Functional results in oral cavity reconstruction using reinnervated versus nonreinnervated free fasciocutaneous grafts.

Recent advances in free-tissue transfer have given the otolaryngologist--head and neck surgeon a number of reliable options for reconstruction of the oral cavity following ablative procedures. One recent modification has been the transfer of free reinnervated fasciocutaneous grafts in the hope of enhancing oral rehabilitation following surgery. To assess the efficacy of this modification, a protocol was established to retrospectively evaluate patients that received either reinnervated or non-reinnervated free-tissue transfers. Factors including site, surgical resection, type of tissue transfer, and follow-up period were controlled. Evaluation of free-graft sensory return and quality of life was carried out through physical examination and patient interview. Speech assessment was carried out using standardized tests of intelligibility administered by a speech pathologist. Swallowing assessment was carried out with videocinefluoroscopic and scintigraphic techniques, and the oropharyngeal swallow efficiency was calculated. Sensory return in the reinnervate free grafts was superior; however, there was not statistical difference between groups in the speech and swallowing tests. Quality of life was judged to be good in both groups. Sensory return and functional outcome in intraoral reconstruction after tumour ablation was reviewed and discussed

Intraductal papillary carcinoma of the pancreas.

We report a case of intraductal papillary adenocarcinoma of the distal pancreatic duct. Although a rare subgroup of exocrine pancreatic tumors, their diagnosis is an important one in view of their favorable prognosis with pancreatectomy. Because of the established behavior of villous tumors of the colon, to which they are similar histologically, these tumors should be resected, even if biopsy shows benign disease. Patients should be followed radiologically for recurrence or the development of new adenoma following resection.

Surgical management of choledochal cysts.

Choledochal cysts are an unusual cause of biliary obstruction with up to 85% of reported cases being of the type I variety, that is, fusiform dilations of the common bile duct. Recommended management of this type I cyst is complete surgical excision; however, difficulties arise in type IVa cysts when the cystic dilation extends up into the intrahepatic biliary tree. The purpose of this study is to review the management of choledochal cysts with particular reference to the type IVa variety. Statistical analysis of outcome differences was undertaken using Fisher's exact test. A total of 23 consecutive patients with choledochal cysts seen at our institution in a 5-year period were reviewed: 8 patients had type I cysts, 1 patient had a type III cyst, and 14 patients had type IVa cysts. All type I cysts underwent complete cyst excision with hepaticojejunostomy and modified Houston loop formation. Of 14 patients with type IVa cysts, 13 underwent complete excision of the extrahepatic portion of the cyst with hepatico- and cystojejunostomy and modified Hutson loop formation. One patient required hepatic lobectomy. With a mean follow-up of 33 months, 4 patients with type IVa choledochal cyst have had episodes of recurrent cholangitis, with access to the library tree being achieved via the Hutson loop in 3 of the 4 patients. Three of these cases represented anastomotic strictures that were treated nonoperatively. We concluded that recurrent cholangitis and anastomotic stricture after resection of type IVa choledochal cysts is frequent and recommend Hutson loop formation at the time of primary resection.

Percutaneous transluminal biopsy of the biliary tract.

Percutaneous transluminal biopsy performed under fluoroscopic control uses interventional access routes and allows direct sampling of biliary tract lesions. The authors report their experience with this technique in 20 patients. The biopsy site was the gallbladder in 9 patients and the intrahepatic or extrahepatic bile ducts in 11. A suspected malignant lesion was the indication for biopsy in 17 patients; 3 patients underwent biopsy of the gallbladder mucosa during ablation therapy. The procedure was performed with the forceps (for 17 patients), brush (for 2) or "scrape" (for 1) technique; diagnostic material was obtained in all but one case. The sensitivity, specificity and overall accuracy of diagnosis in the patients with a suspected malignant lesion were 71%, 100% and 88% respectively. There were no false-positive results. In this series one major complication, hemobilia necessitating transarterial embolization, occurred after the scrape biopsy, and minor, self-limiting gallbladder hemorrhage occurred in one patient. This study shows that percutaneous transluminal biopsy is a reliable technique for examining a variety of biliary tract lesions and can lead to an accurate pathological diagnosis.

Are there predictors for future academic radiologists? A Canadian survey.

In 1990 the authors surveyed all members of the Canadian Association of Radiologists and all graduates of the radiology residency program at the University of British Columbia in the previous 10 years. They compared radiologists with and those without a university affiliation to determine the influences on career choice. The factors considered included teaching, research and publication experience, as well as educational background. Most respondents had decided on a career path during the second half of the residency or later. The authors found certain predictors and influences associated with a greater probability that a radiologist would pursue an academic career. For example, academic radiologists were more likely to have performed research, published and presented the results of their research activities, and taught before undertaking the residency program in radiology than their counterparts who were not affiliated with a university or a residency program. However, class standing in medical school and prior educational experience were similar for academic and nonacademic radiologists. The influences most often cited as leading toward an academic career were a desire to teach, the inspiration of a role model and an interest in research. Job satisfaction was higher among nonacademic radiologists, as indicated by the number that would consider a career change. Most of the respondents disapproved of a special residency curriculum for academic radiologists.

Extracorporeal shockwave lithotripsy of pancreatic duct stones.

Encouraging results with extracorporeal shockwave lithotripsy (ESWL) for pancreatic duct stones have been reported from Europe. We present our experience with the first two North American patients, treated with excellent results in one and limited clinical improvement in the other patient at 1 year follow-up. Targeting of pancreatic duct stones was achieved with either fluoroscopy or ultrasound.

Effectiveness of transcutaneous electrical nerve stimulation (TENS) for analgesia during biliary lithotripsy.

The effectiveness of transcutaneous electrical nerve stimulation (TENS) in controlling pain during biliary extracorporeal shockwave lithotripsy (BESWL) was assessed in 100 patients with symptomatic gallbladder calculi. Patients were divided into four groups: TENS electrodes were placed on the back at cutaneous anesthesia sites and on the right leg and the gallbladder acupuncture site in groups A and B. Electrodes were "turned on" only in group A. In groups C and D, electrodes were placed only on the back at cutaneous dermatomes. Electrodes were "turned on" in group C only. The TENS unit was stimulated at the pulse rate of 60 to 100 microseconds and frequency of 80 to 125 Hz. Lithotripsy was performed with the Lithostar Plus overhead module. The differences in the amount of analgesic used and the pain experiences by the patients in all groups were not statistically significant. The proportion of patients requiring intravenous analgesia in each group was also not significantly different (72%, 80%, 68%, 76% in groups A to D, respectively). Thus, TENS did not help in reducing the amount of intravenous analgesia required or the average pain perceived by the patient during lithotripsy treatment.

Gallbladder contractility: variation in normal subjects.

Gallbladder contractility can be quantified radiologically, but it is not known whether the degree of contraction exhibited by a person's gallbladder varies from day to day. Thirty healthy volunteers were studied with sonography on three separate occasions to determine the variation of individual gallbladder contractility. Using the ellipsoid method, we measured gallbladder volume after an overnight fast (fasting gallbladder volume) and between 45 and 60 min after a standard fatty meal (residual gallbladder volume). Percentage gallbladder contraction was calculated by dividing the difference between the fasting and residual gallbladder volumes by the fasting gallbladder volume and multiplying by 100. The 90 studies in 30 subjects exhibited a wide range of values: fasting gallbladder volume from 1.9 to 45.5 ml, residual gallbladder volume from 0.1 to 21.0 ml, and percentage gallbladder contraction from -10% to 99%. Within each subject, fasting gallbladder volume measurements varied from 1.5 to 26.2 ml (mean +/- two standard deviations, 10.3 +/- 5.1 ml) and residual gallbladder volume from 0.3 to 15.4 ml (5.1 +/- 3.8 ml). Percentage gallbladder contraction varied from 6% to 87% (28% +/- 18%). In 60% of the subjects, percentage gallbladder contraction values varied by more than 20%, and in 20% of the subjects it varied by more than 40%. These data show that a wide variation exists within a normal person in the degree of gallbladder contraction exhibited from one day to another, and a single test for gallbladder contraction can be misleading.

Altered gallbladder contractility after extracorporeal shock-wave cholecystolithotripsy.

Change in gallbladder contractility after biliary extracorporeal shock-wave lithotripsy (ESWL) may significantly influence the clearance of fragments after successful gallstone fragmentation. We assessed changes in gallbladder contractility in response to an oral fatty meal in 50 patients 1 month after biliary ESWL (all fragments were smaller than 3 mm) and also in a separate group of 10 patients 3 months after complete clearance of fragments. The prevalence of persistent lumen-obliterating contraction of the gallbladder after biliary ESWL also was analyzed in 325 patients. Gallbladder contractility remained unchanged in 30, increased in nine, and decreased in 11 of the 50 patients. The average reduction in the fasting gallbladder volume after lithotripsy was 28% (p less than .001). Gallbladder contractility remained unchanged 3 months after complete clearance of fragments in six of 10 patients studied separately. A decrease (n = 2) or increase (n = 2) in contractility was seen in the remaining patients. No significant difference occurred in the average ejection fraction of the gallbladder before lithotripsy and after complete clearance of the fragments. Thirty-four of the 325 patients who have so far undergone biliary ESWL had a completely contracted gallbladder with no lumen visible on sonography. The gallbladder returned to a relaxed state in half of these patients within 1-9 months. Thus, biliary ESWL did not significantly alter gallbladder contractility in 60% of patients. A significant reduction in the volume of the fasting gallbladder occurred after lithotripsy. Successful clearance of fragments did not improve the contractility of stonebearing gallbladders in the majority of patients.

Biliary lithotripsy: correlation between gallbladder contractility before treatment and the success of treatment.

We perform biliary lithotripsy without adjuvant chemolitholytic agents, and therefore fragment clearance depends solely on the gallbladder's ability to evacuate its contents. We studied 205 patients to determine if gallbladder contractility before biliary lithotripsy is a predictor of treatment results and rate of fragment clearance. Percentage gallbladder contraction was calculated from the fractional difference in the sonographically measured gallbladder volumes before and after a fatty meal. Seventy-six patients (37%) were free of stones and fragments, and 129 patients (63%) had residual fragments at comparable follow-up intervals. Statistical analysis showed a significant difference in gallbladder contractility before biliary lithotripsy between the fragment-free group and the residual-fragment group (p = .008). Stone burden before treatment showed no significant difference between the groups (p = .074), but the number of stones was significantly less in the fragment-free group (p = .022). In the fragment-free group, a poor correlation (r = .047) was found between the percentage gallbladder contraction and the rate of fragment clearance. These data indicate that contractility of the gallbladder before treatment correlates with overall success of biliary lithotripsy but is not a predictor of the speed of fragment clearance.

Extracorporeal cholecystolithotripsy without oral chemolitholysis.

One hundred thirty-six patients completed extracorporeal biliary lithotripsy (EBL) for symptomatic cholecystolithiasis. Sonographic evidence of complete clearance of all stone fragments was the only criterion for treatment success, which occurred in 32 of the 71 patients (45%) followed up for 24 weeks and in 36 of the 59 patients (61%) followed up for 52 weeks. The authors' protocol varied from protocols of other researchers primarily in that no adjuvant chemolitholysis was used. However, the number of treatment sessions and total number of shock waves (a maximum of 4,000 shock waves per treatment session, 12,000 shock waves in a patient demonstrating no significant fragmentation, and 20,000 shock waves in a patient whose stones responded well to fragmentation) was higher than those in other reports. The results of treatment and complication rates in this study are comparable with those at centers using both shock-wave lithotripsy and chemotherapy. The authors conclude that EBL is developing into an important alternative to surgery, which was obviated in all patients with complete clearance of fragments from the gallbladder.

Interventional radiology of the biliary tract. Transcholecystic intervention.

Diagnostic and therapeutic biliary intervention by percutaneous access to the gallbladder is an important new area in interventional radiology. The anatomy of the gallbladder, biliary tree, and surrounding viscera is reviewed in this article as a preliminary to discussion of the diagnostic techniques of aspiration, cholangiography, biopsy, and the therapeutic techniques of gallbladder drainage and cholelithotomy. Recently there has been a bewildering proliferation of procedures aimed at removal, fragmentation, and dissolution of gallbladder stones. Several of these are discussed in this article. Removal of common bile duct stones by percutaneous cholecystostomy also is discussed.

Routine liver function tests and serum amylase determinations after biliary lithotripsy: are they necessary?

Shock-wave-induced soft-tissue damage after biliary extracorporeal shock-wave lithotripsy (BESWL) has been reported. Every patient treated in Vancouver has, therefore, had liver function tests and serum amylase levels measured before and within 6 days after BESWL. All patients had symptomatic cholecystolithiasis with normal pre-BESWL biochemistry. Analysis of 311 patients after treatment with the Siemens Lithostar unit showed elevation of one or more laboratory value in 19% (60/311). Serum aspartate transaminase level was most frequently abnormal (38 cases). The majority of abnormalities were mild, less than two times normal levels. Clinically significant complications occurred in five patients (three pancreatitis, one cholecystitis, one common bile duct obstruction); four of these occurred 1 week or more after treatment. The results of routine laboratory tests could not be used to predict complications. No correlation was seen between abnormal values and number of shock waves administered or peak shock-wave pressure. Of 112 patients surveyed at the time of post-BESWL enzyme measurement, 49 (44%) reported a degree of pain, which was severe in eight cases. Presence of severe pain correlated strongly (p less than .001) with abnormal laboratory findings, however not with the degree of abnormality. As results of these laboratory tests are nonspecific, have not been shown to correlate with the degree of severity of BESWL-induced tissue damage, and do not predict complications, the tests are of little value in the absence of clinical signs and symptoms. These conclusions, however, apply only to the Siemens Lithostar Plus with patients treated in the steep left posterior oblique position. Cost savings can be expected if routine post-BESWL biochemical tests are abandoned.

The value of extracorporeal shock-wave lithotripsy in the management of bile duct stones.

We evaluated the role of biliary extracorporeal shock-wave lithotripsy in treating 70 symptomatic patients with bile duct stones in whom endoscopic or percutaneous radiologic attempts at basket extraction had failed. Forty-four patients had common bile and/or common hepatic duct stones, 21 patients had cystic duct stones, and five patients had intrahepatic duct stones. A total of 43 patients (61%) had complete elimination of stone fragments during the initial treatment period. If patients in whom stones were successfully fragmented yet not totally eliminated on initial hospital treatment but who were asymptomatic at follow-up times of 8-22 months are included, the overall successful treatment rate was 83%. Stones were cleared in 26 of 44 common bile/hepatic duct stone patients, spontaneously in seven patients and after endoscopic or percutaneous radiologic intervention in 19 patients. Fifteen (71%) of 21 patients had cystic duct stones successfully cleared. The fragments in two of five patients with intrahepatic duct stones also were cleared. Five patients (7%) had minor side effects. Seven (10%) of 70 patients went on to have surgery. Complications after 30 days occurred in five patients (7%); two required repeated endoscopy with fragment extraction, two required placement of an endoprosthesis, and one died. We conclude that biliary extracorporeal shock-wave lithotripsy is valuable as an adjuvant to standard interventional techniques for removing bile duct stones.

Ablation of the cystic duct and gallbladder: clinical observations.

The cystic duct and gallbladder were ablated in eight patients with acute gallbladder disease who had been treated with minicholecystostomy instead of cholecystectomy because of multiple risk factors. First, endoluminal transcatheter radio-frequency electrocoagulation of the cystic duct was performed under fluoroscopic control, which resulted in complete occlusion in all eight patients. Next, the mucosa of the isolated gallbladder was sclerosed with 95% ethanol and 3% sodium tetradecyl sulfate in one to four sessions; no analgesics were required. The gallbladder volumes of all patients, estimated by means of ultrasound, were 1.5-22 cm3 (average, less than 10 cm3) after a mean follow-up period of 5 months. One patient died of a cerebrovascular accident 15 months after sclerotherapy. In all surviving patients, the gallbladder fistulas are dry and obliterated. These early clinical data indicate that electrocoagulation permits reliable, safe obliteration of the human cystic duct. The authors believe that sclerotherapy of the isolated gallbladder is feasible without toxic effects but that their treatment needs adjustment to achieve complete ablation of the gallbladder mucosa in a shorter period and in all patients.

Iodinated contrast medium as an aid to gallstone dissolution with methyl tert-butyl ether: in vitro study.

Methyl tert-butyl ether (MTBE) floats on bile, whereas gallstones sink. Therefore, stones and MTBE are separated by a layer of bile. This study investigates the effect of contrast medium on flotation of gallstones in bile and its role in stone and fragment dissolution with MTBE. Fresh human gallstones, both calcified and noncalcified, from different patients were tested in vitro for flotation in bile, with and without addition of contrast medium. All gallstones or fragments sank in bile before the introduction of contrast medium. Noncalcified stones floated when the contrast medium-bile volume ratio was 1:6 or more, while double this amount of contrast medium was required to float calcified stones. Fragments did dissolve somewhat in MTBE in the presence of bile alone, but when contrast medium was added, almost complete dissolution occurred. This is thought to be due to increased contact between the fragments and MTBE, both floating on the contrast medium-bile mixture. Contrast material may be a useful adjuvant in gallstone dissolution therapy with MTBE in vivo.

Biliary lithotripsy with the Siemens Lithostar Plus overhead module.

A third shock head has been added to the Lithostar. This overhead module with integrated ultrasound complements the existing bilateral undertable shock heads with biplane x-ray amplifiers for stone targeting. Extracorporeal shock wave treatment of urinary tract stones, pancreatic stones, and stones in the gallbladder and bile ducts has thereby become possible in one true multipurpose lithotripter. Technical information and clinical experience in the biliary tract with the overhead module is presented.