Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis

Background: Endoscopic sphincterotomy [EST] combined with balloon catheters and/or baskets are the routine endoscopic techniques for stone extraction in the great majority of patients. Whereas large common bile duct [CBD] stones are treated conventionally with mechanical lithotripsy, large balloon papillary dilation after endoscopic sphincterotomy [ELPBD] represents the onset of an era in large CBD stone extraction and the management of [impaction]. That is because it seems effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. Studies comparing the efficacy and safety of EPLBD with EST have reported mixed outcomes. The aim of the study to compare the success and complications rates between endoscopic papillary balloon dilation and endoscopic sphincterotomy for enlargement of papillary opening during endoscopic removal of common bile duct stones

Methods: Randomized prospective comparative study was conducted on seventy four patients with CBD stone[s], subjective to therapeutic ERCP procedures for endoscopic extraction of common CBD[s]

The enrolled patients were randomly divided into two groups according to the maneuver for dilate the papillary orifice into: Group I: Thirty one patients underwent EPLBD technique combined with balloon catheters and/or baskets for stone extraction. Group II: Forty three patients underwent EST combined with balloon catheters and/or baskets, which is considered as conventional endoscopic technique for stone extraction in the great majority of patients

Results: Complete extraction CBD stones among the patients of groupl; EPLBD was effective for clearance of [92.5%] of CBD stones in patients with the stone sized < 1cm and in [83%] of patients with stone size > 1cm, [overall clearance rate=87%]

Overall adverse effects of patients of groupl was [29%] as mild self-limiting post ERCP pain occurred in [9.6%] and mild intra- procedure bleeding occurred in [9.6%], whereas more serious complication as melena which occurred in [3.2%], and mild pancreatitis occurred in [6.4%]. Whereas complete CBD stones clearance among the patients of group 2; EST was effective in [96%] of patients with the stone sized < 1 cm, while stone clearance occurred in [56%] in patient with stone size> 1cm, [overall clearance rate=79%]. Overall adverse effects of patients of group 2 was [18.5%] as mild self-limiting post ERCP pain occurred in [7%] and mild intra-procedure bleeding occurred in [4.6%], whereas more serious complications as mild pancreatitis developed in [4.6%], and post ERCP cholangitis in [2.3%] The comparison between the two groups regarding the extraction of CBD stones revealed combination of papillary large balloon dilation after EST is not required in patients whose the CBD stone size < 1 cm. Whereas the clearance rate of CBD stones in the patients with stone size > 1cm among the group 1 was [83%] which better than among the group 2 which was [56%] with nearly statistical difference [P value=0.07]

Conclusion: Conventional EST is an effective method for removal of common bile duct stones < 1 cm in diameter whereas the use of large papillary balloon dilation after endoscopic sphincterotomy improve the clearance rate of bile duct stones> 1cm which is difficult to be extracted by conventional sphincterotomy and extraction devices. Endoscopic papillary large balloon dilation is an adjunctive tool to endoscopic sphincterotomy for removing large or difficult CBD stones

Study of premature atherosclerosis in systemic lupus erythematosus

The cause of accelerated coronary atherosclerosis in systemic lupus erythematosus [SLE] remains unclear, although it is reasonable to believe that dyslipoprotenemia is at least a contributing factor. This study aimed to assess the risk factors contributing to the occurrence of atherosclerosis in a group of SLE patients and explore the different contributing factors. Twenty SLE patients diagnosed according to the ARA criteria, with no special habits, not obese, and with no metabolic diseases. Ten normal matching controls. They were subjected to: blood pressure measurements, SLE disease activity index score [SLEDAI], fibrinogen levels, lipid profile, resting and exercise ECG, carotid Doppler ultrasonography. Patients were 18 females and 2 males. SLEDAI showed mild activity in 35% and moderate activity in 65% of patients. There was a significant increased levels of total cholesterol [TC], triglycerides [TG], low density lipoprotein cholesterol [LDL-C], and reduced levels of high density lipoprotein cholesterol [HDL-C], apo lipoprotein Al [Apo-A1] and HDL/C. Doppler ultrasound of the carotids showed atheromatous plaques in 40%, stenosis in 25% and homodynamic change in 12.5% of Patients. A significant positive correlation could be elicited between the degree of SLEDAI and Serum levels of TC, TG, LDL-C, and Apo-A1. Also, between the prednisone duration and TC, and TDL-C. SLE patients have an increased possibility to have premature atherosclerosis, and corticosteroids play an important role in its development through facilitating a state of dyslipoprotenemia. The use of carotid Doppler ultrasound can provide a good, cheap and non invasive technique for the early detection of subclinical atherosclerosis

Immunomodulatory properties of sand fly Saliva and its role on vertebrate host

The salivary glands of Phlebotomus papatasi and P. langeroni were investigated for their immunomodulatory properties on vertebrate hosts. Laboratory reared sand fly, were used for feeding on hamsters and for extraction of salivary gland. To determine the influence of the sand fly saliva homogenate [SGH] were performed ELISA using sera from injected hamsters by SGH. Frequent feeding of P. papatasi on hamsters were carried out to relate the antibody titre with the biting rate. The mosquito Culex pipiens was allowed to feed on pre-exposed hamsters to P. papatasi bites. Antibodies correlated with the saliva of both species showed low titre and not related either to the time [after feeding and injection] or to the number of fed flies. Saliva of P. langeroni [non vector] recorded higher anti-body titre than P. papatasi. The preliminary experiment of the mosquitoes' feeding [C. pipiens] on pre-exposed hamsters on its saliva showed cross reactions between biting of mosquitoes and sand-flies. More investigations are needed to study the effects of sand fly saliva on human immune responses to evaluate the fly salivary proteins as vaccines for leishmaniasis and to prevent or decrease the sand-flies biting or probably mosquitoes