Johan S. Laméris

The role of radiotherapy in the treatment of bile duct carcinoma

Forty-two patients with irresectable bile duct carcinoma (n = 31) or with microscopic evidence of tumor rest after aggressive surgery for bile duct carcinoma (n = 11) were given radiotherapy consisting intentionally of external-beam therapy and intraluminal 192Iridium (192Ir) wire application(s) following bile drainage procedures. The treatment was well tolerated; complications were mainly infectious and related to the success of the drainage. A median survival of 10 months was achieved for the group as a whole. Patients treated following microscopically incomplete resection survived longer than patients with an irresectable tumor (15 vs 8 months median survival, p = 0.06). Gross lymph node involvement also proved to be a prognostic factor.

Percutaneous metallic self-expandable endoprostheses in malignant hilar biliary obstruction

Forty-five patients with malignant hilar obstruction were treated with a total of 68 percutaneously inserted metallic self-expandable endoprostheses (Wallstents) for palliative biliary drainage. The stent diameter was 1 cm; the length was 3.5 to 10.5 cm. Early complications occurred in seven patients (16%), including cholangitis in four patients (9%). The 30-day mortality rate was 9%, with two procedure-related deaths (4%). Of the 45 patients, 29 died between 10 and 550 days (median, 126 days) after stent insertion. Reobstruction occurred in 13 of these patients after 26 to 184 days (median, 105 days). Sixteen patients were alive 44 to 737 days (median, 305 days) after stent insertion. Reobstruction occurred in four patients after 142 to 279 days (median, 246 days). The cause of reobstruction was proximal overgrowth in seven patients; distal overgrowth in four patients; and tumor ingrowth and proximal overgrowth, tumor ingrowth, hemobilia, and angling of the stent in one patient each. The cause of reobstruction was not established in two patients. Reintervention was performed in 14 patients (31%). Because reobstruction of Wallstent endoprostheses is primarily not stent-related but rather is caused by tumor progression, and because insertion and reintervention is easier, we consider the use of the Wallstent in malignant hilar biliary obstruction advantageous in comparison with plastic stents.

Hickman Catheter–Related Infections in Neutropenic Patients: Insertion in the Operating Theater Versus Insertion in the Radiology Suite

PURPOSE To determine the influence of microbial air quality during Hickman catheter insertion in the operating theater versus insertion in the radiology suite on the incidence of catheter-related infections (CRIs). PATIENTS AND METHODS Hemato-oncologic patients with prolonged neutropenia on antimicrobial prophylaxis were entered onto the study. Catheters were inserted by experienced radiologists under sonographic and fluoroscopic guidance. RESULTS Forty-eight Hickman catheters in 39 patients were inserted (23 in the operating theater, 25 in the radiology suite). CRIs were seen in 16 catheters (33%; six per 1,000 catheter days; eight in each group). Local infections were found in nine catheters (22%; six in the operating theater v three in the radiology suite; not significant [NS]), catheter-related bacteremia was found in 10 (29%; three in the operating theater v seven in the radiology suite; NS). Coagulase-negative staphylococci (CoNS) caused all CRIs. Despite early vancomycin therapy, 11 (69%; four in the operating room group v seven in the radiology suite group; NS) of the catheters with CRIs had to be removed prematurely. At 90 days after insertion, catheter survival was 78% and 60% (NS) for the operating room and radiology suite, respectively. Multivariate analysis showed that neutropenia increased the CRI risk 20-fold (P =.004) and was strongly related to premature catheter removal owing to infection (relative risk = 11.9; P =.009). Neutropenia on the day of insertion was also significantly correlated with CRI (P =.04) and premature catheter removal owing to infection (P =.03). Serial cultures of blood, exit site, and catheter hub did not predict the development of CRI. CONCLUSION The high incidence of Hickman CRI caused by CoNS was not associated with insertion location (operating theater v radiology suite). Neutropenia, including neutropenia on the day of insertion, was a significant risk factor for CRI and infection-related catheter removal.

Measurement of sacroiliac joint stiffness in peripartum pelvic pain patients with Doppler imaging of vibrations (DIV)

OBJECTIVES The research question of the present study was: are sacroiliac joint stiffness levels of peripartum pelvic pain patients different from those of healthy subjects? STUDY DESIGN A cross-sectional comparative sacroiliac joint stiffness analysis of peripartum pelvic pain patients with healthy subjects. In previous studies we introduced a new technique, Doppler imaging of vibrations (DIV), to assess sacroiliac joint stiffness using colour Doppler imaging and vibrations. The measurements were performed on a group of peripartum pelvic pain patients (n=56) and on a control group (n=52). The differences in sacroiliac joint stiffness between the patient group and the control group were tested statistically by means of the Wilcoxons two sample test, the chi-square test and Students t-tests. RESULTS Both patients and controls displayed stiff as well as unstiff joints with no significant difference. There was a significant difference between the groups with regard to the relative difference of sacroiliac joint stiffness between left and right. CONCLUSIONS A diagnostic tool which can possibly be developed in the future could demonstrate an objective finding among women with peripartum pelvic pain. DIV is easy to apply and non-invasive. Asymmetric stiffness of the sacroiliac joints seems to be more directly related to low back pain and pelvic pain, not the stiffness level of a single sacroiliac joint.

The measurements of sacroiliac joint stiffness with colour Doppler imaging: a study on healthy subjects

RATIONALE AND OBJECTIVES Primary peripartum pelvic and low back pain is a common complaint of females. The etiologic relation between pain and pelvic stability has been shown in previous studies, but at present there is no objective clinical testing method to evaluate pelvic stability. METHODS In this study, a dynamic measurement method using sonoelasticity to assess the sacroiliac joint (SI) stiffness was tested in vivo in 14 healthy female volunteers. With the subjects in supine position vibrations were unilaterally applied to the anterior iliac spine. The vibrations were registered by a Colour Doppler Imaging (CDI) transducer over the ipsilateral SI joint. Since the threshold level of the apparatus has a direct relation with the power of the vibrations, the intensity of the vibrations (sonoelasticity) on the sacrum and ilium was measured indirectly in threshold units. The differences between the threshold values were accepted as the power loss of vibrations through the SI joint. One-way analysis of variance-test and T-test for paired samples were applied on the measurement results (P < 0.05). RESULTS Statistically, the results showed a satisfactory intraindividual reproducibility and inter-individual variability. There was no significant difference between the data derived from the left SI joint and right SI joint. CONCLUSIONS Based on the promising results on healthy female volunteers, this method will be specifically used in future studies on patients with peripartum pelvic pain.

Improved assessment of supraclavicular and abdominal metastases in oesophageal and gastro-oesophageal junction carcinoma with the combination of ultrasound and computed tomography

The purpose of the study was to evaluate ultrasound and computed tomography in the assessment of distant metastases, supraclavicular and abdominal, in 113 patients with carcinoma of the oesophagus and gastrooesophageal junction. Ultrasound and computed tomographic findings were compared with the cytological data in 29 patients and with the surgical data in 84 patients. In assessing distant metastases, ultrasound and computed tomography had a sensitivity of 61% and 70%, and a specificity of 93% and 85%, respectively (p = 1.0). When ultrasound and computed tomography were combined the sensitivity increased to 83% and the specificity decreased to 81%. There was no significant difference in the assessment of supraclavicular metastases (p = 0.8), coeliac metastases (p = 1.0) or liver and other non-lymphatic abdominal metastases (p = 1.0) on ultrasound or computed tomography. The results show that both ultrasound and computed tomography should be used for assessment of distant metastases and abnormalities confirmed by image-guided biopsy.

Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures.

BACKGROUND The preferred treatment for stones in the bile duct is endoscopic sphincterotomy followed by stone extraction. When this fails, percutaneous treatment is an alternative to surgery. The purpose of this study was to evaluate the success and complication rate of percutaneous treatment. METHODS Between April 1990 and April 1997, a total of 31 consecutive patients (20 men, 11 women, mean age 70.1 years) underwent percutaneous treatment of bile duct stones (average of 2.2 per patient, range 1 to 10). The percutaneous treatment was considered successful if all stones could be removed. Time and number of sessions needed for imaging, percutaneous treatment, and complications were scored. RESULTS Twenty-seven patients (87%) were free of stones after 2 to 15 sessions (mean 5.6). The median time for treatment was 16 days (3 to 299). Complications occurred in 3 of the 31 patients: one myocardial infarction during extracorporeal shockwave lithotripsy, one pancreatitis, and one bacteremia. None of these complications were life threatening. Four patients (13%) underwent surgery after failed percutaneous treatment. CONCLUSION Percutaneous treatment of bile duct stones is an alternative with a high success rate when endoscopic stone removal fails. Surgery can be avoided in nearly 90% of cases.

Non-surgical palliative treatment of patients with malignant biliary obstruction — The place of endoscopic and percutaneous drainage

Non-surgical methods to treat patients with inoperable malignant biliary obstruction are endoscopic retrograde biliary drainage and ultrasound guided percutaneous transhepatic biliary drainage. During a 2 year evaluation a total of 144 patients were admitted with malignant biliary obstruction: 93 with a mid- or distal common bile duct stenosis; 51 patients with a perihilar stenosis. Endoscopic biliary drainage was performed in 123 patients and ultrasound guided percutaneous biliary drainage in 57 patients. An effect on jaundice was seen in more patients after percutaneous biliary drainage (91%) than with endoscopic biliary drainage (70%). However with the percutaneous method only 63% of patients were drained internally. The site of the stenosis seemed to be an important factor. In patients with perihilar obstruction early complications after endoscopic biliary drainage occurred in 41% of drained patients compared with 3% procedure-related and 28% catheter-related complications with ultrasound guided drainage. A major complication of the endoscopic method in perihilar disease was cholangitis due to inadequate drainage.

THE USE OF COLOR DOPPLER IMAGING FOR THE ASSESSMENT OF SACROILIAC JOINT STIFFNESS: A STUDY ON EMBALMED HUMAN PELVISES

PURPOSE The validity and reproducibility of an instrumented dynamic examination method to measure sacroiliac (SI) joint stiffness was tested in vitro. METHODS Four embalmed human female pelvises were excitated by a pelvic vibrator. A color Doppler imaging (CDI) scanner was used to image the amplitude of vibrations at different sites of the pelvis. Vibrations were applied to the anterior superior iliac spines unilaterally and were received by CDI all over the ipsilateral SI region. Three different stability conditions were created in the SI joints: no intervention, screwed and ligaments cut. Test results were quantified by taking the minimum threshold levels of the bones. The relative difference of vibration intensity between ipsilateral ilium and sacrum at each stability condition is accepted as the stiffness level for the SI joint. RESULTS Statistics showed high reproducibility and significant differences between the stability conditions. Dynamic testing based on the use of vibrations provides visible and quantifiable intra- and inter-individual differences between SI joint stiffnesses. CONCLUSIONS This new method is objective and reproducible. Future in vivo application is promising since there are no technical and safety restrictions.

Imaging of the anorectal region.

Imaging of anorectal region has drastically changed during the last decade. Transrectal ultrasound and transrectal MRI can be used for staging the rectal tumours. Endoanal sonography can be applied for the classification of perianal fistulae and identification of anal sphincter defects in patients with faecal incontinence. Due to the limitations of endoanal sonography, endoanal MRI was introduced to assess the pathology related to the anal sphincter complex. Endoanal MRI seems superior to endoanal sonography. This paper describes the new developments of the imaging techniques and presents new insights in anatomy and pathology of the anorectum.