Paul Janowitz

Dissolution of Gallbladder Stones with Methyl tert-Butyl Ether and Stone Recurrence (A European Survey)

Since there are now several ways to treatsymptomatic gallstone disease, one is able to selecttreatment on the basis of the patients comfort, thepracticability, effectiveness, and side effects of the technique, and the relative costs. In order toassess the present status of contact dissolution withmethyl tert-butyl ether with regard to these aspects,the present enquiry reports the data of 21 European hospitals. Eight hundred three patients wereselected for contact litholysis of cholesterolgallbladder stones using methyl tert-butyl ether.Percutaneous transhepatic puncture of the gallbladderwas performed under x-ray or ultrasound guidance. Dissolutionrate, side effects, and treatment times of 268 patientsfrom one single center were compared to those of 535patients from the other 20 centers. Two hundred sixty-four patients were followed for fiveyears to assess stone recurrence. Physicians were askedhow they assessed the expenditure of the method, thediscomfort to the patients, and the staffing situation. Patients were asked to indicate theiracceptance on an analog scale. Puncture was successfulin 761 (94.8%) patients. Prophylactic administration ofantibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludgeremained in the gallbladder. The most severecomplication was bile leakage, which led 12 (1.6%)patients to have elective cholecystectomy. Toxicinjuries due to the ether were not reported.Methodrelated lethality amounted to 0%, 30-day-lethalityto 0.4%. Stone recurrence rate was about 40% in solitarystones and about 70% in multiple stones over five years. Patients with multiple stones developedrecurrent stones almost twice as often as those withsolitary stones. The probability of stone recurrence inpatients with sludge in the gallbladder after catheter removal was not statistically significantlydifferent from those without sludge. Seventy to 90% ofthe centers found the puncture to be simple and notdistressing for patients and the relation betweenexpenditure and therapeutic success to be acceptable. Theacceptance of contact litholysis by the patients wasexcellent. Contact litholysis when applied by anexperienced team provides real advantages in thetreatment of gallstone disease. The method is technicallysimple, well accepted by the patients, and can be easilyapplied in community hospitals. Contact litholysis maybe of particular value in patients who are not suitable for anesthesia orsurgery.

Computed tomography evaluation of radiolucent gallstones in vivo

Computed tomography facilitates an in vivo classification of gallstones and can aid in the identification of calcifications that escape detection with conventional radiologic procedures. Of patients with radiolucent stones, 54.8% exhibited calcifications either in the form of discrete rims (41.9%) or at the center of the stone (12.9%). Densities of the noncalcified areas of partially calcified stones averaged 40.68±6.8 Hounsfield units (HU), which was not significantly higher than the average of 31.85±3.19 HU for noncalcified stones. Calcified regions showed significantly higher densities (240.0±28.6 HU,p< 0.001,x ± SEM). Of the identified stones, 16.1% showed densities greater than 50 HU. These were primarily bilirubin stones, which cannot yet be treated successfully with conservative therapeutic modalities.

Langzeitergebnisse der ultraschallgesteuerten Alkoholinstillation bei Patienten mit fokaler Schilddrüsenautonomie und Hyperthyreose

ZusammenfassungZiel: Ziel der vorliegenden Arbeit war es, den langfristigen Erfolg einer lokalen Instillation von Alkohol bei der Behandlung der manifesten Hyperthyreose zu untersuchen. Patienten und Methodik: In einem Zeitraum von 56 Monaten haben wir 20 Patienten (13 Frauen und sieben Männer, Durchschnittsalter 67,5±12,3 Jahre) mit einer klinisch manifesten Hyperthyreose in die Studie aufgenommen. Die durchschnittliche Knotenanzahl pro Schilddrüse lag bei den Männern bei 1,4, und bei den Frauen bei 1,2. Die Durchführung der Alkoholinstillation erfolgte unltraschallgesteuert. Die Patienten wurden durchschnittlich 763±452 Tage nachbeobachtet. Ergebnisse: Insgesamt wurden bei 57 Punktionen 264 ml Alkohol injiziert, dies ergibt im Durchschnitt 4,63 ml pro Injektionsbehandlung. Im Durchschnitt wurden 2,85±1,1 Punktionen pro Patient durchgeführt. In 24,5% der Fölle klagten die Patienten über ein Druckgefühl im Bereich der Punktionsstelle, in 21% der Fälle wurde ein Schmerzereignis während bzw. nach der Alkoholinstillation angegeben. Diese Beschwerden waren nach 48 h vollständig abgeklungen. Einmalig wurden ein subkutanes Hämatom (1,7%) und Fieber (1,7%) nach der Punktion beobachtet. Schwere Nebenwirkungen wie Dysphonie oder Blutungen waren nicht zu verzeichnen. Es konnte bei 16 Patienten (80%) nach 50±23 Tagen eine dauerhafte Euthyreose bzw. periphere Euthyreose mit peristierend supprimiertem TSH mit im Normbereich liegenden Werten für fT3 und fT4 erreicht werden. Bei vier Patienten (20%) musste zusätzlich Methimazol gegeben werden. Während derr Beobachtungszeit kam es zu einer Knotenvolumenabnahme auf 39,2% des Ausgangswertes. Eine Hormonsubstitutionstherapie war bei unseren Patienten nicht notwendig. Schlussfolgerung: Die Erfolgsrate der mit höheren Nebenwirkungen behafteten Radiojodtherapie und der Operation wird mit der Alkoholinstillation nicht erreicht. Die konkurrenzlos kostengünstige und nicht invasive Alkoholinstillation ist eine gute Alternative zu den konventionellen Therapiemodalitäten der Hyperthyreose. Dies trifft vor allem auf multimorbide Patienten zu.AbstractAim: The aim of this study was to evaluate the long-term efficacy of treatment of autonomous thyroid nodules with percutaneous ethanol injection under ultrasound guidance. Patients and Methods: In a period of 56 months, 20 patients (13 women and seven men, mean age 67.5±12.3 years) with autonomous toxic thyroid nodules were treated with percutaneous ethanol injection under ultrasound guidance. Ethanol was injected percutaneously on an outpatient basis for a mean of 2.85±1.1 injections per patient, mainly depending on the nodules size. The mean volume of injected ethanol was 4.63 ml. The median follow-up time was 763±452 days. Results: The injection was well tolerated by the patients, a mild to moderate local pain occurred in 21% of sessions. Undesirable effects were not serious and only transient and receded. Major complications like transient dysphonia and common jugular vein trombosis have not been observed. After a mean time of 50±23 days an euthyroid state with normalized basal levels of TSH, fT3 and fT4 was maintained in 16 patients (80%), while four patients (20%) did not completely respond to the treatment. In this patients a therapy with methimazole was carried out. The rate of reduction in the nodular volume was 60.8%. Conclusion: The percutaneous ethanol injection appears to be an effective harmless and low-cost alternative treatment of autonomous thyroid nodules, especially in older and multimorbid patients.

Transhepatic topical dissolution of gallbladder stones with MTBE and EDTA : results, side effects, and correlation with CT imaging

Forty-two patients with symptomatic gallstones (28 women, 14 men, mean age 49.8±13.2 years) were recruited for contact dissolution therapy. Pretreatment CT scans of the gallbladder were obtained in every patient under standard conditions. For contact dissolution treatment of heterogeneous gallstones or gallstones with attenuation values of more than 50 Hounsfield units, methyltert-butyl ether and bile acid ethylene diaminetetraacetic acid were used in alternating administration at time intervals and durations adapted to the individual tolerance of the patients. In the case of gallstones with mean attenuation values under 50 Hounsfield units, the dissolution therapy was performed with methyltert-butyl ether alone. In 12 (28.6%) patients a complete dissolution of gallbladder stones could be achieved; 11 patients (26.2%) revealed gallbladder sludge but no radiologically or sonographically visualized residual stone debris. The remaining 19 (45.2%) patients had residual gallstone debris. Shell fragments in three of five rimmed gallstones, seven of eight laminated gallstones, and all densely calcified stones were refractory to contact dissolution therapy. Dissolution rates correlated well with mean attenuation values, whereas no significant correlation was found between stone number and dissolution rates or between stone diameter and dissolution rates respectively. The mean instillation time required for stones with a mean density of more than 50 HU was 17.7±11.5 hr of bile acid ethylene diaminetetraacetic acid and 5.8±3.2 hr of methyltert-butyl ether. In the case of isodense stones, the average instillation time of methyltert-butyl ether was 12.3±4.7 hr. There was a statistically significant difference in methyltert-butyl ether instillation time between the both groups (P<0.001), but the total instillation time required for stones with a mean density of more than 50 HU was significantly longer (P<0.0001); consequently, in these patients the incidence of severe complications was higher without reaching statistical significance. Mild complications occurred in 95.2% of patients and severe complications were observed in 16.8% of cases. Posttreatment CT examinations after intravenous application of contrast media revealed gallbladder mural hyperemia followed by edematous swelling of the pericystic tissue layer in 96.3% of patients. Eight of eleven patients (72.7%) with gallbladder sludge revealed gallstone recurrence in the course of a 12-month observation period. In the successfully treated group, only one patient experienced gallstone recurrence (P=0.0066). In principle, the use of bile acid ethylene diaminetetraacetic acid dissolution medium made the dissolution of calcified or pigment stones possible, although the side effects are greater than with cholesterol stones. More effective and safer solvents for these more difficult to dissolve stones should be sought.

Computed tomography after ESWL of gallbladder calculi

Computed tomography (CT) was performed on 88 patients before and after extracorporeal shock wave lithotripsy (ESWL) of gallstones to find the effects of ESWL on the gallbladder and surrounding liver tissue. Post-ESWL scans demonstrated a thickening of the gallbladder wall in 25 (28.4%) cases. In one patient an intrahepatic bilioma beside the gallbladder was seen 3 days after ESWL treatment. Hematoma of the gallbladder wall or the adjacent liver tissue was not seen, and neither a hydrops nor biliary-induced pancreatitis was observed. The authors conclude that while some patients undergoing ESWL will show some posttreatment abnormality on CT scans, the procedure is associated with a low frequency of serious gallbladder and liver trauma.

A neural network expert system to support decisions in diagnostic mapping

An expert system module has been integrated into clinical workstations used for report generation and the storage and retrieval of diagnostic images. The expert system works in the background and supports the physicians decisions. The system has been created for ultrasound examinations of the abdomen. The knowledge-based system has been implemented for the same knowledge segment using two different methods: a rule-based approach with the AI-tool Joshua on a Symbolics machine for prototyping and knowledge debugging and a neural network approach based on back propagation. The results show that the neural network is robust and flexible for the mainly associative knowledge found in this application; it performed well in general and, specifically, on subsets of findings entered during the course of an examination. It was therefore decided to combine both components.<<ETX>>

Effect of extracorporeal shock-wave lithotripsy on gallbladder emptying in patients with solitary and multiple gallbladder stones

In a prospective study, we investigated the effect of extracorporeal shock-wave lithotripsy (ESWL) on gallbladder contractility and on fasting and residual gallbladder volume in patients with solitary and multiple gallbladder stones with stone densities<100 Hounsfield units (HU) and adequate gallbladder function. Twenty-five patients (seven males and 18 females, mean age 48.5±11.7 years) treated with ESWL were assigned to either group I, consisting of 13 patients with solitary stones<20 mm diameter, or group II, including patients with two to three stones and maximum stone diameter of 30 mm. ESWL was performed with the MPL 9000 lithotripter. Gallbladder ejection fraction was determined using the method of Dodds after a 12-hr fast and following application of a standard stimulative meal. Gallbladder volume was measured by ultrasound over 90 min at 10-min intervals before ESWL, then at 1, 30, 120, and 210 days after ESWL. At 24 hr after ESWL, residual gallbladder volume increased in group I from 7.4 ml to 13.9 ml (P=0.0567) and in group II from 6.5 ml to 20.2 ml (P=0.0076). Thereafter, residual volumes returned to pre-ESWL levels. In group II, post-ESWL fasting volumes were significantly increased over initial values at all time intervals. Correspondingly, only at 24 hr after ESWL, ejection fractions decreased from 73.1% to 64.9% in group I and from 76.5% to 62.7% in group II. No statistically significant differences in gallbladder contractility between the two groups were observed at any point of the follow-up period. ESWL exerts a no more than transient effect on gallbladder motility, regardless of stone count prior to ESWL. We postulate that changes in residual gallbladder volume and reductions in ejection fraction may be due to transitory disturbances in the gallbladder epithelium and resultant gallbladder wall edema.

Stability of Human Gallbladder Bile: Effect of Freezing

In the present study, the stability of the most essential biliary parameters of human gallbladder bile at -18 degrees C was examined over several months. In 12 patients with gallstone disease (10 female, two male; 52.1+/-13.3 years of age), bile was obtained through fine needle puncture of the gallbladder under local anesthetic. The concentrations of total lipids, cholesterol, phospholipids and bile acids, and the cholesterol saturation index and crystal appearance time were determined before and after freezing over a mean period of 4.38+/-2.9 months. Gallbladder bile obtained by fine needle puncture has proved to be of excellent quality. The total lipid concentration was unchanged before (8.30+/-4.16 g/dL) and after freezing (9.16+/-4.54 g/dL, P=0.6027). The biliary cholesterol, phospholipids and bile acid concentrations, and cholesterol saturation index showed no statistically significant differences before and after freezing. A significant difference arises in the context of subdivision of the group to the nucleation time. Before freezing, most patients had a nucleation time between five and eight days, which shortened to between one and four days after thawing (P=0.0100). The authors conclude that, with the exception of the nucleation time, human gallbladder bile can be stored at -18 degrees C for four months with stability of major lipid components.

Ein elektronisches Tutorsystem zur Aus- und Weiterbildung für die medizinische Ultraschalluntersuchung

Der Medizinstudent sowie der in der Aus- und Weiterbildung stehende Arzt sehen sich heute mit einem explosionsartigen Anwachsen des medizinischen Wissens und einer kaum zu bewaltigenden Datenflut konfrontiert. Als eine Konsequenz werden neue, effektive Methoden der Wissensvermittlung gefordert, die nicht mehr auf reinem Auswendiglernen, sondern einer Organisation des Wissens im problemspezifischen Kontext basieren (Greenes, 1989).

[Morphological changes in the gallbladder after extracorporeal shock-wave lithotripsy].

The present study reports on 51 patients with symptomatic cholecystolithiasis, who accordingly underwent extracorporeal shock-wave lithotripsy (ESWL). In all cases, computed tomography (CT) was performed prior to and after the therapeutic procedure to delineate changes in gall-bladder morphology. Slight edematous thickening of the gall-bladder wall was found in 15 patients. One patient presented a rupture of the gall-bladder with formation of a bilioma in the adjacent liver tissue. In case of calcific concrements, CT revealed a characteristic pattern of fragment distribution following shock-wave treatment, and fragments of various sizes exhibited distinct adhesion to the gall-bladder wall.