Name: a two-step method for percutaneous transhepatic choledochoscopic lithotomy
Uploaded: 2022-09-13T12:30:00
Description: Watch this Scientific Journal Video about A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy at JoVE.com

Die Studie wurde von der Ethikkommission des Second Affiliated Hospital des Shantou University Medical College (Shantou, China) genehmigt.
1. Vorbereitungen
<ol><li>Anwendung strenger Ausschlusskriterien bei der Auswahl von Patienten und Einholung unterzeichneter Einwilligungserklärungen12 (Tabelle 1).</li>
	<li>Wenden Sie die folgenden Zulassungskriterien an:<ol><li>Wählen Sie Patienten aus, die freiwillig die zweistufige PTCSL-Beh...

<ol>
	<li>Shu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+laparoscopic+surgery+for+complex+hepatolithiasis:+a+propensity+score+matching+analysis.">Robotic-assisted laparoscopic surgery for complex hepatolithiasis: a propensity score matching analysis.</a> Surgical Endoscopy. 33 (8), 2539-2547 (2019).</li><li>Korkes, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+treatment+of+complex+biliary+stone+disease+using+endourological+technique+and+literature+review.">Percutaneous treatment of complex biliary stone disease using endourological technique and literature review.</a> Einstein. 13 (4), 611-615 (2015).</li><li>Gamal, E. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+video+choledochoscopic+treatment+of+retained+biliary+stones+via+dilated+t-tube+tract.">Percutaneous video choledochoscopic treatment of retained biliary stones via dilated t-tube tract.</a> Surgical Endoscopy. 15 (5), 473-476 (2001).</li><li>Khalid, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+endoscopic+biliary+exploration+in+complex+biliary+stone+disease:+Case+series+study.">Percutaneous endoscopic biliary exploration in complex biliary stone disease: Case series study.</a> International Journal of Surgery. 24, 73-78 (2020).</li><li>Kim, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+cholangioscopic+treatment+of+patients+with+benign+bilio-enteric+anastomotic+strictures.">Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures.</a> Gastrointestinal Endoscopy. 58 (5), 733-738 (2003).</li><li>Hwang, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+for+recurrent+cholangitis+after+initial+hepatolithiasis+treatment.">Risk factors for recurrent cholangitis after initial hepatolithiasis treatment.</a> Journal of Clinical Gastroenterology. 38 (4), 364-367 (2004).</li><li>Bonnel, D. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Common+bile+duct+and+intrahepatic+stones:+results+of+transhepatic+electrohydraulic+lithotripsy+in+50+patients.">Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients.</a> Radiology. 180 (2), 345-348 (1991).</li><li>Kondo, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+clinicopathologic+study+of+primary+cholesterol+hepatolithiasis.">A clinicopathologic study of primary cholesterol hepatolithiasis.</a> Hepato-gastroenterology. 42 (5), 478-486 (1995).</li><li>Williams, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Updated+guideline+on+the+management+of+common+bile+duct+stones+(CBDS).">Updated guideline on the management of common bile duct stones (CBDS).</a> Gut. 66 (5), 765-782 (2017).</li><li>Makuuchi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonically+guided+cholangiography+and+bile+drainage.">Ultrasonically guided cholangiography and bile drainage.</a> Ultrasound in Medicine &amp; Biology. 10 (5), 617-623 (1984).</li><li>Jeng, K. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+cholangioscopy+in+the+treatment+of+complicated+intrahepatic+biliary+strictures+and+hepatolithiasis+with+internal+metallic+stent.">Percutaneous transhepatic cholangioscopy in the treatment of complicated intrahepatic biliary strictures and hepatolithiasis with internal metallic stent.</a> Surgical Laparoscopy. 10 (5), 278-283 (2000).</li><li>Zhuo, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+choledochoscopic+lithotomy+(PTCSL)+is+effective+for+the+treatment+of+intrahepatic+and+extrahepatic+choledocholithiasis.">Percutaneous transhepatic choledochoscopic lithotomy (PTCSL) is effective for the treatment of intrahepatic and extrahepatic choledocholithiasis.</a> Surgical Laparoscopy, Endoscopy &amp; Percutaneous Techniques. 31 (3), 326-330 (2020).</li><li>Hazey, J. W., McCreary, M., Guy, G., Melvin, W. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+percutaneous+treatment+of+biliary+tract+calculi+using+the+holmium:+YAG+laser.">Efficacy of percutaneous treatment of biliary tract calculi using the holmium: YAG laser.</a> Surgical Endoscopy. 21 (7), 1180-1183 (2007).</li><li>Ozturk, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+surgical+technique+applied+with+urological+instruments+in+bilobar+multiple+hepatolithiasis:+Ultra-mini+percutaneous+hepatolithotomy.">New surgical technique applied with urological instruments in bilobar multiple hepatolithiasis: Ultra-mini percutaneous hepatolithotomy.</a> Turkish Journal of Urology. 43 (3), 371-377 (2017).</li><li>Ozcan, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+removal+of+bile+duct+stones:+results+of+261+patients.">Percutaneous transhepatic removal of bile duct stones: results of 261 patients.</a> Cardiovascular and Interventional Radiology. 35 (3), 621-627 (2012).</li><li>Kint, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+treatment+of+common+bile+duct+stones:+results+and+complications+in+110+consecutive+patients.">Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients.</a> Digestive Surgery. 32 (1), 9-15 (2015).</li><li>Yeh, Y. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+trans-hepatic+cholangioscopy+and+lithotripsy+in+the+treatment+of+intrahepatic+stones:+a+study+with+5+year+follow-up.">Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up.</a> Gastrointestinal Endoscopy. 42 (1), 13-18 (1995).</li><li>Jan, Y. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+trans-hepatic+cholangioscopic+lithotomy+for+hepatolithiasis:+long-term+results.">Percutaneous trans-hepatic cholangioscopic lithotomy for hepatolithiasis: long-term results.</a> Chang Gung Medical Journal. 17 (1), 149 (1994).</li><li>Cheon, Y. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+long-term+results+and+recurrent+factors+after+operative+and+nonoperative+treatment+for+hepatolithiasis.">Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis.</a> Surgery. 146 (5), 843-853 (2009).</li><li>Tsutsumi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparative+evaluation+of+treatment+methods+for+bile+duct+stones+after+hepaticojejunostomy+between+percutaneous+transhepatic+cholangioscopy+and+peroral,+short+double-balloon+enteroscopy.">A comparative evaluation of treatment methods for bile duct stones after hepaticojejunostomy between percutaneous transhepatic cholangioscopy and peroral, short double-balloon enteroscopy.</a> Therapeutic Advances in Gastroenterology. 10 (1), 54-67 (2017).</li></ol>

Intrahepatische und extrahepatische Choledocholithiasis tragen zur Gallenobstruktion bei, und die damit verbundene Cholangitis könnte zu gramnegativer Endotoxämie mit klinischen Manifestationen eines septischen Schocks oder einer Multiorganfunktionsstörung führen. Daher stellen Gallensteine eine komplexe Erkrankung dar, die für Chirurgen eine Herausforderung darstellen kann, insbesondere bei Patienten mit früheren komplexen Bauchoperationen oder Patienten mit abnormaler anatomischer Struktur. PTCSL ist weltweit wei...

Die intrahepatische und extrahepatische Choledocholithiasis ist ein komplexes medizinisches Problem, mit dem Chirurgen konfrontiert sind, und ist in ostasiatischen Ländern sehr verbreitet1. Derzeit ist ein chirurgischer Eingriff für die meisten Choledocholithiasis erforderlich, während die Hauptbehandlungen für Gallengangssteine offene Chirurgie, perkutane transhepatische choledochoskopische Lithotomie (PTCSL), laparoskopische Lithotomie2, perkutane endoskopische Gallenexploration 3,4 und endoskopische retrograde Cholangiopankreatikographie umfassen. Patienten mit bilioenterischer Anastomose oder Billroth-II-Rekonstruktion mit einer abnormalen anatomischen Struktur wie einem zwölffingerdarm-periampullären Divertikel, das den Gallengang durch einen endoskopischen Ansatz schwer zugänglich macht 5,6,7,8, oder die sich früheren komplexen Bauchoperationen, einschließlich partieller Gastrektomie, unterzogen haben, konnten sich keiner endoskopischen Therapie oder laparoskopischen Lithotomie unterziehen. Die endoskopische Therapie ist möglicherweise auch nicht für Hepatolithiasis mit großen und impaktierten Steinen geeignet. Daher kann PTCSL im Allgemeinen eine bessere Wahl sein9.
Der traditionelle PTCS-Ansatz folgt einem solchen Verfahren, um den Sinus allmählich zu erweitern und eine perkutane transhepatische Gallendrainage10,11 durchzuführen, die einen relativ langen Krankenhausaufenthaltszyklus erfordert, normalerweise zwischen 2 und 3 Wochen, was zu einem Potenzial für Gallenfisteln, Gallenwegsinfektionen, Blutungen und Peritonitis mit mehreren expandierenden Scheidengrößen führt. Das Verfahren besteht aus zwei Teilen. Im ersten Schritt wird der Zielgallengang punktiert und der Führungsdraht eingeführt, während der Gallenabfluss beobachtet wird. Dann wird ein Dilatator verwendet, um den Kanal entlang des Führungsdrahtes langsam zu erweitern. Nachdem der Kanal erfolgreich etabliert ist, wird der Dilatator herausgezogen, ein Abfluss in den Zielgallengang eingeführt und der Führungsdraht herausgezogen.
Die perkutane Leberpunktion und -drainage (PTCD) ist abgeschlossen, wenn der Gallenabfluss ungehindert ist und der Abfluss ohne Blutabfluss fixiert ist. Der Sinustrakt wird 1 Woche nach PTCD stabil, wenn er dann erweitert werden kann. Der Führungsdraht wird in das Abflussrohr eingeführt und mit einem 10F-Dilatator durch den Sinustrakt entlang des Führungsdrahtes erweitert und schließlich in einen 10F-Abfluss gelegt. Der Sinustrakt wird einmal pro Woche nach der Operation erweitert, wobei jedes Mal eine 2F-Größe zunimmt, so dass der Sinustrakt 4 Wochen nach PTCD auf 16F erweitert werden kann. Im zweiten Schritt, nach der Erweiterung des Sinustraktes auf 16F, wird die Operation zur Entfernung des Steins mit einer Gallenfaserlinse durchgeführt. Daher erfordert die oben beschriebene traditionelle PTCSL einen Behandlungszyklus und trägt zu einem hohen wirtschaftlichen Druck für die Patienten bei. Darüber hinaus sind die geringe Effizienz der Steinextraktion und wiederholte und mehrfache chirurgische Eingriffe zur Steinentfernung ebenfalls unvermeidliche Nachteile herkömmlicher PTCS, was den Einsatz dieser Technologie einschränkt.
Ab Januar 2013 begannen wir, PTCS für die minimalinvasive Behandlung von Patienten mit komplexer intrahepatischer und extrahepatischer Choledocholithiasis in unserem Krankenhaus anzuwenden, modifizierten jedoch einige wichtige Schritte des traditionellen PTCS. Im ersten Schritt wurde die Operation 1 Woche nach PTCD durchgeführt, gerade als der Sinustrakt stabil wurde, und der Sinus wurde direkt auf 16F erweitert, wobei ein 16F-Expander verwendet wurde, der die präoperative Vorbereitungszeit stark reduzierte. Im zweiten Schritt wurde anders als bei der traditionellen Technologie ein Wolf-Nephroskop anstelle eines herkömmlichen Choledochoskops verwendet, um die Operation durchzuführen, die wir als "zweistufige PTCSL-Methode" bezeichnen. Um festzustellen, ob das PTCSL-Verfahren sicher, minimalinvasiv und effizient war, untersuchte diese Studie retrospektiv 81 Patienten mit intrahepatischer und extrahepatischer Choledocholithiasis, die von Januar 2013 bis Januar 2020 mit der zweistufigen PTCSL-Methode behandelt wurden.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% Normal saline solution</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>16-F series fascia dilator</td>
			<td></td>
			<td>type PLVW, Cook Medical</td>
			<td></td>
		</tr>
		<tr>
			<td>adjustable pressure pump</td>
			<td></td>
			<td>type APL; Guangzhou Jielun Medical Equipment Co. , Ltd, Guangdong Province, China</td>
			<td></td>
		</tr>
		<tr>
			<td>biliary balloon dilator</td>
			<td></td>
			<td>ATB advance; Cook Medical</td>
			<td></td>
		</tr>
		<tr>
			<td>blade</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>camera system</td>
			<td></td>
			<td>1088i HD Camera Control Unit, PAL 220 V; Stryker Corporation</td>
			<td></td>
		</tr>
		<tr>
			<td>Cavity mirror protective sleeve</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>clamp</td>
			<td></td>
			<td>5Fr, Richard Wolf GmbH, Germany</td>
			<td></td>
		</tr>
		<tr>
			<td>color ultrasound machine</td>
			<td></td>
			<td>DC-N2S, Mindray</td>
			<td></td>
		</tr>
		<tr>
			<td>Cook net basket</td>
			<td></td>
			<td>NGE-017115-MB, COOK Medical Inc. , Bloomington, USA</td>
			<td></td>
		</tr>
		<tr>
			<td>drainage pack</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>expander</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>guide wire</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>hydroelectric lithotripter</td>
			<td></td>
			<td>Aymed Medical, <img alt="Equation 1" src="/files/ftp_upload/63206/63206eq01.jpg" style="margin: auto;" />stanbul, Turkey</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;Iodophor</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;Kidney basin</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>light source</td>
			<td></td>
			<td>Voice-control compatible X8000 Xenon Light Source of 300 W;Stryker Corporation, MI</td>
			<td></td>
		</tr>
		<tr>
			<td>Medical syringe</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>puncture needle</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>suction apparatus</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>surgical gauze</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>trocar</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>Wolf nephroscope</td>
			<td></td>
			<td>12-degree Ultra-Wide-Angle Ureteroreno-scope; Richard Wolf GmbH, Germany</td>
			<td></td>
		</tr>
		<tr>
			<td>zebra guide wire</td>
			<td></td>
			<td>type HAW; Cook Medical, Bloomington, IN</td>
			<td></td>
		</tr>
	</tbody>
</table>

a two-step method for percutaneous transhepatic choledochoscopic lithotomy

Die intrahepatische und extrahepatische Choledocholithiasis ist eine Herausforderung im Bereich der Gallenchirurgie. Wir präsentieren unsere Erfahrungen mit einem zweistufigen perkutanen transhepatischen choledochoskopischen Lithotomieverfahren (PTCSL) zur Behandlung anspruchsvoller Gallensteine. Wir überprüften retrospektiv 81 Patienten mit intrahepatischer und extrahepatischer Choledocholithiasis, die von Januar 2013 bis Januar 2020 mit dieser zweistufigen PTCSL behandelt wurden, darunter 40 Männer und 41 Frauen mit einem Durchschnittsalter von 66 Jahren. Im Gegensatz zur traditionellen perkutanen transhepatischen Cholangioskopie (PTCS) wurde ein Kanal direkt durch eine 16F-Amplatz-Hülle hergestellt und der Stein im Kanal mit Hilfe eines Nephroskops entfernt. Die klinische Wirksamkeit und Komplikationen aller Patienten wurden analysiert. Bei einundachtzig Patienten (81/81, 100%) wurden die Gallensteine erfolgreich entfernt; Bei 62/81 Patienten (76,5%) wurden Gallensteine nach der ersten Operation vollständig entfernt; 17/81 Patienten (21%) wurden einer zweiten Operation unterzogen; 2/81 Patienten (2,5%) benötigten eine dritte Operation, um die Steine vollständig zu entfernen. Die Häufigkeit schwerer Blutungen während der Operation betrug 0%, und es gab keine Todesfälle. Die Anwendung der zweistufigen PTCSL-Methode ist sicher und wirksam und trägt zu einer besseren Prognose der intrahepatischen und extrahepatischen Choledocholithiasis bei.

Bei allen Patienten wurden die Gallenwegssteine erfolgreich entfernt, wobei bei 58 Patienten (58/81, 72%) Gallengangssteine nach der ersten Operation vollständig entfernt wurden, bei 18 Patienten (18/81, 22%) eine zweite Operation und bei fünf Patienten (5/81, 6%) bei einer dritten Operation zur vollständigen Entfernung der Steine. Drei Patienten hatten im 5. und 6. postoperativen Jahr eine rezidivierende intrahepatische Cholelithiasis. Es gab 56 Patienten (56/81, 68,7%), die sich einer perkutane...

Watch this Scientific Journal Video about A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy at JoVE.com

A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy

Diese "zweistufige Methode" verbesserte signifikant die Erfolgsrate der perkutanen transhepatischen Choledochoskopie und erreichte eine bessere Prognose der intrahepatischen und extrahepatischen Choledocholithiasis.

Eine zweistufige Methode zur perkutanen transhepatischen choledochoskopischen Lithotomie

Intrahepatic and extrahepatic choledocholithiasis is a challenge in the field of biliary surgery. We present our experience using a two-step percutaneous ...

Dieses Protokoll verbessert signifikant die Erfolgsrate der perkutanen transhepatischen Choledochoskopie und erreicht eine bessere Prognose der intrahepatischen und extrahepatischen Choledocholithiasis. Diese Technik reduziert das Wiederauftreten der intrahepatischen und extrahepatischen Choledocholithiasis und verkürzt die gesamte Lithotripsieperiode, die Operationszeit und den Abstand zwischen Hauteintrittsstellen und gezielten Gallengängen. PTCSL kann eine bessere Wahl für die Behandlung komplexer intrahepatischer und extrahepatischer Choledocholithiasis sein, z. B. bei Patienten, die sich zuvor einer komplizierten Bauchoperation unterzogen hatten oder anatomische Anomalien aufwiesen und sich keiner endoskopischen Untersuchung unterziehen konnten.Diese Technik kann auch für die perkutane Nephrolithotomie verwendet werden, um Nierensteinprobleme zu behandeln. Die Struktur des intrahepatischen Gallengangs ist komplex und anfällig für Verletzungen, was das chirurgische Risiko erhöht, und die visuelle Demonstration kann diese gefährlichen Komplikationen besser vermeiden. Führen Sie eine Woche vor der Operation das Verfahren zur perkutanen transhepatischen Cholangiodrainage oder PTCD durch.Führen Sie einen verweilbaren 8F-Gallendrainageschlauch ein, um die Schwellung des Gallengangs zu entleeren und zu reduzieren. Warten Sie, bis der Sinustrakt eine Woche nach diesem Eingriff stabil ist. Injizieren Sie 20 Milliliter Kochsalzlösung in den Gallengang entlang des Drainagerohrs.Nachdem ein Führungsdraht eingeführt wurde, ziehen Sie das PTCD-Rohr heraus. Um den Fasziendilatator in der Hülle zu platzieren, erweitern Sie den Sinus mit einem 16F-Expander und verbinden Sie einen 16F-Gürteldilatator, so dass die 16F-Hülle den Gallengang erreichen kann, in dem der Stein platziert worden sein könnte. Finde die Steine.Verwenden Sie Klemmzangen, um die Steine zu brechen und zu entfernen. Waschen Sie kleine Steine und pulverisierte Steine mit einer einstellbaren Druckpumpe aus. Lassen Sie am Ende des Eingriffs eine Woche lang einen Drainageschlauch im Inneren des Patienten.Mit PTCSL wurden bei allen Patienten die Gallenwegssteine erfolgreich entfernt. Bei 72% der Patienten wurden die Gallengangssteine nach der ersten Operation vollständig entfernt, während 28% der Patienten mehr als eine Operation benötigten. 56 Patienten wurden einer perkutanen Leberoperation unterzogen und 25 Patienten wurden operiert, indem sie einen Sinus verweilten, der von einem T-Schlauch gebildet wurde.Die Anzahl der Steine entsprach einem von 70 Patienten. Der durchschnittliche Krankenhausaufenthalt betrug 11 Tage. Es gab eine Komplikation einer kleinen Menge an reaktivem Pleuraerguss.Leichte intraoperative Gallenblutungen wurden bei zwei Patienten beobachtet, und ein Patient hatte nach der Operation eine Galleninfektion. Es wurden jedoch keine massiven Blutungen der Gallenwege beobachtet. Präoperativer Ultraschall wurde verwendet, um die Steinposition genau zu lokalisieren und den 8F-Abfluss beizubehalten, und der Sinus wurde direkt mit einem 16F-Expander erweitert.

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Medicine

A Modified Method for Heterotopic Mouse Heart Transplantion

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents available. A difficulty is presented due to the small size of the animal and the considerable technical challenges of the microsurgery involved in heart transplantation. In particular, a high rate of technical failure early after transplantation may result from recipient death and post-operative complications such as hind limb paralysis or a non-beating heart. Here, the complete technique for heterotopic mouse heart transplantation is demonstrated, involving harvesting the donor heart and its subsequent implantation into a recipient mouse. The donor heart is harvested immediately following in situ perfusion with cold heparinized saline and transection of the ascending aorta and pulmonary artery. The recipient operation involves preparation of the abdominal aorta and inferior vena cava (IVC), followed by end-to-side anastomosis of the donor aorta with the recipient aorta using a single running 10-0 microsuture and a similar anastomosis of the donor pulmonary artery with the recipient IVC. Following the operation the animal is injected with 0.6 ml normal saline subcutaneously and allowed to recover on a 37&#160;&#176;C heating pad. The results from 227 mouse heart transplants are summarized with a success rate at 48 hr of 86.8%. Of the 13.2% failures within 48 hr, 5 (2.2%) experienced hind limb paralysis, 10 (4.4%) had a non-beating heart due to graft ischemic injury and/or thrombosis, while 15 (6.6%) died within 48 hr.

A technique is demonstrated for the microsurgical procedure for heterotopic transplantation of hearts in mice, including simplified methods for donor harvesting and recipient vessel anastomosis.

Eine modifizierte Methode zur Heterotope Maus Herz-Transplantation

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents ...

Forschung

Medizin

Preparation and Respirometric Assessment of Mitochondria Isolated from Skeletal Muscle Tissue Obtained by Percutaneous Needle Biopsy

Respirometric profiling of isolated mitochondria is commonly used to investigate electron transport chain function. We describe a method for obtaining samples of human Vastus lateralis, isolating mitochondria from minimal amounts of skeletal muscle tissue, and plate based respirometric profiling using an extracellular flux (XF) analyzer. Comparison of respirometric profiles obtained using 1.0, 2.5 and 5.0 &#956;g of mitochondria indicate that 1.0 &#956;g is sufficient to measure respiration and that 5.0 &#956;g provides most consistent results based on comparison of standard errors. Western blot analysis of isolated mitochondria for mitochondrial marker COX IV and non-mitochondrial tissue marker GAPDH indicate that there is limited non-mitochondrial contamination using this protocol. The ability to study mitochondrial respirometry in as little as 20 mg of muscle tissue allows users to utilize individual biopsies for multiple study endpoints in clinical research projects.

Methods for biopsy of Vastus lateralis, preparation of purified mitochondria, and respirometric profiling are described. The use of small muscle volume makes this technique suitable for clinical research applications.

Vorbereitung und Respirometrische Bewertung der Mitochondrien isoliert aus dem Skelettmuskelgewebe durch perkutane Nadelbiopsie Erhalten

Respirometric profiling of isolated mitochondria is commonly used to investigate electron transport chain function. We describe a method for obtaining ...

In Vivo, Percutaneous, Needle Based, Optical Coherence Tomography of Renal Masses

Optical coherence tomography (OCT) is the optical equivalent of ultrasound imaging, based on the backscattering of near infrared light. OCT provides real time images with a 15 &#181;m axial resolution at an effective tissue penetration of 2-3 mm. Within the OCT images the loss of signal intensity per millimeter of tissue penetration, the attenuation coefficient, is calculated. The attenuation coefficient is a tissue specific property, providing a quantitative parameter for tissue differentiation. 
Until now, renal mass treatment decisions have been made primarily on the basis of MRI and CT imaging characteristics, age and comorbidity. However these parameters and diagnostic methods lack the finesse to truly detect the malignant potential of a renal mass. A successful core biopsy or fine needle aspiration provides objective tumor differentiation with both sensitivity and specificity in the range of 95-100%. However, a non-diagnostic rate of 10-20% overall, and even up to 30% in SRMs, is to be expected, delaying the diagnostic process due to the frequent necessity for additional biopsy procedures. 
We aim to develop OCT into an optical biopsy, providing real-time imaging combined with on-the-spot tumor differentiation. This publication provides a detailed step-by-step approach for percutaneous, needle based, OCT of renal masses.

In Vivo, Percutaneous, Needle Based, Optical Coherence Tomography of Renal Masses

Optical coherence tomography (OCT) is a high resolution imaging technique that allows analysis of tissue specific optical properties providing the means for tissue differentiation. We developed needle based OCT, providing real-time imaging combined with on-the-spot tumor differentiation. This publication describes a method for percutaneous, needle based OCT of renal masses.

In Vivo, perkutane, Nadel Based, Optical Coherence Tomography von Nierentumoren

Optical coherence tomography (OCT) is the optical equivalent of ultrasound imaging, based on the backscattering of near infrared light. OCT provides real ...

Percutaneous Hepatic Perfusion (PHP) with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

Unresectable liver metastases of colorectal cancer can be treated with systemic chemotherapy, aiming to limit the disease, extend survival or turn unresectable metastases into resectable ones. Some patients however, suffer from side effects or progression under systemic treatment. For patients with metastasized uveal melanoma there are no standard systemic therapy options. For patients without extrahepatic disease, isolated liver perfusion (IHP) may enable local disease control with limited systemic side effects. Previously, this was performed during open surgery with satisfying results, but morbidity and mortality related to the open procedure, prohibited a widespread application. Therefore, percutaneous hepatic perfusion (PHP) with simultaneous chemofiltration was developed. Besides decreasing morbidity and mortality, this procedure can be repeated, hopefully leading to a higher response rate and improved survival (by local control of disease). During PHP, catheters are placed in the proper hepatic artery, to infuse the chemotherapeutic agent, and in the inferior caval vein to aspirate the chemosaturated blood returning through the hepatic veins. The caval vein catheter is a double balloon catheter that prohibits leakage into the systemic circulation. The blood returning from the hepatic veins is aspirated through the catheter fenestrations and then perfused through an extra-corporeal filtration system. After filtration, the blood is returned to the patient by a third catheter in the right internal jugular vein. During PHP a high dose of melphalan is infused into the liver, which is toxic and would lead to life threatening complications when administered systemically. Because of the significant hemodynamic instability resulting from the combination of caval vein occlusion and chemofiltration, hemodynamic monitoring and hemodynamic support is of paramount importance during this complex procedure.

Percutaneous Hepatic Perfusion PHP with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

In this manuscript, we describe percutaneous isolated hepatic perfusion with simultaneous chemofiltration as treatment for unresectable liver metastases. This procedure is performed under general anaesthesia in the angiosuite by an experienced team, consisting of an interventional radiologist, a clinical perfusionist and anaesthesiologist.

Die perkutane Leberperfusion (PHP) mit Melphalan als Behandlung für inoperablen Metastasen auf die Leber beschränkt

Unresectable liver metastases of colorectal cancer can be treated with systemic chemotherapy, aiming to limit the disease, extend survival or turn ...

Percutaneous Contrast Echocardiography-guided Intramyocardial Injection and Cell Delivery in a Large Preclinical Model

Cell and gene therapy are exciting and promising strategies for the purpose of cardiac regeneration in the setting of heart failure with reduced ejection fraction (HFrEF). Before they can be considered for use, and implemented in humans, extensive preclinical studies are required in large animal models to evaluate the safety, efficacy, and fate of the injectate (e.g., stem cells) once delivered into the myocardium. Small rodent models offer advantages (e.g., cost effectiveness, amenability for genetic manipulation); however, given inherent limitations of these models, the findings in these rarely translate into the clinic. Conversely, large animal models such as rabbits, have advantages (e.g., similar cardiac electrophysiology compared to humans and other large animals), whilst retaining a good cost-effective balance. Here, we demonstrate how to perform a percutaneous contrast echocardiography-guided intramyocardial injection (IMI) technique, which is minimally invasive, safe, well tolerated, and very effective in the targeted delivery of injectates, including cells, into several locations within the myocardium of a rabbit model. For the implementation of this technique, we also have taken advantage of a widely available clinical echocardiography system. After putting in practice the protocol described here, a researcher with basic ultrasound knowledge will become competent in the performance of this versatile and minimally invasive technique for routine use in experiments, aimed at hypothesis testing of the capabilities of cardiac regenerative therapeutics in the rabbit model. Once competency is achieved, the whole procedure can be performed within 25 min after anaesthetizing the rabbit.

Novel therapeutic strategies in cardiac regenerative medicine require extensive and detailed studies in large preclinical animal models before they can be considered for use in humans. Here, we demonstrate a percutaneous contrast echocardiography-guided intramyocardial injection technique in rabbits, which is valuable for hypothesis testing the efficacy of such novel therapies.

Perkutane Kontrast-Echokardiographie-geführte Intramyocardial-Injektion und Zelle-Lieferung in einem großen präklinischen Modell

Cell and gene therapy are exciting and promising strategies for the purpose of cardiac regeneration in the setting of heart failure with reduced ejection ...

Three-Dimensional Printing Guide Template Assisted Percutaneous Vertebroplasty (PVP)

Percutaneous vertebroplasty (PVP) is considered an effective treatment for the back pain caused by osteoporotic vertebral compression fracture. The accuracy of PVP mainly depends on the surgeons&#39; experience and multiple fluoroscopes during a traditional procedure. Puncture related complications were reported all over the world. To make the surgical procedure more precise and decrease the rate of puncture-related complications, our team applied a three-dimensional printing guide template to PVP to modify the traditional procedure. This protocol introduces how to model target vertebrae DICOM imaging data into three-dimensions in the software, how to simulate operation in this 3-D model, and how to use all of the surgical data to reconstruct a patient specific template for application. Using this template, surgeons can identify suitable puncture points accurately to improve the accuracy of the operation. The whole protocol includes: 1) diagnosis of the osteoporotic vertebral compression fracture; 2) acquisition of CT imaging of the target vertebra; 3) simulation of the operation in the software; 4) design and fabrication of the 3-D printing guide template; and 5) application of the template into an operation procedure.

Three-Dimensional Printing Guide Template Assisted Percutaneous Vertebroplasty PVP

Herein, we present a three-dimensional printing guide template for percutaneous vertebraplasty. A patient with a T11 vertebral compression fracture was selected as a case study.

Dreidimensionale Druckanleitung Vorlage Assistierte Perkutane Vertebropplastik (PVP)

Percutaneous vertebroplasty (PVP) is considered an effective treatment for the back pain caused by osteoporotic vertebral compression fracture. The ...

A Revised Method for Inducing Secondary Lymphedema in the Hindlimb of Mice

Animal models are of paramount importance in the research of lymphedema in order to understand the pathophysiology of the disease but also to explore potential treatment options. This mouse model allows researchers to induce significant lymphedema lasting at least 8 weeks. Lymphedema is induced using a combination of fractioned radiotherapy and surgical ablation of lymphatics. This model requires that the mice get a dose of 10 Gray (Gy) radiation before and after surgery. The surgical part of the model involves ligation of three lymph vessels and extraction of two lymph nodes from the mouse hindlimb. Having access to microsurgical tools and a microscope is essential, due to the small anatomical structures of mice. The advantage of this model is that it results in statistically significant lymphedema, which provides a good basis for evaluating different treatment options. It is also a great and easily available option for microsurgical training. The limitation of this model is that the procedure can be time consuming, especially if not practiced in advance. The model results in objectively quantifiable lymphedema in mice, without causing severe morbidity and has been tested in three separate projects.

This animal model enables researchers to induce statistically significant secondary lymphedema in the hindlimb of mice, lasting at least 8 weeks. The model can be used to study the pathophysiology of lymphedema and to investigate novel treatment options.

Eine überarbeitete Methode zur Induktion von Sekundärlymphödemen im Hinterglied von Mäusen

Animal models are of paramount importance in the research of lymphedema in order to understand the pathophysiology of the disease but also to explore ...

A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral regurgitation in patients with high surgical risk. Echocardiographic guidance in addition to fluoroscopy is the gold standard and should be performed using a standardized technique.
This article lays out our reproducible step by step echocardiographic guide including views, measurements as well as highlighting possible difficulties that may arise during the procedure.
This article provides detailed and chronological echocardiographic views for each step of the procedure, especially preferences between 2D and 3D imaging. If needed, pulse wave, continuous wave and color doppler measurements are described. Furthermore, as there are no official recommendations for the quantification of mitral regurgitation during the percutaneous edge-to-edge-repair procedure, advice is also included for echocardiographic quantification after grasping the mitral leaflets and after device deployment. In addition, the article deals with important echocardiographic views to prevent and deal with possible complications during the procedure.
Echocardiographic guidance during transcatheter mitral valve repair is mandatory. A structured approach improves the collaboration between interventionist and imager and is indispensable for a safe and effective procedure.

This protocol presents in detail how to perform real-time echocardiographic guidance during transcatheter mitral valve repair. The fundamental views and the necessary measurements are described for each stage of the procedure.

Ein vereinfachter schrittweiser Ansatz zur Echoführung während der perkutanen Mitralklappenreparatur

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral ...

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

Verwendung von perkutanen ventrikulären Unterstützungsgeräten bei akutem Myokardinfarkt, der durch kardiogenen Schock kompliziert ist

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

Verwendung eines perkutanen ventrikulären Unterstützungsgeräts / linker Vorhof zu Femurarterien-Bypass-System für kardiogenen Schock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...