Percutaneous transhepatic cholangiography using the "Chiba" needle--80 cases

2-Deoxy-d-glucose Inhibits Rejoining of Radiation-induced DNA Double-strand Breaks in Yeast

Effects of 2-deoxy-D-glucose (2-DG) on radiation-induced DNA double-strand breaks (dsb) have been studied under non-growth conditions in a respiratory-deficient strain of the yeast Saccharomyces cerevisiae. Velocity sedimentation in neutral sucrose gradients was used to measure DNA dsb. Addition of 2-DG to the liquid-holding medium (67 mM phosphate buffer, pH 5, 30 degrees C) at an equimolar concentration with glucose (50 mM) reduced the rate and extent of dsb rejoining. The inhibition of rejoining mediated by 2-DG is reversible for the majority--but not all--of the radiation-induced dsb.

Radiosensitization by 6-aminonicotinamide and 2-deoxy-D-glucose in human cancer cells

The aim was to exploit simultaneous inhibition of glycolytic and pentose phosphate pathways of energy production for radiosensitization using 2-deoxy-D-glucose (2-DG) and 6-aminonicotinamide (6-AN) in transformed mammalian cells. Two human tumour cell lines (cerebral glioma, BMG-1 and squamous carcinoma cells 4197) were investigated. 2-DG and/or 6-AN added at the time of irradiation were present for 4 h after radiation. Radiation-induced cell death (macrocolony assay), cytogenetic damage (micronuclei formation), cell cycle delay (bromodeoxyuridne (BrdU) pulse chase), apoptosis (externalization of phosphotidylserine (PS) by annexin V), chromatin-bound proliferation cell nuclear antigen (PCNA) and cellular glutathione (GSH) levels were investigated as parameters of radiation response. The presence of 2-DG (5 mM) during and for 4 h after irradiation increased the radiation-induced micronuclei formation and cell death, and caused a time-dependent decrease in GSH levels in BMG-1 cells while no significant effects could be observed in 4197 cells. 6-AN (5 microM) enhanced the radiosensitivity of both cell lines and reduced the GSH content by nearly 50% in gamma-irradiated 4197 cells. Combining 2-DG and 6-AN caused a profound decrease in the GSH content and enhanced the radiation damage in both the cell lines by increasing mitotic and apoptotic cell death. Further, the combination (2-DG + 6-AN) enhanced the radiation-induced G2 block, besides arresting cells in S phase and inhibited the recruitment of PCNA. The combination of 2-DG and 6-AN enhances radiation damage by modifying damage response pathways and has the potential for improving radiotherapy of cancer.

Cost-effectiveness analysis of alternative strategies for palliation of distal biliary obstruction after a failed cannulation attempt

OBJECTIVES

Occasionally alternative techniques such as precut sphincterotomy or percutaneous transhepatic cholangiography (PTC) are required to achieve access to the common bile duct. Tradeoffs exist, however, with respect to their complications and costs. Some experts believe that precut sphincterotomy should not be performed at all. We aimed to compare the cost-effectivenesses of metallic biliary stent placement after an initial failed cannulation attempt at ERCP utilizing precut sphincterotomy and placement utilizing PTC for palliation of jaundice. A cost-effectiveness analysis was performed, as viewed from the societal perspective.

METHODS

A decision analysis model was designed comparing precut sphincterotomy and PTC approaches for placement of a metallic biliary stent for palliation of jaundice in a patient with inoperable malignant distal biliary obstruction in whom an initial attempt at ERCP cannulation had failed. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. The outcome measured was cost per year of life.

RESULTS

Sensitivity analysis showed that precut sphincterotomy with subsequent PTC, if necessary, was the most cost-effective strategy provided the precut complication rate was <51% ($9,033/yr), versus $14,741/yr for PTC.

CONCLUSIONS

Precut sphincterotomy followed by PTC (if necessary) is the most cost-effective strategy for palliative biliary stenting in the setting of malignant distal biliary obstruction after a failed ERCP attempt. The endoscopic approach is best practiced by experienced endoscopists who minimize precut complication rates.

Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction

OBJECTIVE

Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs.

METHODS

A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively.

RESULTS

MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach.

CONCLUSIONS

The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.

Alterations in phosphate metabolism during cellular recovery of radiation damage in yeast

We have examined alterations in phosphate pools during cellular recovery from radiation damage in intact, wild-type diploid yeast cells using 31P nuclear magnetic resonance (NMR) spectroscopy. Concurrent cell survival analysis was determined following exposure to 60Co gamma-radiation. Cells held in citrate-buffered saline (CBS) showed increased survival with increasing time after irradiation (liquid holding recovery, LHR) with no further recovery beyond 48 h. Addition of 100 mmol dm-3 glucose to the recovery medium resulted in greater recovery. In the presence of 5 mmol dm-3 2-deoxyglucose (2-DG), LHR was completely inhibited. NMR analyses were done on cells perfused in agarose threads and maintained under conditions similar to those in the survival studies. ATP was observable by NMR only when glucose was present in the recovery medium. In control cells, ATP concentrations increased and plateaued with increasing recovery time. With increasing radiation dose the increase in ATP was of lesser magnitude, and after 2000 Gy no increase was observed. These observations suggest that either the production of ATP in irradiated cells is suppressed or there is enhanced ATP utilization for repair of radiation damage. In CBS with 100 mmol dm-3 glucose, a dose-dependent decrease in polyphosphate (polyP) was detectable with no concurrent increase in inorganic phosphate (Pi). In the absence of an external energy source, such as glucose, there was a slight increase in Pi. This suggests that polyP may be used as an alternative energy supply. When 2-DG was present in the recovery medium, polyP decreased, but there was a simultaneous increase in Pi with increasing radiation dose and recovery time. This suggests that the polyP are hydrolyzed as a source of phosphates for repair of radiation damage.

Primary sclerosing cholangitis: a heterogenous disease

The clinical, radiologic and pathologic features of 37 patients diagnosed as having primary sclerosing cholangitis (PSC) were reviewed. Sixty-two per cent were men, and 35% had ulcerative colitis. The patients demonstrated considerable variability in their natural history and pathology. It appeared that they could be divided into four fairly distant groups (1) sclerosing cholangitis affecting primarily the distal common bile duct; (2) sclerosing cholangitis occurring soon after an attack of acute necrotizing cholangitis; (3) chronic diffuse sclerosing cholangitis; and (4) chronic diffuse sclerosing cholangitis associated with inflammatory bowel disease. It is suggested that the patients in these groups may have different etiologies, may respond to different treatment regimes, and may have different prognoses.

Relations between effectiveness of a diagnostic test, prevalence of the disease, and percentages of uninterpretable results. An example in the diagnosis of jaundice

The relations between effectiveness, the percentages of uninterpretable results of a test, and the prevalence of the disease are studied in the example of the diagnosis of jaundice. Ten hepatologists and ten hepatobiliary surgeons were interviewed, and nineteen articles were reviewed. Accuracies of ultrasonography, endoscopic retrograde cholangiography, and transhepatic cholangiography, as well as of three strategies combining these tests, were ranked by hepatologists in an order that differed from chance, and by surgeons in an order that did not differ from chance. Analyses of published data, taking into account the percentages of uninterpretable results, showed that for a high prevalence of extrahepatic cholestasis, as in jaundiced patients seen by surgeons, there is no significant difference between the respective effectiveness of each test or strategy. We concluded that effectiveness must take into account the percentages of uninterpretable results and must be expressed as a function of prevalence.

Endoscopic retrograde cholangiograms of the normal and post-cholecystectomy biliary tree

The diameter of extrahepatic and intrahepatic bile ducts was measured on 50 normal retrograde cholangiograms and on the cholangiograms of 109 post-cholecystectomy patients undergoing endoscopic retrograde cholangiopancreatography: 70 of the post-cholecystectomy patients had a normal cholangiogram and 39 had retained stone or biliary stricture, of whom 17 were jaundiced. Biliary diameter at all points measured was greater in the post-cholecystectomy patients with no biliary lesion than in normals, and further increased in the presence of pathology (e.g. retained stone). The extent of overlap in biliary diameter between all these three groups is so great that measurement of bile duct calibre cannot separate patients with retained stone from post-cholecystectomy patients without retained stone, or from patients with an entirely normal biliary tree, even in the presence of obstructive jaundice. Methods of evaluating the biliary tract which rely on the measurement of bile duct diameter (e.g. ultrasound) are therefore of limited value in the investigation of post-cholecystectomy patients.

Ultrasound in the differential diagnosis of jaundice

Ultrasound examination was performed in 53 jaundiced patients; successful examination was accomplished in 48. Ultrasonography revealed mechanical biliary obstruction in 34 of 35 patients with obstructive jaundice. Dilatation of the intrahepatic or extrahepatic biliary ducts or the gallbladder was not present in any patient with non-obstructive jaundice. The value of ultrasound examination in the differential diagnosis of jaundice is emphasized.

Complications of percutaneous transhepatic catheterization of the portal vein and its tributaries

The complications of percutaneous transhepatic catheterization of the portal vein and its tributaries were assessed in 406 patients in whom 440 examinations had been performed and 8 unsuccessful attempts. Clinically relevant complications consisting of abdominal or external hemorrhage occurred in 24 cases with fatal outcome in 3. Complications involving the right pleural space occurred in 13 patients: collection of ascitic fluid in 6, bile effusion in 5 and bleeding in 2. Laparotomy was needed in 7 cases due to intraabdominal hemorrhage. The gallbladder was unintentionally punctured in 4 cases. Furthermore, a variety of minor complications of little clinical significance, such as extravasation of contrast medium, subintimal injection of contrast medium and minor intrahepatic hematomas, were observed.

Analysis of the signs of common bile duct obstruction at percutaneous transhepatic cholangiography

The radiological signs of common bile duct obstruction have been analysed in a series of 146 Chiba needle percutaneous cholangiograms. The upward pointing convexity was the most reliable sign, indicating impacted stones in all cases. The least reliable sign was the biconcave caudal cut-off. An inter-observer variation study of the signs indicated that a knowledge of the clinical history did not improve the diagnostic accuracy of film reading.

Determinants of adverse reaction following postoperative T-tube cholangiogram

The incidence, nature, and mechanisms of adverse reaction following postoperative T-tube cholangiogram have received little attention in the medical literature. This paper presents the experience at one hospital over a 30-month period (1975--1977) covering 139 patients who had 170 cholangiograms. Factors examined included intraoperative and postoperative cultures of bile, the use of antibiotics prior to the performance of the cholangiogram, the technique of cholangiography, the interval between operation and cholangiogram. Eleven (6.5%) cholangiograms were followed by an adverse reaction. Two of these reactions were severe, manifested by signs of septic shock. The administration of antibiotics was not associated with a reduction in adverse reactions. The cholangiographic technique of gravity infusion of dye, which effectively limits the amount of pressure generated during the study, was associated with a significant reduction in adverse reactions. No severe reactions occurred following any study performed by the gravity technique. There was no significant correlation between the age of the patient or the number of days postoperative with adverse reaction. A review of the literature suggests that the mechanism for these severe reactions is cholangiovenous reflux. The avoidance of high intraductal pressures (above 25 cm of water) during the performance of postoperative T-tube cholangiogram should significantly reduce the incidence of adverse reactions.

Ultrasound tomography of the liver: Non-invasive method of choice for the differential diagnosis of jaundice

Grey-scale ultrasound tomography was used to examine the liver and biliary tree of 100 consecutive unselected jaundiced patients in a prospective study. It was successful in differentiating between hepato-cellular and obstructive jaundice in 94%. It precisely localised the site of obstruction in 75% of those patients with enlargement of the head of the pancreas from either carcinoma or gall-stones impacted in the Ampulla of Vater. This figure was reduced to 60% when all cases of obstruction were considered. Cirrhosis and chronic active hepatitis were found to be associated with an abnormal pattern of echoes within the liver. These echoes were stronger and more numerous than normal. This association was not apparent with drug-induced cholestasis or acute viral hepatitis. Grey-scale ultrasound tomography is quick, safe and completely non-invasive. It should be the initial investigation of choice in the differential diagnosis of jaundice. When precise localisation of an obstruction is not possible after a repeat attempt, then percutaneous transhepatic cholangiography should be considered.

Hepatobiliary imaging: the use of 99Tcm-pyridoxylidene glutamate scanning in jaundiced adults and infants

99Tcm-pyridoxylidene glutamate (99Tcm-PG) scans have been carried out in 24 jaundiced adults (mean total bilirubin 255 mumol/l and 11 infants with prolonged obstructive jaundice (mean total bilirubin 165 mumol/l). Absence of radioactivity in the gut was interpreted as complete biliary obstruction which was the cause of jaundice in ten adults and six infants. Using this criterion occlusion or patency of the bile ducts was correctly determined in 21 adults and eight infants. False-negative gut images were found in one adult and two infants, and three scans were inconclusive (two adults, one infant). The scan was unable to show details of the site of obstruction or pathology but the technique was simple and atraumatic and was safely performed in patients with serious complications, e.g. renal failure, coagulation defects, septicaemia. In infants the 99Tcm-PG scan compared well with the 131I rose bengal faecal excretion test and with liver biopsy in the investigation of prolonged obstructive jaundice. Repeat scans in infants with biliary atresia were used to assess postoperative bile drainage. It is suggested that 99Tcm-PG scanning is useful screening test in difficult cases of jaundice. It is especially useful in frail patients, and patients with complications.

The early use of fine-needle percutaneous transhepatic cholangiography in an approach to the diagnosis of jaundice in a surgical unit

Fine-needle percutaneous transhepatic cholangiography (PTC) was performed in a series of 46 patients with jaundice or suspected biliary tract disease. The ductal system was successfully outlined in each of 20 patients with dilated intrahepatic ducts and in 19 of 26 patients with intrahepatic ducts of normal calibre. There were two episodes of septicaemia after PTC, one of them fatal. Valuable accurate diagnostic information was obtained in all cases with biliary tract obstruction. A programmed approach to diagnosis of suspected obstructive jaundice is outlined. Fine-needle PTC is an acceptably safe procedure and need not be followed by immediate laparotomy.

Percutaneous transhepatic cholangiography with the Chiba Needle

Percutaneous transhepatic cholangiography using the Chiba needle has been performed on 102 patients. There was an overall success rate of 86 out of 102 cases (84%). Dilated bile ducts were successfully demonstrated in 61 out of 65 patients (94%) and non-dilated ducts in 25 out of 37 patients (70%). Gallbladder filling was achieved in 40 out of 70 cases (67%). The hepatic lymphatics were filled in 32 cases but dilated lymphatics were mainly seen in patients with biliary cirrhosis, inflammatory liver disease or lymphoma. It is suggested that an excessive radiation dose may be given to the radiologist's fingers unless the fluoroscopy diaphrams are kept well coned down. Complications requiring active medical intervention occurred in three cases and emergency surgery in one case.

Diagnosis and management of post-cholecystectomy symptoms: the place of endoscopy and retrograde choledochopancreatography

Endoscopic retrograde choledochopancreatography (ERCP) was employed in 52 patients symptomatic after cholecystectomy in whom barium meal studies and intravenous cholangiography had failed to yield a diagnosis. Cannulation of the papilla of Vater was carried out in 50 of the patients in a mean time of 10 min. Diagnostic information demonstrating a pathological lesion or a normal biliary and pancreatic ductal system was obtained by means of endoscopy and ERCP in 48 cases. There were no serious complications. A pathological lesion was demonstrated in all but one of the patients presenting with jaundice, cholangitis or pancreatitis but the diagnostic yield was not as high in patients with vague upper abdominal symptoms. Endoscopy and ERCP are the investigative procedures of first choice in complex post-cholecystectomy cases in whom intravenous cholangiography fails, gives incomplete information or suggests normality in the face of continuing symptoms or clinical evidence of residual biliary disease.