Background: Endoscopic dilation with stents has been proposed as an alternative to hepaticojejunostomy for management of postoperative biliary strictures. Good long-term results with double 10F ...plastic stent insertion for 1 year have been reported in 74% to 90% of cases. This is a review of our experience with a more aggressive approach.
Methods: The technique, short-term results, and long-term results of placement of increasing numbers of stents until complete disappearance of the biliary stricture are reported. At each exchange, the maximum possible number of stents in relation to the tightness of the stricture and diameter of the bile duct were inserted. All stents were removed at the end of treatment.
Results: The records of 45 of 55 patients with postoperative biliary strictures treated in this manner and observed consecutively were reviewed retrospectively. By intention-to-treat analysis the success rate was 89% (40/45). Early complications developed in 4 (9%) patients (3 cholangitis, 1 pancreatitis) and stent occlusion that required early exchange occurred in 8 (18%) patients. There was 1 death caused by a stroke 2 months after a stent exchange. Forty-two patients completed the protocol (mean number of stents 3.2 ± 1.3; range 1-6). Mean duration of treatment was 12.1 ± 5.3 months (range 2-24 months). Two patients died of unrelated causes during follow-up. Among the remaining 40 patients there was no recurrence of symptoms caused by relapsing biliary stricture at a mean follow-up of 48.8 months (range 2-11.3 years). One patient sustained 2 episodes of cholangitis but without stricture recurrence.
Conclusions: This more aggressive approach to endoscopic treatment with stents may improve long-term results for patients with postoperative biliary strictures. (Gastrointest Endosc 2001;54:162-8.)
The Loppio Oolitic Limestone is a lithostratigraphic unit of the Early Jurassic Trento Platform in the Southern Alps, Northern Italy, which deposited over an area of ca. 3500 km2. It appears as a ...roughly tabular or wedge-shaped sedimentary body with thickness gradually increasing from 0 to ca. 100 m toward the western platform margin. We investigated the sedimentology, petrography and bulk carbonate carbon isotope geochemistry of the Loppio Oolitic Limestone in order to shed light on its depositional setting and origin. The Loppio Oolitic Limestone is made almost exclusively of oolitic grainstone, and can be subdivided in two parts. In the lower part, ooids are poorly sorted and sedimentary structures are scarce or absent. In the upper part, sorting becomes good and sedimentary structures are common. The vertical succession of sedimentary structures and the upward increase in sorting suggest a shallowing upward trend within the oolite. A reddened surface, meteoric cements and dinosaur footprints occur at the top of the unit, testifying for a subaerial exposure which is also confirmed by carbon and oxygen stable isotopic data. In terms of sequence stratigraphy, the Loppio Oolitic Limestone represents a Highstand Systems Tract, bounded at the top by a subaerial exposure surface. Bulk carbonate stable carbon isotope curves across the Loppio Oolitic Limestone from 7 stratigraphic sections could be correlated over distances of tens of km on the whole Trento Platform. This correlation suggests that the deposition of ooids was nearly synchronous across the platform. A negative excursion of carbon isotopes with magnitude of ca. 1‰ VPDB was identified within a lime mudstone unit (“Nodular lithozone” of the Monte Zugna Formation) immediately below the Loppio Oolitic Limestone, which can be correlated to a global perturbation of the carbon cycle in the mid-Sinemurian. The flooding of a wide area of formerly peritidal carbonate platform below the wave base was interpreted as due to an ecological crisis that caused a drop of carbonate production. We suggest that the subsequent recovery of carbonate production is marked by the shallowing upward succession of the Loppio Oolitic Limestone, which quickly occupied the accommodation space formed in consequence of the crisis, thus preventing the platform drowning. The Loppio Oolitic Limestone deposited as an initially highly porous oolitic sand that was then topped by a clayey interval (base of the Rotzo Formation), giving origin to a structural and stratigraphic configuration that could be favourable for the accumulation of hydrocarbons in the subsurface. The recurrence of similar facies superpositions, formed in consequence of perturbations of the carbon cycle with documented climatic effects, is discussed with regard to the Tethysian record of Mesozoic carbonate platforms.
•A continuous oolite body formed over >3000 km2 on a Lower Jurassic Platform.•Its formation coincided with the recovery from a carbonate production crisis.•Reduced carbonate production created accommodation space for ooid deposition.•Reduced carbonate production induced high energy levels across the whole platform.•Carbonate production crises may often led to ooid spreading via these mechanisms.
The investigations of the process of heat and mass transfer in the evaporation of model liquids (distilled water, alcohol mixture, kerosene TC-1) in a vacuum chamber (VC) under parametric ultrasonic ...influence (UI) and vacuum influence (VI) on a liquid with the purpose of using the obtained results for the development of a methods for designing the evaporation system of unused liquid residues of rocket fuel remaining in the launch vehicle (LV) tanks at the end of the mission. The initial data, variable parameters, assumptions and limitations have been determined. Experimental dependences of the temperature variation of model liquids and gas in a VC under UI under conditions of reduced pressure (up to 0.065 kPa) are obtained. The masses of evaporated model fluids and the rate of evaporation are determined. A comparative analysis of the experimental data obtained for various model liquids was carried out, which showed that the evaporation rate increases with increasing amplitude of the bath bottom vibrations, with the highest evaporation rate under the same conditions for kerosene TC-1.
Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and ...training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.
Cholecystectomy is the standard treatment for acute cholecystitis while percutaneous drainage is reserved for high-risk patients. The aim of the present study was to assess the technical success rate ...and clinical efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis.
A total of 35 consecutive patients with acute cholecystitis and without residual common bile duct obstruction were retrospectively identified. Patients were stratified according to the pathogenesis and stages of acute cholecystitis, and the morphology of the cystic duct and/or its insertion in the common bile duct. Primary outcomes were technical success and early and late clinical success.
Endoscopic retrograde cholangiopancreatography (ERCP) was performed within the first 72 hours in 19 patients (54%). Technical success was achieved in 29 patients (83%); drainage was nasocholecystic in 21 of these (72%), plastic stenting in 6 (21%), and a combined method in 2 (7%). The pathogenesis and stage of acute cholecystitis, and the morphology both of the cystic duct and its insertion in the common bile duct, did not influence technical success. Clinical success was achieved in 24 cases (83%) after a median of 3 days (range 2-12). Four patients (14%) died within 3 days due to septic complications, and one accidentally removed the nasocholecystic drain after 24 hours. Late results, available in 21 patients after a median follow-up of 17 months, showed relapse of acute cholecystitis in 2 (10%) (both with stents) and of biliary pain in 2 patients (10%), both of whom had nasocholecystic drainage.
Endoscopic gallbladder drainage seems feasible and effective in resolving acute cholecystitis, but only as a temporary measure because of a 20% relapse rate in long-term follow-up. Prospective studies are necessary to identify which patients would benefit most from this endoscopic technique in the short and long term.
The current visualization of small-bowel strictures using traditional radiological methods is associated with high radiation doses and false-negative results. These methods do not always reveal ...small-bowel patency for solids. The aim is to assess the safety of the Given patency system and its ability to detect intestinal strictures in patients with strictures that are known or suspected radiologically.
The Given patency capsule is composed of lactose, remains intact in the gastrointestinal tract for 40-100 hours post ingestion, and disintegrates thereafter. A total of 34 patients with small-bowel stricture were prospectively enrolled; 30 had a previous diagnosis of Crohn's disease, three had adhesion syndrome and in one ischemic enteritis was suspected. Of the patients, 15 (44.1 %) had previously undergone surgery. Following ingestion, the capsule was monitored for integrity and transit time, using a specially designed Given scanner and also radiologically. Seventeen patients had been enrolled with the intent of using the patency capsule as a preliminary test in patients with small-bowel strictures before undergoing video capsule endoscopy.
30 patients (88.2 %) retrieved the capsule in the stool; it was intact in 20 (median transit time 22 hours), and disintegrated in 10 patients (median transit time 53 hours). Six patients complained of abdominal pain which disappeared within 24 hours. The scanner successfully indicated the presence of the capsule in 94 % of cases. Ten patients underwent video capsule endoscopy following the patency capsule examination; in all of these the video capsule passed through the small-bowel stricture.
This feasibility study has shown that the Given patency capsule is a safe, effective, and convenient tool for assessment of functional patency of the small bowel. It can indicate functional patency even in cases where traditional radiology indicates stricture.
The standard treatment for a Zenker's diverticulum is diverticulotomy, either using the endostapling approach or by surgery. Flexible endoscopic diverticulotomy has similar efficacy and is associated ...with fewer complications but this technique is still under investigation. The aim of this study was to compare the technical results and efficacy of two flexible endoscopic diverticulotomy techniques.
A total of 39 patients with a Zenker's diverticulum were treated using either cap or diverticuloscope assistance to expose the septum, which was then cut with a needle-knife and endocut currents. The severity of symptoms was graded according to their frequencies before the procedure, after 1 month, and to June 2006.
Of the 39 patients enrolled into the study, 28 patients were treated with the cap and 11 with the diverticuloscope, the two groups showing no statistical difference in baseline features. The median length of the Zenker's diverticulum was 4 cm (range 2-8 cm). The procedure time was significantly longer with the cap than with diverticuloscope assistance (P = 0.002). Complications occurred in 9/28 patients in the cap group and in none of the patients in the diverticuloscope group (P = 0.04); the perforations that occurred in five patients (18%) were managed endoscopically and conservatively. The median inpatient stay was 3 days (range 2-8 days). The clinical remission rate, evaluated using a pool of symptoms, was significantly higher after the diverticuloscope-assisted procedure compared with the cap technique (82% vs. 29%, P = 0.004). Multivariate analysis showed that the diverticuloscope-assisted technique was the only significant prognostic factor for efficacy (odds ratio 13.09, 95% CI 2.07-82.53).
The use of the soft diverticuloscope to expose and fix the septum seems to be the optimal approach in terms of increasing the safety and clinical efficacy of flexible endoscopic diverticulotomy.
Bimatoprost (Lumigan™) is a pharmacologically unique and highly efficacious ocular hypotensive agent. It appears to mimic the activity of a newly discovered family of fatty acid amides, termed
...prostamides. One biosynthetic route to the prostamides involves anandamide as the precursor. Bimatoprost pharmacology has been extensively characterized by binding and functional studies at more than 100 drug targets, which comprise a diverse variety of receptors, ion channels, and transporters. Bimatoprost exhibited no meaningful activity at receptors known to include antiglaucoma drug targets as follows: adenosine (A
1–3), adrenergic (α
1, α
2, β
1, β
2), cannabinoid (CB
1, CB
2), dopamine (D
1–5), muscarinic (M
1–5), prostanoid (DP, EP
1–4, FP, IP, TP), and serotonin (5HT
1–7). Bimatoprost does, however, exhibit potent inherent pharmacological activity in the feline iris sphincter preparation, which is prostamide-sensitive. Bimatoprost also resembles the prostamides in that it is a potent and highly efficacious ocular hypotensive agent. A single dose of bimatoprost markedly reduces intraocular pressure in dogs and laser-induced ocular hypertensive monkeys. Decreases in intraocular pressure are well maintained for at least 24 hr post-dose. Human studies have demonstrated that systemic exposure to bimatoprost is low and that accumulation does not occur. The sclera is the preferred route of accession to the eye. The high scleral permeability coefficient Papp is a likely contributing factor to the rapid onset and long-acting ocular hypotensive profile of bimatoprost.
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