[Preoperative diagnosis of proximal bile duct carcinoma using ultrasound and duplex sonography].
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Adenoma, Bile Duct↗
Biomedical subjects
J Triller
Publications and source records attributed to J Triller.
Unresectable malignant biliary obstruction: treatment by self-expandable biliary endoprostheses.
The primary goal in the treatment of malignant obstruction is the relief of jaundice. Although operative biliary bypass is a reliable method of palliation, nonoperative palliation may be desirable in selected patients. We report our experience with forty-eight self expandable metallic biliary endoprostheses (Wallstent) percutaneously placed in 35 patients with irresectable malignant biliary obstruction. In twelve patients more than one stent was necessary to bridge the entire length of the biliary stenosis. The obstruction was due to primary tumors in 14 and to lymph node metastases in 12. In nine patients transanastomotic stents were placed after previous bilioenteric anastomosis because of malignant obstruction. Complications occurred in 11 patients (31.4%), and five patients died within 30 days of stent placement (14.3%). The mean stent patency to date of patients discharged is 6.1 months, and the mean survival 7.2 months. Follow up data is available for 29 patients, and excellent palliation was achieved for more than 75% of the survival time in 22 (76%). Seven patients have had documented stent occlusion requiring further intervention (24%). In this selected group of patients, the results of percutaneous self-expandable stents are encouraging. However, our data does not support the initial reports of self-expandable endoprostheses that suggest an improved result compared to conventional plastic stents. A randomized study using either expandable stents as compared to operative biliary enteric bypass is necessary.
Adenoma, Bile Duct↗
[Therapy of pulmonary arteriovenous aneurysm].
Connections of branches of the pulmonary artery to branches of the pulmonary vein resulting in aneurysmatic dilatation are defined as pulmonary arterio-venous aneurysm (pava). The spontaneous course shows a morbidity of 26% and a mortality of 11% within a six-year observation period following diagnosis. If there is an arterial branch with small diameter (< 15 mm) we recommend the embolisation with the catheter; this procedure is less stressing for the patient and does not involve the loss of pulmonary tissue. If the arterial branch has a big diameter, if a complex pava or a pulmonary abscess is present a conventional surgical resection should be envisaged.
Adult↗
[Percutaneous transhepatic inserted self-expanding metal endoprosthesis in the palliative treatment of malignant obstructive jaundice].
Prospective studies comparing biliary-enteric bypass with implantation of endoprostheses in palliation of malignant obstructive jaundice showed no significant difference. A new self-expandable metal endoprosthesis was introduced to ameliorate the results in terms of early complication and occlusion rate. Between December 1988 and April 1991 we treated 35 patients (32 with malignant obstructive jaundice) by 50 self-expandable endoprostheses. The implantation was successful in 96% of patients. The early complication rate was 37% and the 30-day mortality 14%. In 89% of the patients relief of jaundice after 3 months was found. Recurrent jaundice and cholangitis occurred in 39%, whereas reoperation was necessary in 25%. 16 of 26 patients (61%) with malignant obstructive jaundice where alive after an average of 7.5 months. We found no advantage of the self-expandable endoprostheses compared with conventional plastic stents. Implantation of a self-expandable metal endoprosthesis may be an alternative to surgical bypass in selected cases. It would be interesting to evaluate the endoscopic route of insertion and to compare the results with palliative surgery in randomized studies.
Aged↗
[Catheter embolization of the solitary pulmonary arteriovenous aneurysm].
Catheter embolization with coils was performed as a method of treatment in 3 patients with solitary pulmonary arteriovenous aneurysms (PAVA). This led to permanent occlusion of the PAVA in all cases. There were no complications following embolization. Bearing in mind that other workers also achieved good results by this method, embolization of a solitary PAVA by coils should be preferred to balloon embolization. Surgical treatment should only be carried out for a malformation which is not accessible to embolization or as part of a more complex procedure.
Adult↗
[The catheter embolization of acute hematuria after percutaneous nephrostomy and nephrolitholapaxy].
Angiography was performed on 6 patients with acute haematuria following percutaneous nephrostomy and nephrolitholapaxy; in 3, vessel damage with leak of contrast into the nephrostomy canal or renal parenchyma was demonstrated and in 3 there were one or more pseudoaneurysms with or without arteriovenous fistula. All patients were successfully treated by catheter embolisation. Various catheter techniques (monaxial, coaxial) and embolic materials (Spongostan, Ivalon, coils) were used. The use of a Tracker-18 catheter with micro coils is the method of choice and permits superselective embolisation of bleeding from small peripheral branches with maximal preservation of the renal parenchyma.
Acute Disease↗
Considerable side effects of chemoembolization for colorectal carcinoma metastatic to the liver.
The feasibility of one whole liver chemoembolization (CE) procedure with Angiostat, a vasoocclusive collagen, mitomycin, doxorubicin, and cisplatin was evaluated in eight patients with unresectable colorectal carcinoma metastatic to the liver and good performance status. One heavily pretreated patient showed a partial response in the liver lasting 188 days. Five patients had stabilization of the disease for 85-150 days. The side effects of the treatment were considerable with a fatigue syndrome lasting up to eight weeks, chemical and ischemic hepatitis, severe thrombopenia (WHO grade 4 in 2 pts) and icterus being the most disturbing toxicities. We recommend to restrict CE to patients with a life expectancy of more than 4-6 months confined to protocols, which evaluate efficacy, toxicity and influence on quality of life of CE with various cytotoxic drugs. We further suggest to perform staged unilobar CE at 4- to 6-week intervals rather than whole liver CE.
Adult↗
Intrahepatic arterioportal fistula following conservative treatment of a traumatic liver rupture: case report.
A 16-year-old girl with severe liver injury complicated by the development of an intrahepatic arterial aneurysm and arteriovenous fistula is presented. Nonsurgical treatment combining close observation and repeat hepatic arterial embolization was successful.
Adolescent↗
Femoropopliteal artery occlusion: clinical experience with the Kensey catheter.
In 25 patients, 12 with acute-subacute and 13 with chronic extensive femoropopliteal artery occlusions (mean length, 8 cm), a prospective study was performed after application of the Kensey catheter and subsequent performance of percutaneous transluminal angioplasty (PTA). Passage through the occlusion with the Kensey catheter failed in five patients because of the presence of dissections. As confirmed at angiography, free flow through the obstruction and the runoff bed could be restored with the Kensey catheter, guide wires, balloon dilation, and thrombus aspiration and/or thrombolysis in 24 of the 25 patients (96%). In five patients, peripheral embolisms occurred after application of the Kensey or balloon catheter. Cumulative patency rates, according to findings of a noninvasive examination, were 80% at 3 days, 59% at 6 months, and 38% at 12 months after performance of the combined interventions. Thus, the results obtained with use of this new device have not proved superior to previously reported results with conventional PTA.
Aged↗
Is a fluoroscopic verification of the electrode position necessary in ambulatory intragastric pH monitoring?
To assess whether a fluoroscopic verification of the electrode position is necessary before and whether electrode displacement occurs during intragastric pH measurements, a crossover study was performed in 20 healthy male volunteers. The pH electrode was initially placed in the gastric corpus using pH readings and catheter length only, and the electrode tip was fluoroscopically located before and after the 24-hour study. Only in one study arm was an adjustment of the electrode position allowed, if fluoroscopy showed a position outside the gastric body. Thirty-seven (92%) of all 40 electrodes were in the corpus when placed by pH-metric methods alone. With fluoroscopic guidance, 2 of the 3 electrodes lying outside the corpus could be repositioned as desired. The median night, day or 24-hour gastric pHs measured in the groups with or without replacement of the electrode tip were identical. Displacement after 24-hour measurements did not occur with initially correctly positioned electrodes. Fluoroscopy is not necessary for the verification of the position of electrodes placed by pH-metric techniques in individuals with residual acid secretion, and electrode displacement is rare.
Adult↗
Staging of hilar cholangiocarcinoma by ultrasound and duplex sonography: a comparison with angiography and operative findings.
The pre-operative radiological assessment of proximal bile duct tumours is clinically important as resection may be limited by tumour extension along the bile ducts, into hepatic parenchyma or the adjacent vascular structures. Demonstration of the extent of biliary and vascular involvement can direct additional investigations and definitive treatment. 22 patients with hilar cholangiocarcinoma were studied pre-operatively by conventional ultrasound (US) and duplex sonography (DS). The extent of tumour infiltration and vascular involvement was compared with arteriography and operative findings. Bile duct dilatation and the level of obstruction was documented by US in 22 (100%), and the tumour was shown by US in 19 (86%). In these 19 patients, the extent of extraductal extension compared with operative findings was correct in 13, underestimated in two, and in four infiltration was massed. Vascular patency or involvement was correctly determined by DS in 19 (86%), and by arteriography in 18 (82%). In two of the three incorrect DS interpretations, lobar atrophy and contralateral hypertrophy distorted the hilar anatomy. US with DS is valuable in the pre-operative staging of proximal bile duct tumours in predicting ductal and vascular involvement.
Adenoma, Bile Duct↗
Interventional angiology.
Percutaneous transluminal angioplasty in peripheral artery occlusive disease by balloon catheters is the standard method in interventional angiology. For almost twenty years it has been recommended in the aorto-iliac region for arterial stenoses, and in the femoro-popliteal arteries for stenoses and short occlusions. Due to progress in technology of catheters and guide wires, a primary success rate of more than 90% is to be expected with favourable angiographic conditions. The long-term patency rate of some 90% on the aorto-iliac level exceeds that of 70-90% on the femoro-popliteal level. The patency rate decreases with increasing complexity of the lesions. Subacute/acute occlusions of the femoro-popliteal arteries by thrombosis or embolism are treated successfully in 80% of cases by catheter-thrombolysis and/or thrombus aspiration combined with percutaneous transluminal angioplasty if necessary. Several new techniques are under clinical evaluation, such as laser angioplasty, rotational catheters, atherectomy catheters and stents. Their application in clinical routine has up to now not been justified except for special situations such as obtaining biopsy material by Simpson catheter or maintenance of patency in balloon resistant lesions by stents.
Angiography↗
[Splenic complications in inflammatory pancreatic diseases].
Pancreatitis in combination with splenic and vascular complications is dangerous and potentially lethal. The most common complications are intestinal or intraperitoneal hemorrhage resulting directly from either vascular changes, such as erosion of the splenic artery, formation of a pseudoaneurysm, hemorrhage into a pseudocyst, or rupture of a pseudocyst with perforation into the colon, or complications in the spleen, such as anemic or hemorrhagic infarction, abscess or rupture. CT is the method of choice for the diagnosis of splenic complications of pancreatitis. Angiography is indicated in every severe hemorrhage in the presence of pancreatitis, to demonstrate vascular changes and to localize the source of hemorrhage. In addition, acute arterial bleeding can be successfully treated with catheter embolization.
Acute Disease↗
[Interventional angiography].
Percutaneous transluminal angioplasty (PTA) by balloon catheters is the standard method in interventional angiology. It is recommended in the aorto-iliac region for arterial stenoses, and in the femoro-popliteal arteries for stenoses and short occlusions. Due to progress in technology of catheters and guide wires, a primary success rate of more than 90% is to be expected with favorable angiographic conditions. The long-term patency rate of some 90% on the aorto-iliac level exceeds that of 70-90% on the femoro-popliteal level, with the patency rate decreasing with increasing complexity of the lesions. Subacute/acute occlusions of the femoro-popliteal arteries are treated successfully in 80% by catheter-thrombolysis and/or thrombus aspiration. Several new techniques are under clinical evaluation, such as laser angioplasty, rotational catheters, atherectomy catheters and stents. Their application in clinical routine has up to now not been justified except for special situations such as obtaining biopsy material by Simpson catheter or maintenance of patency in balloon resistant lesions by stents.
Angioplasty, Balloon↗
Combined surgical and interventional radiological approach for complex benign biliary tract obstruction.
In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued. Roux-en-Y hepaticojejunostomy was performed and an extended limb of the jejunum brought to the abdominal wall to allow access for later radiological intervention. Over a 30-month period 58 biliary-enteric anastomoses for benign disease were performed. Seventeen of these 58 patients were managed using the combined approach. Ten of these 17 patients had complex postcholecystectomy strictures and seven had strictures resulting from inflammatory disease, hepatic resection or congenital problems. A new classification of results of management of bile duct strictures is proposed. Seven patients were classified as 'excellent', six 'good', two 'fair' and two 'poor'. Results were obtained at a mean follow-up of 16 months and it seems likely that in some patients major surgical reinterventions were avoided.
Adult↗
90Y-resin particles--animal experiments on pigs with regard to the introduction of superselective embolization therapy.
Resin particles (diameter 45-75 microns) were labelled with 90Y, suspended in a glucose/dextran solution and infused into the kidneys of 3-month-old pigs (tumour model). Both kidneys of each animal were embolized with particles, but only one with active (90Y loaded) particles and the other, for comparison, with inactive particles. The organ measurements showed less than 1% of injected activity in bone, bone marrow, liver and lung compared to greater than 99% retention by the kidneys. Only minimal shunted activity was found in blood (less than 0.27%) and urine (less than 0.07%). There was a clear shrinkage of the 90Y-treated kidneys with a reduction in weight of up to 50%. Histologically, the ischaemic lesions (infarcts and atrophy) were clearly more pronounced and extensive in the 90Y-embolized kidneys than in the non-radioactive embolized kidneys. Furthermore, severe arterial wall changes and fibrotic necrosis due to radiation damage were observed in the 90Y-treated kidneys. It is concluded that with intra-arterially applied particles a dose of about 100 Gy is sufficient to completely destroy tissue-specific structures. Complications due to acute necrosis or inflammatory reactions were not observed, and there were no shunt related alterations seen in the liver or lungs. The 90Y-loaded resin particles are considered suitable for a super selective intra-arterial radioembolization.
Anesthesia↗
Rectal bleeding associated with chronic pancreatitis.
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Adult↗
[Recent instrumental developments in percutaneous transluminal angioplasty (PTA)].
In addition to the balloon-catheter for PTA a number of new devices have been developed in recent years. Among them the most outstanding are laser beam application, mechanical devices for recanalization and endoprostheses for stenting of the vessels. The initial fascination by laser technique in PTA has given way to a matter-of-fact appreciation of the method. Up to now no available laser system achieves better clinical results than conventional PTA in the long run. Although there is much potential in the laser principle, it still is to be regarded as experimental. As for mechanical devices the fast rotating Kensey-catheter has not been proven superior to balloon PTA in our hands neither to remove organized or fresh thrombotic occlusive matter. A slowly rotating catheter (Rotacs) facilitates primary recanalisation of long occlusions prior to balloon dilatation. Atherectomy by the Simpson-catheter provides samples for histological studies but is indicated only in special situations. Numerous other mechanical percutaneous endarterectomy devices are under development, but clinical long term evaluation is not yet available. Vascular stents - self expandable or balloon expandable systems - may serve to keep the newly dilated arterial lumen open and to prevent late recurrences. While in larger vessels such as iliac arteries or aorta good long-term results after insufficient PTA were shown, other indications are still experimental. For all of these newer technologies both their relative effectiveness and the extent to which they may compare with or complement balloon PTA remain to be determined.
Angioplasty, Balloon↗