Percutaneous treatment of benign biliary strictures and biliary manometric perfusion test

BACKGROUND: Benign biliary strictures are usually treated surgically or endoscopically. When these strictures are not accessible by endoscope or when open repair is not possible, percutaneous dilatation treatment is indicated. The efficacy of treatment is usually evaluated by clinical trial which includes leaving a small non-functional catheter in situ and following liver function tests. The evaluation may be effectively done by the biliary manometric perfusion test. AIM: The aim of this paper is to emphasize the importance of percutaneous dilatation treatment of benign biliary strictures with focus on the role of the biliary manometric perfusion test and its future prospects. METHODS AND RESULTS: Based on the literature and our own experience, this article gives a short overview of percutaneous treatment of benign biliary strictures, indications, techniques, complications and results. The treatment of these strictures has an overall success rate between 60 to 90%. This article also explains the biliary manometric test, the technique and its importance in evaluation of treatment success. CONCLUSION: Benign biliary strictures of the hepatic duct junction or bilio-enteric anastomosis are difficult to treat surgically and are endoscopically inaccessible. Percutaneous treatment by balloon dilatation and long term external-internal drainage is feasible in the majority of these patients. It is minimally invasive, safe and effective. The evaluation of the treatment success may be more effectively done by the manometric perfusion test. It is easy, reliable, less time-consuming giving immediate results, and relatively safe.     

DISCUSSION ON THE TREATMENT OF URETHRAL STRICTURE AND FISTULÆ BY EXCISION

For hard tunnel strictures and in cases of perineal fistula we should be bolder to adopt the principle of excision rather than that of mere external urethrotomy.A preliminary suprapubic cystotomy is advised, and also the avoidance, as far as possible, of the indwelling catheter. All fistul? should be excised completely, not merely opened, scraped and drained.The operator should not be in too great a hurry to pass sounds of too large a calibre after the operation, as in many cases there is little tendency to re-formation of the stricture.     

Scoring system to improve cost effectiveness of open access endoscopy.

The introduction of an open access general practitioner endoscopy service may result in many unnecessary examinations being performed. In an attempt to prevent this, 235 patients attending for endoscopy were interviewed and the results analysed to determine which factors best discriminated between those with major disease (ulcers, cancers, oesophageal strictures; n = 48) and those without (n = 187). The six characteristics which best discriminated between the two groups were increasing age, history of vomiting, male sex, smoking, and a past history of peptic ulcer or hiatus hernia. With the use of these six features a scoring system was devised, designed to give an indication of the likelihood of finding such disease in an individual patient. This was assessed prospectively in a further 356 patients. The results showed that by utilising this scoring system it would be possible to reduce the number of examinations performed by 30% yet still detect 98% of serious disease. If confirmed in further prospective studies, this scoring system (or a modification) could more accurately assess individual priority for endoscopy and enable optimum use to be made of limited resources.     

Contemporary Management of Bulbar Urethral Strictures

Urethral stricture disease (USD) is a progressive scar-forming disease commonly encountered by urologists and is challenging to manage. USD most frequently occurs in the bulbar urethra. Patients typically present with chronic obstructive voiding symptoms but may develop recurrent urinary tract infections, detrusor failure, or renal disease. The authors review the pathophysiology, diagnostic workup, and evidence-based management of bulbar urethral strictures (BUS). There are multiple surgical options to treat BUS. Endoscopic techniques (eg, dilation and urethrotomy) are suitable for the initial management of short strictures but new evidence-based guidelines recommend against repeated endoscopic treatment. Urethroplasty is the gold standard treatment for BUS of all lengths, with anastomotic techniques appropriate for strictures <2 cm and tissue substitution performed for longer strictures. New techniques, such as non-transecting urethroplasty, lack long-term data but may represent a paradigm shift in the field. Future treatments may utilize tissue-engineered grafts and agents that inhibit inflammation and scar formation.     

Decompression of malignant biliary obstruction by duodenoscopic intubation of bile duct.

Interest is increasing in non-operative methods of relieving malignant obstruction of the bile duct, and drainage tubes and prostheses may be placed in the bile duct via the percutaneous transhepatic route. Two cases are described, however, in which a duodenoscope was used and the approach was via the papilla of Vater. This method allows temporary or permanent drainage tubes to be placed through malignant strictures. This endoscopic approach is less invasive and should be safer than that by the transhepatic route; furthermore, removing and replacing a blocked endoprosthesis should be easier. Further study is needed, as the procedure is technically more difficult and its role in managing biliary strictures has yet to be defined.     

X-ray method for examination of patients with obstructive diseases of the large bowel

The paper presents a new priority X-ray method for examining the large bowel in patients with strictures. It is based on the principle of one-stage double contrasting, that has been substantially modified and supplemented by some distinctive signs and original methodological techniques. A randomized study of 150 patients with stenotic tumors of the distal colon assessed this method in comparison to traditional irrigoscopy and classical double contrasting. The study provided strong evidence for the advantage of the proposed method over the well-known ones. In the presence of stenosis, this method makes it possible to completely examine all the portions of the large bowel in 90% of the cases, to reduce the time of examination by almost 15 minutes and a radiation load per patient by 4 m3v. When the method is applied, the informative value of X-ray characteristics of a colonic stricture maximally retains. This is of great value in examining the category of patients with obstructive diseases of the large bowel, which presents a problem in making a differential diagnosis.     

Metabolites ofStreptomyces noursei

The production variability of secondary metabolites was studied after treatment with mutagenic factors. 852 isolates were examined, out of which 308 after X-irradiation, 277 after u. v.—irradiation and 267 after treatment with nitrogen mustard. According to the production of individual secondary metabolites examined it was possible to divide the strains obtained into 4 groups.     

Free vascularized appendix transfer for reconstruction of penile urethras with severe fibrosis

Despite the development of newer techniques with a free radial forearm tube flaps for phallus reconstruction, severe urethral strictures are still seen in such cases after irradiation or repeated infection because of the paucity of healthy, well-vascularized tissue. For urethral reconstruction in cases with poorly vascularized tissue as well as for total penile creation, a new technique involving a free vascularized appendix transfer combined with a radial forearm osteocutaneous flap was successfully used in two cases. The appendix provides a normal tube structure composed of a muscular tubular layer lined with mucosal epithelium. It has no hair and has rich vascularization. This results in little stricture at the junction with the original urethra, no occurrence of urethral stones, and possible postoperative enlargement of the diameter with changes in catheters. This method will allow a patient with severe fibrosis around the urethra to undergo one-stage phallus reconstruction with minimal complications.     

Characterization of envelope proteins from Pasteurella haemolytica and Pasteurella multocida

A method was devised for the reproducible isolation of envelopes from Pasteurella haemolytica serotype A2. It was also possible to prepare envelopes from other serotypes of P. haemolytica and Pasteurella multocida using this methodology. Examination of these preparations by SDS-PAGE showed major differences between strains of P. haemolytica and strains of P. multocida which allowed the clear distinction of isolates of these species. Amongst the P. haemolytica serotypes it was possible to distinguish envelope preparations made from A biotype and T biotype organisms easily, but it was not possible to identify individual serotypes from each other. Envelope profiles were sufficiently different between the individual P. multocida serotypes examined to allow each to be identified by its polypeptide profile. Experiments using radiolabelling, antibody absorption, and susceptibility to protease digestion, together with heat modifiability and detergent solubility characteristics indicated that 13 of the envelope proteins were probably surface-located. A high molecular mass immunogenic envelope protein was shown, by immunoblotting, to be present in all strains of P. haemolytica and P. multocida examined.     

Percutaneous Transhepatic Balloon Dilation of Biliary-Enteric Anastomotic Strictures after Surgical Repair of Iatrogenic Bile Duct Injuries

Purpose

To evaluate the efficacy of percutaneous balloon dilation of biliary-enteric anastomotic strictures resulting from surgical repair of laparoscopic cholecystectomy-related bile duct injuries.

Material and Methods

A total of 61 patients were referred to our institution from 1995 to 2010 for treatment of obstruction at the biliary-enteric anastomosis following surgical repair of laparoscopic cholecystectomy-related bile duct injuries. Of these 61 patients, 27 underwent surgical revision upon stricture diagnosis, and 34 patients were managed using balloon dilation. Of these 34 patients, 2 were lost to follow up, leaving 32 patients for analysis. The primary study objective was to determine the clinical success rate of balloon dilation of biliary-enteric anastomotic strictures. Secondary study objectives included determining anastomosis patency, rates of stricture recurrence following treatment, and morbidity.

Results

Balloon dilation of biliary-enteric anastomotic strictures was clinically successful in 21 of 32 patients (66%). Anastomotic stricture recurred in one of 21 patients (5%) after an average of 13.1 years of follow-up. Patients who were unsuccessfully managed with balloon dilation required significantly more invasive procedures (6.8 v. 3.4; p = 0.02) and were left with an indwelling biliary catheter for a significantly longer period of time (8.8 v. 2.0 months; p = 0.02) than patients whose strictures could be resolved by balloon dilation. No significant differences in the number of balloon dilations performed (p = 0.17) or in the maximum balloon diameter used (p = 0.99) were demonstrated for patients with successful or unsuccessful balloon dilation outcomes.

Conclusion

Percutaneous balloon dilation of anastomotic biliary strictures following surgical repair of laparoscopic cholecystectomy-related injuries may result in lasting patency of the biliary-enteric anastomosis.     

Comparative assessment of hemodynamic parameters in ventricular septal defect, obtained by Doppler echocardiography and catheterization of cardiac cavities

The study was undertaken to assess hemodynamic parameters by Doppler echocardiography in patients with ventricular septal defect (VSD) and pulmonary hypertension. Seventy-two patients aged 5 months to 9 years (mean 2.5 years) who had isolated VSD were examined. The authors conclude that it is possible and necessary to assess hemodynamics in the lesser circulation by using Doppler echocardiography. The method permits monitoring the time course of changes in the right heart, which makes it possible to follow the natural history of disease without applying invasive studies.     

Possibility of using near infrared irradiation for early cancer diagnosis

Penetration of near infrared radiation (NIR) through biological tissues (human wrist, muscle and skin of hen, muscle of mollusk) was studied. The possibilities of visualizing various objects within biological tissues were examined. It is found that: (a) it is possible to see small objects with millimeter and sub-millimeter dimensions; and (b) by using NIR rays it is possible to distinguish different parts of small homogeneous biological tissues. NIR can be a possible tool in the near future to visualize millimeter size cancerous outgrowths located inside human body cavities. It will enable diagnosis of cancer at an early stage of development.     

Methodologic aspects of evaluating brush samples from biliary strictures by cytology and DNA flow cytometry

OBJECTIVE: To present a method of increasing the cell yield from brush samples of the biliary tree for measurement of DNA content by flow cytometry (FCM). STUDY DESIGN: One hundred eight cell specimens from 86 patients were studied by FCM for DNA ploidy and cell cycle composition. All specimens were cytologically classified into benign, suspicious for malignancy and malignant. Two methods for preparation of the cell material were compared. RESULTS: Enzymatic treatment of formalin-fixed brushes for release of cell nuclei was superior to mechanical removal of the cells. The fraction of samples not possible to assess was reduced from 27% to 4%, and good quality histograms increased from 21% to 62%. Aneuploidy was detected in 7% of benign and 57% of suspicious malignant samples. Using DNA analysis in addition to cytology as a diagnostic marker for cancer, the sensitivity increased from 12% to 31%. CONCLUSION: FCM of cells from biliary strictures can be used routinely as an adjunct to cytology for DNA analysis.     

Biological testing of chitosan‐collagen‐based porous scaffolds loaded with PLGA/Triamcinolone microspheres for ameliorating endoscopic dissection‐related stenosis in oesophagus

ObjectivesEndoscopic submucosal dissection (ESD), a preferential approach for early oesophageal neoplasms, inevitably results in oesophageal strictures in patients. Clinical use of glucocorticoids through submucosal injection is beneficial for inhibiting oesophageal stricture following injury; however, it also has limitations, such as dose loss and perforation. Hence, alternatives to glucocorticoid therapy should be developed.MethodsA novel porous composite scaffold, ChCo‐TAMS, composed of chitosan, collagen‐I and triamcinolone acetonide (TA) loaded into poly (lactic‐co‐glycolic) acid (PLGA) microspheres (TAMS), was successfully constructed and subjected to biological testing to ameliorate oesophageal ESD‐related stenosis.ResultsThe synthesized biomaterials displayed unique properties in inhibiting the activation of macrophages, chemokine‐mediated cell recruitment and fibrogenesis of fibroblasts. Further application of the scaffolds in the rat dermal defect and porcine oesophageal ESD model showed that these novel scaffolds played a robust role in inhibiting wound contracture and oesophageal ESD strictures.ConclusionsThe developed composite scaffolds provide a promising clinical medical device for the prevention of post‐operative oesophageal stricture.     

Characterization of Otostrongylus circumlitus from Pacific harbor and northern elephant seals

Otostrongylus circumlitus (Railliet, 1899) from Pacific harbor seals (Phoca vitulina richardsi) and northern elephant seals (Mirounga angustirostris) were examined using morphological and molecular methods to determine whether northern elephant seals along the central California coast are infected by the same species of Otostrongylus as are Pacific harbor seals in the same area. Fixed nematodes were examined and measured using light microscopy. The polymerase chain reaction (PCR) was used to amplify and sequence the second internal transcribed spacer (ITS-2) and D3 expansion (26S) regions of ribosomal DNA of O. circumlitus from Pacific harbor and northern elephant seals. The ITS-2 region was also amplified from Parafilaroides sp. from the Pacific harbor seal, northern elephant seal, and California sea lion (Zalophus californianus) and used for restriction fragment length polymorphism (RFLP) analysis. Morphologically, it was not possible to distinguish O. circumlitus from Pacific harbor and northern elephant seals, and over a consensus length of 443 base pairs (bp) for ITS-2 and 321 bp for D3 the sequences of O. circumlitus from both hosts were identical. With the PCR-RFLP assay, it was possible to distinguish O. circumlitus from Parafilaroides sp. The results suggest that O. circumlitus is the same species in Pacific harbor and northern elephant seals, and molecular methods make it possible to distinguish this nematode from related nematodes.     

Stability in vitro of uridine diphosphoglucose pyrophosphorylase in Dictyostelium discoideum

The stability of uridine diphosphoglucose pyrophosphorylase was examined in extracts prepared at different stages of development in Dictyostelium discoideum. In the early stages, the kinetics of inactivation were nonlinear, and, therefore, it was not possible to determine the specific enzyme activity. In the later stages of development, the enzyme was stable, but it could be rapidly inactivated by a heat-labile inhibitor present in extracts prepared at an early stage.     

Structure-activity Relationship for FR901464: A Versatile Method for the Conversion and Preparation of Biologically Active Biotinylated Probes

The structure-activity relationship for FR901464, a potent cell-cycle inhibitor, was examined by synthesizing its analogs. A versatile method for converting FR901464 was devised. This method made it possible to synthesize biologically active FR901464-biotin conjugates which could be used to isolate the binding proteins.     

Structure-activity relationship for FR901464: a versatile method for the conversion and preparation of biologically active biotinylated probes

The structure-activity relationship for FR901464, a potent cell-cycle inhibitor, was examined by synthesizing its analogs. A versatile method for converting FR901464 was devised. This method made it possible to synthesize biologically active FR901464-biotin conjugates which could be used to isolate the binding proteins.     

Method of electron-autoradiographic study of nucleic acid biosynthesis in bacteria during phagocytosis

Leukocytes from healthy men exposed to Staphylococcus epidermis were incubated with 3H-uridine and 3H-thymidine. The level of nucleic acid synthesis by phagocyted bacteria was examined by electron microscopic autoradiography. The method makes it possible to correlate bacterial and phagocyte functions with their ultrastructures.