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P Born

Publications and source records attributed to P Born.

At least 19 recordsLinked to original sources
PubMed2000

Long-term outcome in patients with advanced hilar bile duct tumors undergoing palliative endoscopic or percutaneous drainage.

OBJECTIVE: Advanced tumors of the hepatic duct bifurcation (Klatskin tumors) present problems to the endoscopist in deciding which procedure to use for palliative treatment of the resulting cholestasis--endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD), or both. There are technical difficulties with all forms of treatment for stenoses in the hilar region and intrahepatic bile ducts, and there are as yet no clear data on which type of drainage is feasible or preferable. SUBJECTS: 59 consecutive patients (30 men, 29 women; mean age 71 years) underwent palliative treatment for malignant hilar bile duct tumors of Bismuth stages II-IV during a three-year period (1992-94). METHOD: A retrospective analysis was carried out, and long-term follow-up data were obtained from telephone interviews with the patients, relatives, or referring physicians. RESULTS: The 59 patients were treated using ERCP (n = 20) or PTBD (n = 39). Three died within 30 days, and six were lost to follow-up. Clinically adequate drainage was achieved in 78% (n = 46) of the total patient group. Patient survival was a median of six months (range 0.5-38), and was slightly longer when the primary drainage procedure was successful (7.5 months). Initial complications occurred in 11% after ERCP and in 33% after PTBD, with a 30-day mortality of 5%. After the initial intervention, five patients who received ERCP treatment had to be switched to PTBD during the longer-term course. Three of these five patients died within 30 days of the PTBD insertion. CONCLUSIONS: Palliative treatment in patients with advanced Klatskin tumors is still suboptimal, even when combined endoscopic and percutaneous techniques are used in the same institution, allowing treatment to be tailored to the individual patient's needs. There is therefore a need for improvements in existing forms of treatment, as well as for the development of new forms of treatment.

Adult↗
PubMed2000

Endohyperthermia--experimental evaluation of a new therapeutic approach for treatment of biliary carcinoma.

BACKGROUND AND STUDY AIMS: To improve the prognosis of patients with unresectable, locally advanced bile duct carcinoma, new treatment strategies need to be evaluated. Hyperthermia has been successfully applied as part of multimodal therapy in esophageal and rectal carcinoma. We performed in-vitro and in-vivo experiments with a new intraluminal hyperthermia system in the biliary tract. METHODS: A radiofrequency system (13.56 MHz, Endoradiotherm XERT-200A; Olympus Optical Co., Tokyo, Japan) was used with a special intraluminal microelectrode (diameter 4.5 mm, length 40 mm) covered by a silicone balloon with cooling water and a large counter electrode for focusing the electromagnetic field around the electrode. The heating capacity of the endohyperthermia unit was examined in vitro in a muscle-equivalent phantom (agar 4 %), in isolated livers of pigs and cows, as well as in vivo in anesthetized sheep. Continuous thermometry was done with thermosensors at the applicator surface, and with multichannel thermocouple probes in the environment of the applicator. RESULTS: Endohyperthermia induced a homogeneous heating of the phantom and the isolated liver bile duct preparation to a temperature > or = 40 degrees C in an area at least 10 mm in depth. After placement of the applicator into the common bile duct of anesthetized sheep, endohyperthermia led to a consistent and repeatable heating of the surrounding tissue to 40.5 +/- 0.5 degrees C at 1 cm distance, and 39.9 +/- 0.7 degrees C at 2 cm distance. Blood pressure, heart rate, and systemic temperature did not change in vivo. Histological examination of the bile duct showed superficial mucosal necrosis (depth 100-200 microm), microvascular damage with petechiae, congestion and edema of the bile duct wall and adventitia after hyperthermia treatment in vivo. CONCLUSIONS: The intraluminal endohyperthermia system produces consistent and repeatable heating of the surrounding tissue. Since effective thermal power can reach a depth of up to 2 cm, tumors may also be heated adequately.

Animals↗
PubMed1999

Initial experience with a new Yamakawa-type prosthesis for long-term percutaneous transhepatic drainage.

BACKGROUND AND STUDY AIMS: In a previous study evaluating the problems of long-term percutaneous transhepatic biliary drainage (PTBD) using Yamakawa-type prostheses in patients with benign and malignant stenoses, breakage of the tube proved to be a serious problem, occurring in 19.7 % of PTBD exchanges. As a consequence of these results, a new PTBD tube made of Tecothane has been developed. PATIENTS AND METHODS: From September 1997 to September 1998, this new PTBD tube was applied in 64 patients (39 men, 25 women; median age: 70, range 29-89) in the treatment of benign (n = 30) or malignant stenoses (n=31; three stenoses remained indeterminate), and the course was followed. RESULTS: A total of 134 stent exchanges were performed, 52 of these being ahead of schedule (39 %). Not a single case of breakage occurred. However, other PTBD-related problems remained unchanged. Patients accepted the new prosthesis very well; among 19 patients who had experience of both the new one and the conventional one, 11 had preferences-eight for the new one and three for the old one. CONCLUSIONS: This new Tecothane prosthesis has solved the problem of PTBD breakage, which was often accompanied by serious problems. As was to be expected, other PTBD-related problems were not substantially affected. Nevertheless, this new tube represents progress in the percutaneous treatment of biliary stenoses.

Adult↗
PubMed1999

Long-term results of endoscopic and percutaneous transhepatic treatment of benign biliary strictures.

BACKGROUND AND STUDY AIMS: Benign biliary strictures, mostly associated with biliary surgery, are of growing importance for the therapeutic endoscopist. In the short term, endoscopic therapy has success rates similar to those of surgery. With regard to the long-term results, fewer data are available, particularly concerning forms of treatment including percutaneous transhepatic biliary drainage (PTBD) as an additional tool. The present study was aimed at allowing evaluation of the short and long-term results of endoscopic and percutaneous treatment in patients with benign biliary strictures. PATIENTS AND METHODS: The charts of 40 consecutive patients treated during the period 1992-1994 (12 men, 28 women; median age 60.5 years, range 24-86) were analyzed retrospectively. Long-term follow-up was carried out by direct contact. In almost all of the cases, the endoscopic treatment consisted of papillotomy and stenting (single stent treatment 10 or 11.5 Fr); Yamakawa-type prostheses (14 or 16 Fr) were used in the PTBD patients. RESULTS: The primary treatment was successful in 37 of the 40 patients, including nine of 21 patients (43 %) treated endoscopically and 28 of 31 patients (90%) treated using the percutaneous approach. The complication rates after endoscopic retrograde cholangiopancreatography (ERCP) were 14%, compared with 26% after PTBD. Relief of the stricture was achieved in 25 patients after a median period of stent treatment of nine months (range 3-44), while recurrences were seen in six patients with stents in place for only 4.5 months (range 1-8), and in one patient with a metal stent. Therapy failed in two patients, and three were lost to follow-up. Serious long-term complications were rare, but there was a fatal complication in one patient with metal stents. The follow-up period was 44 months (range 11-66). Three patients underwent successful primary surgery, and three more underwent successful surgery after stricture recurrence; all were free of complaints after 49 months (range 40-44). CONCLUSIONS: Endoscopic and percutaneous treatment of benign biliary strictures is not only a short-term treatment, but also an adequate long-term therapeutic alternative to surgery, with tolerable complication rates. The period of stenting appears to influence the outcome, and the diameter of the stents used also probably plays a role. Prospective studies are required for further evaluation of these observations.

Adult↗
PubMed1998

Randomized study of intracorporeal laser lithotripsy versus extracorporeal shock-wave lithotripsy for difficult bile duct stones.

BACKGROUND: Endoscopic treatment modalities are well established for the removal of bile duct stones. For the small percentage of stones that are difficult or impossible to extract by conventional means, more sophisticated endoscopic techniques or associated modalities such as intracorporeal laser lithotripsy (ILL) and extracorporeal shock wave lithotripsy (ESWL) have to be applied. Little is known, however, about the relative value of these different techniques. We therefore compared endoscopic ILL with ESWL in patients with difficult bile duct stones in a prospective randomized study. METHODS: The study included 60 patients (35 women; mean age 70+/-15 years) with bile duct stones in whom standard extraction failed (n=33) or in whom the papilla was not accessible, thus requiring percutaneous access (n=27). They were randomized to receive ESWL under fluoroscopic targeting (maximum discharge number per session: 6000) or ILL using a pulsed dye laser with an automatic stone recognition system, which was mostly performed (28 of 30 cases) under cholangioscopic control. Endoscopic removal of fragments was attempted within the subsequent (ESWL) or the same (ILL) session. Failure was defined as failure to remove all ductal stones/fragments after a maximum of three lithotripsy sessions. RESULTS: There were no statistical differences in background variables between the two groups. Bile duct clearance was achieved in 22 of 30 patients (73%) in the ESWL group and in 29 of 30 patients (97%) in the ILL group (p < 0.05). The number of treatment sessions (ESWL 3.0+/-1.3; ILL 1.2+/-0.4; p < 0.001) and the duration of treatment (ESWL 3.9+/-3.5 days; ILL 0.9+/-2.3 days; p < 0.001) were also significantly different in favor of ILL. Two minor complications occurred in each group; there was no 30-day mortality. Crossover therapy to ILL led to stone removal in seven of the eight cases in which ESWL failed, whereas ESWL fragmented the stone in the single patient in whom ILL failed. CONCLUSIONS: ILL is more effective in the treatment of difficult bile duct stones than ESWL in terms of stone clearance rate and treatment duration.

Aged↗
PubMed1998

Long-term results of percutaneous transhepatic biliary drainage for benign and malignant bile duct strictures.

BACKGROUND: Long-term percutaneous transhepatic biliary drainage (PTBD) is a valid alternative to surgery in patients with benign or malignant bile duct strictures in whom endoscopic drainage has failed. However, few data are available on the long-term outcome with percutaneous drainage, specially when the application of Yamakawa-type prostheses is considered. METHODS: During 1996, 48 patients who were either treated with primary PTBD insertion followed by PTBD exchanges (n = 15) or who presented only for exchange of an earlier PTBD (n = 33) were included in the study. Thirty-one patients had malignant strictures, and 17 had benign ones. The PTBD catheters were scheduled for exchange every 3 months or earlier if signs and symptoms of obstruction or other problems were present. The data were collected prospectively during each follow-up visit and included both symptoms and the status and function of the PTBD at the time of exchange. RESULTS: Although PTBD was highly effective in relieving jaundice (progression of cholestasis was observed in only 2 cases), 73 of the 157 PTBD exchanges (47%) had to be carried out earlier than scheduled. Premature exchange was needed for clinical reasons, such as fever indicating PTBD dysfunction, in only 19% of these cases. The other reasons were related to the PTBD catheter and consisted of bile leakage alongside the drain (33%), PTBD disconnection or complete dislocation (30%), or occlusion suspected during regular flushing of the drain (15%). In most cases exchanging the drain was sufficient to solve the problem; in cases of complete dislocation, dilation of the same tract (n = 6) or fresh puncture and establishment of a new drainage site (n = 2) were necessary. Reducing the PTBD exchange interval from 3 to 2 months would have decreased the number of premature stent exchanges by 26%. CONCLUSIONS: Although PTBD is an effective method of biliary drainage, there are frequently minor problems-mostly catheter-related-which require premature exchange of the drain in almost half of the cases, and this may affect the patients' quality of life. Improvements in PTBD materials and catheter design are therefore needed. The effectiveness of reducing the intervals between PTBD exchanges should also be examined.

Adult↗
PubMed1998

Visual activation in infants and young children studied by functional magnetic resonance imaging.

The purpose of this study was to determine whether visual stimulation in sleeping infants and young children can be examined by functional magnetic resonance imaging. We studied 17 children, aged 3 d to 48 mo, and three healthy adults. Visual stimulation was performed with 8-Hz flickering light through the sleeping childs' closed eyelids. Functional magnetic resonance imaging was performed with a gradient echoplanar sequence in a l.5-T magnetic resonance scanner. Six subjects were excluded because of movement artifacts; the youngest infant showed no response. In 10 children, we could demonstrate areas of signal decrease during visual stimulation in the occipital cortex (mean decrease 2.21%), contrary to the signal increase observed in the adult controls (mean increase 2.82%). This decrease may be due to a higher proportional increase in oxygen extraction compared with increase in cerebral blood flow during activation. The different response patterns in young children and adults can reflect developmental or behavioral differences. Localization of the activation seemed to be age-dependent. In the older children and the adults, it encompassed the whole length of the calcarine sulcus, whereas it was restricted to the anterior and medial part of the calcarine sulcus in the younger infants. This may reflect a different functional organization of the young child's visual cortex or the on-going retinal development.

Adult↗
PubMed1998

HMO quality and financial performance: is there a connection?

Following the continuing expansion of managed care is a growing public interest in the quality of care provided by managed care organizations. Public and private organizations are actively developing systems for measuring and monitoring quality of care with the intention of holding plans more accountable for quality improvements and encouraging health care consumers to make responsible choices. This article examines correlations between a prevention-based quality measure and other commonly used measures of differentiating health plans, including financial performance and profit status. The findings are instructive in efforts to develop a quality measurement system that incorporates a variety of measures of plan performance.

Financial Management↗
PubMed1997

Clinical and neuropathological study of six patients with spastic paraparesis associated with HTLV-I: an axomyelinic degeneration of the central nervous system.

Between 1990 to 1994, 6 TSP/HAM patients, 3 women and 3 men with an average age of 57.1 years (39 to 76 years old), who died in the Salvador Hospital were submitted to postmortem examination. The mean time of paraparesis was 7 years (3 to 17 years), and 2 patients had pseudobulbar signs. Three cases had macroscopic atrophy of the spinal cord. Histologically, all cases had lesions in the pyramidal tracts and 4 cases showed somatotopic lesions of the Goll's tracts which followed a "dying back" ascendant and descendant distribution, respectively. In 2 cases, both of which had intellectual impairment, demyelination of the subcortical and parathalamic areas was observed without U fiber involvement. Abnormal vessels with gross thickening of the adventitia, many of them with lymphocytic cuffs, were seen everywhere, especially in the spinal cord, brain stem, midbrain and meninges, but no relation between these findings and the parenchymal lesions was observed. Also, in the cases with posterior column involvement, neuronal changes and proliferation of satellite cells in the dorsal ganglia were found. All cases showed histological sialoadenitis and none had inflammatory muscle changes. We conclude that the lesions affected the neuraxis in a systemic axial fashion as in degenerative diseases, and did not seem to be secondary to vascular or inflammatory abnormalities.

Adult↗
PubMed1996

[Antibiotic prophylaxis using cefuroxime in bile duct endoscopy].

OBJECTIVE: To assess prospectively the effectiveness of a single prophylactic dose of cefuroxim before therapeutic endoscopy, in view of the general practice not to give antibiotics routinely. PATIENTS AND METHODS: In a prospective study endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography with drainage (PTCD) together with simultaneous stone extraction, dilatation or stent implantation were performed in 99 patients (51 men, 48 women; mean age 60.6 +/- 19.2 years). Group A (n = 49) received 1500 mg cefuroxim i.e. 30 min before the procedure, while none was given to group A patients (n = 50). Several blood cultures were taken up to 60 min after the endoscopy. The number of septicaemias (bacteraemia with fever, rigor, circulatory reactions, leukocytosis or leukopenia) were noted. Bile cultures were obtained in 56 patients with indwelling biliary drainage. RESULTS: Incidence of bacteraemia was 6.1% (3 of 49) in group A, 16% (8 of 50) in group B, but this difference is not statistically significant. The septicaemia rate was 6.1% in group A and 10% in group B (not significant). There were eleven positive blood cultures with 12 different microorganisms, Escherichia coli in four (A: n = 3). In vitro cefuroxim sensitivity was 53.3%. 25 different bacterial species were isolated from 73.2% of bile cultures, of which 53.4% were sensitive to cefuroxim and 8.2% moderately so. CONCLUSION: Although the obtained differences between the two groups were not statistically different, the reduction in bacteraemia/septicaemia rate may be of clinical use. Further studies are needed with higher dosages or antibiotic combinations to improve these results.

Adult↗
PubMed1996

Initial experience with a new, partially covered Wallstent for malignant biliary obstruction.

BACKGROUND AND STUDY AIMS: Metal billiary stents have been shown to be superior to plastic stents with regard to patency and the risk of dislocation. However, tumor ingrowth through the mesh continues to be a significant problem. We report here on our preliminary experience with covered metal stents. PATIENTS AND METHODS: Ten patients (mean age 68 years) with malignant biliary obstruction, who were not considered to be surgical candidates, received a partially covered Wallstent. The patients were followed up prospectively for one year, including laboratory tests, abdominal ultrasound, and plain abdominal radiographs during the first three months, and by monthly telephone interview thereafter. RESULTS: Stent insertion was technically successful in all patients, and led to a reduction in bilirubin levels from 8.4 mg/dl to 0.7 mg/dl. The mean survival of the patients was 7.5 months after the diagnosis of malignancy, and six months after stent insertion; only two patients were still alive after 12 months. During the observation period, four patients suffered from stent dysfunction for periods of one to nine months. These dysfunctions included three stent occlusions, which were successfully treated by inserting plastic stents, and one dislocation, which was treated by endoscopic replacement of the stent. There appeared to be a correlation between the narrowest stent diameter immediately after release and stent dysfunction. CONCLUSION: Covering biliary metal stents is a potential solution to prevent tissue ingrowth. However, current prototypes need to be improved in order to achieve this goal.

Aged↗
PubMed1996

Factor XIII in chronic inflammatory bowel diseases.

Severe acute inflammation in chronic inflammatory bowel disease is associated with large wound areas and ulcerations that show spontaneous hemorrhage or marked friability. Therefore, an enormous potential of hemostasis and wound healing is required. Coagulation studies demonstrate a deficiency of factor XIII that is important for both clot formation and wound healing. Consequently, the substitution of factor XIII may be beneficial; the first case reports present favorable clinical results. In a prospective pilot study, we treated 12 patients with therapy-resistant ulcerative colitis. The colitis activity index (CAI) and the endoscopic score (ES) according to Rachmilewitz were elevated; all patients suffered from hematochezia. After substitution therapy with factor XIII concentrate (1,250 U/d) the stool frequency dropped and no further hematochezia was detected. The CAI and the ES declined highly significantly. Because of these encouraging results two placebo-controlled multicenter trials have been initiated. In the first study, patients with acute stage of ulcerative colitis associated with severe intestinal blood loss are treated with two different dosages of factor XIII concentrate (1,250 and 500 U/d, respectively) or placebo for 10 days. In the second trial, patients with therapy-resistant ulcerative colitis with a lack of remission in spite of a consequent therapy for 2 weeks are included; factor XIII concentrate or placebo is administered for 10 days. The aim of both trials is an end of intestinal bleeding and the fostering of a more effective wound-healing process.

Adult↗
PubMed1996

A minimally invasive palliative approach to advanced pancreatic and papillary cancer causing both biliary and duodenal obstruction.

BACKGROUND: In patients with both duodenal and biliary obstruction in whom endoscopic drainage is not feasible, the standard approach has been gastroenterostomy plus biliodigestive anastomosis. We present our results of percutaneous biliary drainage in combination with gastroenterostomy. PATIENTS AND METHODS: Twenty-one patients, who received permanent percutaneous transhepatic biliary drainage (PTBD) and gastroenterostomy in case of symptomatic gastric outlet obstruction were retrospectively evaluated. RESULTS: PTBD insertion succeeded in all patients; minor complications were encountered in 47.6% of cases. Bilirubin fell from 9.2 mg/dl (SD 7.6) to 4.9 mg/dl (SD 3.6). Gastroenterostomy, either open (n = 10) or laparoscopic (n = 6), had to be performed in 16 patients before, during or after PTBD. Thirty day mortality was 23.8%, not related to the procedure, but due to advanced neoplastic disease. Mean survival and hospital stay were 4.9 months (SD 3.6) and 21.5 days (SD 7.3) respectively. CONCLUSIONS: The combination of PTBD and gastroenterostomy offers a promising alternative to surgery. However efforts to reduce complications as well as the duration of hospital stay are necessary.

Adult↗
PubMed1995

[Hemorrhage caused by duodenal varices].

HISTORY AND CLINICAL FINDINGS: A 53-year-old man had been passing tarry stools and bright red blood per rectum for 6 days. He had a history of pyloroplasty for duodenal ulcers, alcoholic liver cirrhosis, stage B in Child's classification, a Le Veen shunt for ascites, grade I oesophageal varices and several episodes of intestinal bleeding of uncertain cause on repeated endoscopies. Haemoglobin levels was now 4.4 g/dl. Neither oesophago-gastro-duodenoscopy nor colposcopy, radiological examination of the small intestine nor scintigraphy discovered the source of bleeding. Computed tomography revealed varices in the horizontal part of the duodenum, confirmed by arteriography. TREATMENT AND COURSE: At a second endoscopy, this time with a long scope, acute bleedings were seen in the venous convolutions and stopped with 4 ml Polidocanol. Bleeding recurred after 10 days, thought to be due to persisting portal hypertension. A transjugular intrahepatic portosystemic stent shunt (TIPSS) was inserted to lower the pressure. Colour-coded Doppler examination at the time of another bleeding 10 weeks later demonstrated occlusion of the TIPSS. It was re-opened by balloon catheter dilatation, since when there have been no further episodes of bleeding. CONCLUSION: The implantation of a TIPSS is a new causative treatment for recurrent bleeding from ectopic varices due to portal hypertension that cannot be treated by endoscopy.

Angiography↗