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Biomedical subjects

A Maydeo

Publications and source records attributed to A Maydeo.

11 recordsLinked to original sources
PubMed2003

Techniques of selective cannulation and sphincterotomy.

Selective access into the desired duct followed by incision of the sphincter, i. e. sphincterotomy, forms the cornerstone of any endoscopic intervention within the pancreaticobiliary system. The apprehensive beginner's performance and hesitance is aggravated by ignorance of ampullary anatomy and he considers selective cannulation to be the greatest hurdle. An understanding of ampullary morphology and its variations is vital in achieving selective cannulation. Technological advances have assisted in the form of development of better accessories, progressing from "immovable" catheters to movable cannulae and to single-, double-, and even triple-lumen sphincterotomes. Orientation along the long axis of the bile duct ensures access and avoids inadvertent and hazardous manipulation of the pancreatitic duct. Using guide wires, especially the 'angulated-tip' glide wire improves cannulation successs rates considerably. Precut accessotomy complements wire-guided selective cannulation, and can be used analogously to a controlled surgical incision to facilitate cannulation of the desired system after deroofing the papilla layer by layer. Published data have validated its role, demonstrating high efficacy and minimal complications when it is properly performed. Biliary sphincterotomy, using the right mode of blended current in the 11-12 o'clock direction and with the tip of the sphincterotome wire, provides a clean and bloodless splitting open of the sphincter of Oddi. Pancreatic precut, over-the-stent papillotomy and sphincterotomy over a guide wire have all been proven to be safe and effective measures, in large groups of patients. In special situations, such as where there are impacted stones or ampullary lesions, needle-knife infundibulotomy achieves reliable access. Techniques such as saline infiltration into the papilla and subtle body movements to re-position the scope enable biliary cannulation in difficult situations. Alterations in anatomy, for instance post Billroth II gastrectomy, no longer discourage the endoscopist from attempting intervention. Application of knowledge of reverse anatomy, specially designed instruments, and adherence to the proper technique improves success in these patients. Our experience of 9000 sphincterotomies over the past 12 years with minimal morbidity stands proof to the principles and techniques highlighted in this monograph. We recommend these to all aspiring endoscopists, with the assurance of improved technical success when they are implemented.

Biliary Tract Diseases↗
PubMed1998

Advances in therapeutic endoscopic treatment of common bile duct stones.

Advances in cannulation techniques and instruments have helped in difficult bile duct cannulation and thus stone extraction. For small common bile duct (CBD) stones, endoscopic papillary balloon dilatation has been proposed as an alternative to endoscopic papillotomy (EPT). The technique must undergo further evaluation before recommending its routine use. For most patients with bile duct stones, EPT remains the method of choice. Out of 8204 patients treated in three surgical endoscopy centers (Chile, Germany, and India), 86% to 91% of all CBD stones could be extracted subsequently after EPT using a Dormia basket; 4% to 7% required mechanical lithotripsy (ML) before removal and 3% to 10% of the patients needed other sophisticated techniques, such as electrohydraulic lithotripsy (EHL), laser-induced shock-wave lithotripsy (LISL), or extracorporeal shock-wave lithotripsy (ESWL). The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Permanent stenting can be offered to poor risk patients instead of extensive procedures to clear the bile duct. Using currently available nonsurgical techniques, fewer than 1% of all patients with bile duct stones still require surgical intervention.

Algorithms↗
PubMed1996

A new guide wire papillotome for patients with Billroth II gastrectomy.

BACKGROUND AND STUDY AIMS: Guide wire-assisted papillotomy is a well-established technique in conventional biliary endoscopy, but has not been previously employed in Billroth II patients, due to the lack of an appropriate papillotome that can accommodate a guide wire. We therefore designed a Billroth II papillotome that can be inserted over a guide wire. PATIENTS AND METHODS: Over a 12-month period, 24 patients (18 males, six females, median age 72 years), who had previously undergone a Billroth II gastrectomy and who were referred to our department for therapeutic biliary endoscopic procedures, were included in this study. RESULTS: The papilla could be reached in 22 patients, but the procedure failed in two due to an excessively long afferent loop. Cannulation of the bile duct with the standard Billroth II papillotome was possible in 11 patients; the remaining 11 patients, in whom free cannulation failed, underwent cannulation over the guide wire. Diagnostic endoscopic retrograde cholangiography revealed bile duct stones in 17 patients, and malignant-appearing common bile duct stenoses in five patients. Papillotomy was successfully performed using the guide wire Billroth II papillotome in all patients, without complications. CONCLUSION: The Billroth II papillotome is effective and safe in patients in whom free cannulation has failed using the standard Billroth II papillotome.

Aged↗
PubMed1996

Endoscopic retrograde cholangiography in the era of laparoscopic cholecystectomy.

OBJECTIVE: To assess the value of endoscopic retrograde cholangiography (ERC) as an adjunct in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Four hundred and sixty consecutive patients with cholelithiasis were evaluated for LC over a four-year period (January 1991 to January 1995). Forty four (9.6%) patients underwent pre-operative ERC on a suspicion of harboring common bile duct (CBD) stones. Ten other patients who presented with acute gallstone pancreatitis also had pre-operative ERC as soon as the acute attack had settled. Endoscopic sphincterotomy (ES) and stone extraction were done if indicated. After LC, four patients underwent ERC for cystic or CBD related complications. RESULTS: Cannulation was possible in all patients undergoing ERC. Of 44 patients with suspected CBD stones, 33 (75%) actually had stones. In 30 patients the stones could be extracted. Three patients had large stones which could not be extracted. Of 10 patients with acute gallstone pancreatitis, CBD stones were found in only one. In the 4 patients who developed ductal complications, ERC was used to place stents in three and to extract a missed CBD stone in one. Three patients developed fever after ERC and three others had transient hyperamylasemia. There were no other ERC related problems. CONCLUSION: In patients undergoing LC, ERC is a useful adjunct both pre- and post-operatively.

Adult↗
PubMed1991

Endoscopic sclerotherapy--personal experience.

Over the last 12 years, treatment of bleeding esophageal and gastric varices has improved considerably. By the use of new techniques and with increased experience the results of endoscopic sclerotherapy have been optimized. Acute variceal bleeding, esophageal or gastric, can now be reliably and definitively stopped using the tissue adhesive Histoacryl Blau. This is also applicable to all patients irrespective of their liver status at presentation. As expected, the mortality of acute variceal bleeders has decreased considerably, no death from bleeding occurring in the last 5 years. This has obviated the need for emergency surgery, balloon tamponade or vasopressin infusion. Using an aggressive sclerotherapy technique in the bleeding-free interval, varices of all grades can now be effectively eliminated within an average of 3 sessions covering 3-4 weeks. With the intra- cum peri-variceal injection technique not only are the visible veins eradicated, but also fibrosis of the inner esophageal wall is achieved at the same time. If careful attention is paid to certain details of the technique and instruments, and with close follow-up, patients of portal hypertension can now live well in terms of liver function, without the danger of further variceal bleeding.

Endoscopy, Gastrointestinal↗
PubMed1990

Endoluminal ultrasound for the diagnosis and staging of pancreatic cancer.

For pancreatic cancer, endosonography is at present the most accurate method of imaging, especially for detecting small lesions and assessing the extent of locoregional tumour spread. Although the overall accuracy of tumour detection is nearly 100%, differentiation between cancer and pseudotumours of inflammatory origin may sometimes present a problem. Clinical history, symptoms and other imaging techniques, particularly ERCP, should therefore always be considered. On the other hand, endosonography is indicated when the other imaging techniques are negative or doubtful in the presence of a high index of clinical suspicion. In cases with proven malignant tumours, it should be performed for proper staging. The overall accuracy of staging the primary tumour is 80-90%, whereas for detecting lymph nodes it is around 75%. In contrast to angiography, endosonography gives more detailed information of major vessel involvement, an important factor in deciding whether the tumour is resectable. Endosonography is, however, not suitable for the detection of distant metastasis due to the limited penetration of ultrasound. The newly developed echoduodenoscopes, equipped with a working channel and an elevator, provide the possibility for improved accuracy of biopsy under endosonographic guidance, and under clinical evaluation. This should further improve the differentiation between pancreatic cancer and inflammatory pseudotumours, which continues to be a significant clinical problem. So far no procedure-related complications of endosonography have been reported. An adequate experience in conventional ultrasound and endoscopy is essential, however, in order to achieve reliable results.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1990

ESWL and gallstone dissolution with MTBE via a naso-vesicular catheter.

Endoscopic placement of a naso-vesicular catheter was successful in 90% (45/50) of patients with cholecystolithiasis. The first 7 patients were treated by MTBE dissolution alone. Dissolution was discontinued after a maximum of 14 days, as only two patients were rendered stone free. In one patient, 3 tiny pigment stones were sucked out through the catheter, and in another inoperable patient a pigtail endoprosthesis was finally inserted into the gallbladder. In the remaining 36 patients, combined ESWL and MTBE dissolution therapy was carried out. Treatment was broken off by one patient after one week, and interrupted in another due to catheter dislodgement. After an average of 10 days with 1-9 ESWL sessions (average: 3) complete stone clearance was achieved in 60% (20/34) of patients. Fourteen of the patients who completed treatment, and the one with catheter dislodgement still have sludge in the gallbladder, which is being treated with oral bile acids. The procedure-related complication rate was 10% (3 pancreatitis, 1 cystic duct perforation and 1 guidewire impaction). The mortality rate was zero. There was no evident complication due to either ESWL or MTBE dissolution.

Catheterization↗
PubMed1990

A new technique for replacing an obstructed biliary endoprosthesis.

We report on a new method of stent exchange using a threaded device that enables removal of the clogged stent while simultaneously maintaining the original pathway without withdrawing the endoscope. With this method stent replacement has become more reliable, safer, simpler and quicker. This technique is also suitable for removal of stents dislodged inside the duct.

Cholestasis↗
PubMedDate not supplied

Laparoscopic cholecystectomy in patient with portal cavernoma and portal hypertension.

Successful laparoscopic cholecystectomy has been reported in patients with cirrhosis of liver with portal hypertension; the procedure has, however, not been reported in patients with portal vein thrombosis, portal cavernoma and portal hypertension. We report an 18-year-old man with portal hypertension due to portal vein thrombosis and portal cavernoma who had symptomatic gallstone disease and was successfully treated with laparoscopic cholecystectomy.

Adolescent↗