"Mother-baby" biliary endoscopy: the University of Chicago experience.

OBJECTIVE: The "mother-baby" technique of peroral cholangioscopy is a relatively recent development in biliary endoscopy and permits direct visualization of the biliary tree. This paper presents the experience of one institution with this new technique. METHODS: We used the Olympus mother-baby endoscopy system at the University of Chicago and at one of its affiliated hospitals to examine and treat selected lesions in the biliary tree that had eluded successful diagnosis or treatment by standard means. In addition, we used the baby endoscope alone through surgically created percutaneous tracts to treat selected patients with retained stones. RESULTS: From July 1990 to June 1993, peroral cholangioscopy was performed 18 times in 12 patients at the University of Chicago and affiliated hospitals. The baby endoscope was successfully passed into the bile duct in 15 of 18 cases (83.3%). Additionally, the baby endoscope alone was used through a T-tube or cholecystostomy tract 10 times in six patients. Complications occurred in two patients and were minor; there were no fatalities. With refinement of technique, successful passage of the baby endoscope was accomplished in 100% of patients undergoing peroral cholangioscopy. CONCLUSIONS: Direct visualization of the biliary tree with the ability to sample (brush, biopsy) or treat (basket removal, electrohydraulic or laser lithotripsy) lesions significantly aided in the care of all patients in whom the baby endoscope was successfully passed by providing the correct diagnosis and, when appropriate, by allowing definitive treatment of lesions. The eventual role of this technique in the current cost-conscious climate is unclear, but at present it should be limited to selected referral centers.

Transnasal biliary drainage for treatment of common bile duct leakage and bile peritonitis.

A new nonoperative method for treating postoperative common bile duct leaks by endoscopic placement of a nasobiliary stent is described. Two patients were treated successfully by placing a nasobiliary stent above the point of bile leakage, acting to divert the flow of bile and to allow the fistula to close.

Protein origin of the volatile fatty acids isobutyrate and isovalerate in human stool.

Normal human stool contains five commonly recognized volatile fatty acids, of which three (acetate, propionate, and butyrate) are the product of carbohydrate degradation. We investigated whether the remaining two volatile fatty acids, isobutyrate and isovalerate, are produced by degradation of amino acids. Stools from six healthy subjects were incubated with albumin, valine, leucine, tryptophan, phenylalanine, glucose, or sucrose under atmospheres containing oxygen in the range of 0% to 5%. Isobutyrate was produced only from albumin and valine, and isovalerate was produced only from albumin and leucine. Glucose- and sucrose-containing incubates produced only acetate, propionate, and butyrate. The rate of production for each of the volatile fatty acids was constant over the various oxygen concentrations tested. We conclude that isobutyrate and isovalerate in stool are formed from valine and leucine degradation respectively. Quantitation of individual fecal volatile fatty acid excretions may reflect intracolonic degradation of protein and carbohydrate.

Improved technique for measuring fecal energy loss in normal and malabsorbing humans.

Fecal energy concentration is measured by bomb calorimetry on freeze-dried stool samples. Some of the energy-containing fecal compounds are volatile in the pH ranges of normal stool and hence may be lost during sample preparation. We found that significant amounts of volatile fatty acids and lactic acid are lost during lyophilization. Fecal alkalization caused an increase of 9.8% of measurable energy in stools from normal individuals and 25% in stools from patients with untreated exocrine pancreatic insufficiency. We conclude that previous reports of fecal energy concentration that did not use an alkalization procedure are probably underestimations. We recommend fecal alkalization before lyophilization in future measurements of fecal energy excretion.