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Biomedical subjects

T Rösch

Publications and source records attributed to T Rösch.

At least 109 records · Page 6Linked to original sources
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

Metal stents for benign and malignant bile duct strictures stents for benign and malignant bile duct strictures.

Self-expanding metal stents provide a much larger diameter--up to 30 Fr--in comparison with plastic stents, which have a maximum diameter of 12 Fr. Although they have consequently been found to be far superior to plastic prostheses, they are not removable, and in benign strictures metal stents should therefore be used only in exceptional situations. Metal stents are the preferred mode of treatment for malignant strictures, provided the patient has a sufficient life expectancy although this is hard to predict in individual cases. Metal stents also seem to be superior in hilar malignancy, but the data here are limited. Future developments may include the use of covered metal stents and self-expanding stents (made of plastic or other materials) that are removable or self-dissolving.

Bile Duct Diseases↗
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↗
PubMed1997

Endosonographic differentiation of benign and malignant stromal cell tumors.

BACKGROUND: Endosonography (EUS) is a valuable technique for diagnosing gastrointestinal stromal cell tumors. However, EUS features that are predictive of malignancy in these tumors have not been defined. METHODS: Videotapes and photographs of EUS examinations performed prior to surgical resection of 35 stromal cell tumors (9 malignant) were blindly reviewed by a single examiner. EUS features associated with malignancy were determined. Interobserver agreement in interpreting these features was then measured among a panel of five expert endosonographers who judged EUS videotapes of 35 resected stromal cell tumors (10 malignant). RESULTS: Stepwise logistic regression analysis demonstrated that tumor size (diameter > 4 cm), irregular extraluminal border, echogenic foci, and cystic spaces were independently associated with malignancy in stromal cell tumors (p < 0.05). Interobserver agreement for irregular extraluminal border, echogenic foci, and cystic spaces, as measured by mean kappa statistic, was 0.43, 0.39, and 0.28, respectively. For the five experts, the sensitivity for detecting malignancy ranged between 80% to 100% when at least two of the three features were judged to be present. The likelihood of finding malignancy ranged between 0% to 11% for the experts when all three features were judged absent. CONCLUSIONS: Tumor size and certain EUS features are useful for predicting malignancy in stromal cell tumors. Absence of these features indicates benign disease. Agreement among experts in interpreting these EUS features is fair to moderate.

Diagnosis, Differential↗
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

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

Treatment of esophagorespiratory fistulas with silicone-coated self-expanding metal stents.

Nine self-expanding silicone-coated modified Gianturco metal stents were inserted in 8 patients (mean age, 58.2 years) for palliation of malignant esophagorespiratory fistulas caused by esophageal (n = 5) or bronchial (n = 3) carcinoma. One patient with a fistula above a 12-cm-long malignant stenosis received two overlapping stents. The implantation procedure was well tolerated by all patients under intravenous sedation and analgesia. After release, the stents expanded to their full diameter, leading to complete occlusion of the fistulas and bridging of the concomitant stenoses. Two patients with lung cancer received an additional tracheobronchial stent before esophageal stent insertion. Failure to maintain complete contact between the proximal stent margin and the esophageal wall led to insufficient sealing of the fistula of 1 patient and recurrent aspiration, manifested 6 days after stent implantation (overall success, 87.5%). The other patients could swallow semi-solid food until death. Seven patients died of advanced metastatic disease after 21 to 121 days (mean, 54 days) and 1 patient of massive hemoptysis 10 days after stent placement, which could be regarded as a complication (procedure-related mortality rate, 12.5%). These preliminary results suggest that peroral insertion of the modified silicone-coated Gianturco stent is a rapid, reasonably safe, and effective procedure for palliation of malignant esophagorespiratory fistulas.

Adenocarcinoma↗