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Hemodialysis is an important component of chronic renal replacement therapy, which is increasingly being provided with indwelling venous catheters. Catheter malfunction is commonly dealt with using Urokinase instillation or endovascular catheter stripping. We describe the application of a simple technique that allows the indwelling dialysis catheter to be replaced in a subcutaneous tunnel following manipulation for flow problems. Function was restored in all catheters without occurrence of tunnel infection or catheter-related sepsis. Preliminary results offer evidence of the efficacy of the technique in salvaging dialysis catheters, especially in patients with difficult vascular access.

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Clinical observations on patients with hemobilia secondary to percutaneous biliary procedures and laboratory studies on animals with experimentally induced hemobilia indicate that the presence of fresh blood or clot within the biliary tree may yield an erroneous impression of duct size in ultrasound examinations. Recognition of this potential source of error becomes increasingly important as the use of percutaneous procedures for the relief of biliary obstruction increases.

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Seventeen patients underwent monooctanoin infusion and biliary stone removal through the percutaneous transhepatic biliary drainage tract. In the first five patients, monooctanoin was infused until the stone(s) became smaller or disappeared; basket extraction was not attempted until this reduction was observed. An average of 22 hospital days was required for the procedure. In the next 12 patients, basket extraction was attempted after as few as 3 days of infusion, without waiting for a reduction in stone size. After infusion, these stones became extremely friable, fragmented easily, and were atraumatically removed through the fresh liver tract. The average hospital stay for these patients was 7 days, with no complications. The ability of monooctanoin to soften some stones allows an earlier, more aggressive approach to stone removal through the transparenchymal tract without risk of soft-tissue laceration; use of the infusion significantly decreases the hospital stay.

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Percutaneous cholecystostomy can be a useful technique for the ill, elderly, or high-risk patient, since he or she is spared open surgery. We used it successfully in a medically unstable woman with acute acalculous cholecystitis. Her drainage catheter, often the source of complications with the procedure, may have been removed too early: A small asymptomatic subdiaphragmatic fluid collection and ileus developed. However, both resolved in 48 hours.

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Percutaneous transcholecystic cholangiography was performed in three patients with normal-sized bile ducts and suspected obstructive jaundice, and it was performed 14 times in eight normal dogs. In every instance there was good demonstration of both the intra- and extrahepatic biliary tree. There were no significant clinical complications. Transcholecystic cholangiography is a technically easy, valuable alternative to transhepatic cholangiography for opacification of nondilated bile ducts.

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In five patients with bile duct obstruction, a previously inserted endoprosthesis became occluded. After repeat percutaneous biliary drainage, the prostheses were mechanically unclogged, removed, or removed and replaced. No patient required surgery, and no prosthesis reoccluded. We discuss technique for deoccluding and, if necessary, removing and replacing obstructed stents.

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Small biliary calculi discovered after the T-tube track has closed can be removed with a percutaneous transhepatic biliary catheter. Mono-octanoin can be used to reduce the size of large calculi for percutaneous extraction.

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In recent years, newer techniques have become available to the clinician for the diagnosis and treatment of biliary and pancreatic disease. This article emphasizes interventional procedures through the liver, such as percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, and ancillary techniques. Also discussed are the nonsurgical management of bile duct calculi and the diagnosis and treatment of pancreatic tumors, abscesses, and pseudocysts.

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The preventative effect of anticoagulant (heparin) and antiplatelet aggregators (dipyridamole, low-dose aspirin, and ticlopidine), which are well known as antithrombotic agents, were recognized in this study of the development of stress ulcers in rats under cold restraint stress. On the basis of these findings, we suggest that the development of stress ulceration has a thrombotic etiology and that antiplatelet aggregators may be useful in the treatment of critically ill patients with stress ulcers.

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A new gallstone solvent, monooctanoin, was tested in vitro on gallstones from 43 patients and compared with heparin, sodium dehydrocholate, and saline. Monooctanoin proved to be an excellent solvent, far superior to the other agents. It can completely dissolve or substantially reduce the size of most gallstones (except those composed of bilirubinate) in a relatively short time. Monooctanoin has been used on the bile duct stones in humans with favorable results. It can often eliminate the need for basket extraction of retained bile duct calculi. Potentially, it may be used to dissolve bile duct or gallbladder calculi in patients who are poor surgical risks.

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Successful treatment with cimetidine of a case of severe metabolic alkalosis secondary to gastric hypersecretion in the short bowel syndrome has been presented.

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A comparative study of absorbable suture materials in the presence of digestive fluids has been made. At day 7, plain and chromic catgut had lost 81% and 64% respectively of their initial tensile strengths in bile at a temperature of 37 degrees C, whereas Dexon and Vicryl preserved 82+ and 49% respectively of theirs. Plain and chromic catgut are completely dissolved in gastric juice within two days and had lost about 90% of their initial tensile strength in pancreatic juice on day 4. They produce significant tissue reaction. Dexon and Vicryl appear to be similar in their tissue reaction which is minimal. However, the former is stronger than the latter in the presence of bile. We believe the surgeon who undertakes any type of biliary tract surgery may wish to review his choice of absorbable suture material used in view of the information presented herein.

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Three techniques of retention suture application are compared for inflammatory complications. The conventional technique is compared with two new devices. Using the derivation for pressure generation, reasons are provided for the varying degree of inflammation found. Advantages of the nonspan bridging device, which allows for more precise control of applied force, are emphasized.

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