Aspects of the current treatment modalities for symptomatic gallstones

Extracorporeal shock wave lithotripsy (ESWL) of gallbladder stones was clinically introduced in 1985. Before that, cholecystectomy had been the unchallenged standard therapy for symptomatic gallbladder stones for over a century. Expectations with regard to ESWL ran rather high after publication of the first results in a large series of patients. This actuarial analysis of 175 patients indicated that not less than 91 % of the patients rendered stone free at a negligible complication rate. Lay press interpreted these data as if surgery would soon become obsolete for the majority of gallstone patients, an interpretation also heard from optimistic physicians at scientific meetings. As a consequence of this optimism, an unbridled purchase of gallstone lithotriptors occured by hospitals all over Gerntany, the country of origin ofESWL. This optimism seemed justified because a decade earlier, ESWL revolutionized urological practice. Shortly after the introduction of ESWL, surgery for urinary tract stones became restricted to less than 5 % of the patients

Urachus Fistula: A Rare First Presentation of Diverticulitis

Urachus fistulas are rare, especially in adulthood. In grown-ups urachus fistulas are usually a reflection of Crohn's disease. We present a patient in whom an urachus fistula was the first presentation of diverticulitis of the sigmoid colon. The need for proper preoperative diagnostic imaging is discussed

Role of extracorporeal shock wave lithotripsy in hepato-biliary-pancreatic surgery

Since the early 1980s extracorporeal shock wave lithotripsy (ESWL) has partially replaced major operative procedures in various fields of surgery. In the interest of the patient, it is important to determine the exact role of ESWL in surgery. Comparing our own prospectively followed patients with other patient series, we have tried to assess this role. We treated 133 patients with cholecystolithiasis, 80 patients with choledocholithiasis, and 17 patients with pancreatic stones using a second- generation lithotriptor, the Siemens Lithostar (Siemens, Erlangen, Germany). The results suggest a limited role of ESWL for cholecystolithiasis, in which it is reserved for patients with high operative risk and patients who reject an operation. For choledocholithiasis ESWL seems to become an integral part of the treatment in the elderly patient in whom endoscopic stone removal proved impossible. Finally, ESWL could become a first option for the treatment of intractable pain in patients with chronic calcifying pancreatitis

Radiographic features of oral cholecystograms of 448 symptomatic gallstone patients: Implications for nonsurgical therapy

Since radiographic findings on oral cholecystography (OCG) have implications for the eligibility for nonsurgical therapy of elderly patients, we investigated the OCGs of 448 symptomatic gallstone patients (109 male, 339 female; mean age, 49.8 ± 14 (range, 21–88)). Opacification of the gallbladder was found in 323 cases (72.1%). Calcifications of gallstones were found in 85 opacified gallbladders (26.3%). Solitary and multiple stones were calcified in 35.3% and 18.2%, respectively (P 40 years), there was a significant increase in calcifications (P < 0.02) and a non-significant increase in opacification with increasing age. It is concluded that age is a determinant for calcification of gallstones and not opacification of the gallbladder. Since multiple stones are proportionately observed more in clinical studies than in epidemiologic studies, it is suggested that multiplicity of stones predisposes to biliary complaints. That solitary stones are more likely to be calcified than multiple stones, adds to the hypothesis that solitary and multiple stones have a different pathogenesis. Elderly patients, in whom nonsurgical therapy is most likely to be indicated and cost-effective, are less likely to be suitable for this form of treatment, since age is a determinant for stone calcification

Liver fibrosis after extracorporeal shock-wave lithotripsy of gallbladder stones - A case report

We encountered significant liver fibrosis in a healthy young patient undergoing laparoscopic cholecystectomy for symptomatic gallstone disease. Twelve months prior to cholecystectomy the patient underwent multiple extracorporeal shock-wave lithotripsy (ESWL) sessions with adjuvant oral bile-acid therapy. Since the site of fibrosis corresponded clearly to the shock-wave transmission path, which was in accordance with animal studies, it was concluded that this liver fibrosis was a side effect of biliary ESWL. Based on these findings and the literature, we conclude that further assessment of the long-term safety of ESWL is still warranted, especially in patients undergoing multiple ESWL sessions

The Immune Landscape of Cancer

We performed an extensive immunogenomic anal-ysis of more than 10,000 tumors comprising 33diverse cancer types by utilizing data compiled byTCGA. Across cancer types, we identified six im-mune subtypes\u2014wound healing, IFN-gdominant,inflammatory, lymphocyte depleted, immunologi-cally quiet, and TGF-bdominant\u2014characterized bydifferences in macrophage or lymphocyte signa-tures, Th1:Th2 cell ratio, extent of intratumoral het-erogeneity, aneuploidy, extent of neoantigen load,overall cell proliferation, expression of immunomod-ulatory genes, and prognosis. Specific drivermutations correlated with lower (CTNNB1,NRAS,orIDH1) or higher (BRAF,TP53,orCASP8) leukocytelevels across all cancers. Multiple control modalitiesof the intracellular and extracellular networks (tran-scription, microRNAs, copy number, and epigeneticprocesses) were involved in tumor-immune cell inter-actions, both across and within immune subtypes.Our immunogenomics pipeline to characterize theseheterogeneous tumors and the resulting data areintended to serve as a resource for future targetedstudies to further advance the field

Critical limb ischemia after accidental subcutaneous infusion of sulprostone.

Contains fulltext : 86683.pdf (publisher's version ) (Open Access)A 34-year-old patient was treated with constant intravenous infusion of sulprostone because of postpartum hemorrhage from a hypotonic uterus. The arm in which sulprostone had been infused was painful 23 h after infusion. A day later, the arm was found to be blueish, edematous and extremely painful as a result of arterial spasm. The vasospasm was probably caused by accidental subcutaneous infusion of sulprostone as a result of a displaced intravenous catheter. A diagnosis of critical limb ischemia was made. Treatment with the prostacyclin-analogue iloprost resulted in full recovery. Critical limb ischemia as a serious complication of sulprostone has not been previously reported.1 augustus 199