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Conventional percutaneous procedures for treating patients with recurrent hepatolithiasis associated with complicated intrahepatic biliary strictures require multiple dilation sessions before stone extraction. We modified the approach, reducing the number of dilation sessions required and using newer lithotripsy and irrigation methods. We suggest that the modified procedures are superior to conventional management and demonstrate their utility in clearing hepatolithiasis.Percutaneous transhepatic stricture dilation and cholangioscopic lithotripsy were performed to treat patients with right recurrent hepatolithiasis with complicated intrahepatic biliary strictures. Conventional methods were used in 40 patients (Group A). Modified methods, including simplification of tract establishment and stricture dilation and electrohydraulic lithotripsy (EHL) were used in 60 patients (Group B).Group B patients had fewer complications (massive hemobilia: 0% versus 15%, P = 0.0032, cholangitis: 0% versus 17.5%, P=0.0012), tolerated the procedures better (intolerable pain: 0% versus 12.5%, P=0.0087), had a higher rate of success (residual stones: 3.3% versus 20%, P=0.0132; remaining asymptomatic and stone-free: 81% versus 50%, P = 0.0021), a shorter hospital stay (17.8 +/- 4.4 days versus 36.2 +/- 5.5 days, P0.001) and lower overall expense (USD 2689 versus USD 3848) than Group A patients.We believe that the modified methods are superior to conventional treatment in that they effectively decrease procedural complications and cost, and significantly improve treatment results.

Percutaneous stricture dilatation and cholangioscopic lithotomy has become a mainstay in the treatment of patients with recurrent hepatolithiasis associated with intrahepatic biliary strictures. In a consecutive series of 125 patients who underwent percutaneous management of recurrent hepatolithiasis from 1987 to 1999, there were 15 patients in whom the procedure failed to clear the stones. A second percutaneous transhepatic route was established for subsequent treatment. A reappraisal of its indications and efficacy was done. Treatment through a second route was helpful for patients with bilateral strictures, angulated duct, difficult strictures, large impacted stones, a subcutaneous jejunal limb, or hemobilia developing in the first route. Strictures remained impacted in 1 of the 15 patients (failure rate, 7%), with the remaining having complete clearance of stones. Cholangitis occurred in two patients; no other complications were encountered. A second percutaneous route is very helpful for the management of complicated hepatolithiasis and biliary stricture.

For recurrent hepatolithiasis coexisting with a complicated long-segment intrahepatic biliary stricture, repeated surgeries, balloon dilation of the stricture, and external-internal stenting may still fail to solve the problem. We tried using a Gianturco-Rosch metallic Z internal stent (Wilson-Cook Medical, Inc., Bloomington, IN, USA) with the aid of percutaneous transhepatic cholangioscopy (PTCS) to treat such patients. Eight patients had a Z stent placed through a percutaneous transhepatic biliary drainage tract. Immediately after stent placement, PTCS was inserted via the percutaneous transhepatic biliary drainage route and a part of the wire skirt not firmly anchored in one of the eight patients was detected. It was successfully repositioned using PTCS. Recurrent cholangitis developed in three patients 6, 7, and 30 months, respectively, after stent placement. PTCS was undertaken again through a reestablished percutaneous transhepatic biliary drainage route and revealed sludge in their stent lumens. We cleared it by PTCS. No further cases of cholangitis occurred in later follow-up. PTCS is useful in ensuring adequate stent position, diagnosing and treating the causes of recurrent cholangitis, and prolonging the function of stents.

To determine the alterations of the p16/MTS1 gene in oral squamous cell carcinoma (OSCC), we examined in Taiwanese patients the mutation, deletion and methylation of p16/MTS1 in primary OSCCs associated mostly with betel quid (BQ)/tobacco use. Among 110 tumors undergoing mutational analyses, seven (6%) showed mutations in exon 2 or the intron 1/exon 2 splice site. All but one mutation disrupted the encoded proteins. Base transitions represented the vast majority (6/7) of the mutations identified in BQ/tobacco consuming subjects. It was noted that 15/56 (27%) tumors examined by restriction fragment methylation analysis revealed a significant level of methylation in different loci of exon 1 as compared with the respective non-cancerous tissue. Mutation of p16/MTS1 was exclusively identified in carcinomas of buccal mucosa, whereas methylation of the p16/MTS1 promoter region occurred preferentially in carcinomas of the tongue (54%) rather than at other sites (22%). Homozygous deletion was not found in 56 paired samples examined, nor was hemizygous deletion indicated in 12 informative cases. The results indicated aberrant methylation and mutation as the molecular abnormality of p16/MTS1 in the OSCC from Taiwanese.

A case of watershed infarction in the spinal cord is reported. The patient underwent bronchial artery embolization for control of massive hemoptysis. The bronchial arteriogram was carefully examined and focused on blood supply to the spinal cord prior to embolization. Acute paraparesis followed the embolization procedure even though there was no visible spinal supply on the arteriogram. Magnetic resonance imaging showed a hyperintensity lesion over the watershed region which is located at the central portion of the upper thoracic cord. This case is reported to emphasize the significant role which angiographically invisible small vessels can play in the blood supply to the spinal cord. The vascular system of the spinal cord and the prevention of spinal cord ischemia secondary to embolization are further discussed here.

Biliary stricture represents a challenging problem in the treatment of hepatolithiasis because of its association with treatment failure and stone recurrence. The long-segment type of stricture is difficult to manage and is likely to recur. To investigate the necessity for biliary stenting after balloon dilatation therapy, 20 consecutive patients with long-segment strictures who had 22 stents (group 1) were compared with ten patients who refused stenting (group 2). The long-segment strictures in group 1 were located on the right side in 80 per cent of patients, on the left side in 10 per cent, and were bilateral in 10 per cent. The stents, varying from 8 to 12 Fr, were retained for at least 6 months. They were inserted through the routes of a matured T tube track (five cases), percutaneous transhepatic track (14 cases), a jejunal limb (two cases) and a fistula (one case). Complications of stenting consisted of dislodgement (one case), haemobilia (two cases), cholangitis (two cases) and intrahepatic abscess (one case). The cumulative probability of stricture recurrence in group 1 was 10 per cent, 15 per cent and 21 per cent at 2, 3 and 4 years, respectively, whereas in group 2 it was 80 per cent at 2 years (P < 0.003). The results suggest that intrahepatic biliary stenting after balloon dilatation appears necessary and helpful in the management of hepatolithiasis with long-segment biliary strictures.