Balloon Dilatation Of Strictures Research Articles

Pancreatic Stent-Induced Ductal Injury

Purpose: Pancreatic duct (PD) stent placement is increasingly performed for prevention of post-ERCP pancreatitis in patients at high risk. PD stents can result in injury especially in normal ducts, but the clinical significance and outcomes of subsequent endoscopic therapy are not known. Methods: Patients included all those referred from outside facilities to a single pancreaticobiliary center for management of stent-induced PD injury over 3 years. All pts had initially normal PD diameter without evidence of chronic pancreatitis, and all PD stents were placed for prevention of post-ERCP pancreatitis. Results: 7 pts were referred for symptomatic PD stent-induced duct injury. At initial outside ERCP, all had small caliber (<or = 3 mm) PD with normal PD anatomy (N = 5) or pancreas divisum (N = 2). Indication for initial ERCP with prophylactic PD stent placement was suspected SOD with empirical biliary ± pancreatic sphincterotomy without SO manometry (N = 5), or minor papillotomy for pancreas divisum with acute recurrent pancreatitis (N = 1) or marginally elevated lipase (N = 1). All had conventional polyethylene 5 F (N = 6) or 7 F (N = 1) stents <4 cm in length in place for <2 weeks, except one pt who was lost to follow up with stent in place for one year. At presentation at a mean interval of 19 months after 1st ERCP, all pts had recurrent abdominal pain requiring hospitalization; of these 5/7 (71%) had acute recurrent pancreatitis, and 3/7 (43%) were on daily narcotics. By secretin MRCP/EUS/ERCP, all had a PD stricture within 2 cm of major or minor papilla and 5/7 (71%) upstream PD dilation (mean 4.6 mm, [3 mm–8.2 mm]). 2/5 (40%) pts undergoing EUS had new parenchymal changes suggestive of chronic pancreatitis. All patients were treated with pancreatic sphincterotomy (if not done already), balloon dilation of stricture, and placement of multiple 3–5 F soft polymer pancreatic stents depending on duct diameter; all but one required multiple (2–11) ERCPs for therapy. All had improvement or resolution of pancreatic strictures and recurrent pancreatitis. 4/7 had sustained clinical response with resolution of pain, 1/7 fair response with repeated ERCPs, and 2/7 poor response, with referral for total pancreatectomy with auto-islet transplantation. Conclusion: PD stent-induced ductal injury with significant clinical consequences can occur after a relatively brief interval of stenting using conventional polyethylene 5 F stents. Endoscopic therapy is moderately effective but some patients develop irreversible damage. Further investigation is required to determine prevalence and risk factors for stent-induced injury and to improve configuration and material of stents.

Face and Construct Validity of a Computer-Based Virtual Reality Simulator for Endoscopic Retrograde Cholangiopancreatography

Introduction: The American Society for Gastrointestinal Endoscopy encourages curriculum-based simulator use for endoscopic retrograde cholangiopancreatography (ERCP) training, though little data currently exist related to this recommendation. The study aim was to determine face and construct validity of a high-fidelity ERCP simulator and to assess its perceived utility as a training tool. Methods: Twelve subjects were grouped into novice (n = 4; ≤25 ERCPs), intermediate (n = 4; 100-200 ERCPs), and expert (n = 4; >200 ERCPs) skill levels. After 30 minutes of monitored practice to ensure simulator familiarity, subjects completed two cases. Case 1 requires stent placement with optional sphincterotomy for cystic duct leak. Case 2 involves common bile duct brushing and balloon dilation for stricture plus sphincterotomy and stent placement for duct decompression. Performance measures include times to complete procedure, reach papilla, and apply flouroscopy; number of attempts to cannulate the papilla, pancreatic duct, and common bile duct; number of contrast injections; use of endoscopic tools, and complications. By online survey, subjects assessed the graphics, procedural accuracy, difficulty, and haptics, plus overall realism and training potential of the simulator using Likert-type scales. Data are given as medians and analyzed using proper nonparametric tests. Results: Age, post-graduate year, and prior endoscopy and ERCP experience positively correlate with skill level (all p < 0.001). There was no difference between groups with regard to gender, handedness, or interest in ERCP. For all cases combined, total procedure time differed across novices (607 sec), intermediates, and experts (332 sec; p = 0.009). For the same measure, Case 1 differentiated all skill levels (p = 0.024) while Case 2 distinguished only novice from expert (487 sec, 273 sec; p = 0.043). Across all skill levels and regardless of interest in ERCP, opinions were similar regarding graphics (moderately realistic), accuracy (similar to real procedure), difficulty (somewhat less difficult), overall realism (moderately realistic), and haptics. As skill level decreased, subjects felt the haptics were comparable to real ERCP (p < 0.001). Subjects (67%) believe the simulator has definite training potential. Conclusions: The two simulated cases on the GI Mentor II™ differentiate novice, intermediate, and expert skill levels (construct validity) for ERCP based on total procedure time. The majority of subjects felt the simulated graphics, procedural accuracy, and overall realism exhibit face validity, though haptics seemed most appreciated by novices. In addition, subjects believe it is a useful training tool.

Retrograde Per Anal Double Balloon Enteroscopy (rDBE) Is a Successful Technique for the Diagnosis and Therapeutic Intervention of a Wide Variety of Small Intestinal Luminal Lesions

Background/Aims: Double balloon enteroscopy (DBE) has emerged as a useful endoscopic technique for the diagnosis of, and intervention for, a wide range of luminal pathology, including obscure GI bleeding, inflammatory bowel disease, celiac disease, lymphoma, and vascular lesions. Antegrade (oral) DBE remains the most common approach to the evaluation of the small bowel. The major objectives of this study are to describe our experience with retrograde DBE (rDBE) with regard to procedural success, diagnostic yield, and therapeutic intervention. Methods: A single center retrospective chart review of 72 consecutive patients who underwent rDBE from January 2005 to November 2007. Results: In this study, 38 patients were female (53%), with a mean age of 60 ± 18.1 years (range 17-91 y). The most common indications for rDBE were obscure overt (n = 30, 41.7%) and obscure occult hemorrhage (n = 16, 22.2%). Other indications included polyp or mass (n = 9, 12.5%), mucosal changes including erosions or nodularity (n = 6, 8.3%), stricture (n = 4, 5.6%), angioectasias/vascular abnormalities (n = 3, 4.2%), and altered bowel habits/suspected Crohn's disease (n = 3, 4.2%). Mean procedure duration was 115 ± 16.5 minutes (range 90-165 min). The DBE system was successful in reaching the proximal ileum in 17 patients (23.6%), the mid-ileum (n = 40, 55.6%), the distal ileum (n = 7, 9.7%), the mid-jejunum (n = 2, 2.8%), and the distal jejunum (n = 5, 6.9%). The success rate for small bowel intubation was 98.6%. Findings included angioectasia/vascular lesions (n = 10, 13.9%), mucosal changes (n = 10, 13.9%), ulcers (n = 5, 7%), polyps (n = 3, 4.2%), strictures (n = 3, 4.2%), diverticula (n = 2, 2.8%), and fresh blood (n = 1, 1.4%). Normal variants (including lymphoid hyperplasia or dilated lacteals) were noted in 3 cases (4.2%), and non-small bowel findings (e.g., hemorrhoids or colon polyps) in one (1.4%). Interventions were performed in 38 patients (52.8%), including argon plasma coagulation for angioectasia or overt bleeding (n = 11, 15.3.%), other hemostatic techniques (n = 2, 2.8%), and balloon dilation of strictures (n = 4, 5.5%). Tattoo marking of the proximal extent of the examination was performed in 9 cases (12.5%). Conclusions: In our experience with more than 70 patients over the past 2 years, rDBE is successful in reaching the small intestine in the vast majority of cases. We demonstrate that rDBE is useful for a variety of indications. Mucosal findings were diagnosed in nearly 50% of patients leading to either biopsy or therapeutic intervention. This series highlights the increasing utility of DBE in general, particularly from the retrograde approach for distal small bowel lesions.

Diagnosis and Minimally Invasive Treatment of Salivary Gland Obstruction

Salivary obstruction is usually due to either calculi or strictures. These may be diagnosed using a combination of sialography and high resolution ultrasound. Minimally invasive techniques such as fluoroscopy guided basket retrieval of calculi or balloon dilation of strictures are successful techniques and may be carried out in a general hospital setting. These techniques may be developed for use under ultrasound guidance.

The role of interventional radiology for complications of cholecystectomy

Abstract This report summarizes diagnostic and therapeutic radiologic procedures in 45 patients who suffered major complications from cholecystectomy. Complications were divided into (1) bile duct injury or ligation and (2) a variety of pathologic fluid collections. Specific lesions were bile duct injury (n = 6), accidental bile duct ligation (n = 12), ductal stricture (n = 12), abscess (n = 11), biloma (n = 7), hematoma (n = 5), infected pancreatic pseudocyst (n = 3), and stones (n = 2). Presenting problems were sepsis, jaundice, and intermittent cholangitis. The patients underwent 104 interventional radiologic procedures including 29 percutaneous transhepatic cholangiograms, 21 percutaneous biliary drainages, 12 balloon dilatations of strictures, drainage of 11 abscesses, 8 bilomas, 5 hematomas, and 3 pancreatic pseudocysts. Stones were removed by baskets in 2 patients; 12 pressure and perfusion studies were performed. One hundred of 104 procedures were successful; there was one failed biliary drainage, one unsuccessful stricture dilatation, one unsuccessful hematoma drainage, and one recurrent biloma. Thirty patients were spared another operation. The percutaneous procedures were beneficial although not curative in 14 of 15 patients who underwent reoperation; in those patients the procedures helped to establish a diagnosis, improve the patient's preoperative status, or serve as a landmark for the surgeon to locate and repair the ligated or injured duct. One patient died after reoperation, a 2.2% mortality rate. Sectional imaging studies combined with interventional radiologic procedures help to diagnose promptly and effectively treat major complications of cholecystectomy. These interventional procedures either cure the complication and obviate reoperation or aid the surgeon by relieving sepsis and jaundice before reoperation and providing an intraoperative guide for bile duct reconstruction. (SURGERY 1990;W7:632–8.)

Balloon dilation of a urethral stricture in a dog

A 2-year-old male neutered Scottish Terrier presented with dysuria caused by complete urethral obstruction due to a stricture secondary to catheter-induced trauma. The urethral obstruction was resolved by balloon dilation of the stricture under fluoroscopic guidance.

Therapie von Canaliculus-communis-Stenosen mittels Ballonkatheterdilatation

To examine the clinical outcome of the balloon dilatation in stenosis of the canaliculus communis. 18 nasolacrimal ducts with epiphora and proven obstruction of the canaliculus communis by dacryocystography (DCG) were treated with balloon dilatation in local anaesthesia. All patients were treated electively. In 16/18 cases the balloon dilatation was technically successful, in 2 patients the guide wire failed to pass the obstruction and the wire could not be placed in the nasal cavity. There were no complications. Over a mean follow-up of 6 months there were 2 reobstructions, one of these led to an occlusion of the canaliculus communis. 14/18 (77,8%) cases after DCP were treated successful, 11/18 cases were free of symptoms after DCP, in 4/18 cases the epiphora improved. Until recently in stenosis of the canaliculus communis the only therapeutic option was surgical procedure followed by silicone tube intubation. The results were often disappointing. In contrast to this balloon dacryocystoplasty is a minimally-invasive alternative in the therapy of stenosis of the canaliculus communis resulting in good clinical outcome during follow up.

Endoscopic Interventions for the Patients with Symptomatic Choledochal Varices

Endoscopic Interventions for the Patients with Symptomatic Choledochal Varices Do Hyun Park, Myung-Hwan Kim, Sang Soo Lee, Jung Sik Choi, Sung Koo Lee, Dong Wan Seo Background: Choledochal varices describe extrahepatic bile duct abnormalities such as stricture or indentation of bile duct by compression of collateral vessels in patients with extrahepatic portal venous obstruction (EHPVO). Cholestasis, biliary pain, fever, and cholangitis may be present in these patietns. This study was designed to evaluate the role of endoscopic interventions including long-term follow-up and procedure-related complications in patients with symptomatic choledochal varices. Methods: Record for 14 patients with extrahepatic portal vein obstruction and cavernous transformation on US, CT and MRCP with MR angiography who underwent ERCP for various biliary symptoms were retrospectively reviewed. Results: Median age of enrolled patients was 48 year (range 27-73). Male to female ratio was 1.5:1. Median follow-up period was 38.5 months. Endoscopic sphincterotomy was performed all enrolled patients, balloon dilation for stricture due to bile duct varices was performed at 2 of 14 patients, stenting for bile duct stricture due to bile duct varices was performed at 4 of 14 patients. After endoscopic intervention, recurrence of cholangitis and biliary pain occurred in one of 14 patients. Remaining patients were asymptomatic during follow-up periods. Procedure-related complication was unexpected torrential bleeding associated balloon dilation for stricture (nZ1), and balloon sweeping for stone removal (nZ1). However, successful hemostasis was achieved by prompt transpapillary endoscopic balloon compression and use of terlipressin in these patients. Conclusion: Endoscopic interventions may be useful in patients with choledochal varices for symptomatic improvement. However, endoscopic interventions for symptomatic choledochal varices should be cautiously performed because of unexpected massive bleeding during ERCP. In this situation, transpapillary endoscopic balloon compression with intravenously infusion of terlipressin may be useful for hemostasis of bleeding choledochal varices. T1300 Interpretation of Post Procedural ERCP Spot Films by Radiologists Is Prone to Significant Error Chirag Patel, Jacques Van Dam, Robert Mindelzun, Subhas Banerjee Background: ERCP has evolved from a diagnostic to a predominantly therapeutic procedure, where decisions regarding interventions need to be made immediately. Over time, radiology support during ERCP has declined due to time and other constraints. Radiologists are now rarely present during the procedure and typically ‘post read’ saved spot films. Post reading cannot guide decision making during this dynamic test and it is unclear whether it is as accurate as a dynamic read. This study was undertaken to evaluate discrepancies between endoscopists’ dynamic reading of fluoroscopic images and spot films and radiologists’ post reading of spot films alone. Methods: We reviewed the charts of 108 consecutive patients who underwent ERCP at a major US university hospital, performed by two experienced therapeutic endoscopists. Radiologists were not present during ERCP. 100 patients for whom both endoscopy and radiology reports were available (endoscopy nZ108; radiology nZ100) were analyzed for clinically relevant discrepancies. All 100 cases were also subsequently ‘post read’ in a blinded fashion by two endoscopists and an experienced GI radiologist to arrive at a consensus interpretation, against which the discrepancies were compared. Results: The radiology post read (RPR) missed 65 significant findings in 43 patients, while the endoscopy dynamic read missed 2 significant findings in 2 patients. RPR correctly identified only 20 of 34 patients with CBD stones (SensitivityZ59%; 95% CI Z 4175%), 18 of 24 biliary strictures (75%; 53-89%), 46 of 65 cases of biliary dilation (71%; 58-81%), 41 of 56 biliary stents (73%; 59-84%), 5 of 10 pancreatic ductal (PD) strictures (50%; 20-80%), 6 of 15 PD stents (40%; 17-67%) and 14 of 15 cases of PD dilation (93%; 66-100%). RPR identified 100% of bile leaks (3 of 3), PD stones/ calcifications (13 of 13) and pancreatic cysts (2 of 2). RPR identified only 61 of 143 intraductal endoscopic interventions. Conclusions: 1. Radiology interpretation of post ERCP spot films does not guide decision making during this dynamic test and adds little to the endoscopist’s read of the study. 2. The significant error rate in radiology reports is likely due to an interpretation based solely on spot films, whereas endoscopists have access to dynamic intraprocedural fluoroscopic and endoscopic images. 3. Cost analysis of endoscopist interpretation alone versus the current practice of dual interpretation will be presented.

ERCP Teaching for GI Nurses/Assistants: In Vitro Practice with a Mechanical Simulator

Background: Successful ERCP procedures require close coordination between endoscopist and GI assistant. Although assisting with ERCP requires more skills, there are no established methods for teaching or assessing competency of assistants. Most training programs target the endoscopists and seldom cater to the assistants. Simulator training is limited by cost and availability, thus most ERCP assistants learn “on the fly.” Aim: To evaluate the role of ERCP practice using a mechanical simulator to train GI nurses/assistants. Methods: We conducted a training course to teach nurses basic skills with assisting diagnostic and therapeutic ERCP. Nurses completed a pre-practice survey detailing their overall ERCP experience prior to training. Using a mechanical simulator with a built-in simple bile duct stricture, 17 nurses from university and community hospitals were taught how to assist with four basic tasks using real standard ERCP accessories. They observed a live teaching demonstration of the practice procedures by an experienced biliary endoscopist prior to hands-on practice. Procedures included: 1. Negotiation of CBD stricture with guide wire, 2. Balloon dilation of stricture, 3. Cytology brushing, and 4. Insertion of a plastic stent. An external pinhole camera was used in place of fluoroscopy to monitor events within the bile duct. The endoscopy and “fluoroscopy” images were projected onto two separate monitors. Assistants were divided into groups of 4 and rotated through 4 different stations, working with GI fellows and experienced GI attendings. Each nurse assisted with at least one set of ERCP procedures. Participant's times to complete the tasks were recorded individually. Results: A pre-practice survey indicated 8/17 (47%) nurses had little to no prior ERCP experience while the remaining 9/17 (53%) had participated in > 25 ERCPs. Only 3/17 (17.6%) had assisted with > 100 ERCPs. All 17 assistants were able to complete the specified tasks irrespective of their prior ERCP experience or training with a mean time of 33.4 minutes (range 15-45). Conclusions: The mechanical simulator provides a safe and risk-free training setting for assistants to learn and practice different ERCP skills with no patient involvement. All participants were able to learn and assist with the ERCP tasks regardless of prior ERCP experience. The mechanical simulator provides an effective, economical, and mobile tool for ERCP training.

AIDS Cholangiopathy.

AIDS is an advanced disease with systemic and infectious complications that can be fatal. When a patient with AIDS presents with right upper quadrant or midepigastric pain, cholestasis, and symptoms of cholangitis, AIDS cholangiopathy should be suspected and appropriate diagnostic and therapeutic interventions should be initiated. Opportunistic infections such as Cryptosporidium and cytomegalovirus are the most common cause of AIDS cholangiopathy. Four distinct cholangiographic abnormalities have been demonstrated by endoscopic retrograde cholangiopancreatography, the most common being papillary stenosis with sclerosing cholangitis. Antimicrobial therapy is often ineffective. Highly active antiretroviral therapy may enhance immune function and offers the best medical therapy to clear the opportunistic infections. Ursodeoxycholic acid has a limited benefit in patients with sclerosing cholangitis and cholestasis. Endoscopic sphincterotomy has been shown to relieve pain and biliary obstruction in patients with papillary stenosis. Balloon dilation of strictures and stent placement decompress the biliary system and may be helpful. Cholecystectomy is recommended to treat acalculous cholecystitis, and celiac plexus block may be offered to patients with terminal disease and intractable abdominal pain.

Small Bowel Ulcers.

Treatment of small intestinal ulcers depends on the cause of the ulcers. Ulcerations of the small intestine (apart from duodenal ulcers) are uncommon. Two diverse syndromes of idiopathic small bowel ulcerations include the isolated nonspecific ulcer and idiopathic chronic ulcerative enteritis (ICUE). Treatment of isolated nonspecific ulcers include discontinuation of medications known to cause nonspecific ulcerations, balloon dilation of strictures, and segmental resection of involved segments. Treatment of ICUE includes a diet trial of gluten restriction and consideration of early surgery because of the potential for associated malignancies. Steroid therapy has not been shown to be effective in the treatment of ICUE.

Endoscopic therapy of ITBL-strictures in liver-transplanted patients

Introduction: Ischemic type biliary lesions (ITBL) in liver-transplanted patients are a difficult challenge to endoscopic therapy. ITBL has to be diffentiated by ERC from complications of choledocho-choledocho-side-toside-anastomosis and from papillary stenosis among others. Stenosis caused by ITBL as well as papillary stenosis can be treated successfully by ERC. We examined the outcome of endoscopic therapy in ITBL patients. Methods: From the beginning of the liver transplantation programme at our clinic in 1988 until now (11/1/1997) 935 orthotopic liver transplantations have been performed. Thereupon, 23 transplanted patients developed ITBL and most of them required endoscopic therapy. Therapy comprised endoscopic spincterotomy, balloon dilatation of stenoses, internal stenting and basket extraction of calculi. Results: 14 patients were treated due to progressive ITBL-induced stenoses by balloon dilatation subsequent to endoscopic sphincterotomy. In 6 out of 14 patients dilatation therapy failed due to rapid progression of ITBL. Calculi, sludge and debris could be extracted from 9 out of 14 patients. In 4 of these patients stenting was performed to treat stenoses in the donor-CBD or in the hepatic ducts. 5 patients presented a papillary stenosis requiting endoscopic sphinkterotomy. 12 of 23 ITBL patients deteriorated thus receiving retransplantation of the liver. The average time to retransplantation was 12 month. Endoscopic therapy could help many patients to survive for many month until retransplantation was possible. At the time of firstly diagnosing ITBL 3 patients presented only extrahepatic lesions (ITBL type I referring to the Neuhaus-classification) and 5 others circumscribed intrahepatic lesions (ITBL type II). These patients could by successfully treated by ERC. Further 15 patients were afflicted by multiple intraand extrahepatic stenoses (ITBL type III) thus always requiring retransplantation. Discussion: ITBL is a servere complication of liver transplantation. Endoscopic therapy is able to treat successfully many transplantationassociated stensoses. Thus, problems caused by cholestastis, cholangitis and cholelithiasis can be prevented or reduced significantly.Thereby, patients deteriorating progessively due to intraand extrahepatic stenoses (ITBL-type Ill) can be stabilized over many month to bridge the time until retransplantation. Moreover, patients with stenoses restricted to the extraor intrahepatic bile ducts (ITBL-type I and II) can be prevented from retransplantation by endoscopic measurements.

High altitude pulmonary edema: hemodynamic aspects.

Over 30 years ago hemodynamic studies on patients with high altitude pulmonary edema (HAPE) excluded the prior contention that the basic cause was left ventricular failure and correctly implicated the pulmonary circulation as the culprit. Physiological studies during the acute stage have revealed a normal pulmonary artery wedge pressure, marked elevation of pulmonary artery pressure, severe arterial unsaturation, and usually a low cardiac output. Pulmonary arteriolar (pre-capillary) resistance was elevated. A working hypothesis of the etiology of HAPE suggests that hypoxic pulmonary vasoconstriction is extensive but not uniform. The result is overperfusion of the remaining patent vessels with transmission of the high pulmonary artery pressure to capillaries. Dilatation of the capillaries and high flow results in capillary injury with leakage of protein and red cells into the alveoli. While hypoxic vasoconstriction appears to be the major cause of patchy vascular obstruction the occurrence of thrombi in the pulmonary vessels may also play a role in more severe and advanced cases. The above concept of the mechanism of HAPE has been further supported by animal studies showing pulmonary edema occurring when increased pressure and flow is produced in a portion of the pulmonary vascular bed. Clinical studies which have supported this concept include the susceptibility to HAPE of patients with an absent pulmonary artery, pulmonary edema occurring in pulmonary embolism, following removal of pulmonary arterial thrombi and following balloon dilatation of stenoses of branches of the pulmonary artery. In addition to those hemodynamic factors an increase in capillary permeability due to cell derived products resulting from capillary wall injury is an important aspect of edema formation.

Percutaneous removal of retained intrahepatic stones utilizing combination of techniques with emphasis on a preshaped angulated catheter: review of 170 patients

Intrahepatic stones are frequently associated with recurrent cholangiohepatitis and complete surgical removal of the stones is almost always difficult because of the large number of stones and the associated bile duct strictures. One hundred and seventy patients with retained intrahepatic stones underwent percutaneous stone removal utilizing pre-shaped angulated catheters, 9-F polyethylene tubes with different angles of distal tip, and Dormia baskets under fluoroscopy with a combination of techniques including irrigation-suction, crushing of large stones, balloon dilatation of strictures and extracorporenal shock wave lithotripsy. The procedure was performed through a mature T-tube tract (168 patients) and a mature transhepatic tube tract (two patients). Stones were exclusively intrahepatic in 125 patients, whereas 45 patients also had stones in the common bile duct.

Percutaneous removal of retained intrahepatic stones with a pre-shaped angulated catheter: review of 96 patients.

Intrahepatic biliary stone disease is prevalent in East Asia and there is a high frequency of retained intrahepatic stones after surgical treatment. Percutaneous removal of retained intrahepatic stones with a pre-shaped angulated catheter and a Dormier basket was attempted in a group of 96 patients who had a T-tube. Seventy-six had multiple intrahepatic stones, confined to one hepatic lobe in 52 patients. Stones were exclusively intrahepatic in 68 cases. Biliary strictures were present in 92 cases (95.8%). A combination of techniques was used including pre-shaped angulated catheters, irrigation suction, balloon dilatation of strictures, crushing of large stones and extracorporeal shockwave lithotripsy. Retained stones were completely removed in 48 cases, and incompletely removed in 22 cases. The overall success rate was 72.9%. There were only minor complications. No mortality or significant morbidity requiring hospitalization occurred. Angular deformity, stricture of bile ducts and impacted stones were the most frequent factors responsible for failure or incomplete removal of retained stones. Fluoroscopically guided percutaneous interventional procedures with a pre-shaped angulated catheter are useful complementary procedures to surgery for patients with intrahepatic stones. The major benefits of an individually angulated catheter are safety and easy access to small peripheral bile ducts.

Laser angioplasty of peripheral vessels: complementary procedures

From 1987 to 1991 we treated 167 peripheral arteries in 143 patients by laser-assisted balloon angioplasty using a Neodymium YAG laser. Embolism fo1lowing or accompanying laser angioplasty was treated by aspiration and local lysis with urokinase in 10 cases. To improve long term results balloon dilatation of stenoses of the proximal vessel was performed in 36 cases (5 iliac arteries, 30 femoral arteries, 1 bypass), and of the distal vessel in 31 (16 femoropopliteal arteries, 15 crural arteries). Percutaneous transluminal angioplasty of recurrent stenosis within the recanalised segment was necessary in 11 patients. It was also possible 1o reopen 10 reocclusions, 6 by aspiration and local lysis and 4 by a second laser angioplasty. Both the high technical success rate (90.4%) and the good long term results (cure rate after 3 years 66.8%) are due in part to complementary procedures.

Inflammatory Bowel Disease Revisited: Surgery Today and Tomorrow

Both topical and systemic medical therapy are helpful in controlling the symptoms in patients with ulcerative colitis. However, no drug therapy is known to influence the natural history of Crohn's disease. Surgical management is often required for the complications of acute colitis unresponsive to medical treatment and for socially incapacitating diarrhoea and urgency due to ulcerative colitis. The gold standard of such surgical treatment is a panproctocolectomy with end ileostomy. In young patients with a good anal sphincter, total colectomy with the formation of an ileal pouch-to-anus anastomosis obliterates the disease and usually results in satisfactory continence. There appears to be no prospect of using gut transplantation in the management of this disease. In the absence of curative medical treatment for Crohn's disease surgical intervention is often needed to control the complications of Crohn's disease. The initial complication that makes the disease symptomatic is stenosis from the healing of asymptomatic ulcers. If strictures can be detected early, they can be treated before secondary complications such as abscess or fistula occur. Some success is being achieved with balloon dilatation of strictures. For the first presentation of ileo-caecal Crohn's disease limited resection offers good long-term cure without the need for continued medical therapy. For recurrent and multiple strictures strictureplasty offers a safe alternative to extensive resection.

Percutaneous removal of residual intrahepatic stones.

In the Orient there is a high frequency of residual intrahepatic stones after biliary tract surgery. Percutaneous removal of residual intrahepatic stones was attempted in a group of 74 patients. Stones were exclusively intrahepatic in 57 patients, whereas 17 patients also had stones in the common bile duct. Biliary strictures were present in 60 cases (81%). A combination of techniques was used, including preshaped angulated catheters, irrigation-suction, balloon dilation of strictures, and crushing of large stones. In 36 cases all stones were removed and in 14 cases most stones were removed, for a success rate of 67.6%. Biliary stricture was the factor most often responsible for failure.

Percutaneous management of benign biliary disease.

Thirty-two patients had percutaneous drainage for benign disease of the biliary system, and in 81% of the patients the catheter could be removed. The patients' conditions were of 3 types: choledocholithiasis, biliary strictures, and primary sclerosing cholangitis. Fourteen patients had balloon dilatation of strictures in the biliary tract. As in malignant disease, many patients may be managed entirely by percutaneous methods and surgery avoided, but the results with percutaneous drainage are more gratifying.