Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.

Iodized oil uptake assessment with cone-beam CT in chemoembolization of small hepatocellular carcinomas

AIM:To evaluate the utility of assessing iodized oil uptake with cone-beam computed tomography(CT)in transarterial chemoembolization(TACE)for small he-patocellular carcinoma(HCC).METHODS:Cone-beam CT provided by a biplane flat-panel detector angiography suite was performed on eighteen patients(sixteen men and two women;41-76 years;mean age,58.9 years)directly after TACE for small HCC(26 nodules under 30 mm;mean diam-eter,11.9 mm;range,5-28 mm).The pre-procedural locations of the tumors were evaluated using tripha-sic multi-detector row helical computed tomography(MDCT).The tumor locations on MDCT and the iodized oil uptake by the tumors were analyzed on cone-beam CT and on spot image directly after the procedures.RESULTS:All lesions on preprocedural MDCT were de-tected using iodized oil uptake in the lesions on cone-beam CT(sensitivity 100%,26/26).Spot image depictediodized oil uptake in 22 of the lesions(sensitivity 85%).The degree of iodized oil uptake was overestimated(9%,2/22)or underestimated(14%,3/22)on spot image in f ive nodules compared with that of cone-beam CT.CONCLUSION:Cone-beam CT is a useful and conve-nient tool for assessing the iodized oil uptake of small hepatic tumors(< 3 cm)directly after TACE.

Therapeutic efficacy and stent patency of transhepatic portal vein stenting after surgery

AIM To evaluate portal vein(PV) stenosis and stent patency after hepatobiliary and pancreatic surgery, using abdominal computed tomography(CT).METHODS Percutaneous portal venous stenting was attempted in 22 patients with significant PV stenosis(> 50%)-after hepatobiliary or pancreatic surgery- diagnosed by abdominal CT. Stents were placed in various stenotic lesions after percutaneous transhepatic portography. Pressure gradient across the stenotic segment was measured in 14 patients. Stents were placed when the pressure gradient across the stenotic segment was > 5 mm Hg or PV stenosis was > 50%, as observed on transhepatic portography. Patients underwent followup abdominal CT and technical and clinical success, complications, and stent patency were evaluated.RESULTS Stent placement was successful in 21 patients(technical success rate: 95.5%). Stents were positioned through the main PV and superior mesenteric vein(n = 13), main PV(n = 2), right and main PV(n = 1), left and main PV(n = 4), or main PV and splenic vein(n = 1). Patients showed no complications after stent placement. The time between procedure and final follow-up CT was 41-761 d(mean: 374.5 d). Twenty stents remained patent during the entire follow-up. Stent obstruction-caused by invasion of the PV stent by a recurrent tumor- was observed in 1 patient in a follow-up CT performed after 155 d after the procedure. The cumulative stent patency rate was 95.7%. Small in-stent low-density areas were found in 11(55%) patients; however, during successive follow-up CT, the extent of these areas had decreased.CONCLUSION Percutaneous transhepatic stent placement can be safe and effective in cases of PV stenosis after hepatobiliary and pancreatic surgery. Stents show excellent patency in follow-up abdominal CT, despite development of small in-stent low-density areas.