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December 1981, Volume 31, Issue 12

A Personal View

Selected Abstracts

Percutaneous Transhepatic Biliary Drainage Technique, Results, and Applications. Joseph T. Ferrucci, Jr., Peter R. Mueller and Willam P. Harbin. Radiology, 1980, 135:1.
SIXPY-TWO CONSECUTIVE patients who had percutaneous transheptaic biliary drainage perĀ­formed are presented. Internal drainage was achieved in 44 of the 62 patients, 71.4 per cent. External drainage was achieved in 12 of the 62 patients, 19.3 per cent. The over-all success rate was 93.5 per cent. No deaths attributable to the procedure were reported in this series. The incidence of delayed cholangitis is reported at 14.5 per cent.
The technique and instrumentation used are carefully described. The biliary ducts are first opacified by conventional percutaneous fine-needle transhepatic method. An 18 gauge sheathed needle is used to puncture a main hepatic duct. The various guide wires used are described. After a guide wire is passed through the cannula, an appropriate catheter is passed over the guide wire. Manipulation of both guide wire and the citheter allows positioning of the catheter. The guide wire can often be passed through a strictured area of the bile duct into the duodenum. The catheter can then be advanced over the guide wire into the duodenum.
For internal drainage in most patients, the drainage catheter used was the Ring biliary catheter with multiple side holes. The Ring catheter is described and the methods used for positioning the catheter are carefully explained. For external drainage, the Muller biliary catheter was used. This catheter and the methods of its placement arc clearly described. Postprocedural care and results are carefully described in a detailed manner.
The indications for this procedure are: palliative and therapeutic decompression, stricture dilation and percutaneous stone extraction. It was noted that decompression may allow for improved preparation of patients for operation.
-William K. Koyama

Transhepatic Cholangiography: Complications and Use Patterns of the Fine-Needle Technique; a Multi-Institutional Survey. Willam P. Harbin, Peter R. Mueller and Joseph T. Ferrucci, Jr. Radiology, 1980, 135:15.
THE: AUTHORS report their first multi-institutional study of percutaneous fine-needle transhepatic cholangiography. Eighty questionnaires were mailed to 80 hospitals and 30 questionnaires were received containing detailed reports on 1,713 procedures. To this, 293 patiens from the Massachusetts General Hospital and Harvard Medical School were added. A total of 2,006 procedures were correlated.
Serious complications amounted to 3.4 per cent of the total procedures reported. Of this, 0.20 per cent were deaths directly related to the procedure. The over-all success rate in visualizing the intrahepatic and extrahepatic ducts was 97.8 per cent. It was observed that if the operator made 12 to 14 needle passes, the over-all success rate rose to 99 per cent. If the operator made less than 6 needle passes, the over-all success rate was 95.5 per cent. A 97.8 per cent success rate was noted when the biliary ducts were dilated. A success rate of 70.2 per cent was also observed if the biliary ducts were nondilated. Four patients died because of bile peritonitis, intraperitoneal bleeding, sepsis and abscess and in the fourth instance an autopsy was not performed.
Of the 2,006 procedures, 1,620 were done by surgeons who had performed upon less than 25 patients. Sepsis was found to be the most frequent complication. Of patients with common duct stones, 71 to 90 per cent were found to have infected bile. If the common duct obstruction was secondary to a malignancy, the bile was infected in 25 to 36 per cent of the patients. The use of prophylactic antibiotic was strongly recommended before the procedure. In two patients, a small pneumothorax developed. Neither patient required chest tubes. It was also stated that if ultrasound demonstrates dilated ducts, the cho-langiographer should persist in the attempts to visualize the biliary ducts. It was believed that the 98 per cent success rate indicates the fine-needle transhepatic cholangiography to be the most definitive nonsurgical method of separating medical from surgical jaundice. It was also noted that the comparison figures relating to sheathed-needle transhepatic cholangiography were not accurate because in most instances the patients underwent surgical exploration shortly after the procedure. With regard to endoscopic retrograde cholangiopancreatography, it was thought that the percutaneous fine needle cholangiography was the procedure of choice because of the high success rate, low complication rate, lower cost, greater availability and ease of performance. The article is well researched and carefully organized, so as to facilitate the reader\'s understanding of the impact of a multi-institutional study of a relatively new procedure. There arc 55 references with this article.
-William K. Koyama.

Irradiation for Inoperable Carcinoma of the Lung and High Performance Status.
James D. Cox, Ritsuko Komaki and Donald R. Eierst. F.A.M.A., 1980, 244:1931.
Nearly one-third of the patients with carcinoma of the lung are inoperable and many of them are relatively asymptomatic. Thirty years ago, Karnosfsky and Burchenal recognized the importance of symptoms in the short term prognosis of patients with cancer. They developed a scale ranging from 100 to 0 to reflect the degrees of symptoms and incapacitation.
From January 1, 1971 through June 30, 1975, 197 patients who were previously untreated received a full course of megavoltage irradiation for inoperable carcinoma of the lung at the Medical College of Wisconsin Affiliated Hospitals. Of these 197 patients, 92 had a performance status of 80 to 100 on the Karnosfsky scale. Of 54 patients, 59 per cent, whose tumors were controlled locally by irradication, 22 per cent survived five years. None of the 38 patients with uncontrolled thoracic disease lived beyond 27 months. Eight patients were alive and free of disease 53 to 100 months after treatment. Patients having few symptoms with inoperable bronchial carcinomas can live many years if the tumor is controlled by irradiation.
It is necessary to deliver high doses of irradiaton 6,000 to 6,500 rads in six to seven weeks to improve local control rate. Other new methods of treatment should be investigated in patients with inoperable carcinoma of the lung and high performance status.
-Beatriz E. Amendola

Use of Blood in Elective Surgery. Deba P. Sarma, F.A.M.A., 1980, 243:1536.
Elective surgical procedures for which blood was ordered during a 12 month period were tabulated to show the number of units of blood cross-matched versus the number transfused intraoperatively or within 24 hours of operation. Over-all, in 546 procedures, the ratio of units cross-matched to units transfused was 4.29which is considered to be significantly higher than a more acceptable ratio of 2.5. Especially high ratios of units cross-matched per unit transfused were noted for cholecystectomy, vagotomy, spinal, fusion, total knee replacement, transurethral resection of the prostate, lithotomy, laminectomy, mediastinoscopy and thoractomy. It was recom-mended that the blood should be typed and screened for antibodies rather than typed and cross-matched for procedures in which the ratio of units transfused per patient cross-matched is less than 0.5. The implementation of this procedure would help reduce the need for a large blood inventory, save personnel time and lower the number of units of blood that are out-dated.
-Robert I). Sigky

Treatment of Advanced Breast Cancer With Norethisterone Acetate.
Marco Varini, Gabriele Tangini, Maurizio Mauri and Sergio D. Pietro. Tumori, 1979, 65:703.
The medical records of 84 postmenopausal women treated with norethisterone acetate administered orally for advanced carcinoma of the breast were analyzed. Twenty-one patients were not evaluated because of insufficient data. Of the 63 patients who were evaluated, complete plus partial response was obtained in 21, 33.3 per cent, with a median duration of ten months. Disease stabilization was observed in 16 patients for median duration of five months, while 26 patients showed progressive disease while on treatment.
The best results were observed at the level of soft tissue metastasis and in patients over 70 years of age. However, valuable responses have also been recorded in women with metastases to the bone and lung. The activity and the lack of toxicity of this compound are comparable to other progestins.
-Robert K.T. Liem

Survival and Response to Chemotherapy for Advanced Colorectal Adenocarcinoma; an Eastern Cooperative Oncology Group Report.
Philip Lavin, Arnold Mittelman, Harold Douglass Jr., and others. Cancer, 1980, 46:1436.
Thirteen hundred and fourteen patients with advanced measurable carcinoma of the colon and rectum were studied by the Eastern Cooperative Oncology Group and the results are reported. Each patient had histologically confirmed adenocarcinoma of othe colon or rectum with unresectable residual, recurrent or metastatic disease. Patients who had not previously had chemotherapy were studied in one group and those who had had previous chemotherapy were looked at separately. The patients all received either single or multiple drug therapy. The results of the study confirm that patients who underwent chemotherapy before being entered into this study were less likely to experience an objective tumor response. Furthermore, these patients had a shorter median survival time than did patients with no chemotherapy prior to study entry. Patients who had not had chemotherapy before entry into the study were separated into ten treatment programs which basically fell into four classification.

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