The evaluation of corticosteroid therapy in conjunction with plasma exchange in the treatment of renal cholesterol embolic disease. A report of 5 cases.

In this report, we describe 5 patients with cholesterol atheroembolic renal failure. In 3 of the 5 patients, combined therapy with corticosteroids and plasma exchange was performed. These 3 patients survived, with 2 showing an improvement in renal function. The 2 remaining patients died of multifactorial causes. The literature on therapy for cholesterol atheroembolic renal failure is reviewed and the efficacy of combined therapy by use of corticosteroids and plasma exchange is evaluated.

Preoperative assessment of congenital bile duct dilatation using intraductal US.

BACKGROUND: Although congenital bile duct dilatation is frequently associated with biliary tract cancer, conventional cholangiography often does not demonstrate small ductal tumors. This is the first prospective study of the value of intraductal ultrasonography (US) in the examination of the extrahepatic bile ducts in patients with congenital bile duct dilatation. METHODS: Intraductal US via a transpapillary route was used in consecutive patients with congenital bile duct dilatation. A 2.0 mm diameter, 20 MHz frequency catheter probe was used. The images were correlated with the results of histologic examination of the resection specimens. RESULTS: Intraductal US was performed successfully via the transpapillary route in 8 of 10 patients. In the other 2 patients, the percutaneous transhepatic route was used. In the 6 patients with cylindrical dilatation, intraductal US demonstrated the entire extrahepatic bile duct. In 1 patient, it showed a bile duct cancer not demonstrated by cholangiography. In 2 of the 4 patients with cystic dilatation, intraductal US did not demonstrate the entire extrahepatic bile duct because of the low penetration depth of the probe. Percutaneous transhepatic cholangioscopy was required in these patients. CONCLUSIONS: Intraductal US is useful for demonstrating cancers in the extrahepatic bile ducts in patients with congenital cylindrical ductal dilatation.

Bile duct wall thickness measured by intraductal US in patients who have not undergone previous biliary drainage.

BACKGROUND: We investigated the bile duct wall thickness measured on intraductal US in patients who had not undergone biliary drainage, with special attention to the influence of cancer at the distal bile duct, bile duct stones, obstructive jaundice, longitudinal cancer extension, and primary sclerosing cholangitis on wall thickness. METHODS: The study included 183 patients. Patients who had undergone previous biliary drainage were excluded. Intraductal US was performed by the transpapillary route with use of a thin-caliber ultrasonic probe (2.0 mm diameter, 20 MHz frequency). The bile duct wall thickness (width of the inside hypoechoic layer) was retrospectively measured on US images. RESULTS: Bile duct wall thicknesses of the common hepatic duct for the control group (n = 95), cancer at the distal bile duct group (n = 9), bile duct stone group (n = 56), and obstructive jaundice group (n = 17) were 0.6 +/- 0.3 mm (mean +/- SD), 0.8 +/- 0.5 mm, 0.8 +/- 0.6 mm, and 0.8 +/- 0. 5 mm, respectively. No significant differences (p > 0.05) were found between them. However, wall thickness for the cancer extension to the common hepatic duct group (n = 4, 2.0 +/- 0.4 mm) and sclerosing cholangitis group (n = 2, 2.5 +/- 0.4 mm) were significantly greater than in the other groups (p < 0.005). CONCLUSIONS: In patients who have not undergone previous biliary drainage, the bile duct wall thickness was not thicker in patients with obstructive jaundice. However, the duct wall was significantly thicker in patients with either longitudinal cancer extension or primary sclerosing cholangitis compared with that of other groups.

Characterization of biliary strictures using intraductal ultrasonography: comparison with percutaneous cholangioscopic biopsy.

BACKGROUND: We determined the accuracy of intraductal ultrasonography (IDUS) in distinguishing between bile duct cancer and benign bile duct disease. METHODS: Patients (n=42) who required bile duct biopsy using percutaneous transhepatic cholangioscopy (PTCS) to evaluate bile duct strictures or filling defects were studied. A thin-caliber ultrasonic probe (2.0 mm diameter and 20 MHz frequency) was inserted into the bile duct, and its images were prospectively reviewed before PTCS. RESULTS: Disruption of the bile duct wall structure, seen on IDUS, was associated with malignancy in 25 of 26 patients. When IDUS demonstrated a lesion with normal bile duct structure, six of nine patients were found to have no malignancy. IDUS demonstrated no intraductal lesion in seven patients, and bile duct biopsy also did not indicate cancer in any of these patients. The accuracy, sensitivity, and specificity of IDUS for diagnosing bile duct cancer were 76%, 89%, and 50%, respectively. When used in tandem with IDUS, the sensitivity of bile cytology (64%) and PTCS (93%) improved to 96% and 100%, respectively. CONCLUSIONS: The accuracy of IDUS for diagnosing bile duct cancer was less than that of PTCS (95%). However, the sensitivity for bile cytology, or bile duct biopsy improved when performed in combination with IDUS.

Influence of biliary drainage catheter on bile duct wall thickness as measured by intraductal ultrasonography.

OBJECTIVE: To determine the influence of biliary drainage catheter placement on bile duct wall thickness, we performed intraductal ultrasonography (IDUS) in patients before and after biliary drainage. METHODS: Patients underwent IDUS before and after either short-term (n = 9, 6 to 8 days) or long-term (n = 9, 14 to 35 days) biliary drainage using a thin (2.0 mm diameter), 20 MHz probe inserted by means of a transpapillary route or a percutaneous tract. The bile duct wall thickness (mean +/- standard deviation) was retrospectively measured at the upper portion of the common hepatic duct. RESULTS: The bile duct wall thickness increased from 0.8+/-0.4 mm (predrainage) to 2.0+/-1.6 mm (post-drainage) in the long-term group (p < 0.001) but was not significantly increased in the short-term group. CONCLUSIONS: The bile duct wall thickness as measured on IDUS appears to be increased after placement of biliary drainage catheters.

The role of endoscopic balloon sphincteroplasty in patients with gallbladder and bile duct stones.

We clarified the significance of endoscopic balloon sphincteroplasty (EBS) in the therapeutic treatment of biliary tract stones in the present era of laparoscopic cholecystectomy (LC). Patients with cholecysto-choledocholithiasis (n = 33) were treated by EBS. After endoscopic retrograde cholangiography (ERC), a balloon catheter (8 mm in diameter and 3 cm in width) was inserted into the bile duct using a guidewire, and positioned at the sphincter of Oddi. After inflating the balloon catheter, bile duct stones were removed by mechanical lithotripsy, a basket catheter, or a balloon catheter. In all patients, bile duct stones were removed by EBS without endoscopic sphincterotomy. No complication occurred except for 2 cases of mild pancreatitis, which was resolved within 48 hours. Twenty-four patients underwent LC before or after EBS. The remaining 9 patients did not undergo LC due to a poor-risk status for general anesthesia. None of them, however, experienced cholecystitis or colicky attacks after EBS. The combination of EBS and LC is an excellent method for treating cholecysto-choledocholithiasis.

Limitations of intraductal ultrasonography in differentiating between bile duct cancer in stage T1 and stage T2: in-vitro and in-vivo studies.

BACKGROUND AND STUDY AIMS: We investigated whether intraductal ultrasonography (IDUS) could distinguish between stage T1 and T2 bile duct cancer. MATERIALS AND METHODS: In-vitro study. Resected bile duct specimens (n = 8) were immersed in a water tank and were pierced with straight pins to clarify the normal layer structure. Ultrasonosgraphic images (20MHz) of the positions of pin echoes were compared to the positions of pin holes as seen on histologic analysis of the specimens. In-vivo study. A thin-caliber high-frequency (6 Fr, 20 MHz) ultrasonic probe was inserted into the bile duct via a transhepatic route or a transpapillary route in 26 patients with bile duct cancer who underwent surgical resection. RESULTS: In-vitro study. The inner hypoechoic layer on the IDUS image corresponded not only to the fibromuscular layer but also to a part of fibrous layer of the perimuscular loose connective tissue on histologic analysis, especially in the cases with moderate to severe bile duct wall fibrosis. The outer hyperechoic layer corresponded to the subserosal fat tissue. In-vivo study. In four of six patients with tumor limited to the inside hypoechoic layer on IDUS images, the histologic findings showed tumor invasion to the fibrous layer of the perimuscular loose connective tissue. Due to this limitation, accuracy of IDUS in T-staging was only 20/26 (77 %). CONCLUSIONS: IDUS cannot reliably distinguish bile duct cancer in stage T1 from that in stage T2.

Assessment of pancreatic parenchymal invasion by bile duct cancer using intraductal ultrasonography.

BACKGROUND AND STUDY AIMS: This study was performed to clarify the diagnostic accuracy of intraductal ultrasonography (IDUS) in assessing pancreatic parenchymal invasion by bile duct cancer. PATIENTS AND METHODS: Preoperative assessment of pancreatic parenchymal invasion was carried out by IDUS via a percutaneous tract or a transpapillary route in 18 patients with extrahepatic bile duct cancer. Various probes with diameters of 1.4, 2.0, 2.4, 2.6 and 3.2 mm, and frequencies of 7.5, 15, 20 and 30 MHz were used. All patients underwent angiography and endoscopic ultrasonography (EUS). In the first six cases, IDUS and EUS images were analyzed retrospectively without knowledge of the operative outcome or the results of other imaging tests. In the subsequent 12 cases, the IDUS und EUS images were prospectively reviewed prior to surgery. The diagnostic accuracy of IDUS was compared with angiography and EUS by means of a histopathological examination of the resected specimens. RESULTS: The accuracy of IDUS, EUS, and angiography in assessing pancreatic parenchymal invasion was 100%, 78% and 61%, respectively. However, IDUS could not assess pancreatic capsular invasion. The accuracy of IDUS in assessing horizontal tumor extension to the intrapancreatic bile duct and to the hepatic side was 83% and 72%, respectively. CONCLUSIONS: IDUS proved useful for assessing the extension of cancer invasion to the pancreatic parenchyma, but not to the pancreatic capsule or mucosal surface.