[Bile duct drainage: when plastic, when metal?].
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Bile Duct Neoplasms↗
Biomedical subjects
H J Wagner
Publications and source records attributed to H J Wagner.
Relief of malignant obstructive jaundice by endoscopic or percutaneous insertion of metal stents.
From January 1990 through July 1992 we attempted to treat 42 patients (21 men, 21 women; mean age 69 +/- 2 years) with obstructive jaundice due to inoperable malignant biliary obstructions with insertion of metal stents. 67% of the patients had stenoses of the distal common bile duct, 5% of the proximal common bile duct, and 28% had hilar lesions. Obstructions were due to pancreatic cancer (47%), gallbladder cancer (13%), cholangiocarcinoma (20%), and lymphoma of metastatic cancer (20%). We inserted a total of 51 Wallstents and 17 Strecker Stents with a technical success of 100%. The functional success was 95%. The mean bilirubin level decreased from 18.2 +/- 1.7 mg/dl before to 1.5 +/- 0.2 after stent insertion. In the first 30 days one patient (2%) with hilar malignancy developed an early reobstruction due to tumor bleeding and debris. The 30-day mortality rate was 2%. 2 (5%) patients developed recurrent jaundice within the 3-month follow-up period; 1 had tumor overgrowth of the metal stent, 1 had tumor ingrowth through the mesh. Metal biliary endoprotheses offer sufficient initial relief of malignant obstructive jaundice with reduced morbidity and mortality compared to the placement of conventional plastic stents. However, the long-term results are impaired by stent occlusion due to tumor ingrowth or overgrowth.
Aged↗
cAMP-mediated second messenger mechanisms are involved in spinule formation in teleost cone horizontal cells.
A number of light adaptive changes of teleost horizontal cells are mediated by dopamine D1 receptors coupled positively with the cAMP second messenger system. Spinules, finger-like extensions from horizontal cell dendrites directed towards the cone pedicle cytoplasm, are formed in response to a stimulation of D1 receptors. We studied the second messenger mechanism associated with this process using isolated dark-adapted cyprinid retinae. Increasing intracellular cAMP concentrations by adding a membrane permeable analogue, or by stimulating the adenylate cyclase and simultaneously blocking the degradation of cAMP, resulted in a significant increase of spinule numbers in spite of the absence of light. In contradistinction to using isolated retinae for pharmacological experiments, injection of drugs into the vitreous had inconsistent or negative results.
1-Methyl-3-isobutylxanthine↗
[Metal or plastic endoprostheses in malignant obstructive jaundice. A randomized and prospective comparison].
In a prospective randomized trial 58 patients (24 men, 34 women, mean age 67 +/- 13 [42-89] years) with inoperable malignant jaundice were treated with synthetic (S; n = 29) or expanding metal endoprostheses (M; n = 29). After endoscopic retrograde cholangiopancreatography patients were divided into a group with hilar (K: n = 7; M: n = 6) or distal involvement (K: n = 22, M: n = 23). In two cases with hilar involvement (28%) a synthetic endoprosthesis could not be implanted, while early prosthesis occlusion (after 2 days) was observed in one case. But in this group it was possible to implant all metal stents. In the group with distal involvement both synthetic and metal endoprostheses were successfully implanted. In the M group the proportion of patients with prosthesis failure (13.6%) was significantly higher than in the S subgroup (40.9%). The cholangitis incidence was 9% in the M group, significantly less (P less than 0.05) than in the K group (40.9%). Duration of hospital stay to treat prosthesis-related complications was significantly less in the M group (average 2.9 days) than the K group (12.9 days). It would be a great advance in palliative tumour treatment if it were possible significantly to reduce, by means of metal stents, the incidence of late cholangitis and the duration of hospital stay necessary to treat late complications. But improvement in the technique of implanting metal stents would be essential before their general use in distal lesions can be recommended.
Adult↗
[The palliative therapy of malignant esophageal obstruction with self-expanding metal endoprostheses].
A total of 23 self-expanding metal stents were implanted in 17 patients (12 men, 5 women; mean age 66 [44-83] years) with inoperable malignant obstruction of the oesophagus or the oesophago-gastric junction. A primary success was achieved in all, a good functional result in 16 (94%). There were no complications. In the follow-up period (mean of 15.2 +/- 13 weeks) re-obstruction by the tumour process occurred in three patients. Twelve patients died after a mean survival time of 15.8 +/- 14 weeks. In ten of these the stent was still patent at death, while two had again developed dysphagia. The cumulative patency rate of the stents was 79%. These observations indicate that self-expanding metal stents can achieve satisfactory palliation in dysphagia due to a malignancy. The mortality and morbidity rates of the method seem to be less than those of other palliative measures.
Adenocarcinoma↗
Localization and function of dopamine in the adult vertebrate retina.
Dopamine (DA) has satisfied many of the criteria for being a major neurochemical in vertebrate retinae. It is synthesized in amacrine and/or interplexiform cells (depending on species) and released upon membrane depolarization in a calcium-dependent way. Strong evidence suggests that it is normally released within the retina during light adaptation, although flickering and not so much steady light stimuli have been found to be most effective in inducing endogenous dopamine release. DA action is not restricted to those neurones which appear to be in "direct" contact with pre-synaptic dopaminergic terminals. Neurones that are several microns away from such terminals can also be affected, presumably by short diffusion of the chemical. DA thus affects the activity of many cell types in the retina. In photoreceptors, it induces retinomotor movements, but inhibits disc shedding acting via D2 receptors, without significantly altering their electrophysiological responses. DA has two main effects upon horizontal cells: it uncouples their gap junctions and, independently, enhances the efficacy of their photoreceptor inputs, both effects involving D1 receptors. In the amphibian retina, where horizontal cells receive mixed rod and cone inputs, DA alters their balance in favour of the cone input, thus mimicking light adaptation. Light-evoked DA release also appears to be responsible for potentiating the horizontal cell-->cone negative feed-back pathway responsible for generation of multi-phasic, chromatic S-potentials. However, there is little information concerning action of DA upon bipolar and amacrine cells. DA effects upon ganglion cells have been investigated in mammalian (cat and rabbit) retinae. The results suggest that there are both synaptic and non-synaptic D1 and D2 receptors on all physiological types of ganglion cell tested. Although the available data cannot readily be integrated, the balance of evidence suggests that dopaminergic neurones are involved in the light/dark adaptation process in the mammalian retina. Studies of the DA system in vertebrate retinae have contributed greatly to our understanding of its role in vision as well as DA neurobiology generally in the central nervous system. For example, the effect of DA in uncoupling horizontal cells is one of the earliest demonstrations of the uncoupling of electrotonic junctions by a neurally released chemical. The many other, diverse actions of DA in the retina reviewed here are also likely to become model modes of neurochemical action in the nervous system.(ABSTRACT TRUNCATED AT 400 WORDS)
Amphibians↗
Technical failure of biliary metal stent deployment in a series of 116 applications.
Biliary metal stents are thought to offer improved long-term palliation of malignant biliary obstruction due to a lower incidence of migration and clogging. Placement of these stents is technically more complicated than that of plastic endoprostheses and requires two experienced physicians. We report the incidence and reasons for apparent malfunction of expandable metal stent deployment (Wallstents and Strecker stents). In 116 applications of 82 Wallstents (endoscopic approach: n = 33, transhepatic approach: n = 49), we observed 19 cases of stent malfunction due to technical problems of stent delivery. In 13 cases (15.8%), the restraining membrane of the Wallstent could not be retracted sufficiently to deliver the stent. There were 6 (17.6%) failures in 34 cases of Strecker stent deployment. In 3 cases, we noted difficult balloon removal, including avulsion of the balloon catheter shaft within the endoscope during attempted balloon removal in one case. In one case, the Strecker stent could only be released partially, requiring subsequent endoscopic extraction. In two patients, only partial expansion of one end of the Strecker stent could be achieved. Given the significant malfunction rate of expandable metal stents during stent delivery, further improvements in the delivery system of the metal stents are required.
Cholestasis, Extrahepatic↗
Self-expanding metal stents for palliation of malignant esophageal obstruction--a pilot study of eight patients.
We sought to determine whether the application of a self-expanding metal stent enables palliation of malignant dysphagia with minimal risk. The results of pilot studies from two centers are reported. We treated 8 inoperable patients with a 14 mm self-expanding metal stent (Wallstent). The stent was applied without general anesthesia under mild i.v. sedation. The procedure was successful in all cases. No side effects were noted. In one patient, tumor ingrowth through the meshes of the stent occurred. This patient was additionally treated with a percutaneous gastrostomy. One patient experienced tumor overgrowth of the proximal end, necessitating laser treatment. Three patients were still alive after three months. The mean number of cumulative endoscopic interventions per patient was 2.2 (SD: +/- 2; median 2). The mean observation time was 10.7 weeks +/- 2 (median 12). Dysphagia was graded from 0 (normal swallowing) to 4 (inability to swallow saliva). Dysphagia was significantly (p less than 0.0005) reduced from grade 3.1 (SD: +/- 0.35) to 0.5 (SD: +/- 0.5) immediately after stenting. 62.5% of the patients were able to manage a virtually normal diet (in one of these patients dysphagia recurred six weeks after stent placement due to tumor ingrowth). Six patients (75%) were able to ingest all necessary calories orally. The application of a 14 mm self-expanding metal stent in cases of inoperable malignant esophageal obstruction seems to offer safe and effective palliation of malignant dysphagia.
Adenocarcinoma↗
[A prospective study to determine the recanalization time with a guide wire/recanalization catheter system in arterial occlusions].
The success rate and time taken for recanalization was determined in a prospective study of 82 consecutive unselected patients (53 men, 29 women; mean age 65.7 +/- 13, from 28 to 88 years). There were 106 complete occlusions of infrarenal arteries and a hydrophilic guide wire with a special 5-F recanalization catheter was used. Mean occlusion length was 12.97 +/- 10 cm (from 1 cm-45 cm). 79.3% of occlusions were in the femoro-popliteal territory, 6.6% were iliac and 14.1% tibial. 101 of the 106 occlusions were recanalized (95.3%). Mean recanalization time was 120.8 +/- 228.1 s (from 1 s-1440 s), mean recanalization velocity was 0.11 cm/s. The majority of obstructions could be recanalized in less than one minute. The five occlusions which could not be recanalized were distal lesions in the superficial femoral artery and which were longer than 10 cm; two were calcified. There were no complications resulting from the recanalization apart from three perforations which were clinically not apparent. Consequent angioplasty proved successful in 78.1% of these patients.
Adult↗
Detection and quantification of latently infected B lymphocytes in Epstein-Barr virus-seropositive, healthy individuals by polymerase chain reaction.
We designed a highly sensitive and specific polymerase chain reaction assay for the detection of Epstein-Barr virus (EBV)-related sequences in B-cell DNA of EBV-seropositive healthy individuals. By using this assay, we were able to amplify at least 10 copies of a plasmid containing the BamHI-W region, which is repeated up to 11 times within the EBV genome, in the presence of 1 microgram of EBV-negative DNA, indicating that one virus genome was detectable from 150,000 cells. In 15 of 16 tested individuals, EBV-related sequences were found frequently when the DNA from 10(6) B lymphocytes was examined and 1 microgram of DNA was used in each polymerase chain reaction. When the results of amplifying the diluted plasmid were used as a semiquantitative standard, the number of EBV genomes detected could be estimated to range between 50 and less than 1 from 10(6) B lymphocytes. The results of our study will provide the basis for further investigations of the characteristics of the latent carrier state in healthy EBV-seropositive individuals, such as the determination of the number of virus copies per cell and expression of antigens.
Antibodies, Viral↗
Acute embolic occlusions of the infrainguinal arteries: percutaneous aspiration embolectomy in 102 patients.
Percutaneous aspiration embolectomy (PAE) was performed on acute embolic occlusions of infrainguinal arteries unrelated to percutaneous transluminal angioplasty or chronic atherosclerotic arterial occlusive disease. Of 102 patients, most (62.7% [n = 64]) had limb-threatening ischemia (stages III and IV according to the Fontaine classification); 86.3% (n = 88) had cardiac disease that caused the embolic occlusion. The clinical success rate was 87.3% (n = 89). Major complications occurred in 8.8% (n = 9) of the cases. The 30-day mortality was 3.9% (n = 4). In comparison with Fogarty-catheter embolectomy, PAE has a higher success rate and a lower mortality. PAE has several advantages: It is a simple technique with reduced invasiveness, combines a diagnostic and a therapeutic procedure, enables treatment of tibial and pedal vessels, and can be combined with all other angioplastic methods.
Acute Disease↗
[Prospective study of the timing of recanalization with a conventional guide wire/catheter system in arterial occlusions].
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Adult↗
[The fitness of dialysis patients to drive a motor vehicle].
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Automobile Driving↗
[Rotation aspiration thromboembolectomy].
Rotating aspiration thromboembolectomy (RAT) was performed in 32 patients (11 women and 21 men; mean age 68 [41-92] years with infrainguinal arterial occlusion, various conventional angioplasty techniques having been unsuccessful. Mean length of occlusion was 19.7 cm (2-47 cm). 17 patients were in stage IIb, 8 in stage III and 7 in stage IV (Fontaine classification). RAT consists of mechanical fragmentation of thrombotic or embolic occlusion material during simultaneous infusion of urokinase, followed by aspiration of the material. Primary success (residual stenosis less than or equal to 50%) was demonstrated by angiography in 31 of 32 patients, while primary clinical success (reduction by at least one Fontaine stage) occurred in 29 patients. These results demonstrate that RAT is a suitable method for the percutaneous intraluminal treatment of long thrombotic or embolic occlusions in which conventional angioplasty techniques have previously failed.
Adult↗
Dopamine and plasticity of horizontal cell function in the teleost retina: regulation of a spectral mechanism through D1-receptors.
The negative feed-back interaction between horizontal cells (HCs) and cones in the cyprinid fish retina is thought to be mediated by horizontal cell spinules. These are "plastic" structures, largely absent from the dark-adapted retina and formed anew during light adaptation. We have previously shown that horizontal cell feed-back is similarly enhanced by light adaptation. The role of the interplexiform cell transmitter dopamine in both processes has been studied in the roach retina. Application of dopamine to dark-adapted retinae induced spinule formation in a dose-dependent way. The effect of dopamine was mimicked by dibutyryl-cAMP and suppressed selectively by D1 receptor antagonists. The effect of light in inducing spinule formation was lost in retinae depleted of endogenous dopamine. However, application of exogenous dopamine to these retinae triggered normal spinule formation. For all pharmacological treatments used, there was a strong correlation between spinule number and degree of feed-back activity in biphasic horizontal cells. Thus, when the spinule content of the cone pedicles was high, biphasic horizontal cell responses exhibited strong depolarizing components and vice versa. It is concluded that light-evoked formation of spinules in HC dendrites involves the action of dopamine upon D1 receptors. Spinules, in turn, are likely to be presynaptic terminals mediating the dynamic negative feed-back effect of horizontal cells upon cones.
Animals↗
Characterization of a GABAergic population of interstitial amacrine cells in the teleost retina.
We used postembedding immunocytochemistry with an antiserum against BSA-conjugated GABA to study the inner plexiform layer of a cyprinid teleost, the roach. In this part of the retina, we observed a distinct banding pattern of GABA-positive material. There was a narrow unstained region separating the distal sublamina a from the proximal sublamina b; each sublamina was further subdivided into four (a) and two (b) sublayers of heavier staining, respectively. Using three-dimensional reconstruction of series of half-micron tangential sections, we were able to characterize a population of interstitial amacrine cells which contained GABA-like immunoreactive material. These cells had elliptical dendritic fields (area: about 0.04 mm2) and conspicuous, thick processes (dia. 4-5 microns). In tangential sections, the dendrites of individual cells appeared to be in close contact, occasionally resulting in difficulties in defining the boundaries of a single dendritic field. Two sub-populations of these cells were observed, one in each sublamina. By comparison with a catalogue of Golgi impregnated amacrine cells and cells microinjected with Lucifer Yellow or HRP, the identity of this type of interstitial amacrine cell is established and its possible physiological properties discussed. Apart from this GABA positive type, a second population of interstitial amacrine cell was observed which did not show positive reaction to the GABA antiserum used.
Animals↗
Biocytin: intracellular staining, dye-coupling and immunocytochemistry in carp retina.
Correlation of electrophysiological and morphological, including ultrastructural, characteristics of neurones is important for understanding the functional organization of neuronal systems. Further correlation with neurotransmitter content is essential for determining the neurochemical(s) used by a given neurone for propagating its signal. The two main neuronal markers presently available (lucifer yellow and horseradish peroxidase) are not satisfactory for correlating all three aspects. We have devised a new simple procedure whereby retinal interneurones can be labelled with biocytin by positive ionophoresis of an unbuffered solution. Biocytin readily crosses gap junctions thus revealing extensive networks of coupled cells. In the case of H1 horizontal cells, which are known to be GABAergic, the neurotransmitter can also be demonstrated by superimposed immunocytochemistry.
Animals↗
Dendritic contacts between neighboring homologous amacrine cells in carp retina.
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Animals↗