[Image guided drainage of pelvic fluid collections: results in 42 patients]. / Drainage radiologique des collections pelviennes: résultats chez 42 malades.

PURPOSE: To review the etiology, location, and morphology of pelvic collection as well as the technique and results of image guided drainage. MATERIALS AND METHODS: From June 1996 to August 2002, we performed image guided drainage of pelvic fluid collections in 21 males and 21 females. In patients where a direct contact between the collection and the endocavitary probe was present, the drainage was performed either by transrectal or transvaginal approach using 10F, 12F, 14F or 16F catheters according to the viscosity of the fluid. When the patients were no longer septic, when drainage had stopped, the drains were removed at day 5. When a fistula was present, the drain was left in place until the fistula healed. RESULTS: The most common location of pelvic collections was the cul-desac (43%). A total of 81% of pelvic abscesses were digestive in origin, either from the colon or appendix. Transrectal or transvaginal drainage was possible in 83% of cases. Mean follow-up was 41 months. No drainage related complication was recorded. In two patients with collections of clear fluid, a simple aspiration was performed without insertion of a drain. In the 40 other patients, a drainage catheter was inserted. Twenty-nine patients were cured after 15 days of drainage. Two patients had recurrent collections. Image guided drainage failed in five patients, and all underwent successful surgical management. CONCLUSION: Image guided drainage of pelvic collections is a safe and effective procedure. Failures were due to initially undiagnosed pathology requiring surgical treatment.

Placement of metallic stents for treatment of postoperative biliary strictures: long-term outcome in 25 patients.

OBJECTIVE: This study was undertaken to evaluate the results of our 7-year experience with Gianturco-Rosch metallic stents, used for the management of postoperative biliary strictures. SUBJECTS AND METHODS: From January 1989 to April 1995, self-expanding Gianturco-Rosch metallic stents were placed in 25 patients with postoperative bile duct stenosis. All patients had a history of bile duct injury during cholecystectomy. Twenty-four patients had a conventional open cholecystectomy and one patient had a laparoscopic cholecystectomy. Eight patients had stenosis at the level of the common bile duct. The other 17 patients, who had undergone surgical repair of the bile duct, had a stricture at the level of the hepaticojejunostomy. These anastomotic strictures recurred after simple cholangioplasty. Patients were monitored for 9-84 months (mean, 55 months). Treatment was considered successful if the initial stenosis did not recur. Treatment was considered a failure if the initial stenosis recurred within the stent. RESULTS: Two patients had early complications: one had bile pleural effusion, treated with percutaneous drainage, and the other had arterial hemobilia, treated with embolization. Eighteen (72%) of 25 patients had no recurrence of the initial strictures. Among these patients, 11 had no further symptoms of biliary obstruction and seven, all with strictured hepaticojejunostomies, had recurrent episodes of cholangitis caused by secondary sclerosing cholangitis or intrahepatic stone formation. Seven (28%) of 25 patients had recurrence of the initial stenoses, causing repeated episodes of cholangitis. Among these seven patients, six had common bile duct stenoses and one had an anastomotic stricture. Recurrent biliary obstruction was treated surgically or with percutaneous methods, despite the presence of the metallic stent. CONCLUSION: Gianturco-Rosch stent placement should be considered in patients with postoperative bile duct stenoses in whom another operation is not indicated and cholangioplasty has failed. The results are better in patients who have hepaticojejunostomy strictures rather than common bile duct strictures. Overall, a long-term recurrence rate of cholangitis of more than 50% of patients was seen because of recurrence of the original stenosis or intrahepatic bile duct obstruction.

Indications for cholangioscopy.

Cholangioscopy permits new diagnostic and therapeutic procedures. It can be performed via the peroral route when anatomical conditions are suitable. This procedure was attempted in 6 cases (lithiasis in 5, malignant stenosis in 1): cholangioscopy proved possible in 4 cases, and lithotripsy was successful in 2 cases out of 3. Percutaneous transhepatic cholangioscopy was performed when peroral cholangioscopy was not possible (non-accessible papilla, hepatico-jejunostomy), or failed. In 17 patients with common bile duct (CBD) stones, unextractable by conventional procedures 14 underwent a cholangioscopy with electrohydraulic lithotripsy. Sixteen had complete clearance of the CBD. Cholangioscopy was attempted in 18 patients with intra-hepatic lithiasis. Lithotripsy was necessary in 10 cases and stenosis dilatation in 8. Results were excellent in 15 patients, and good in 3 with diffuse intra-hepatic lithiasis. In the case of lithiasis, the complication rate of the procedure was 29.5% and 27.7% for CBD and intrahepatic stones, respectively, and the mortality rate was 8.5% (n = 3). These complications (bleeding and cholangitis) are closely related to the percutaneous route. In malignant stenosis (n = 5), cholangioscopy was performed for diagnostic purposes in one case, extraction of a stent in one case and endobiliary laser treatment in 3 cases.

[Dissolution of gallbladder lithiasis with methyl-tert-butyl-ether. Preliminary results: 9 cases]. / Dissolution de la lithiase vésiculaire par le méthyl-tert-butyl-éther (MTBE). Résultats préliminaires: 9 observations.

Nine patients with gallstones were treated by injection of methyl-tert-butyl-ether (MTBE) into the gallbladder. Complete or incomplete dissolution was observed in 5 of the 9 patients. The 4 failures were due to 2 main factors: poor selection of the patients (2 of them had pigment gallstones) and inadequate mixture with the solvent floating above the bile and gallstones. In addition, 4 complications were noted, all of them being resolved by medical treatment. A better selection of the patients and a more efficient technique of MTBE injection should improve these results.

Intracorporeal electrohydraulic shock wave lithotripsy of common bile duct stones: preliminary results in 7 cases.

We performed contact endobiliary electrohydraulic shock wave lithotripsy in 7 high-risk patient with unextractable common bile duct stones after EPT. The lithotripsy electrode was brought into contact with the stone through a percutaneous transhepatic approach in 5 cases and an endoscopic route in 5 cases. Firing of the shock wave was performed under fluoroscopic control in 4 patients and under endoscopic guidance via a transhepatic percutaneous cholangioscopy in 2 and peroral cholangioscopy in one case. Stones were fragmented in all the cases but one. Fragments were evacuated into the duodenum by simple lavage through the transhepatic drain in 5 cases, and by duodenoscopy in one. In 2 patients, hemobilia, which was controlled by transfusions, was observed. This type of percutaneous contact lithotripsy requires multiple maneuvers, which increase the risk and the hospital stay. Extracorporeal shock wave lithotripsy is simpler, but also has disadvantages. Peroral lithotripsy under endoscopic control performed immediately after EPT would be the most practical solution, but this technique implies the use of new fiberscopes and other energy supplies that are easier to handle.

[Contribution of gastroscopy with aimed biopsy to the diagnosis of early gastric cancer]. / Apporto della gastroscopia con biopsia mirata nella diagnosi del cancro gastrico iniziale

Gastroscopy was carried out in 320 patients with gastric cancer. In 35 instances, the tumour was located in the mucosa or barely extended into the submucosa. Diagnostic corroboration was obtained by means of biopsies conducted during the examination. Gastric fibroscopy can now offer early diagnosis of carcinoma of the stomach. A barium meal often fails to reveal these lesions, especially in the initial stages, nor can it indicate whether an ulcer is benign or a tumour. The fact that biopsy can be performed at the same time is of fundamental importance in determing whether medical or surgical management should be chosen.