[Percutaneous diagnosis and therapy of the bile ducts and gallbladder. Feasibility and status]

Percutaneous transhepatic access to the bile duct has opened up new possibilities not only for diagnosis by means of cholangiography and cholangioscopy with endoscopically guided biopsy by small-bore equipment, but also for the treatment of benign and malignant obstructive jaundice. In malignant disease recanalization of the obstruction is possible by means of laser, intracavitary irritation, internal bile drainage in Klatskin tumors, large-diameter endoprostheses (e.g., a Y-shaped prosthesis) or metal stents. In benign disease, balloon dilatation of inflammatory stenoses, stone extractions from the bile duct or gallbladder by means of Dormia baskets, ultrasound or piezoelectric shockwave-contact lithotripsy and chemical litholysis are possible. Very often percutaneous access is a real alternative to surgical intervention.

Bacteremia following operative endoscopy of the upper gastrointestinal tract

The rate of bactaeremia following surgical endoscopy of the upper gastrointestinal tract is reported with up to 50% depending on the therapeutic measure performed. In a prospective study we examined 160 patients treated by surgical endoscopy of the upper digestive tract. The rate of bactaeremia showed a significant difference with 12.5% after diagnostic and 28.96% after surgical endoscopy. Our results recommend a single shot antibiotic prophylaxis depending on the endoscopic measure performed and the patient's individual risk.

[Wide-gauge bile duct endoprostheses with a port irrigation system. A new method of prolonging the drainage function]

The maintenance of adequate drainage by the bile ducts is crucial in all the endoscopic or percutaneous transhepatic procedures used today for the treatment of obstructive jaundice. We use wide-gauge polyurethane bile duct endoprostheses (F16; 5.3 mm - F20; 6.7 mm). Occlusion need not be expected to occur earlier than 4-6 months after placement. The implantation of a subcutaneous port system connected to the prosthesis by means of an F5 (1.6 mm) catheter allows not only X-ray examination of the function, but also lavage of the prosthesis and the biliary ducts. It is possible to add bile-dissolving substances, thus preventing crystallization of bile. In this way the patency of the prosthesis can be maintained for substantially longer. This also means a definite improvement in the quality of life.

[Extracorporeal piezoelectric gallstone lithotripsy: initial surgical experience with a new treatment. Technique and indications]

The extracorporeal piezoelectric lithotripsy (EPL) is a new method for non-operative therapy of symptomatic gallbladder and problematic bile duct stones. The rare intrahepatic calculi were similarly disintegrated. Best results were reached with EPL as adjuvant measure or combined with oral cheno- and ursodeoxycholic acid therapy. EPL compared to other lithotripsy techniques is performed without any analgesia. That means advantage and patient's benefit.

Large-bile-duct stones--extracorporeal piezoelectric lithotripsy as adjuvant measure for endoscopic basket extraction

Extracorporeal piezoelectric lithotripsy (EPL) was performed in 12 patients with large-bile-duct stones and intrahepatic stones. The Piezolith 2300 lithotripter (Wolf, Knittlingen, FRG) was used in all patients in whom routine endoscopic approaches for removal of the calculi had failed or were considered inappropriate because of large stone size or difficult localization. In 9 of the 12 patients the stones were fragmented. Complete stone clearance from the bile ducts was obtained in 8 of 10 patients by EPL alone or combined with one of the following: endoscopic extraction, mechanical lithotripsy or installation of solvents. Adjuvant EPL in conjunction with endoscopic therapy increased the success rate of nonsurgical treatment for bile duct stones from 73% to 95%. No clinically significant side effects or complications were noted.

Granulocyte elastase in assessment of severity of acute pancreatitis. Comparison with acute-phase proteins C-reactive protein, alpha 1-antitrypsin, and protease inhibitor alpha 2-macroglobulin

Complexes of granulocyte elastase and alpha 1-antitrypsin are markers for granulocyte activation. In 75 patients with acute pancreatitis these complexes were immunologically determined daily in plasma during the first week of hospitalization. Patients were classified into three groups: mild pancreatitis (I, less than or equal to 1 complication, N = 34), severe pancreatitis (II, greater than or equal to 2 complications, N = 29), lethal outcome (III, N = 12). Initially, granulocyte elastase (mean +/- SEM) was lower in group I (348 +/- 39 micrograms/liter) as compared to groups II (897 +/- 183 micrograms/l) and III (799 +/- 244 micrograms/liter), P less than 0.001 for I vs II + III. Initial elastase concentrations greater than 400 micrograms/liter were consistent with a severe or fatal course of the disease but did not distinguish between severe and lethal pancreatitis. In patients with mild or severe disease, mean elastase concentrations decreased continuously during the following days (197 +/- 15 micrograms/liter in mild cases, 325 +/- 30 micrograms/liter in severe cases at day 7). In patients with lethal disease, however, mean elastase concentrations even increased at day 2 and remained higher than 700 micrograms/liter during the observation period. At days 1 and 2 the predictive value for severe or lethal disease of raised (greater than 400 micrograms/liter) elastase concentrations [positive predictive value (PPV) 82%, negative predictive value (NPV) 81%] was better than that of elevated (greater than 100 mg/liter) C-reactive protein (PPV 73%, NPV 73%), elevated (greater than 4.0 g/liter) alpha 1-antitrypsin (PPV 59%, NPV 50%), or decreased (less than 1.5 g/liter) alpha 2-macroglobulin (PPV 82%, NPV 67%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cholelithiasis--non-surgical intervention. Definitive and combined use]

New endoscopic and radiological techniques, together with pharmacological developments, prompted by high-surgical risk patients or those developing bile duct stones after prior cholecystectomy--but also by the wish to have less invasive alternatives available, have led to a variety of non-operative therapeutic modalities in gallstone diseases. Both endoscopic and radiological procedures are employed to remove stones from the biliary tract and gallbladder. Extracorporeal lithotripsy and chemical litholysis are being increasingly employed to treat gallbladder stones. Laparoscopic cholecystectomy is a new operative possibility. These different approaches, sometimes used in combination, are associated with different preconditions for success. Indications and results must be measured against the gold standard of cholecystectomy.

Technical aid for facilitating emergency endoscopy

Emergency endoscopy is usually complicated by unfavorable examination conditions. The irrigating capability of the instrument is inadequate. The use of an easy-to-operate volume- and pressure-driven irrigation pump has proved very efficient and safe in the hands of an experienced endoscopist, and helps establish the correct diagnosis or provide proper treatment.

Endoscopic percutaneous gastrostomy using a modified instrument for puncture of the abdominal wall and the stomach

A new instrument for the puncture of the abdominal wall and stomach while performing endoscopic percutaneous gastrostomy is described. It has several advantages as compared with the instruments used so far, one of which is that it makes the method safer and easier.

[Posthepatic jaundice caused by abnormalities of the pancreaticobile duct system in early childhood]

Anomalies of the pancreatico-biliary tract present the most frequent cause of posthepatic cholestasis in the young child, whereas calculous disease or infections or compression by vascular abnormalities or neoplasms are less frequent. Generally, abdominal pain and jaundice begin acutely and increase following progressive biliary congestion. The preoperative diagnosis by ERCP or PTC or the intraoperative diagnosis of a relevant pancreaticobiliary anomaly stress the necessity of an operative management performing a bypass of the Sphincter Oddi and of the site of the anomaly. Local operative revision alone seems to be associated with a frequent relapse of cholestasis.

[The value of ultrasound diagnosis in blunt abdominal and thoracic injuries]

In a prospective study, real-time ultrasonography was applied as the initial imaging procedure in 103 consecutive patients with blunt abdominal or thoracic trauma. Additional peritoneal lavage was not performed. Pathological findings were present in 22 patients (21%). Sensitivity of the examination was 95.5%, with two false positive results, specificity was 97.5% with one false negative result. Lesions of intraabdominal or thoracic organs were demonstrated directly by ultrasonography in 14 patients. In the remaining patients free fluid was discovered in the abdominal cavity. Splenic and hepatic lesions occurred most frequently followed by hematothorax. Ultrasonography can be recommended as the initial imaging procedure, giving a high amount of information in the primary diagnosis of blunt abdominal thoracic trauma.

[A new Y-endoprosthesis for drainage of bile duct obstruction of the hepatic bifurcation]

Biliary decompression in cases of central tumorous biliary obstruction requires surgical or internal/external catheter bypass techniques. The development of a 14-F Y-shaped-polyurethane endoprosthesis stent provides the possibility to drain the left and right biliary system simultaneously. The endoprosthesis is placed by a combination of external transhepatic and endoscopic approach. The tip of the singular choledochal stent segment is placed within the choledochus or duodenum.

Endoscopic percutaneous cecostomy (EPC)

Endoscopic decompression of the distended colon has become a useful method of treating non-obstructive colonic ileus. We propose a method of establishing a cecal fistula by means of percutaneous puncture of the colon and pull-through of a Pezzer catheter. Although until now we have only performed this procedure twice, it seems to be a valuable therapeutic approach in cases of paralytic distension of the large bowel.

[Percutaneous transhepatic cholangioscopy. A new method for the diagnosis of bile duct malignancies]

Percutaneous transhepatic cholangioscopy combines the advantages of endoscopic and radiological examinations. It makes it possible to assess the intraluminal spread of bile duct disease as well as histological and cytological examination of biopsies obtained under vision. Eight PTCs were performed without complication in seven patients with cancer of the bile duct. In four, the histology and extent of the tumour was defined endoscopically before any surgical intervention. In three others the results of treatment were objectified. A flexible choledochoscope, as used intraoperatively, was employed (CHF-P10). A stepwise dilatation of the percutaneous access-route was undertaken in several sessions in order to avoid bleeding complications. The procedure is done without general anaesthesia.

[Percutaneous transhepatic cholangioscopy. A new approach to the diagnosis of bile duct tumors]

New surgical and radiotherapeutic regimens for the treatment of carcinoma of the bile ducts require histologic diagnosis as well as diagnostic delineation of the tumor. Percutaneous transhepatic cholangioscopy fulfils these requirements. This technique combines the advantages of radiological and endoscopic diagnostic procedures in the biliary tract. Cholangioscopy has been performed successfully in four patients with malignant tumors of the bile ducts and we did not observe any complications.