidly become the prime modality for removal of the gallbladder. However, as laparoscopic techniques for treating choledocholithiasis are evolving, we reviewed our experience with acute gallstone pancreatitis since the inception of laparoscopic cholecystectomy. Between November 1989 and March 1993, we treated 57 patients with acute gallstone pancreatitis. Cholecystectomy was performed during the initial admission in 46 patients (81%, group I), while 11 (19%) underwent delayed cholecystectomy at a second admission 2 to 9 weeks later (group II). Within group I, eight patients (17%) were thought to have contraindications to laparoscopic cholecystectomy and underwent open cholecystectomy. In the remaining 38 patients of group I, laparoscopic cholecystectomy was completed successfully. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 23 of these patients (61%) and endoscopic sphincterotomy was performed in 6 patients (26%). In four other patients, the intraoperative cholangiogram revealed common bile duct stones that were removed using laparoscopic techniques. The 11 patients in group II were all treated by laparoscopic cholecystectomy; of these patients, 3 underwent preoperative endoscopic stone removal and 1 had choledocholithiasis managed laparoscopically. Postoperative hospitalization averaged 4 +/- 1 days (mean +/- SEM), and there was no major morbidity or 30-day mortality. This is the first large series of acute gallstone pancreatitis in the era of laparoscopic cholecystectomy. Our experience suggests that laparoscopic cholecystectomy with or without ERCP should be the primary approach for treating acute gallstone pancreatitis in the 1990s.

Acute Disease↗
PubMed1994

Laparoscopic duodenal diverticulectomy following hemorrhage.

A 53-year-old man on warfarin therapy for an aortic valve prosthesis suffered a massive upper gastrointestinal hemorrhage. Urgent endoscopy revealed active bleeding from the apex of a large duodenal diverticulum. Bleeding was successfully controlled with heater-probe applications, and the patient recovered uneventfully. Because of the patient's lifelong need for anticoagulation therapy, elective laparoscopic duodenal diverticulectomy was subsequently done using intraoperative endoscopic guidance. The patient returned to full activity and diet within 3 days and has remained stable during the postoperative interval. We describe here a new minimal access approach to a complicated duodenal diverticulum combining laparoscopic and endoscopic techniques.

Diverticulum↗
PubMed1993

Diagnosis and management of biliary complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the operation of choice for symptomatic cholelithiasis. However, this operation may result in serious biliary complications. Our aims were to review our experience with biliary complications of laparoscopic cholecystectomy and to document the mechanisms of the injuries and the techniques of managing these complications. We treated 20 patients with biliary complications of laparoscopic cholecystectomy. Symptomatic collections of bile (bilomas) were present in five patients. One of these patients underwent operative ligation of an accessory bile duct in the gallbladder bed, whereas the others had percutaneous or endoscopic therapy. In the remaining 15 patients (of whom 13 were referred from other hospitals), injuries to the major bile ducts were managed by combined radiologic, endoscopic, and operative therapies. In 10 of these patients (67%), the mechanism of injury was the misidentification of the common bile duct as the cystic duct. In 3 of 15 patients, a noncircumferential injury to the lateral aspect of the common bile duct occurred. The Bismuth levels of the remaining bile duct injuries were type I in 3, type II in 4, type III in 3, and type IV in 2. Early outcome of therapy for these bile duct injuries has been favorable. One patient was lost to follow-up, and 2 died of nonbiliary causes, whereas 12 patients are alive and well with normal serum liver enzyme levels at 4 to 19 months postoperatively (mean: 14 months). The most common cause of major bile duct injury during laparoscopic cholecystectomy is mistaking the common bile duct for the cystic duct. Most bilomas can be managed successfully with noninvasive methods. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury, suggesting that patients with biliary complications of laparoscopic cholecystectomy should be referred to specialty centers for optimal care.

Abdominal Pain↗
PubMed1992

Preliminary experience using endoscopic ultrasonography in the diagnosis of choledocholithiasis.

Twenty patients with symptomatic cholelithiasis and suspected choledocholithiasis were evaluated in an ongoing prospective trial using endoscopic ultrasonography (EUS), standard abdominal ultrasonography (US) and ERCP for the detection of choledocholithiasis prior to laparoscopic cholecystectomy. EUS was used successfully to image the extrahepatic bile duct in all patients. EUS detected three of four proven bile duct stones and correctly identified 16 bile ducts as stone free, thus being more accurate than standard abdominal US. The preliminary results of this ongoing prospective trial and the experience reported by other authors suggest that EUS may be as sensitive as ERCP in the detection of choledocholithiasis.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1992

Percutaneous cholecystolithotomy: analysis of results and complications in 58 consecutive patients.

Percutaneous cholecystolithotomy was attempted in 58 consecutive patients. Patients were considered for percutaneous cholecystolithotomy only if they had symptomatic gallstones and a strong contraindication to surgical cholecystectomy. The procedure consisted of three parts: (a) initial percutaneous cholecystostomy, (b) tract dilation and stone removal, and (c) tract evaluation and tube removal. Local anaesthesia and intravenously administered analgesia were used in all procedures. Percutaneous cholecystolithotomy was successful in removing all of the stones in 56 patients (97%), including cystic duct calculi in 15 patients and common duct calculi in 10 patients. Major complications occurred in five patients (9%); in four cases, they were related to bile leakage after the cholecystostomy tube was removed. Thirty-day mortality was 3% (two patients). Advantages of percutaneous cholecystolithotomy include avoidance of general anesthesia and the ability to treat patients in any disease setting, including acute cholecystitis. Percutaneous cholecystolithotomy, although technically demanding, is an effective alternative to surgical cholecystectomy in elderly and debilitated patients.

Adult↗