Endoscopic application of photodynamic therapy for cholangiocarcinoma.

BACKGROUND: Previous studies indicate that photodynamic therapy provides effective relief from biliary obstruction in advanced cholangiocarcinoma. This report describes a method of applying photodynamic therapy in the biliary tract by using accessories available in the United States. METHODS: Endoscopic retrograde cholangiography was performed to define the proximal and distal extent of intraductal tumor. Patients were injected with 2 mg/kg of sodium porfimer. Forty-eight hours later a commercially available cylindrical diffusing laser fiber was inserted into an 8F biliary catheter equipped with a 0.038 inch side-hole at its distal tip. After positioning of a 0.035 inch guidewire proximal to the biliary stricture, the preloaded catheter was advanced over the guidewire by using the monorail technique. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm.(2) RESULTS: Fourteen treatments were performed on 6 patients with tumors of Bismuth types IV (n = 2), III (n = 3), or II (n = 1). By using the preloaded biliary catheter, adequate positioning of the laser fiber was achieved in all patients. A fracture of the diffuser tip occurred during 1 of the treatments. Two patients developed acute cholangitis and 2 patients experienced skin phototoxicity. CONCLUSIONS: Photodynamic therapy for cholangiocarcinoma is safe and technically feasible with a preloaded biliary catheter and a monorail technique for catheter positioning.

Improved diagnostic yield of endoscopic biliary brush cytology by digital image analysis.

OBJECTIVE: To evaluate the accuracy of digital image analysis (DIA) for distinguishing between benign and malignant strictures of the biliary tract. PATIENTS AND METHODS: Our pathology databank was used to identify all biliary brush cytology specimens obtained during endoscopic retrograde cholangiopancreatography between June 1997 and June 1999. Corresponding medical records were reviewed to determine whether patients had benign or malignant strictures. Strictures were further classified into benign strictures with negative routine cytology, malignant strictures with negative routine cytology, and malignant strictures with positive routine cytology. Papanicolaou-stained smears of available brush cytology specimens were destained and then restained with Feulgen dye. Nuclear images were quantified for DNA content without knowledge of stricture type. DNA histograms were generated and ploidy results compared with the class of stricture. RESULTS: We analyzed 27 specimens from 69 confirmed benign or malignant strictures. Assuming that the presence of any aneuploid cells indicated malignancy, the sensitivity of DIA was 85%. Furthermore, aneuploid cells were detected by DIA in 13 of 16 specimens in which routine cytology was unrevealing. CONCLUSION: Ploidy assessment by DIA has potential to enhance the sensitivity of diagnosing malignant strictures compared with routine cytology alone.

Diagnosis and therapy of biliary tract malignancy.

Bile duct and gallbladder cancer are relatively uncommon. Predisposing factors include primary sclerosing cholangitis and gallstones larger than 3 centimeters. Patients present with signs of biliary obstruction and cholestasis. A serum CA 19-9 elevated above 100 U/mL is a useful marker. The diagnosis is implied on imaging studies and confirmed by tissue obtained at endoscopic retrograde cholangiopancreatography or surgery, or by the clinical course. Surgery is the only curative therapy and survival is improved with resection of early stage disease. Endoscopic or percutaneous transhepatic stenting provides effective palliation. Generally, survival is less than 1 year.

Results of direct percutaneous endoscopic jejunostomy, an alternative method for providing jejunal feeding.

OBJECTIVE: To assess the results of direct percutaneous endoscopic jejunostomy (DPEJ) as a method for jejunal feeding. PATIENTS AND METHODS: We conducted a retrospective study of all patients who were referred for DPEJ between October 1998, when the procedure was implemented at our institution, and January 2000. Medical records were reviewed to assess technical success, complications, and the need for repeat procedures. Patient satisfaction with DPEJ was also evaluated by means of standardized telephone interviews. RESULTS: In 26 (72%) of 36 patients, DPEJ placement was successful. During the mean follow-up of 107 days, none of the patients with DPEJ required reintervention for tube malfunction or displacement. Two patients developed a persistent enterocutaneous fistula following the removal of the DPEJ tube. No other procedure-related complications were noted. Fifteen (78%) of 19 patients who responded to follow-up questions reported an overall satisfaction rating of 8 or higher on a 10-point scale (1, completely dissatisfied, to 10, completely satisfied). CONCLUSIONS: We conclude that DPEJ is an effective and safe method for providing jejunal tube feeding. A low reintervention rate along with high patient satisfaction makes DPEJ an attractive alternative to the more commonly placed jejunostomy feeding tubes.

Evaluation and endoscopic palliation of cholangiocarcinoma. Management of cholangiocarcinoma.

Patients with a cholangiocarcinoma usually develop symptoms of biliary obstruction which dominate the course of their illness. At presentation, the diagnosis may be difficult to establish due to the desmoplastic nature of this tumor. Location and extent of the tumor, however, are more effectively evaluated by current radiologic techniques. Following these staging procedures, most patients are found to be unsuitable for curative resection. Therefore, establishing effective biliary drainage to relieve symptoms of obstruction becomes the most critical therapeutic goal in these patients. In the past, surgical biliary bypass procedures were advocated, but were associated with high perioperative morbidity and mortality rates. Endoscopic biliary stenting produces quick and effective relief of symptoms from biliary obstruction due to cholangiocarcinoma. Initially, successful biliary drainage is possible in most patients. However, subsequent stent occlusion or spread of tumor into nonstentable intrahepatic ducts leads to recurrent jaundice. Local therapies including (192)Ir brachytherapy and photodynamic therapy may prevent or postpone these problems.

Does pulmonary airway inflammation relate to intercellular adhesion molecule (ICAM-1) in bronchoalveolar lavage specimens? A pilot study.

BACKGROUND: The objective of this study was to assess the value of intercellular adhesion molecule-1 (ICAM-1) levels in bronchoalveolar lavage (BAL) specimens. METHODS: BALs from 44 unselected patients undergoing routine diagnostic bronchoscopy with bronchoalveolar lavage were studied. Cell-free supernatants of the BAL specimens were frozen at -70 degrees C until tested. BAL ICAM-1 concentration was measured using enzyme immunoassay and degree of patient illness assessed by modified APACHE II scores. RESULTS: ICAM-1 in BAL fluid was positively correlated to the patient illness score (modified APACHE II) at a p value of 0.026. No such association was found between ICAM-1 levels and cigarette use or infection with pneumocystis carinii, although a few individuals in the smoker's group with pulmonary infection had 10-fold elevations of BAL ICAM-1. CONCLUSIONS: BAL ICAM-1 may relate to the pulmonary pathogenic process as supported by the association between modified APACHE II scores and ICAM-1 values. Specific pulmonary-related diagnosis and BAL ICAM-1 did not produce significant relationships in this study.