Endoscope affects decision making in cholesteatoma surgery.

OBJECTIVE: The aim of the present study was to evaluate the use of intraoperative otoendoscopy as a factor that could influence surgical decision-making in cholesteatoma surgery. MATERIALS AND METHODS: The material of this study included 82 ears with acquired cholesteatoma that were operated on. They were divided into 4 groups according to the surgical technique chosen and the use of the endoscope. Group I included 22 ears that underwent canal wall-down (CWD) tympanomastoid surgery, group II included 20 ears that underwent CWD tympanomastoid surgery with intraoperative use of endoscopy, group III included 20 ears that underwent canal wall-up (CWU) tympanomastoid surgery, and group IV included 20 ears that underwent CWU tympanomastoid surgery with intraoperative use of endoscopy. Endoscopy was used as a complementary tool to microscopy. The follow-up period ranged from 12 to 48 months. RESULTS: Intraoperative remnants of cholesteatoma matrix were detected during both CWU and CWD by the use of the rigid endoscope. However, its incidence was higher in the CWU group (50%) than in the CWD (30%) group. Most of these remnants were in the sinus tympani (37.5%). The mean duration of follow-up was 18.19 (+/-8.7) months. Postoperative residual cholesteatoma was much higher in the CWU group (25%) than in the CWD group (5%). All residuals were from groups of patients in whom intraoperative endoscopy was not used in the primary surgery. CONCLUSION: Our results showed that the use of the endoscope gave the surgeon better control over the pathology, thus achieving better eradication. Stated differently, the use of the endoscope raised the surgeon's confidence level about total removal and thus encouraged the surgeon to keep the canal wall intact while removing cholesteatoma in hidden areas. Therefore, the use of endoscope could be considered an additional tool that may affect decision-making in cholesteatoma surgery.

Roscoe Miller award. Fatty-meal sonography for evaluating patients with suspected partial common duct obstruction.

We evaluated the efficacy of fatty-meal sonography for identifying patients with partial common duct obstruction. The test consisted of initial control measurements of common duct diameter followed by repeated measurements every 15 min for 60 min after a fatty meal consisting of Lipomul (1.5 ml/lb). The rationale proposed for the fatty-meal test is that in the presence of partial common duct obstruction, fat-induced increases in bile flow related to increased circulating levels of cholecystokinin are associated with an increase in the diameter of the common duct. Initial analysis of our data indicated that a change in diameter of +/- 1 mm was within the range of measurement error or possibly physiologic variation. In 44 control subjects (24 without a gallbladder), the common duct diameter either remained unchanged, showed an insignificant change of +/- 1 mm, or decreased (greater than or equal to 2 mm). The common duct diameter never showed an increase of more than 1 mm. The results of fatty-meal sonography in 47 patients with suspected partial common duct obstruction were negative in all 28 true-negative cases (specificity, 100%) and were positive (common duct increased by greater than or equal to 2 mm) in 14 of 19 true-positive cases (sensitivity, 74%). Thus, in this study a positive test finding always indicated partial common duct obstruction. Of the true-positive cases, fatty-meal sonography correctly identified seven of eight patients with cryptic obstructive sphincter-of-Oddi dysfunction (stenosis or dyskinesia) and five of nine patients with commun duct stones. We conclude that fatty-meal sonography is a useful noninvasive screening test for evaluating patients with suspected partial common duct obstruction.

Efficacy of quantitative hepatobiliary scintigraphy and fatty-meal sonography for evaluating patients with suspected partial common duct obstruction.

In this study we evaluated by blinded design the diagnostic efficacy of two noninvasive techniques, quantitative hepatobiliary scintigraphy (QHS) and fatty-meal sonography (FMS), for evaluating patients with suspected partial common duct obstruction. Quantitative hepatobiliary scintigraphy was performed on 56 cholecystectomized individuals (22 asymptomatic controls, 28 patients with suspected partial common duct obstruction, and 6 nonjaundiced cirrhotics) and FMS was done in 51 cases. For QHS, time-activity curves were generated for regions of interest over the liver, hepatic hilum, and common duct. For FMS, we measured common duct diameter before and 45 min after a fatty meal (Lipomul, 1.5 ml/kg). Each of the 28 patients with suspected partial common duct obstruction and 6 cirrhotic patients underwent endoscopic retrograde cholangiography, often accompanied by sphincter of Oddi manometry. Findings from these examinations were taken as the gold standard to determine the presence or absence of conditions that could account for intermittent symptomatic partial common duct obstruction. The most sensitive indicators for a positive test were a 45-min isotope clearance of less than 63% for QHS and a common duct increase of greater than or equal to 2 mm after the fatty meal for FMS. Of 28 patients with suspected partial common duct obstruction, 15 were judged to be true-positive and 13 true-negative. The 6 cirrhotic patients were without common duct obstruction. The study findings showed that each test had a 67% sensitivity that improved to 80% when the findings from both test results were combined. The specificity of QHS was 85% and that of FMS was 100%. All 6 cirrhotic patients had negative findings on FMS and 4 were false-positive on QHS. The true-positives included 8 patients with a small common duct stone and 6 with obstructive sphincter of Oddi dysfunction (4 stenosis, 2 dyskinesia). We conclude that noninvasive QHS and FMS afford good sensitivity and specificity for evaluating cholecystectomized patients with suspected partial common duct obstruction.

Computed tomography examination of periampullary neoplasms.

The hospital records of 24 patients with periampullary neoplasms were reviewed. The clinical triad of jaundice, pain, and weight loss and the radiographic imaging triad of dilated biliary ducts, dilated pancreatic duct, and periampullary mass should suggest the diagnosis of periampullary neoplasm.

Sonographic evaluation of resting gallbladder volume and postprandial emptying in patients with gallstones.

We investigated fasting gallbladder volume and gallbladder emptying in response to a fatty meal in 20 patients with asymptomatic gallstones and compared the results with findings from healthy controls. Compared with control subjects without gallstones, the majority of patients with gallstones exhibited a higher resting gallbladder volume, less fractional emptying after a fatty meal, and a higher postmeal residual volume. These abnormalities all appeared to stem from an abnormally high resting gallbladder volume. Whether the increased gallbladder volume and decreased postprandial fractional emptying in the gallstone patients represents a primary or secondary abnormality remains to be determined. The results suggest that in some patients decreased gallbladder contractility may contribute to gallstone development or proliferation.

Sonographic measurement of gallbladder volume.

Sonographic images of the gallbladder enable satisfactory approximation of gallbladder volume using the sum-of-cylinders method. The sum-of-cylinder measurements, however, are moderately cumbersome and time consuming to perform. In this investigation, in vitro and in vivo testing was done to determine that a simple ellipsoid method applied to sonographic gallbladder images yields reasonable volume approximations that are comparable to the volumes calculated by the sum-of-cylinders method. Findings from a water-bath experiment showed that measurement of gallbladder volume by the ellipsoid method closely approximated the true volume with a mean difference of about 1.0 ml. The results of in vivo studies in five volunteers demonstrated that the gallbladder contracted substantially after a fatty meal and that volumes calculated by the ellipsoid and sum-of-cylinders methods were nearly identical. Thus, a simple ellipsoid method, requiring negligible time, may be used to approximate satisfactory gallbladder volume for clinical or investigative studies.