Management of common bile duct stones: controversies and future perspectives

BACKGROUND: The advent of endoscopic and minimally invasive techniques for diagnosis and treatment has revolutionised the management of bile duct stones. Yet several controversies still surround the optimal means of investigation and treatment. DISCUSSION: Scoring systems that classify patients according to their risk of harbouring bile duct stones are likely to decrease the number of unnecessary preoperative endoscopic cholangiopancreatograms (ERCPs) at the expense of a higher rate of positive intra-operative diagnosis, unless magnetic resonance cholangiopancreatography (MRCP) is used to supplement the clinical information. The current treatment that is generally preferred for patients with a high probability of bile duct stones is ERCP followed by laparoscopic cholecystectomy (LC), but the routine use of ERCP in this context has certain limitations. An alternative approach is offered by carrying out the necessary cholangiogram during LC. Laparoscopic choledochotomy requires technical skill and costly equipment and should usually be followed by T-tube drainage of the duct. A recent survey in Spain has shown that most surgeons prefer ERCP plus LC, but one recent randomised controlled trial showed advantages for the single-stage laparoscopic treatment of bile duct stones in terms of a shorter hospital stay; success rates and complication rates were similar for the two procedures. The authors support the consensus statement that the choice of diagnostic and therapeutic strategy should depend on local circumstances and available expertise.     

Hydatid disease of the interventricular septum causing pulmonary dissemination

Pulmonary dissemination of a cardiac cyst is a rare condition. In the present study, we report a case of a 20-year-old patient with cardiac hydatosis located in the interventricular septum, which was previously diagnosed and treated as pulmonary hydatid disease. Diagnosis was made by spiral computed tomography and treated surgically with median sternotomy and cardiopulmonary bypass. Diagnosis and proper surgical excision of the cardiac hydatid cyst prevented potentially lethal complications such as cyst rupture with recurrent pulmonary dissemination and anaphylaxis.     

Patients with myelodysplastic syndromes benefit from palliative therapy with amifostine, pentoxifylline, and ciprofloxacin with or without dexamethasone

Thirty-five patients with myelodysplastic syndrome (MDS) were registered on protocol MDS 96-02 and were receiving continuous therapy with pentoxifylline 800 mg 3 times a day and ciprofloxacin 500 mg twice a day by mouth; dexamethasone was added to the regimen for the partial responders and the nonresponders after 12 weeks at a dose of 4 mg by mouth every morning for 4 weeks. Amifostine was administered intravenously 3 times a week at 3 dose levels (200 mg/M(2), 300 mg/M(2), and 400 mg/M(2)) to cohorts of 10 patients each. Therapy has been continued for 1 year in responders. Twenty-nine have completed at least 12 weeks of therapy and are available for response evaluation. Of the 21 men and 8 women (median age, 67 years), 20 had refractory anemia (RA), 3 had RA with ringed sideroblasts (RARS), 5 had RA with excess blasts (RAEB), and 1 had chronic myelomonocytic leukemia (CMMoL). Five had secondary MDS. No differences were noted in response rates among the 3 dose levels. Seven patients did not respond at all, and 22 showed an improvement in cytopenias (76%). Three had a triple lineage response, 10 had a double lineage response, and 9 had a single lineage response (8 of 9 in absolute neutrophil count [ANC] and 1 had more than a 50% reduction in packed red blood cell transfusions). Fifteen patients responded only after the addition of dexamethasone, whereas 7 responded before. When examined by lineage, 19 of 22 showed improved ANC, 11 of 22 demonstrated more than 50% reduction in blood transfusions, improved Hb levels, or both, and 7 of 22 showed improvement in platelet counts. Interestingly, the responses were frequently slow to appear, and continued improvement in counts was seen up to 12 months of therapy and beyond. This study supports the feasibility of treating patients with MDS with the unique approach of cytoprotection and anticytokine therapies as well as the principle that prolonged commitment to treatment is desirable when noncytotoxic agents are administered. (Blood. 2000;95:1580-1587)     

Bimatoprost: Mechanism of Ocular Surface Hyperemia Associated with Topical Therapy

Bimatoprost is a safe and well‐tolerated intraocular pressure (IOP) lowering drug that was approved in the United States in 2001 for the treatment of glaucoma and ocular hypertension. It is highly efficacious and produces greater mean reductions in IOP than other currently available antiglaucoma drugs. Conjunctival hyperemia is a common side effect of bimatoprost, but the hyperemia is typically mild and transient. No association has been found between signs of inflammation and the presence of hyperemia in bimatoprost‐treated patients. Preclinical studies have elucidated the pharmacological mechanism of bimatoprost‐related hyperemia and have examined the possible involvement of inflammation. Bimatoprost, as well as the free acid of latanoprost, elicited endothelium‐de‐pendent vasorelaxation in the rabbit jugular vein preparation, a quantitative in vitro model for ocular surface hyperemia (OSH). The vasorelaxant responses to either bimatoprost or latanoprost free acid were significantly inhibited by L‐NAME, a nitric oxide synthase inhibitor. Similarly, the in vivo OSH responses to topically applied bimatoprost or latanoprost in dog eyes were significantly inhibited by L‐NAME. As predicted, prostaglandin E₂ (PGE₂)‐induced conjunctival hyperemia was not inhibited by L‐NAME, since PGE₂ has a direct relaxant effect on the vascular smooth muscle. In‐life observations and histopatho‐logical assessment of ocular surface tissues following bimatoprost treatment were performed for multiple‐dose one month, 6 month, or 12 month safety studies in rabbits, dogs, and non‐human primates. Results of these studies showed no evidence of bimatoprost‐re‐lated inflammation in the ocular surface tissues. In summary, OSH related to bimatoprost treatment in laboratory animals occurs by endothelial‐derived nitric oxide‐mediated vasodilatation and is not associated with inflammation. These studies suggest that conjunctival hyperemia, a side effect of bimatoprost treatment, results from non‐inflammatory, pharmacologically based vasodilatation.     

Predominace of a novel Mycobacterium tuberculosis genotype in the Delhi region of India

Using IS 6110 -restriction fragment length polymorphism (RFLP) and spoligotyping, genetic variations of 83 Mycobacterium tuberculosis strains isolated from tuberculosis patients from two wards in a hospital in Delhi and a rural chest clinic near Delhi were analysed. The vast majority of the isolates (75%) were closely related and this novel genogroup was designated the 'Delhi type'. Both drug-sensitive and drug-resistant strains were found among strains of this genogroup. A minority of the strains harboured a single IS 6110 copy and only one strain belonged to the Beijing genotype, a genotype that is predominant in other parts of Asia. A comparison of the RFLP and spoligotype with existing data suggests that the predominance of Delhi genogroup is geographically limited to the Indian subcontinent and perhaps to specific regions in India. Despite the high prevalence of the M. tuberculosis strains of the Delhi type, the strains could easily be discriminated due to polymorphisms in the IS 6110 patterns. Future studies may disclose the genetic characteristics of strains belonging to the Delhi genotype, analogous to the recently observed virulence among the Beijing genogroup.     

Evaluation of an Active Humidification System for Inspired Gas

ObjectivesThe effectiveness of the active humidification systems (AHS) in patients already weaned from mechanical ventilation and with an artificial airway has not been very well described. The objective of this study was to evaluate the performance of an AHS in chronically tracheostomized and spontaneously breathing patients.MethodsMeasurements were quantified at three levels of temperature (T°) of the AHS: level I, low; level II, middle; and level III, high and at different flow levels (20 to 60 L/minute). Statistical analysis of repeated measurements was performed using analysis of variance and significance was set at a P<0.05.ResultsWhile the lowest temperature setting (level I) did not condition gas to the minimum recommended values for any of the flows that were used, the medium temperature setting (level II) only conditioned gas with flows of 20 and 30 L/minute. Finally, at the highest temperature setting (level III), every flow reached the minimum absolute humidity (AH) recommended of 30 mg/L.ConclusionAccording to our results, to obtain appropiate relative humidity, AH and T° of gas one should have a device that maintains water T° at least at 53℃ for flows between 20 and 30 L/m, or at T° of 61℃ at any flow rate.     

Ultrasonography,laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation

The aim of this study is to correlate the US, laboratory, and cholangiography findings in pediatric liver transplant patients with biliary complications, trying to identify reliable decision‐making tools for the management of these complications. Retrospective review was carried out of US results in 39 consecutive patients, from 2011 to 2013, with biliary complications after LT, documented by PTC. According to US biliary dilation, patients were classified as: mild, moderate, and severe, and according to laboratory findings as: normal or abnormal serum bilirubin and level of serum GGT. Data were correlated with PTC findings, divided in three groups: mild, moderate, and severe/occlusive BDS. There was no statistically significant correlation between the US findings and the laboratory findings and between US findings with PTC. There was a statistically significant correlation between GGT and cholangiography. In our series, abnormal US could not predict the severity of BDS on PTC. Bilirubin results were not able to predict the US findings either. GGT results demonstrated a statistically significant correlation with the severity of BDS found on PTC. These findings emphasize the role of GGT in the evaluation and decision of biliary interventions in pediatric liver transplant recipients.     

Pulmonary function profile in chronic congestive heart failure and the effect of ipratropium bromide

Twenty-five symptomatic patients of chronic heart failure were subjected to spirometry to detect abnormalities of pulmonary function and to assess the effect of ipratropium bromide in reversing or minimising these abnormalities. All the patients exhibited abnormal pulmonary function manifesting as obstructive (15/25) or restrictive (10/25) ventilatory defect. There was overall improvement in lung functions with ipratropium bromide especially in those with obstructive ventilatory defects and mostly comprised of smokers. Forced expiratory volume in one second increased by 47.7 percent (p < 0.02), forced expiratory volume in one second/forced vital capacity ratio by 14.1 percent (p < 0.001) and maximal voluntary ventilation by 40.6 percent (p < 0.05) in these patients. It is concluded that ipratropium bromide can prove as a promising adjunctive therapeutic intervention in improving quality of life in patients of chronic congestive heart failure who are incapacitated by dyspnoea and have clearly documented ventilatory defects.