Choledochoscopy? Post-exploratory fluorocholangiography? Or both?

Per-operative, post-exploratory fluorocholangiography and choledochoscopy were evaluated prospectively in 59 consecutive patients undergoing bile duct exploration for calculus disease. Fluorocholangiography showed filling defects in 13 cases and was valuable in localisation of stones, assessment of ampullary patency and visualisation of intrahepatic radicles. Choledochoscopy confirmed stones in nine cases, gave immediate confirmation of four false positive X-rays, enabled removal of five residual stones and biopsy of one benign stricture. This study suggests that fluorocholangiography should be performed routinely after duct exploration. Choledochoscopy is a useful adjunct but need only be performed in patients with abnormal X-ray findings; to confirm residual stones and aid in their removal or to permit biopsy of strictures.     

Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy

Background: This study compares laparoscopic ultrasonography to fluorocholangiography in detecting common bile duct (CBD) stones and delineating biliary anatomy.     

术中胆道造影在单纯胆囊结石术中的应用

目的 探讨经胆囊管胆道造影透视在胆囊结石胆囊切除术中的特殊价值。方法 胆囊结石胆囊切除术中常规胆道造影透视（ＦＩＯＣ）８６例,成功率１００％。结果 ＦＩＯＣ平均时间２０分钟,ＦＩＯＣ发现：胆总管结石６例,占７％,及时中转手术避免了漏诊。ＦＩＯＣ未引起胆道及胆总管损伤,术后并发胰腺炎１例,可能与ＦＩＯＣ有关。结论ＦＩＯＣ迅速,安全,显影清晰定位准确,是单纯胆囊结石胆囊切除术的重要辅助手段,值得推广应     

Clinical reliability of perioperative fluorocholangiography

The use of mobile image intensifier and television monitor permits easy performance of direct visualization of the biliary tract during surgery (fluorocholangiography). The routine use of fluorocholangiography has certain advantages over the standard technique of operative cholangiography: rapid direct visualization permits proper positioning of the instrument and the patient, thus many pitfalls can be avoided (gas, air bubbles, superposition of bone structures); multiple exposures at varying angles can be obtained if suspicious areas are seen; the intrahepatic ducts can be fully visualized; the functioning of the sphincter can be evaluated under direct vision; and direct visualization permits considerable time savings. In this study, operative cholangiography was routinely performed on 1,600 consecutive operations on the biliary tract using this technique. The reliability of operative fluorocholangiography was evaluated and compared to other published forms of operative cholangiography. The principal conclusions of the authors are as follows: the false-positive results of operative fluorocholangiography are 16.8% (57 of 339 common bile ducts explored, 57 of 1,600 cholangiographies); 22 retained stones were subsequently found in the 1,600 patients; the reliability of operative fluorocholangiography is, therefore, approximately 95%; and operative fluorocholangiography is superior to conventional cholangiography, and its routine use contributes significantly to the reduction of the rate of negative choledochal explorations and residual stones.

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Resumen La utilización del intensificador de imagen móvil con monitor de televisión permite realizar facilmente la visualización directa del tracto biliar durante la cirugía (fluorocolangiografía). El uso rutinario de la fluorocolangiografía tiene ciertas ventajas sobre las técnicas estándar de colangiografía operatoria: la visualización directa y rápida permite posicionar debidamente tanto al aparato como al paciente, con lo cual se eliminan artefactos (gas, burbujas de aire, superposición de estructuras óseas); se pueden obtener mÚltiples exposiciones en ángulos variados frente a áreas sospechosas; los canales intrahepáticos pueden ser totalmente visualizados; el funcionamiento del esfínter puede ser evaluado bajo visión directa; y la visualización directa resulta en considerable ahorro de tiempo. En el presente estudio se realizó colangiografía operatoria en el curso de 1,600 operaciones consecutivas sobre el árbol biliar utilizando esta técnica. La confiabilidad de la fluorocolangiografía operatoria fue evaluada y comparada con los resultados en publicaciones sobre otras formas de colangiografía operatoria. Las conclusiones principales de los autores son las siguientes: los resultados positivos-falsos de la fluorocolangiografía son del orden de 16.8% (57 de 339 exploraciones del colédoco, 57 de 1,600 colangiografías); 22 cálculos retenidos aparecieron más tarde en los 1,600 pacientes; la confiabilidad de la fluorocolangiografía es, por lo tanto, de aproximadamente 95%; y la fluorocolangiografía operatoria es superior a la colangiografía convencional, y su utilización rutinaria contribuye en forma significativa a la reducción de la tasa de exploraciones negativas del colédoco y de cálculos residuales.

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Résumé L'emploi de l'exploration radiologique opératoire avec amplificateur de brillance permet la visualisation directe des voies biliaires au cours de l'intervention. Elle est supérieure à la cholangiographie fluoroscopique classique car: La visualisation rapide permet de placer en bonne position l'opéré et l'instrument ce qui évite de multiples pièges: gaz, bulles d'air, superposition du squelette et des voies biliaires; l'examen sous différentes positions est possible dès lors que des images suspectes sont constatées; les canaux biliaires intrahépatiques sont visualisés. Le fonctionnement du sphincter peut Être étudié sous le contrÔle de la vue; la durée de l'exploration est réduite. Les auteurs ont employé cette méthode comme exploration de routine au cours de 1600 opérations biliaires et ont confronté les résultats obtenus à ceux des autres méthodes cholangiographiques. De cette expérience ils ont tiré les conclusions suivantes: 1) Les faux positifs de la cholangiographie fluoroscopique classique atteignent un taux de 16.8%; 2) Vingtdeux calculs de la voie biliaire principale qui seraient passés inaperÇus ont été trouvé; 3) Le taux de fiabilité de la méthode atteint par conséquent 95%; 4) L'exploration cholangiographique sous amplificateur de brillance est supérieure à la cholangiographie classique et son emploi contribue de manière significative à la diminution de nombre des explorations cholédociennes négatives et des calculs méconnus.

     

Intraoperative cholangiography during laparoscopic cholecystectomy

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intra-operative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.     

Role of radiation therapy in gastrointestinal cancer

The intradiation techniques in the last several decades has resulted in a wider application of radiation therapy to the treatment of gastrointestinal cancer. Controlled and uncontrolled clinical trials have shown benefit for preoperative and/or postoperative irradiation in carcinoma of the rectum and rectosigmoid. Endocavitary radiation techniques have been employed successfully in early, accessible rectal cancers as an alternative to abdominal perineal resection. High-dose external beam irradiation with and without concomitant chemotherapy has produced encouraging results in locally advanced, unresectable pancreatic carcinoma. Benefit for radiotherapy in locally advanced gastric carcinoma has been demonstrated as well. In carcinoma of the esophagus, radiotherapy has resulted in long-term control in selected patients and also has been employed with modest success in combination with surgery. Interstitial radiation techniques, intraoperative electron beam therapy, and fast neutrons, heavy charged particles, and other forms of high linear energy transfer radiation are being investigated and may eventually find greater application.     

Acute and long-term complications of therapeutic radiation for skull base tumors

Acute toxicity from radiation of skull base tumors typically resolves spontaneously within days to weeks after completion of therapy. Long-term complications have a latency of months to years after radiation and are usually irreversible. The need to keep the probability of chronic toxicity at an acceptable level has determined the upper limits of radiation doses for the treatment of tumors. The threat of chronic toxicity thus affects the ability to control skull base tumors with radiation. Use of conformal radiation techniques with image guidance, allowing minimization of normal tissue volume receiving significant radiation doses and close regulation of doses to specific structures, provides a low probability of long-term complications. Such conformal techniques may result in improved tumor control by allowing delivery of higher radiation doses to the tumor while maintaining an acceptable level of risk for chronic toxicity. Symptoms resulting from chronic radiation toxicity are indistinguishable from those due to tumor progression. In most cases in which radiation is used to treat tumors throughout the body, symptoms developing months after radiation are secondary to tumor recurrence and not due to toxicity from radiation. Notable exceptions are pituitary hormonal dysfunction after radiation for pituitary adenoma and cranial neuropathy after radiosurgery for vestibular schwannoma. With the recent evolution in radiosurgery techniques involving MR imaging guidance, decreased single doses in SRS, and fractionation of radiation dose in SRT, the probabilities of vestibular schwannoma progression and cranial nerve toxicity are approximately equal. Even in the case of visual field deficit after radiation therapy for a pituitary macroadenoma (for which the probability of tumor mass progression is only 5%-10%), the cause of the deficit is more likely to be progressive tumor than radiation-induced neuropathy. Consequently, diagnosis of a late-term radiation complication must be made only after verifying that the tumor has not progressed.     

Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery

Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. However, the use of biplanar fluoroscopy and other intraoperative imaging modalities is associated with the risk of significant radiation exposure in the patient, surgeon, and surgical staff. Radiation exposure in the form of ionizing radiation can lead to cellular damage via the induction of DNA lesions and the production of reactive oxygen species. These effects often result in cell death or genomic instability, leading to various radiation-associated pathologies including an increased risk of malignancy. In attempts to reduce radiation-associated health risks, radiation safety has become an important topic in the medical field. All practitioners, regardless of practice setting, can practice radiation safety techniques including shielding and distance to reduce radiation exposure. Additionally, optimization of fluoroscopic settings and techniques can be used as an effective method of radiation dose reduction. New imaging modalities and spinal navigation systems have also been developed in an effort to replace conventional fluoroscopy and reduce radiation doses. These modalities include Isocentric Three-Dimensional C-Arms, O-Arms, and intraoperative magnetic resonance imaging. While this influx of new technology has advanced radiation safety within the field of spine surgery, more work is still required to overcome specific limitations involving increased costs and inadequate training.     

Radiosurgery for pituitary tumors and craniopharyngiomas

Standard techniques of conventional radiation therapy have been used for many years to treat pituitary adenomas and craniopharyngiomas. These techniques are not always effective and carry with them morbidity in the form of damage to the normal pituitary gland, damage to the hypothalamus, the potential of damage to the visual system and to intellectual functions of the brain and a small but real risk of the development of secondary malignancies. In an effort to avoid these complications and to provide more effective adjunctive radiation therapy, techniques of stereotactic delivery of high-dose radiation to the pituitary region have been developed, known as radiosurgery. The history of the development of radiosurgery and its application to pituitary problems are recounted in this article, as are a number of the controversies that currently exist and need to be considered as these modalities of stereotactic radiosurgery are applied more frequently and to better effect in the future.     

Carcinoma of the female urethra: a review of results with radiation therapy

Low stage female urethral carcinoma is curable by radiation therapy alone and is amenable to brachytherapy techniques whereby high doses of irradiation can be delivered safely. A 60 to 80 per cent 5-year survival rate with preservation of bladder function and control can be expected with good radiotherapeutic techniques. Except for stage Tis or early stage T1 lesions of the anterior urethra that can be treated with limited surgical excision, irradiation should be considered as an alternative to more extensive surgery for low stage bulky lesions. While there has been some success with radiation therapy alone for advanced disease, the cure rate probably can be improved with a combined approach using surgery, radiation therapy and possibly chemotherapy.     

Noninvasive assessment of cutaneous alterations in mice exposed to whole body gamma irradiation using optical imaging techniques

We report the results of a study carried out to investigate the potential of optical techniques such as optical coherence tomography, Mueller matrix spectroscopy, and cross-polarization imaging for noninvasive monitoring of the ionizing radiation exposure-induced alterations in cutaneous tissue of mice. Radiation dose-dependent changes were observed in tissue microvasculature and tissue optical parameters like retardance and depolarization as early as 1 h post radiation exposure. Results suggest that these optical techniques may allow early detection of radiation dose-dependent alterations which could help in screening of population exposed to radiation.     

Conformal and stereotactic radiotherapy in hepatocellular carcinoma

Historically, Radiation Therapy (RT) has played a minor role in the treatment of hepatocellular carcinoma, especially because of toxicity related to conventional techniques. However, high radiation doses can now be given safely by means of 3D-conformal techniques and other more specialized techniques. 3D-conformal RT, in which both target definition and treatment planning are based on three-dimensional image data sets, provided good local control in several series. As an evolution of cranial radiosurgery, stereotactic body radiation therapy (SBRT) is currently being employed as a new tool for the treatment of HCC, as it offers the opportunity of achieving radioablation for tumors up to 6 cm in diameter with a minimal risk of radiation induced liver disease. SBRT is distinguished by the fact that both planning and treatment are guided by reference to a system of external stereotactic coordinates. As a consequence, SBRT may succeed in minimizing geometric treatment uncertainties, thus allowing the delivery of high doses to the target, given in a small number of fractions. In several published series of SBRT for HCC, actuarial 5-year local control rates higher than 80% have been achieved In short, radiation therapy should be considered as a useful addition to the treatment spectrum of HCC.     

Choledochoscopy and operative fluorocholangiography in the prevention of retained bile duct stones

Choledochoscopy has become a clinically accepted adjunct to choledochotomy as a result of recent advances in optics and instrumentation technology. Experience with this diagnostic modality during the past 18 years has led to the development of a compact, right-angled, rigid, rod-lens choledochoscope. Because of the excellent image quality and easy manipulation of this new instrument, choledochoscopy can be easily incorporated into routine surgical procedures on the biliary tract. Clinical results of choledochoscopy in a recent series of 120 consecutive choledochotomies are presented. The incidence of retained stones was reduced to 2%. Further advantages were: direct endoscopic removal of calculi, biopsy of biliary tumors, and immediate interpretation of questionable operative cholangiograms. Direct visual diagnosis of the problematic distal duct facilitated appropriate operative management without prolonging operating time. The procedure was carried out without increasing the complication rate beyond that of standard choledochotomy. The standard technique of operative cholangiography, using a portable x-ray machine, has many disadvantages, including extended operating time, blind exposure of the films, a high incidence of blurred or technically inadequate films, and frequent need to repeat the procedure. A technique of operative fluorocholangiography is described which uses fixed equipment that incorporates modern advances in diagnostic radiology, but is modified to suit the surgical environment. The contrast material inflow is observed by television-fluoroscopy and the exposures, using indirect radiographic techniques, are made under visual control. The advantages of this new technique are: aimed small format film technique, automatic exposure (brightness, contrast) control, serial films (6–12 instead of 3), reduction of radiation, high quality films, and a significant decrease of time required for a complete examination (5 min). The value of operative fluorocholangiography is emphasized for assessment of sphincter function and duct motility, as well as for the localization of bile duct stones.

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Résumé Au cours des 18 dernières années, les progrès de l'optique et de l'instrumentation ont permis de construire un cholédocoscope compact, rigide, à angle droit, à fibres de verre. La cholédocoscopie est devenue un complément utile de la cholédocotomie. L'image étant excellente et la manipulation facile, l'instrument peut être utilisé en routine au cours de l'opération. Nous présentons les résultats de la cholédocoscopie dans une série récente de 120 cas. La fréquence des calculs oubliés dans le cholédoque a été réduite à 2%. L'instrument présente d'autres avantages: extraction endoscopique sous vision directe des calculs, biopsie des tumeurs de l'arbre biliaire, interprétation immédiate des images douteuses de la cholangiographie peropératoire. Le diagnostic visuel des lésions du cholédoque distal facilite le traitement opératoire sans prolonger la durée de l'intervention. La technique n'augmente pas la fréquence des complications de la cholédocotomie.La technique standard de la cholangiographie peropératoire, avec un appareil de radiographie portatif, a plusieurs désavantages: allongement du temps opératoire, temps d'exposition des films mal précisé, radiographies fréquemment imparfaites et mal exposées, nécessité de répéter l'examen. Nous décrivons une technique de cholangiographie peropératoire utilisant un appareillage fixe, perfectionné et adapté à la salle d'opération. L'introduction et le passage du produit de contraste sont surveillés sous amplificateur de brillance et les clichés sont faits sous contrôle de la vue. Cette nouvelle technique permet d'utiliser des films de petit format et des films en série (6–12 au lieu de 3), elle offre un contrôle automatique de l'exposition (luminosité, contraste) et donc des clichés de haute qualité, elle réduit la dose de radiation et le temps nécessaire à l'examen (5 minutes). La cholangiographie peropératoire est un examen intéressant qui précise la fonction du sphincter, la motilité du cholédoque et la localisation des calculs.

     

Radiotherapy in the treatment of breast cancer: a personal retrospective

Allan Langlands commenced training as a radiation oncologist in 1960 and has continued to treat patients with breast cancer for over 30 years. Moved to Westmead Hospital in Sydney he played a role in the development of radiation oncology in Australia. With an extensive research record (authoring over 200 peer-reviewed papers) this article reflects the changes in breast cancer treatment which have occurred over this period. The incorporation of evidence from the clinical trials in breast cancer management, changes in radiation therapy techniques and incorporation of patient choice in treatment decisions are discussed.     

Surgical audit of patients undergoing common bile duct exploration for stone

One hundred and sixty-four patients operated on for calculus disease of the common bile duct during the period 1977-85 were followed in a special clinic; the attendance for follow-up at 1, 3, 5 and 7 years was 90, 74, 60 and 54 per cent respectively. Eleven patients died during the study period (6.7 per cent), none of the deaths being attributable to biliary tract disease. The overall incidence of retained calculus was 2.4 per cent (four patients), but no cases of retained calculi were recorded in the last 4 years of the study; in this period, with the advent of choledochoscopy and fluoroscopic cholangiography, the incidence of the supraduodenal compared with the transduodenal approach to the common bile duct increased significantly (P less than 0.001). Twenty-two of 56 patients (39 per cent) followed up for 5 years remained or became symptomatic after surgery, the majority of whom had underlying conditions unrelated to disease of the biliary or pancreatic tree. This specific follow-up clinic has been of value in the long-term audit of patients undergoing bile duct surgery for choledocholithiasis and it has verified that a change of policy from transduodenal to supraduodenal choledochotomy with preservation of the sphincter, and use of the choledochoscope and fluorocholangiography, produce better results.     

The less than whole breast radiotherapy approach

The addition of conventional whole breast irradiation (WBI) to breast conserving surgery (BCS) reduces the risk of early breast cancer recurrence and leads to a statistically and clinically significant improvement in overall survival. However, the long duration of conventional WBI regimens negatively impacts on quality of life. This has led investigators to evaluate an alternative approach of delivering radiation to a limited volume of tissue around the tumour cavity only (partial breast irradiation) and delivering a larger than standard dose of radiation with each treatment (accelerated partial breast irradiation, APBI). This approach may be achieved by a number of techniques: interstitial brachytherapy, intracavitary brachytherapy using the Mammosite device, intraoperative techniques using electrons or low-energy photons, external beam radiotherapy or permanent seed implant. This articles will review the rationale for the less that whole breast radiotherapy approach and describe the techniques by which it can be achieved and the results obtained to date. Finally, the 7 prospective randomised controlled trials of conventional WBI versus APBI which are open and currently recruiting patients will be discussed.     

CT scanography for limb length determination

The authors present an alternative to classic techniques used to measure limb length discrepancy radiographically. CT scanography seems to have advantages over currently-used Bell-Thompson roentgenography in that it uses less radiation and is of no increase in cost.     

Preoperative radiotherapy in rectal cancer: conventional fractionation

Experiences on preoperative radiation therapy with conventional fractionation for rectal cancer are reviewed. Results in terms of local control, survival and sphincter preservation are focused in resectable disease; the impact on resectability, local control and survival are analysed in unresectable disease. Randomized trials reported in the 80s, demonstrated a significant impact on local control with a pre-op dose of 34.5-40 Gy vs surgery alone. An increased risk of complications was reported because of the suboptimal treatment techniques used. No increase in operative mortality was noted and no impact on survival was reported. Recent non-randomized trials demonstrated more acceptable toxicity with appropriated treatment techniques. Doses of 45-50.4 Gy allowed an high clinical remission rate and downstaging at surgery. A longer interval between radiation therapy and surgery (4-6 weeks) influenced these results and about 75% of patients, who were declared to need an abdominoperineal resection at diagnosis, underwent conservative surgery. Retrospective studies in unresectable disease reported a resectability rate of 39.64% after 45-60 Gy of pre-op radiation therapy. Surgical resection demonstrated an impact on survival in most of these patient series. In conclusion, preoperative radiation therapy with conventional fractionation allows downstaging of initial disease with possible impact on local control, sphincter preservation in resectable disease and surgical resection in unresectable disease.     

Brachytherapy for clinically localized prostate cancer: optimal patient selection

The objective of this review is to present an overview of each modality and delineate how to best select patients who are optimal candidates for these treatment approaches. Prostate brachytherapy as a curative modality for clinically localized prostate cancer has become increasingly utilized over the past decade; 25% of all early cancers are now treated this way in the United States (1). The popularity of this treatment strategy lies in the highly conformal nature of radiation dose, low morbidity, patient convenience, and high efficacy rates. Prostate brachytherapy can be delivered by either a permanent interstitial radioactive seed implantation (low dose rate [LDR]) or a temporary interstitial insertion of iridium-192 (Ir192) afterloading catheters. The objective of both of these techniques is to deliver a high dose of radiation to the prostate gland while exposing normal surrounding tissues to minimal radiation dose. Brachytherapy techniques are ideal to achieve this goal given the close proximity of the radiation source to tumor and sharp fall off of the radiation dose cloud proximate to the source. Brachytherapy provides a powerful means of delivering dose escalation above and beyond that achievable with intensity-modulated external beam radiotherapy alone. Careful selection of appropriate patients for these therapies, however, is critical for optimizing both disease-related outcomes and treatment-related toxicity.