Steffen Fieuws

Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder

BackgroundThe probability that a patient has common bile duct stones (CBDS) is a key factor in determining diagnostic and treatment strategies. This prospective cohort study evaluated the accuracy of clinical models in predicting CBDS for patients who will undergo cholecystectomy for lithiasis.MethodsFrom October 2005 until September 2006, 335 consecutive patients with symptoms of gallstone disease underwent cholecystectomy. Statistical analysis was performed on prospective patient data obtained at the time of first presentation to the hospital. Demonstrable CBDS at the time of endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC) was considered the gold standard for the presence of CBDS.ResultsCommon bile duct stones were demonstrated in 53 patients. For 35 patients, ERCP was performed, with successful stone clearance in 24 of 30 patients who had proven CBDS. In 29 patients, IOC showed CBDS, which were managed successfully via laparoscopic common bile duct exploration, with stone extraction at the time of cholecystectomy. Prospective validation of the existing model for CBDS resulted in a predictive accuracy rate of 73%. The new model showed a predictive accuracy rate of 79%.ConclusionClinical models are inaccurate in predicting CBDS in patients with cholelithiasis. Management strategies should be based on the local availability of therapeutic expertise.

Rates of visual field loss before and after trabeculectomy.

Purpose:  To compare the rates of change in the visual field (VF) in patients with glaucoma before and after trabeculectomy.

Prospective Comparison of Hydrogel-coated Microcoils versus Fibered Platinum Microcoils in the Prophylactic Embolization of the Gastroduodenal Artery before Yttrium-90 Radioembolization

PURPOSE To prospectively assess the performance of hydrogel-coated versus fibered microcoils in the prophylactic occlusion of the gastroduodenal artery (GDA) before yttrium-90 ((90)Y) radioembolization. MATERIALS AND METHODS A total of 43 patients were randomized to receive fibered microcoils (n = 15), detachable hydrogel-coated microcoils (n = 13), or pushable hydrogel-coated microcoils (n = 15). Numbers of coils used, duration, dose-area product (DAP), contrast agent load, and coil migration were assessed. At the time of yttrium-90 ((90)Y) radioembolization, persistent GDA occlusion was analyzed. RESULTS In all patients, the embolized GDA was still completely occluded at the time of (90)Y radioembolization. Mean numbers of microcoils used per patient were 11.5 (fibered microcoils), 2.9 (detachable hydrocoils), and 5.5 (pushable hydrocoils), with all numbers significantly different (P<.0001). Mean DAPs were 16,283 mGy/cm(2)±16,545 (standard deviation) for fibered microcoils, 13,786 mGy/cm(2)±5,990 for detachable hydrocoils, and 35,757 mGy/cm(2)±74,493 for pushable hydrocoils (P = .87). Mean durations of GDA coil embolization were 20 minutes for fibered microcoils, 25 minutes for detachable hydrocoils, and 32 minutes for pushable hydrocoils (P = .0015). Mean contrast agent loads were 9 mL for fibered microcoils, 11 mL for pushable hydrocoils, and 7 mL for detachable hydrocoils (P = .13). One case of coil migration occurred with each type. CONCLUSIONS Hydrogel-coated and fibered microcoils are equally effective for prophylactic occlusion of the GDA before radioembolization. The number of coils used is higher with fibered microcoils compared with pushable and detachable hydrocoils, but the reduced number of hydrocoils comes at the cost of increased procedure duration.