Long-term follow-up of percutaneous transhepatic biliary drainage (PTBD) in patients with benign bilioenterostomy stricture.

BACKGROUND AND AIMS: Anastomotic strictures are well-known complications after bilioenterostomy. Endoscopic procedures are usually not possible in patients with a bilioenterostomy. Hence, percutaneous transhepatic biliary drainage (PTBD) has become the treatment of choice for the management of these patients. The main goal of the present study was to analyze the long-term follow-up of PTBD in such patients. METHODS AND PATIENTS: Between January 1996 and December 2006, 44 patients with benign anastomotic stricture after bilioenterostomy were identified by an analysis of the PTBD database, hospital charts, and cholangiograms. RESULTS: In 27/44 patients the percutaneous transhepatic biliary drain was successfully removed after 19.9 +/- 16.1 months (treatment success in 61.4 %). During a mean follow-up of 53.7 +/- 28.4 months after removal of the drain, no evidence was found of recurrent strictures in these patients. Ten out of 44 patients carry permanent drains (22.6 % of patients with ongoing treatment, mean follow-up 46.4 +/- 54.7 months) without the option for further surgery owing to concomitant disease (n = 2) or because they refused further surgery (n = 8). In 7 out of 44 patients (16 %) PTBD treatment was deemed to have failed and the patients underwent repeat operation. CONCLUSIONS: PTBD should be considered the treatment of choice in patients with benign anastomotic stricture after bilioenterostomy, especially after stricturing of a hepatojejunostomy.

Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses - analysis of 93 interventions.

BACKGROUND: Subepithelial gastric tumors are common findings during upper gastrointestinal endoscopy. Tumor resection is mostly done laparoscopically, but there is still discussion concerning the size of lesion for which the treatment may be minimally invasive; additionally there is very little data available concerning patient outcome after minor access surgery. METHODS: Clinicopathologic features and survival data of 93 consecutive patients undergoing a combined laparoscopic-endoscopic approach for gastric submucosal tumors were prospectively analyzed. Analysis included preoperative diagnostic work-up, perioperative data, and postoperative complications. Follow-up was carried out for patients with GIST to check for tumor recurrence. RESULTS: It was possible to resect 88 of 93 lesions by the laparoscopic-endoscopic approach, with tumor-free margins in all patients. Intraoperative endoscopy facilitated exact tumor localization in 92 patients. Most lesions were removed by endoscopic-laparoscopic wedge resection or, less frequently, by a combined transgastric approach. Mean operative time was 90.7 min; the postoperative hospitalization was 7.3 days. Adverse events appeared in 7.5%, and conversion to open surgery was required in 6.5%. For patients suffering from gastrointestinal stromal tumors, there was no tumor recurrence at a mean follow-up of 40 months. CONCLUSIONS: Combined laparoscopic-endoscopic "rendez-vous" procedures are easy to perform and offer a curative approach for almost all gastric submucosal lesions. The technique is associated with low morbidity and short hospitalization. Though even patients with large GISTs of intermediate and high risk were treated, no tumor recurrence has been observed to date.

A novel and practicable ERCP training system with simulated fluoroscopy.

INTRODUCTION: Simulators facilitate the acquisition of technical skills for endoscopy. Here, we describe the development, introduction, and first evaluation of a novel generation of mechanical endoscopic retrograde cholangiopancreatography (ERCP) simulation models with simulated fluoroscopy, the X-Vision ERCP Training System. METHODS: A custom-made modular ERCP simulation system was built with the use of universally obtainable materials and tools. The trainee controls ERCP activities on two screens: the aspect of the papilla and duodenum is shown on the conventional endoscopy monitor, and the trainee's actions in the equivalents of the pancreaticobiliary ducts are shown on the viewing screen of the model. Thereby, the latter screen serves as a substitute for fluoroscopy. Currently, four different models are available, allowing simulation of selective cannulation of the pancreatic or bile duct, intubation of differently arranged papillae, stent placement, and sphincterotomy of a biopapilla. The X-Vision ERCP Training System was first used during an ERCP course attended by 26 endoscopists. Trainees were supervised by an ERCP expert and an experienced ERCP nurse at each training model. The training system was evaluated by the participants and experts using a specific questionnaire. RESULTS: During the course there were no technical problems related to the X-Vision ERCP Training System. After sphincterotomy the organic papillae could easily be exchanged within less than 15 seconds. Overall, the X-Vision ERCP Training System achieved favorable results in all categories assessed. CONCLUSION: The new X-Vision ERCP Training System is simple and effective. A first evaluation in the context of an ERCP course showed impressive results.

Changes in intra-abdominal pressure, hemodynamics, and peak inspiratory pressure during gastroscopy in a porcine model.

BACKGROUND AND STUDY AIMS: The aim of this experimental study was to assess the effect of gastric insufflation on intra-abdominal pressure (IAP) and associated hemodynamic and respiratory changes during upper gastrointestinal endoscopy. METHODS: Measurements were taken from pigs under general anesthesia with controlled ventilation. Gastroscopy was carried out with continuous insufflation of air by a standard endoscopic light source/insufflator. The cardiac index and global end-diastolic volume index (GEDVI; reflecting preload) were measured by transpulmonary thermodilution. IAP, heart rate, mean arterial pressure (MAP), central venous pressure, systemic vascular resistance index (SVRI; reflecting afterload), peak inspiratory pressure (PIP), and oxygenation (SaO (2)) were also recorded. RESULTS: A total of 266 paired measurements (at the time of transpulmonary thermodilution) were taken from 14 animals. During air insufflation, we observed a significant rise in IAP in all animals up to intermittent values of 22 mm Hg. IAP and PIP correlated well (r = 0.666, P < 0.001), with the latter reaching values as high as 45 mbar in one pig, leading to respiratory compromise. Only marginal changes in heart rate, and a continuous, almost significant rise in MAP (due to a significant increase in SVRI) were recorded. We observed a slight increase in GEDVI, predominantly during the initial phase of air insufflation. The cardiac index showed no substantial changes. There were no episodes of hemodynamic instability, nor a decline in SaO (2). CONCLUSIONS: Air insufflation during gastroscopy resulted in a significant increase in IAP. The main clinically relevant finding was a steady increase in SVRI. Major increments in PIP suggest a role of intra-abdominal hypertension in otherwise unexplained respiratory compromise during upper gastrointestinal endoscopy.

Prospective study on bright lumen magnetic resonance colonography in comparison with conventional colonoscopy.

The aim of this prospective trial was to evaluate sensitivity and specificity of bright lumen magnetic resonance colonography (MRC) in comparison with conventional colonoscopy (CC). A total of 120 consecutive patients with clinical indications for CC were prospectively examined using MRC (1.5 Tesla) which was then followed by CC. Prior to MRC, the cleansed colon was filled with a gadolinium-water solution. A 3D GRE sequence was performed with the patient in the prone and supine position, each acquired during one breathhold period. After division of the colon into five segments, interactive data analysis was carried out using three-dimensional post-processing, including a virtual intraluminal view. The results of CC served as a reference standard. In all patients MRC was performed successfully and no complications occurred. Image quality was diagnostic in 92% (574/620 colonic segments). On a per-patient basis, the results of MRC were as follows: sensitivity 84% (95% CI 71.7-92.3%), specificity 97% (95% CI 89.0-99.6%). Five flat adenomas and 6/16 small polyps (< or =5 mm) were not identified by MRC. MRC offers high sensitivity and excellent specificity rates in patients with clinical indications for CC. Improved MRC techniques are needed to detect small polyps and flat adenomas.

Colonoscopy and polypectomy with a side-viewing endoscope.

BACKGROUND AND STUDY AIMS: Some colorectal polyps cannot be adequately viewed using forward-viewing colonoscopes because of their location behind mucosal folds or bends in the bowel. We performed polypectomy using side-viewing duodenoscopes for these problematic polyps in order to avoid incomplete polypectomy or the need for surgical intervention. PATIENTS AND METHODS: Between April 2000 and August 2003, polypectomy with a side-viewing endoscope was intended in 15 patients (seven men, eight women; mean age 63.7 years, median age 59 years, range 38-88 years) at our institution. In all these patients, polypectomy had been attempted previously with a forward-viewing colonoscope by at least one experienced endoscopist without success. The duodenoscope was advanced with slight bending of the tip to achieve a sloped forward view. RESULTS: Colorectal polyps were macroscopically completely removed in 11/15 patients. One polyp near the ileocecal valve could only be partially removed with the side-viewing endoscope; and one large flat rectal adenoma, one recurrent rectal polyp (after a previous incomplete conventional polypectomy), and one polyp near the ileocecal valve could not be removed. We observed no procedure-related complications. Endoscopic follow-up was possible in seven of the 11 patients in whom the polyps were successfully resected, with no evidence of recurrence (mean follow-up 27 months). CONCLUSIONS: Polypectomy with the side-viewing duodenoscope is a safe and effective method. It is a therapeutic option when polyps are not adequately accessible using a conventional approach.

Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series.

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastrointestinal cancers has been shown to be effective in treating mucosal malignancies, but en bloc resection (where the entire tumor is removed in one piece) is often not achieved using conventional cap EMR. Other techniques, developed in Japan, include the application of different types of knife such as the insulated-tip instrument. We report our preliminary experience of the use of this knife, in conjunction with other techniques, in attempting en bloc resection of early mucosal cancers and adenomas and in the removal of submucosal tumors (SMTs) of the upper gastrointestinal tract. PATIENTS AND METHODS: A total of 37 patients (26 men, 11 women, age range 53 - 86) were included in the study; 23 patients had 24 mucosal lesions amenable to EMR, and 14 patients had SMTs shown on endosonography to spare the muscularis propria. Lesions were located in the esophagus (n = 13), the stomach (n = 24), and the duodenum (n = 1); 40 % of the mucosal lesions were 20 mm or larger (mean size 18mm), whereas the mean size of the submucosal lesions was 23 mm. After submucosal saline injection, circumcision and dissection of the mucosal lesions was attempted with the aim of achieving en bloc resection. For SMTs, cap mucosectomy of the overlying mucosa was done first, and the tumors were then freed using saline injection, and finally resected using snare polypectomy. RESULTS: The strict aim of the study, i. e. complete tumor removal in a single piece, was achieved in only 25 % of the mucosal lesions (some failures were due to unrecognized submucosal infiltration) and 36 % of the SMTs. When a more liberal definition of success was assumed, this rate increased to 65 % for mucosal lesions (piecemeal, no tumor found at surgery or follow-up endoscopy with biopsy) and 79 % for SMTs (piecemeal). No severe complications necessitating surgery or leading to major morbidity occurred. However, clinically significant complications were found in six patients (minor perforation managed conservatively (n = 1), severe pain without perforation (n = 1), bleeding requiring reintervention (n = 3), and aspiration (n = 1)). CONCLUSIONS: Although we are convinced that methods of achieving en bloc resection of mucosal cancers and SMTs must be pursued, the insulated-tip knife in conjunction with conventional endoscopes still has limitations. Innovative endoscope design (double-channel scopes) as well as the development of new accessories will help to overcome the current limitations and further promote endoscopic tumor resection.

Bacteriobilia in percutaneous transhepatic biliary drainage: occurrence over time and clinical sequelae. A prospective observational study.

BACKGROUND: In the diagnosis and treatment of biliary disorders, establishing percutaneous transhepatic biliary drainage (PTBD) is an invasive procedure that can potentially lead to infectious complications in both the short and long-term. We therefore prospectively analysed the time course and spectrum of biliary bacteria in patients undergoing PTBD. METHODS: Forty-nine patients (19 F, 30 M; mean age 64 years) with malignant (65%) or benign (35%) biliary disorders were included, 20 of whom had a newly established PTBD (group A), while the remaining 29 had already had their PTBD in situ (group B) for a mean of 8 months. Bacteriological analyses of bile and blood were carried out, and clinical symptoms and laboratory values were obtained. RESULTS: Biliary bacteria were found in 60% of cases during the initial PTBD placement, and 24 h later this rate had already increased to 85%; two or more microorganisms were found in 40% initially and in 70% after a few days. At later PTBD exchanges, bacteriobilia was found in 100%, with all patients harbouring multiple organisms. Whereas the initial spectrum was mixed, Escherichia coli and enterococci (97% each), Klebsiella (73%) and Bacteroides species (37%) later predominated; Candida increased initially from 15% to 80%, but later decreased to 30%. Clinical signs of cholangitis were observed in 30% initially (no sepsis), but decreased to 6% at later exchanges. CONCLUSIONS: Bacteriobilia is initially a frequent, and later a regular, event in PTBD; however, clinically significant complications are rare during the long-term course and limited to the initial, more invasive, phase of PTBD. A knowledge of the bacterial spectrum is important for selecting appropriate antibiotic coverage if complications arise and/or major interventions such as surgery are planned.

[Chronic mucocutaneous candidosis with severe esophageal stricture]. / Chronisch mukokutane Candidose mit hochgradiger Osophagusstenose.

Since seven years, the 23-year-old woman suffered from severe dysphagia and cutaneous Candida-granulomas on the right side of the head, the nose and both hands. The therapy with different oral antimycotics was ineffective. Intravenously and orally administered high-dose fluconazole has induced healing of the mucocutaneous lesions. The esophageal stenosis, most likely caused by esophageal candidosis, was found as the origin of dysphagia. It was successfully treated by fluconazole and endoscopic dilatations.

Treatment of achalasia: the short-term response to botulinum toxin injection seems to be independent of any kind of pretreatment.

BACKGROUND: It has been suggested that intrasphincteric injection of botulinum toxin (BTX) may represent an alternative therapy to balloon dilatation in achalasia. The aim of the present study was to test the effectiveness of botulinum toxin injections in achalasia patients, as assessed using lower oesophageal sphincter pressure (LOSP) and symptom scores, and to compare the response in patients with different types of pretreatment (no previous treatment, balloon dilatation, myotomy, BTX injection). METHODS: Forty patients who presented with symptomatic achalasia were treated with BTX injection (48 injections in 40 patients). Some of the patients had received prior treatment (seven with myotomy, seven with dilatation and eight with BTX). The symptoms were assessed using a global symptom score (0-10), which was evaluated before treatment, 1 week afterwards, and 1 month afterwards. Manometry was also carried out before and after treatment. Three different selections of patients were studied: all patients; untreated patients; and patients with prior BTX, dilatation, or myotomy. RESULTS: After BTX injection, there was a significant reduction in LOSP (before, 38.2+/-11.3 mmHg; 1 week after, 20.5+/-6.9 mmHg; 1 month after, 17.8+/-6.8 mmHg; P < 0.001). The global symptom score and symptom subscores (dysphagia, regurgitation, chest pain) were significantly decreased after 1 week and 1 month. When the beneficial effects following BTX injection were compared (untreated vs. pretreated), neither changes in LOSP nor beneficial effects on the symptom scores significantly differed. After 6 months, 67.7% of all treated patients were still in symptomatic remission (subgroups: previously untreated patients, 61.5%, n = 26; prior dilatation, 71.4%, n = 7; prior myotomy, 71.4%, n = 7; prior BTX, 73.9%, n = 8). CONCLUSIONS: BTX injection offers an alternative treatment for achalasia which is safe and can be performed in an outpatient setting. The initial response to BTX, in terms of symptom scores and LOSP, appears to be independent of any prior treatment. A number of patients do not adequately respond to balloon dilatation or myotomy, which are the first-line treatment modalities in achalasia patients. BTX injection can be performed in these patients, and symptomatic benefit can be expected in the same percentages as with BTX injection in untreated patients.

Treatment of achalasia: botulinum toxin injection vs. pneumatic balloon dilation. A prospective study with long-term follow-Up.

BACKGROUND AND STUDY AIMS: In patients with achalasia, intrasphincteric injection of botulinum toxin (BTX) has been suggested as an alternative regimen to balloon dilation and has been shown to be superior to placebo injection. The aim of the present study was to test the effectiveness, the long-term outcome and the cumulative costs of BTX injection in consecutive patients with symptomatic achalasia in comparison with pneumatic balloon dilation. PATIENTS AND METHODS: 37 patients, who presented with symptomatic achalasia between January 1994 and December 1996 were treated with either BTX injection (n = 23) or pneumatic dilation (n = 14). Patients with short-term or long-term symptomatic failures of the initial procedure were treated again, either with the same or with the alternative method, depending on the initial response and on the patient's wish. Symptoms were assessed using a global symptom score (0 - 10) which was evaluated before treatment and 1 week, 1 month and then every 6 months after the treatment. In addition, body weight and recurrence of symptoms were noted and manometry was carried out before and after treatment. The patients were regularly contacted for the long-term follow-up. RESULTS: There were significant improvements in the global symptom scores of all patients treated, in both the BTX injection group (before 8.2 +/- 1.3, after 3.0 +/- 1.6) and the dilation group (before 8.3 +/- 1.1, after 2.3 +/- 1.9). There was also a significant decrease of lower esophageal sphincter pressure after treatment in the BTX group and the dilation group. There were no significant differences with regard to overall treatment failure and long-term outcome between patients who had or had not received previous treatment. No major complications were encountered in either group. An actuarial analysis over 48 months comparing patients receiving BTX injection or balloon dilation demonstrated that after 12 months neither therapy was significantly superior. After 24 months a single pneumatic dilation was superior to a single BTX injection, and after 48 months all patients treated by BTX injection had experienced a symptomatic relapse. In contrast, 35 % of all patients treated by dilation and 45 % of patients treated successfully by dilation were still symptom-free in an intention-to-treat analysis after 48 months. When the overall costs of treatment and further treatment after recurrence were compared, dilation and BTX injection showed a similar cost-effectiveness (costs per symptom-free day) after 48 months. CONCLUSIONS: BTX injection, which can be performed in an outpatient setting, is as safe and cost-effective as balloon dilation in symptomatic achalasia. Taking into account the lower long-term efficacy of BTX injection therapy, however, it is an alternative only in a minority of older or high-risk patients.

Gray-scale sonographic findings in a patient with pseudomyxoma peritonei.

Pseudomyxoma peritonei is a rare condition in which the abdominal cavity fills with thick mucoid material as a result of either a benign or malignant disease. We report the findings with gray-scale sonography and laparoscopy in a 74-year-old man with pseudomyxoma peritonei. After paracentesis and drainage of the ascites, sonography visualized hypoechoic nodules in the peritoneum at the surface of the liver and between bowel loops. Laparoscopy revealed mucoid material diffusely throughout the abdominal cavity. The diagnosis of pseudomyxoma peritonei was confirmed by cytologic examination of peritoneal fluid and histologic examination of laparoscopically obtained specimens.

A new system for rapid large-caliber percutaneous transhepatic drainage in patients with obstructive jaundice: a prospective randomized trial.

UNLABELLED: BACKGROUND AND STUDY, AIMS: Percutaneous access to the biliary tract is an important diagnostic and therapeutic tool in the management of biliary diseases. It is usually chosen when the endoscopic approach via endoscopic retrograde cholangiopancreatography (ERCP) fails, or is not possible. Once established, the percutaneous tract is then used for the treatment of biliary stones and strictures. To establish a percutaneous tract with a caliber large enough for cholangioscopy to be performed, or for a large-bore permanent drainage tube to be inserted, stepwise dilation up to 14 Fr or 16 Fr is usually required. We present here a new method of rapid dilation using specially designed materials, including a stiffenable guide wire and specially adapted bougies. PATIENTS AND METHODS: Consecutive patients undergoing percutaneous drainage for biliary diseases were included in this prospective study, over a 19-month period. After establishment of a 10-Fr transpapillary drain, the patients were randomly assigned to either conventional percutaneous transhepatic biliary drainage (PTBD) or stepwise dilation using the new method, aiming at a need for only one further session, using a specially designed stiffenable metal guide wire of 6.6 Fr and plastic bougies. The details of the procedure (duration, materials used, technical ease), initial and later complications, assessment by the patients, and procedural costs were compared between the two groups. RESULTS: Of the 60 patients included, 29 were randomly assigned to group I (the new method) and 31 to group II (the conventional approach); there were no significant differences between the two groups in terms of clinical data or biliary pathology. The clinical efficacy of PTBD was similar in the two groups, although three patients in group II were switched to the new procedure because of failure of dilation using the conventional approach. The rates of major complications (four of 29 in group I, five of 31 in group II) and patient tolerance were also similar. However, the new procedure led to a significant reduction in the cumulative procedure duration (20.1 minutes vs 30.1 minutes), mean number of sessions (1.1 vs. 1.7), and mean number of hospital days (2.0 vs 5.5), and was therefore also cost-effective, reducing costs from a mean of 5813 to 2581 German marks (DM) per patient. CONCLUSIONS: The new system for rapid establishment of large-caliber PTBD offers significant advantages in terms of saving hospital resources while maintaining clinical efficacy.

Long-term outcome in patients with advanced hilar bile duct tumors undergoing palliative endoscopic or percutaneous drainage.

OBJECTIVE: Advanced tumors of the hepatic duct bifurcation (Klatskin tumors) present problems to the endoscopist in deciding which procedure to use for palliative treatment of the resulting cholestasis--endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD), or both. There are technical difficulties with all forms of treatment for stenoses in the hilar region and intrahepatic bile ducts, and there are as yet no clear data on which type of drainage is feasible or preferable. SUBJECTS: 59 consecutive patients (30 men, 29 women; mean age 71 years) underwent palliative treatment for malignant hilar bile duct tumors of Bismuth stages II-IV during a three-year period (1992-94). METHOD: A retrospective analysis was carried out, and long-term follow-up data were obtained from telephone interviews with the patients, relatives, or referring physicians. RESULTS: The 59 patients were treated using ERCP (n = 20) or PTBD (n = 39). Three died within 30 days, and six were lost to follow-up. Clinically adequate drainage was achieved in 78% (n = 46) of the total patient group. Patient survival was a median of six months (range 0.5-38), and was slightly longer when the primary drainage procedure was successful (7.5 months). Initial complications occurred in 11% after ERCP and in 33% after PTBD, with a 30-day mortality of 5%. After the initial intervention, five patients who received ERCP treatment had to be switched to PTBD during the longer-term course. Three of these five patients died within 30 days of the PTBD insertion. CONCLUSIONS: Palliative treatment in patients with advanced Klatskin tumors is still suboptimal, even when combined endoscopic and percutaneous techniques are used in the same institution, allowing treatment to be tailored to the individual patient's needs. There is therefore a need for improvements in existing forms of treatment, as well as for the development of new forms of treatment.

Long-term results of endoscopic and percutaneous transhepatic treatment of benign biliary strictures.

BACKGROUND AND STUDY AIMS: Benign biliary strictures, mostly associated with biliary surgery, are of growing importance for the therapeutic endoscopist. In the short term, endoscopic therapy has success rates similar to those of surgery. With regard to the long-term results, fewer data are available, particularly concerning forms of treatment including percutaneous transhepatic biliary drainage (PTBD) as an additional tool. The present study was aimed at allowing evaluation of the short and long-term results of endoscopic and percutaneous treatment in patients with benign biliary strictures. PATIENTS AND METHODS: The charts of 40 consecutive patients treated during the period 1992-1994 (12 men, 28 women; median age 60.5 years, range 24-86) were analyzed retrospectively. Long-term follow-up was carried out by direct contact. In almost all of the cases, the endoscopic treatment consisted of papillotomy and stenting (single stent treatment 10 or 11.5 Fr); Yamakawa-type prostheses (14 or 16 Fr) were used in the PTBD patients. RESULTS: The primary treatment was successful in 37 of the 40 patients, including nine of 21 patients (43 %) treated endoscopically and 28 of 31 patients (90%) treated using the percutaneous approach. The complication rates after endoscopic retrograde cholangiopancreatography (ERCP) were 14%, compared with 26% after PTBD. Relief of the stricture was achieved in 25 patients after a median period of stent treatment of nine months (range 3-44), while recurrences were seen in six patients with stents in place for only 4.5 months (range 1-8), and in one patient with a metal stent. Therapy failed in two patients, and three were lost to follow-up. Serious long-term complications were rare, but there was a fatal complication in one patient with metal stents. The follow-up period was 44 months (range 11-66). Three patients underwent successful primary surgery, and three more underwent successful surgery after stricture recurrence; all were free of complaints after 49 months (range 40-44). CONCLUSIONS: Endoscopic and percutaneous treatment of benign biliary strictures is not only a short-term treatment, but also an adequate long-term therapeutic alternative to surgery, with tolerable complication rates. The period of stenting appears to influence the outcome, and the diameter of the stents used also probably plays a role. Prospective studies are required for further evaluation of these observations.

Initial experience with a new Yamakawa-type prosthesis for long-term percutaneous transhepatic drainage.

BACKGROUND AND STUDY AIMS: In a previous study evaluating the problems of long-term percutaneous transhepatic biliary drainage (PTBD) using Yamakawa-type prostheses in patients with benign and malignant stenoses, breakage of the tube proved to be a serious problem, occurring in 19.7 % of PTBD exchanges. As a consequence of these results, a new PTBD tube made of Tecothane has been developed. PATIENTS AND METHODS: From September 1997 to September 1998, this new PTBD tube was applied in 64 patients (39 men, 25 women; median age: 70, range 29-89) in the treatment of benign (n = 30) or malignant stenoses (n=31; three stenoses remained indeterminate), and the course was followed. RESULTS: A total of 134 stent exchanges were performed, 52 of these being ahead of schedule (39 %). Not a single case of breakage occurred. However, other PTBD-related problems remained unchanged. Patients accepted the new prosthesis very well; among 19 patients who had experience of both the new one and the conventional one, 11 had preferences-eight for the new one and three for the old one. CONCLUSIONS: This new Tecothane prosthesis has solved the problem of PTBD breakage, which was often accompanied by serious problems. As was to be expected, other PTBD-related problems were not substantially affected. Nevertheless, this new tube represents progress in the percutaneous treatment of biliary stenoses.