The treatment of iatrogenic injuries of CBD: Surgery vs endoprostheses

Analysis of the long-term results of 83 Roux-en-Y bilio-enteric anastomosis and 25 endoscopic stentings for iatrogenic biliary strictures, has allowed, in spite of drawbacks of a retrospective study, the identification of good indications for treatment. The good long-term results of surgical treatment (84.3%) after a mean follow-up of 8.5 years, have a favorable relationship with an intrahepatic preexisting dilatation of the biliary tree in the absence of chronic rough inflammation of the biliary wall. Otherwise, endoscopic stenting can be a good indication both as definitive treatment and complementary to surgery. On the contrary, the Hutson-Russell loop cutaneous choledochojejunostomy can represent a viable access to intrahepatic biliary tree for endoscopic instrumentation in case of recurrent anastomotic stricture. The long-term results are roughly similar after endoscopic (mean follow-up 23.6 months) and surgical treatment. The cases with unsatisfactory evolution after endoscopic management are the long strictures with late treatment with long-standing biliary infections. Nevertheless follow-ups of endoscopic series are too short to say that long-term results are really definitive. Short and incomplete strictures with bilio-cutaneous fistula have to be thought a good indication to endoscopic treatment. In our opinion self-expanding metallic stents have not to be used in benign strictures

Recurrent CBD stones: Evolution from open to laparoscopic surgery

Therapeutic policy and results of 25 years' experience in the management of CBD stones have been analyzed. The whole experience has been divided into three periods: open surgery of CBD stones (1969-1983), 636 cases of CBD lithiasis; endoscopic management of CBD stones (1984-1990), 149 cases of CBD lithiasis; era of laparoscopic cholecystectomy (1991-1994), 501 laparoscopic cholecystectomies with 37 cases of CBD stones (7.4%). The main peculiar issues characterizing the three periods are represented by the following points: a) progressive drop of percentage of CBD lithiasis (from 14.6% to 7.4%) as a consequence of under-utilization of diagnostic means (i.v. cholangiography, ERCP, intraoperative cholangiography) and, also, as a consequence of a total confidence in postoperative endoscopic management of recurrent CBD stones (85-90%); b) increased percentage of deliberately abandoned CBD stones when an endoscopic management is available (from 5.2% to 8.7%). For the same reason we have recorded a decrease of 'tactical' bilio-enteric anastomoses and sphincterotomies (from 9.5% to 2.7%). The well documented early morbility (2%) but mainly the late complications of endoscopic sphincterotomies suggest a great caution to avoid abusive indications in young patients. In our opinion the endoscopic approach is indicated in case of infected obstruction, in critically ill patients with biliary severe acute pancreatitis and in case of high surgical risk

Severe Metabolic Abnormalities in the White Matter of Patients with Vacuolating Leukoencephalopathy with Subcortical Cysts. A Proton MR Spectroscopic Imaging Study

Vacuolating megalencephalic leukoencephalopathy (VML) with subcortical cysts is a neurodegenerative disorder clinically characterized by megalencephaly with onset in the first year of life, progressive ataxia, spasticity and relatively spared cognitive function. Conventional MRI findings consist of diffusely abnormal cerebral white matter with subcortical cysts. Recent single-voxel proton MR spectroscopy studies have shown mild metabolic abnormalities in the white matter. We report here a combined proton MR imaging and MR spectroscopic imaging (1H-MRSI) study on 2 new, unrelated patients with this rare disorder. 1H-MRSI examinations, which can provide simultaneously metabolic information from many different brain regions, showed inhomogeneous decreases in all normally detected metabolites with significant widespread decreases in the ratio of N-acetylaspartate to creatine+phosphocreatine and concomitant small increases in lactate in the white matter of both hemispheres. Metabolic abnormalities were milder in the frontal white matter and more severe in the posterior white matter. The 1H-MRSI pattern of the gray matter was normal in both patients. In one patient, a subsequent 1H-MRSI examination (performed 3 years after the first) confirmed the presence of widespread decreases in the ratio of N-acetylaspartate to creatine+phosphocreatine in the white matter. We conclude that severe metabolic abnormalities can be found in the white matter of VML patients. This suggests that, despite the apparently mild clinical course, a severe neurodegenerative process may occur in the white matter of these patients

Endoscopie sphincterotomy in Billroth II patients

Endoscopic sphincterotomy (ES) is particulary difficult in patients with previous Billroth II gastrectomy, when a reverse approach to enter and cut the papilla must be used. A further method using a diathermic needle type cutter has been proposed by us in Billroth II patients in 1984. Now we have developed a modified technique, positioning a naso biliary tube in the common bile duct before starting ES. So the phincterotomy can be performed by a diathermic needle using the catheter as a guide. In this way the risk of perforation of the posterior duodenal wall and of pancreatitis are avoided because the cutting direction and the depth of the section are well controlled maintaining the diathermic needle upward respect to the position of the catheter. Over the last 10 years 2082 ERCP and 1557 ES have been carried out in our Endoscopic Unit. Of these 98 ES have been performed in Billroth II patients. Technical implications and results are described

Computer applications to digestive endoscopy

Esculape est un système de gestion de données établi à l'usage d'unités d'endoscopie digestive travaillant avec un système informatique en réseau ou avec un ordinateur personnel de type MS-DOS. Ce système permet les activités suivantes: compiler le rapport du diagnostic, des investigations et procédés opératoires des voies digestives supérieures ― inférieures ― bilio-pancréatiques y compris la laparoscopie, de stocker les données d'endoscopie et les données cliniques et de les récupérer, de produire automatiquement le rapport, de saisir et de stocker les images en cours d'examen endoscopique et de les traiter simultanément, de fournir l'analyse statistiques des données enregistrées, enfin d'enregistrer et de décoder les observations histologiques relatives aux patients. L'élaboration du rapport est simplifiée grâce à l'utilisation de fenêtres (windows), de menus à options et de la méthode automatique «POP-UP