Successful Stone Research Articles

Factors influencing the outcome of extracorporeal shock wave lithotripsy in the management of salivary calculi

To identify the factors that affect outcome (stone clearance, partial clearance without symptoms, and residual stone with symptoms unchanged) of extracorporeal shock wave lithotripsy (ESWL). To develop and validate a predictive model for outcome of treatment. Prospective controlled trial. There were 142 salivary calculi (78 submandibular, 64 parotid) entered into a prospective clinical trial of ESWL. The results were analyzed and a predictive model generated, which was validated using a second group of patients treated by the same technique. ESWL achieved complete success (stone and symptom free) in 67 (47.15%) of cases (submandibular 28/78, 35.9%; parotid 39/64, 60.9%). Partial success (residual stone and symptom free) was obtained in a further 49 (34.5%) (submandibular 29/78, 37.2%; parotid 20/64, 31.3%). Failure occurred in 26 (18.3%) of cases (submandibular 21/78, 26.9%; parotid 5/64, 7.8%). ESWL can eradicate salivary calculi but its effectiveness is dependant mainly on size of the stone. Using a regression analysis model stone clearance can be reliably predicted based on stone size. A less important factor is the radiodensity of the stone, whereas a greater proportion of parotid calculi are eliminated by ESWL than submandibular calculi.

Large balloon dilation for the treatment of recurrent bile duct stones in patients with previous endoscopic sphincterotomy: preliminary results

Objective. Endoscopic sphincterotomy (ES) is an established method to treat common bile duct (CBD) stones. Inevitable sequence after ES is a substantial risk of recurrent choledocholithiasis and occasional difficulty in removal of large or multiple CBD stones after ES even when mechanical lithotripsy (ML) is employed. In turn, a new endoscopic technique, large balloon dilation (LBD) after ES, has been introduced. The objective was to analyze the efficacy and safety of LBD in patients with recurrent bile duct stones who have previously undergone ES. Patients and methods. From December 2007 to November 2009, 24 patients with recurrent choledocholithiasis and a history of ES were treated with LBD without additional ES. The size of the balloon for LBD was 15–20 mm and the duration of balloon dilation was 30 s. Results. Successful stone removal and complications such as perforation, pancreatitis, and bleeding were evaluated as procedure-related outcomes. Postoperative CBD stone recurrence was evaluated as the short term outcome. Complete duct clearance rate without using ML was 96% (23/24 patients) and all stone removal was achieved in one session. Failure to remove stones occurred in one (4.2%) patient. There were no procedure-related complications although one case of aspiration pneumonia occurred after the endoscopy. Recurrent choledocholithiasis after LBD was observed in 12.5% (3/24) of the cases overall. Conclusions. LBD is an effective and safe method in patients with recurrent choledocholithiasis not only to treat large stones but also to prevent further recurrence.

Harnwegsinfektionen und Urolithiasis

The classic "infection stone" struvite is formed as a result of metabolic activity of urease-positive bacteria from alkaline urine with pH-values above 7.5. Due to improved infection diagnostics and antibiotic therapy, the occurrence of infection-related urinary stones in the western industrialized world decreases, despite the generally increasing prevalence rates of urolithiasis in these societies. Struvite is often associated with other mineral phases. These accessory mineral phases could indicate other, non-infection-related causes of urinary stone formation. Thus, mineral analysis is always recommended. Struvite stones as well as struvite encrustations on urinary tract implants are characterized by rapid growth. The rapid growth-related embedding of urease-positive bacteria in the crystalline material makes the urinary stone a persistent source of recurrent urinary tract infections. According to the German Society of Urology guidelines on urolithiasis, a patient with the diagnosis "infection stone" should be assigned to the "high-risk" patient group. Complete stone and debris removal, as well as a special metaphylaxis strategy are required to initiate successful stone therapy.

Extracorporeal Shock Wave Lithotripsy for Ureteral Stones: Do Decompression Tubes Matter?

Extracorporeal shock-wave lithotripsy (SWL) offers an effective and minimally invasive method for treating ureteral stones. In the current study we investigated whether the presence of a double-J (JJ) stent or a percutaneous nephrostomy (PCN) has any impact on the SWL success rates for ureteral stones. All adult patients with ureteral stones treated with the second-generation Siemens Lithostar® Multiline (Siemens, Erlangen, Germany) lithotriptor between 2002 and 2007 were included. Exclusion criteria comprised radiolucent or nonsolitary stones, calculi >10 mm in diameter in the lower ureter, stones that were pushed back into the kidney during JJ stent insertion and patients who had undergone stent or nephrostomy tube insertion after initiation of SWL therapy, though having started treatment as "tubeless." In total, 342 individuals were divided into 3 groups: group I (n = 56) consisted of patients with a PCN; group II (n = 73) included patients with a JJ stent; and group III (n = 213) comprised individuals without any decompression tubes. All patients were reviewed in the outpatient clinic. The mean age for all patients was 50.1 years (range 16-90 years) and the mean ureteral stone size was 9.4 mm (SD = 3.6 mm). Successful stone clearance was achieved in 60.7%, 47.9%, and 59.2% of the 3 groups, respectively. There was no statistically significant difference in success rates between the aforementioned groups. The results of the current study suggest that the presence of either a PCN or a JJ uretral stent does not exert any influence on stone clearance after SWL treatment.

What is the learning curve for Paediatric Percutaneous Nephrolithotomy?

Purpose Paediatric urinary tract stones are infrequent in the U.K. In our unit. PCNL is performed jointly by the paediatric urologist and paediatric radiologist only. We reviewed our experience to determine what constituted the ‘learning curve’ for paediatric PCNL. Material and Methods We reviewed the notes of 26 children who underwent PCNL in 2 years. Measures of outcome to achieve competence was defined as time taken (number of cases) to attain the plateau phase of the learning curve. Defined outcome measures were success of first pass puncture and track formation, complete stone clearance by preoperative fluoroscopy and postoperative ultrasonography, overall time required for the procedure and complications. Results There were 28 episodes of PCNL. The first 4 cases performed under supervision had a successful puncture and track formation and complete stone clearance without complications. The overall time required was 97 minutes (46-128). Of the next 4, two had a failed puncture. The remaining two had successful track formation and complete stone clearance without complications. The overall operating time was 183 minutes (150-237). The subsequent 20 (including the two with failed puncture) had a successful puncture and complete stone clearance in all but the last case with abnormal calyceal anatomy in a scarred upper pole. Of these a first pass puncture was successful in all cases after case 12. There were no complications. The overall operating time was 146 minutes (90-220). All children were discharged within 48 hours of surgery. Conclusions Numerous factors are responsible for determining the learning curve for paediatric PCNL including the stone burden, dilatation of the collecting system and renal scarring. In our review a consistent steady state was achieved after 12 cases. Failure may still occur in difficult cases despite overcoming the learning curve.

1585 THE EFFECTS OF SWL FAILURE ON OUTCOMES OF SUBSEQUENT PNL IN PATIENTS WITH RENAL CALCULI

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopic or Percutaneous Stone Removal II1 Apr 20101585 THE EFFECTS OF SWL FAILURE ON OUTCOMES OF SUBSEQUENT PNL IN PATIENTS WITH RENAL CALCULI Joo Yong Lee, Joon Seok Kwon, Sung Yul Park, Young Woo Son, Hong Sang Moon, Yong Tae Kim, Hong Yong Choi, and Tchun Yong Lee Joo Yong LeeJoo Yong Lee More articles by this author , Joon Seok KwonJoon Seok Kwon More articles by this author , Sung Yul ParkSung Yul Park More articles by this author , Young Woo SonYoung Woo Son More articles by this author , Hong Sang MoonHong Sang Moon More articles by this author , Yong Tae KimYong Tae Kim More articles by this author , Hong Yong ChoiHong Yong Choi More articles by this author , and Tchun Yong LeeTchun Yong Lee More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1351AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Shockwave lithotripsy (SWL) and percutaneous nephrolithotripsy (PNL) is mainstay in treating renal calculi. Especially, PNL is prime treatment when SWL fails. The purpose of this study is to evaluate effects of SWL failure on the outcomes of subsequent PNL. METHODS The study population included 108 patients who underwent PNL from January 2002 to June 2009. In all, 73 patients underwent PNL alone for treating renal calculi (Group 1) and 35 underwent PNL after SWL failure (Group 2). Characteristics of patients and calculi included age, gender, body mass index, ASA score, size of renal calculi, location of calculi, presence of staghorn stone, bilaterality, multiplicity, and presence of hydronephrosis. The outcomes of PNL were assessed by factors of operation time, duration of hospitalization, duration of nephrostomy catheterization, estimated blood loss, transfusion rate, success rate, and stone free rate. Success was defined as presence of asymptomatic remnant calcifications less than 0.4cm on plain KUB film. RESULTS Characteristics of patients and calculi showed no significant difference between two groups. Mean size of calculi in both groups were 2.79±1.68 and 2.45±1.28 cm, respectively (p=0.307). Percentage of multiplicity was 49.3 and 68.6%. (p=0.059). Mean duration of nephrostomy catheterization was 5.67±2.13 days in group 1 and 7.34±3.92 days in group 2 (p=0.023). Mean duration of hospitalization was also shorter in group1 (11.18±5.02 vs 14.00±7.46 days) (p=0.048). There was no significant difference in operation time between two groups. However, noticeable statistical differences were present regarding estimated blood loss (195.89 vs 528.57 mL, p=0.001) and transfusion rate (16.4 vs 51.4%, p<0.001) between two groups. Success rate (83.6 vs 88.6%, p=0.493) and stone free rate (74.0 vs 74.3%, p=0.951) were equal in both groups. CONCLUSIONS Subsequent PNL after SWL failure was as successful as PNL performed alone. However, patients treated with PNL after failure of SWL showed more blood loss, higher transfusion rate, thus longer hospitalization. Seoul, Republic of Korea© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e612-e613 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joo Yong Lee More articles by this author Joon Seok Kwon More articles by this author Sung Yul Park More articles by this author Young Woo Son More articles by this author Hong Sang Moon More articles by this author Yong Tae Kim More articles by this author Hong Yong Choi More articles by this author Tchun Yong Lee More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.

Percutaneous transhepatic choledochoscopic lithotomy as a rescue therapy for removal of bile duct stones in Billroth II gastrectomy patients who are difficult to perform ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is more difficult and dangerous in patients with Billroth II (B II) gastrectomy than those with normal anatomy. To evaluate the clinical efficacy of percutaneous transhepatic choledochoscopic lithotomy (PTCSL) for removing common bile duct stones in B II gastrectomy patients who are difficult to perform ERCP. This study was designed as prospectively uncontrolled in a large tertiary referral center. In 20 patients, mostly men, with bile duct stones and an earlier B II gastrectomy, PTCSL was tried because of failed ERCP and high risk. The PTCSL was performed using electrohydraulic lithotripsy or papillary balloon dilation. Successful stone removal and complications were measured. Stone removal was achieved in all 20 patients. The mean number of procedures and session time were 4.5 and 45 min, respectively. Minor PTCSL-related complications, such as fever, hemobilia, hyperamylasemia, and wound pain, occurred in five patients (25%). There were no major procedure-related complications, including perforation or mortality. The PTCSL procedure is an effective and safe rescue therapy for common bile duct stones in B II gastrectomy patients with failed ERCP and high risk.

Stent-Associated Urinary Calculi

A 54-year-old man was referred because of a 6-month history of lower urinary tract symptoms, microhematuria, and dull pain in the right flank. He had undergone shock-wave lithotripsy for the treatment of a 20-mm renal stone on the right side 12 years earlier. At that time, a double pigtail stent had been inserted after successful stone disintegration. However, the patient did not return for follow-up to have the stent removed. During the years after the stent placement, he had a few intermittent urinary infections. Plain radiography of the kidneys, ureters, and bladder showed a calcified double pigtail stent (solid arrows) . . .

Powered endoscopic dacryocystorhinostomy with mucosal flaps

The technique described for endoscopic dacryocystorhinostomy (DCR) allows complete exposure of the lacrimal sac after creation of a large bony ostium. In addition, preservation of the lacrimal mucosa allows apposition of the nasal mucosa to the lacrimal mucosa, allowing healing by first intention and thereby avoiding granulation tissue formation with subsequent scarring. These principles have been espoused as the corner stones for success for the traditional external DCR, but can now be achieved without an external incision or disruption of the lacrimal pump seen with the external approach. This technique has a 95% anatomical patency, which is as good as the best results obtained by the external DCR.

Treatment of complicated upper urinary calculi with Ho: YAG laser lithotriptor by minimally invasive percutaneous nephrolithotomy

Objective To investigate the clinical outcomes of Ho: YAG laser lithotripter with minimal-ly invasive percutaneous nephrolithotomy incomplicated upper urinary calculi treatment. Methods Totally 12 eases of patients with upper ureteral calculi and 25 eases of renal calculi patients were treated with Ho: YAG laser lithotriptor by minimlly invasive percutaneous nephrolithotomy. Results All the upper ureteral calculi patients achieved stone-free at 1 session. And polypus( 1 ease) ,granulation(9eases) ,granulations wraped up(2 eases) were reseeted with Ho: YAG laser vaporization ablation. Of 25 eases with renal calculi 20 achieved stone free at 1 session. The remained stones ranged from 0. 5 to 0. 8 cm in 5 patients were expectorated in 1 month(2 eases treated by medicine and 3 eases treated by ESWEL). The overall successful stone fragmentation rate with stone-free ex-peetoration of the ureteral and renal calculi was 86. 4% ( 32/37 ). All the patients recovered well postoperatively and no major complications observed. Conclusion The technique of Ho: YAG laser lithotriptor with minimally invasive pereutaneous nephrolithotomy is safe and effective for the treatment of complicated upper urinary calculi, especially accompanied with polypus and granulation, and has advantages of minimal trauma and easy recovery. Key words: Minimally invasive percutaneous nephrolithotomy; Ho: YAG laser lithotriptor; Complicated Upper urinary calculi

Management of late biliary complications in patients with gallbladder stones in situ after endoscopic papillary balloon dilation

Patients with untreated gallbladder stones in situ are at high risk for late biliary complications after endoscopic papillary balloon dilation (EPBD) and bile duct stone extraction. Few data exist on the short-term and long-term results in these patients after the recurrence of bile duct stones and acute cholecystitis. The aim of this study was to evaluate the outcome of late biliary complications in patients with gallbladder stones in situ after EPBD. Fifty-six patients who developed late biliary complications, including bile duct stone recurrence (n=43) and acute cholecystitis (n=13), were managed at our institutions. We investigated the short-term and long-term outcomes after the management of late biliary complications. Complete removal of recurrent bile duct stones was achieved in 38 of 43 patients (88%) by repeated EPBD alone. Pancreatitis after repeated EPBD occurred in two patients (5%). After successful bile duct stone extraction by EPBD, none of the 16 patients who underwent cholecystectomy developed late biliary complications (mean follow-up period of 5.2 years), wheras re-recurrent bile duct stones occurred in three of the 21 patients (14%) with gallbladder stones left in situ (mean follow-up period of 4.4 years)(P=0.1148). Re-recurrent bile duct stones were successfully treated endoscopically. One of the eight patients who did not undergo cholecystectomy for acute cholecystitis had a recurrence of cholecystitis, which was managed conservatively. The long-term outcomes of late biliary complications are favorable when patients with concomitant gallbladder stones undergo cholecystectomy. Re-recurrent bile duct stones are considerable when gallbladder stones are left in situ, but should be treated endoscopically.

The Effectiveness and Safety of Minor Endoscopic Sphincterotomy Plus Large Balloon Dilation for Removal of Bile Duct Stones in Patients with Periampullary Diverticula

Background: Endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) is a useful method to remove bile duct stones. PAD have been reported to be associated with the risk of complications and difficulty of stone removal. However, the effectiveness and safety of minor EST plus LBD in patients with PAD for removal of bile duct stones is not well known. Objective: The aim of this study is to evaluate the effectiveness and safety of minor EST plus LBD for removal of bile duct stones in patients with PAD. Patients and Intervention: Total one hundred thirty nine patients with bile duct stones were included. Among them, 73 patients (median age 70 years (40∼89); 37 men, 36 women) had PAD and 66 patients (median age 64 years (23∼89); 39 men, 27 women) had normal papilla. PAD were classified in 3 different types according to the position of the major duodenal papilla; type1, inside the diveticulum; type2, in the margin of the diverticulum; type3, near the diverticulum. LBD (10 to 20 mm balloon diameter) was performed after minor EST. Main outcome measurements: Successful stone removal and complications such as pancreatitis, bleeding. Results: The mean age was significantly increased in PAD group compared with normal group (69.9 vs 62.1, P< 0.001). PAD group compared with normal group resulted in similar outcomes in terms of overall complete stone removal (94.5% vs 93.9%), complete stone removal in single session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%). Complications were similar between the 2 groups (11.0% vs 7.6%, P=0.497). Clinical outcomes according to types of PAD were similar. Conclusions: Minor EST plus LBD was effective and safe treatment modality for removing bile duct stones in patients with PAD. The types of PAD did not influence clinical outcome.

Tamsulosin for Ureteral Stones in the Emergency Department: A Randomized, Controlled Trial

The alpha-adrenergic antagonist tamsulosin hydrochloride has become an increasingly common adjunct in the treatment of ureteral calculi; however, its efficacy in a general emergency department (ED) population has not been investigated. We conducted a randomized, controlled trial of adult ED patients with distal ureteral calculi diagnosed by computed tomography scan. Patients were randomized to receive either a 10-day course of ibuprofen and oxycodone plus tamsulosin or ibuprofen and oxycodone alone. The primary outcome measure was successful spontaneous ureteral stone expulsion at 14 days. Secondary outcomes included time to stone passage, self-reported pain scores, number of colicky pain episodes, unscheduled return ED/primary care visits, number of days of missed work/usual function, amount of analgesic used, and adverse events. Eighty subjects were enrolled in the study, with 77 completing the trial. Mean stone size was 3.6 mm (95% confidence interval [CI] 3.4 to 3.9). Successful spontaneous stone expulsion at 14 days was similar between the groups, with 27 (77.1%) subjects in the tamsulosin group and 24 (64.9%) subjects in the standard therapy group reporting spontaneous stone passage, a difference of 12% (95% CI -8.4% to 32.8%). At 2-, 5-, and 14-day follow-up, there were no clinically important (or statistically significant) differences between the groups for any secondary outcome measure. No adverse events were reported in either group. In this cohort of adult ED patients with distal ureteral calculi, treatment with tamsulosin did not substantially improve any of the studied outcome measures compared with treatment with ibuprofen and oxycodone alone.

Endoscopic Sphincterotomy Combined With Large Balloon Dilation Can Reduce the Procedure Time and Fluoroscopy Time for Removal of Large Bile Duct Stones

We sought to evaluate the safety, efficacy, and feasibility of endoscopic sphincterotomy plus large balloon dilation (ESLBD) and to compare procedural time and fluoroscopy time of ESLBD with those of endoscopic sphincterotomy (EST) alone for patients with large bile duct stones. Retrospective analysis. A total of 101 patients with large bile duct stones were treated: 53 were treated by ESLBD and 48 with EST alone. ESLBD resulted in similar outcomes in overall successful stone removal (100% vs. 97%) and complications (4% vs. 6%); however, although the rate of complete stone removal in the first session using ESLBD tended to be higher than when EST alone was used, it was not statistically significant (96% vs. 85%, P=0.057). Mechanical lithotripsy was required significantly more often in the EST group compared to the ESLBD group (25% vs. 6%, P<0.01). Total procedure time in the ESLBD group was significantly shorter than that of the EST group (32 vs. 40 min, P<0.05). Total fluoroscopy time in the ESLBD group was significantly shorter in the EST group (13 vs. 22 min, P<0.05). ESLBD is an effective and safe treatment in patients with large bile duct stones. In addition, ESLBD appears to decrease procedure time and fluoroscopy time and reduce the need for mechanical lithotripsy as compared to EST alone.

Introduction to the Special Section

In a span of merely 10 years, the school counseling profession has reinvented itself. Since the late 1990s, school counseling has progressed from the tradition of a responsive services focus to a proactive and programmatic system that is inextricably integrated with the mission of schools. The national standards of the American Counselor Association (ASCA, 1997; Campbell & Dahir, 1997), the Transforming Counseling Initiative (Education Trust, 1997), and the ASCA (2003, 2005) National Model have directed school counselors to respect the past and embrace the present but forge a new vision to the future. The challenges facing students and 21st-century schools have influenced the paradigms and practices that forward the profession and place a renewed emphasis on supporting student achievement, social justice advocacy, and school counselor accountability. * We Are in Charge of Our Destiny The imperative of any professional organization is to choose with intentionality how to lead the organization and propel its members forward by anticipating what the future may hold and establish a foundation to shape its destiny. Theobald suggested that we need to envision the society we really want and to develop a plan to move from the present into the future that we choose to shape (Maples, 1984). More than 20 years ago, Inbody (1984) identified six basic premises that were critical to the future of school counseling: 1. What the school counseling profession does today wild have an impact on the quality of the field of school counseling and educational environments in which school counselors and students must live. 2. Scientific methods of researching school counseling can be used for anticipating the various futures school counselors could create unknowingly. 3. There is no longer just one future that awaits the school counseling profession but many different possible futures, depending on what school counselors and the profession choose today. 4. counselors assume a moral urgency in their responsibility to future generations of students and school counselors. 5. Technology continues to serve as a powerful tool for school counselors; however, school counselors are responsible for technology integration and use in the future in a way that may have been inconceivable 20 years ago. 6. Prior to unleashing the power of an idea on the school counseling profession and students, an extensive study of the future impact of that idea must be mounted. (adapted from pp. 216-217) Despite the passage of more than 2 decades, these premises still ring true. The purpose of this special section, School Counseling in the 21st Century: Where Lies the Future? is not to dwell on the past but to ponder the next wave of innovation that will forward the profession. The contributors have worked with the assumption that the ASCA (2003, 2005) National Model and the Transforming Counseling model (Education Trust, 1997) will become firmly embedded themselves in the hearts and minds of the 100,000 school counselors in public schools. In our crystal ball, 21st-century school counselors are in a powerful and pivotal position to effectively demonstrate how the complement of academic rigor and affective development is the formula to student success (Stone & Dahir, 2006). They recognize and embrace the critical part they play as key members of the educational leadership team and rise to the challenge to share in the responsibility of preparing students to meet the expectations of higher academic standards while assisting them to become productive and contributing members of society. Counselor educators, practitioners, and future school counselor candidates for degrees have established a new way of work as leaders, collaborators, advocates, and systemic change agents in concert with the dynamics of the educational landscape, the globalization of society and economics, and the plethora of diverse student needs. …

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Risk Factors for Recurrent Bile Duct Stones after Endoscopic Clearance of Common Bile Duct Stones

We aimed to explore the risk factors contributing to the recurrence of common bile duct (CBD) stones after successful endoscopic stone clearance, focused on the anatomical factors of CBD and presence or absence of ursodeoxycholic acid (UDCA)/RowacholR medication. One hundred fourteen patients who underwent CBD stone(s) extraction by endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy at our institution from August 2004 to January 2007 were included. Univariate and multivariate analyses for the risk factors including the distal CBD angle, length of the distal CBD arm and medication such as ursodeoxycholic acid (UDCA) and/or RowacholR for recurrent CBD stone(s) were performed. The recurrence of CBD stone(s) was found in 22 (19.3%) patients. On univariate analysis, presence of pneumobilia, presence of type 1 or type 2 periampullary diverticulum, mechanical lithotripsy and multiple sessions of ERCP were significant contributors for the recurrence of CBD stone(s). On multivariate analysis, the presence of type 1 periampullary diverticulum (OR 7.90, 95% CI: 1.56-40.16) and multiple sessions of ERCP (OR 7.56, 95% CI: 2.21-25.87) were significant contributors. Acute distal CBD angulation (<135), shorter distal CBD arm (<36 mm), technical difficulty of CBD stone(s) clearance, and the prescription of UDCA and/or RowacholR were not significantly associated with the recurrence of CBD stone(s). The recurrence of CBD stone(s) was more commonly found in the patients group with type 1 periampullary diverticulum and multiple sessions of ERCP. Therefore, patients with these risk factors should be on regular follow up.

A Case of Unusual Pulmonary Embolism Due to Extensive Thrombosis after PTC

Purpose: A 49 year old female with a past medical history of anxiety and hypothyroidism presented to an outside institution with a complaint of intermittent epigastric abdominal pain and symptoms suggestive of biliary colic. The patient gave a history of having had a cholecystectomy and further workup with a CT scan revealed a common bile duct stone. No other abnormalities were noted except for an incidental finding of mal-rotation of the bowel. ERCP was attempted, but was unsuccessful due to difficulties related to her bowel anatomy. The patient then underwent a Percutaneous Trans-hepatic Cholangiogram (PTC) with successful CBD stone extraction and drainage. Two weeks later she began to complain of fever, cough and some abdominal pain and was started on Ciprofloxin by her primary doctor outside the hospital in attempt to treat what was thought to be pneumonia. Her stent was removed one week after the onset of fever via ERCP. The patient continued to have persistent fever and in addition, began to complain of worsening dyspnea and a dry cough. At this point she was suspected of having pneumonia and bronchodilators along with another antibiotic were started. Due to lack of improvement and persistent fever for four weeks a CT scan of the chest was performed as an outpatient which showed a pulmonary embolism and questionable early formation of a liver abscess. The patient was then admitted to our institution for further workup and care. On presentation, she had a fever of 101.7, tachycardia and hypotension. Except for a fever, the remainder of her physical exam was unremarkable. CT scan of the abdomen with IV contrast revealed an 8 cm lesion in the right hepatic lobe consistent with a neoplasm versus an abscess. In addition, there was thrombosis of the middle hepatic vein with extension into the inferior vena cava and the right atrium. There was also a right lower lung nodule, measuring 2 cm that appeared to have cavitations consistent with a septic embolus. Venous sonography of the lower extremities was positive for a left common femoral deep venous thrombosis. A needle biopsy of the liver lesion was performed with findings consistent with a hepatic abscess. The patient was treated in the intensive care unit with intravenous heparin and antibiotics, and her fever resolved within 24 hours of admission. She was discharged after 10 days of hospitalization on Coumadin and antibiotics. Although portal vein and hepatic vein thrombosis are associated with pyogenic liver abscesses, the extent of thrombosis from the hepatic veins into the inferior vena cava and right atrium, along with a septic pulmonary embolus as a complication to PTC and stent placement has not been reported.

Transoral removal of submandibular hilar stone and sialodochoplasty

To evaluate the efficacy of intraoral stone removal and sialodochoplasty in 59 patients with hilar submandibular stones. Prospective, randomized, controlled study. Fifty-four patients underwent complete stone removal without significant complications, and five had unsuccessful removal of stones. The 54 patients with successful stone removal were randomized to additional sialodochoplasty (n = 28) or not (n = 26). Salivary scintigraphy was performed before and 6 months after surgery. Salivary secretory function of the affected gland was less than that of a normal gland but returned to normal after stone removal. Symptom recurrence and recovery of salivary gland function were not affected by sialodochoplasty; rather, they were affected by successful removal of the stones. Hilar submandibular stones can be transorally removed with high success rate, low-level risk, and substantial recovery of gland function. Sialodochoplasty may have no effect in preventing symptom recurrence.