Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey.

Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

[Primary pancreatic lymphoma. A rare cause of pain-free icterus]. / Primäres Pankreaslymphom. Seltene Ursache eines schmerzlosen Ikterus.

HISTORY AND FINDINGS: A 54-year-old man was admitted because of increasing pain-free jaundice during the preceding two weeks. There was no resistance on palpation of the abdomen. The liver was palpable and of normal consistency, two finger-breadths below the right costal margin. Neither spleen nor lymph nodes were palpable. INVESTIGATIONS: Total bilirubin was 7.9 mg/dl, alkaline phosphatase 467 U/l, gamma-GT 850 U/l. WBC and differential counts were normal. The tumour marker CA 19-9 was raised to 117 U/l. Ultrasonography revealed dilatation of the intra- and extrahepatic bile ducts and a 3 cm echo-poor tumour in the head of the pancreas. Colour Doppler sonography showed both portal and splenic veins to be patent. Endoscopic retrograde cholangiopancreatography demonstrated a mild stenosis of the main pancreatic duct at the transition between the head and body of the pancreas, and a filiform stenosis of the choledochal duct. CT showed an nonhomogeneous head of the pancreas. As the suspected malignant tumour of the head of the pancreas seemed resectable no preoperative fine-needle biopsy was performed. TREATMENT AND COURSE: Whipple's operation (partial duodenopancreatectomy) was performed, but a small tumour infiltration in the portal vein had to be left. The resected specimen surprisingly showed a 2.5 cm centroblastic-centrocytic lymphoma which had infiltrated the head of the pancreas. Postoperative imaging showed para-aortic lymph nodes in the abdomen, maximally 1 cm in diameter. Subsequent radiotherapy was without complication. CONCLUSION: Primary pancreatic non-Hodgkin lymphoma is a rare lesion with special therapeutic consequences. The difficult differential diagnosis from pancreatic carcinoma is usually possible only, in operable cases, from the resected specimen. Every inoperable pancreatic tumour should be biopsied in case it is a malignant lymphoma.

-Severe hemobilia after percutaneous transhepatic biliary drainage. Successful treatment by arterial catheter embolization-. / Schwere Hämobilie nach perkutan-transhepatischer biliärer Drainage. Erfolgreiche Behandlung durch arterielle Katheterembolisation.

We report on an 44-year-old man with Billroth-I-reoperation and transformation into Roux-Y-anastomosis, which was performed because of ulcer-relapse. The postoperative course was complicated by obstructive jaundice and cholangitis. Ultrasound and computed tomography could not clarify the cause. The subsequently performed percutaneous transhepatic cholangiography showed several small concrements in the biliary tract. For decompression of the dilated bile ducts percutaneous transhepatic biliary drainage was applied. Following that the patient developed recurrent episodes of hemobilia, which made the transfusion of altogether 17 units of blood necessary. Angiography clarified the bleeding source showing leakage of the right hepatic artery. By means of repeated selective transcatheter embolization definite hemostasis was achieved. Transcatheter embolotherapy is recommended as initial treatment to control serious iatrogenic hemobilia.

[AIDS--Crohn disease as a diagnostic error. Case report]. / AIDS--Morbus Crohn als Fehldiagnose. Eine Kasuistik.

A twenty six year old homosexual male with the diseases Hepatitis B, Lues, Gonorrhoea, ascending myelitis, lymphadenitis got additionally a chronic-inflammatory bowel disease, which first was discussed as Crohn's disease. Two "attacks" were "successfully" treated with Methylprednisolone. The patient died twelve month later in the follow of a pneumocystitis carinii pneumonia. The cause of the symptoms of the chronic-inflammatory bowel disease was a cytomegalovirus infection with acquired immune deficiency-syndrome.

[Light- and thermomeasurement in endoscopy (author's transl)]. / Licht- und Wärmeprobleme in der Endoskopie.

An optimal lighting is necessary in order to recognize alterations and smallest lesions during the endoscopy. It is not only a problem of the light power. The Celvin number of the light limits the recognition of the color. The resolution power will be reduced when the lighting is too high or too low. It would be desirable to have light generators which always produce the same lighting independent of the distance between the tip of the endoscope and the object. There is no danger for the patient because of the high temperatures in the light generators.