monooctanoin and Bile-Duct-Diseases

Endoscopic sphincterotomy and percutaneous approaches to the biliary tract have revolutionized the treatment of bile duct stones. Both the endoscopic and transhepatic approaches are less invasive than open surgery. This is an advantage for the mostly elderly and frail patients with common bile duct stones. Other patients with intrahepatic stones, e.g. young patients with oriental lithiasis, may also profit from the non-surgical approach. In this latter group it is often difficult for the surgeon to obtain access to the stone-bearing bile ducts. Due to the anatomical situation, size or impaction of stones the non-surgical approach, including mechanical disintegration, may primarily fail. Several techniques such as intracorporeal lithotripsy using electrohydraulic probes or laser light, extracorporeal shockwave lithotripsy or direct contact dissolution are now available and often allow complete clearance of the bile ducts. If a kidney lithotripter with radiographic devices is available, it should be used after an attempt at mechanical lithotripsy has failed (Figure 1). According to the literature, experience with this method is greater than with any other 'third-step approach'. The procedure is simple, relatively safe and successful in approximately 80% of patients. However, in at least one third of patients, several sessions have to be performed and further endoscopy is frequently required for extraction of fragments. Intracorporeal techniques may become the procedure of choice in the future, at least in patients with common bile duct stones. At the moment, however, the different devices are still not fully developed and too susceptible to damage. A further major drawback, especially with high-energy electrohydraulic intracorporeal lithotripsy, is the danger of bile duct injury or even perforation, so that most procedures must be performed under optical control. The use of contact dissolution cannot generally be recommended. Treatment with mono-octanoin or modified mono-octanoin solvents takes too long, is often not successful and has a high rate of side-effects. MTBE may shorten the procedure considerably, but is suitable only for cholesterol stones, and the danger of spill-over into the intestine with absorption and systemic side-effects has to be weighed against the probability of success.

Topics: Bile Acids and Salts; Bile Duct Diseases; Caprylates; Cholelithiasis; Cyclohexenes; Ethers; Glycerides; Humans; Laser Therapy; Limonene; Lithotripsy; Lithotripsy, Laser; Methyl Ethers; Solvents; Stents; Terpenes

Mono-octanoin can be used either alone or as an adjunct to other techniques to dissolve cholesterol bile duct stones. This solvent can be administered through an existing T tube, through the nasobiliary route, or percutaneously through the liver. Unlike basket extraction, which requires a mature T-tube sinus tract, mono-octanoin can be used immediately postoperatively or for home dissolution therapy. The endoscopic extraction of bile duct stones has a 1 percent mortality rate and a 5 to 7 percent complication rate. Special mixtures of mono-octanoin, bile acids, and ethylene diaminetetraacetic acid (EDTA) are being evaluated to dissolve pigment stones. The use of methyl tert-butyl ether is still experimental but very effective. To be most successful, mono-octanoin treatment must be used in properly selected patients.

Topics: Bile Acids and Salts; Bile Duct Diseases; Caprylates; Catheters, Indwelling; Cholelithiasis; Ethers; Glycerides; Humans; Solvents

Topics: Bile Duct Diseases; Caprylates; Chenodeoxycholic Acid; Cholelithiasis; Deoxycholic Acid; Ethers; Glycerides; Humans; Lithotripsy; Methyl Ethers; Solvents; Ursodeoxycholic Acid

Topics: Bile Acids and Salts; Bile Duct Diseases; Caprylates; Cholelithiasis; Cholesterol; Cyclohexenes; Edetic Acid; Ethers; Glycerides; Humans; Limonene; Methyl Ethers; Pigments, Biological; Recurrence; Solubility; Terpenes

Dissolution of bile duct calculi is complicated by the facts that about 30-40% of them are pigment stones and the stone cannot be unambiguously identified by radiography before the start of therapy. Thus it does not appear logical only to infuse irrigation media that dissolve cholesterol (cholate, Capmul) but to use solutions that also dissolve calcium bilirubinate. Calcium bilirubinate is the most important compound in primary pigment stones in the bile duct. Thin sections of calcium bilirubinate stones can be dissolved in EDTA 4Na. The rate is determined by the temperature, the pH, and the surface tension of the solution. In vitro experiments showed that cholesterol stones and composition stones can be dissolved more rapidly by alternating therapy with an EDTA solution and a Capmul preparation than by monotherapy with glycerol octanoate, and that bovine pigment stones can also be disaggregated. Since calcium bilirubinate stones consist up to 20-60% of an organic matrix, a mixture of glycerol octanoate and EDTA was prepared containing SH-activated papain. It was possible, by using this mixture, to disaggregate human calcium bilirubinate stones. The process of dissolution is complex and is not yet understood in detail. It is supposed that the important steps are the extraction of calcium, the chemical solution and molecular dispersion of bilirubin and cholesterol, and the disaggregation of the structure of the stone by surface-active substances. The irrigation media have but little effect on black pigment stones. Toxicity studies have shown that cholate, glycerol octanoate, and glycerol octanoate preparations are locally toxic and can lead to cholangitis and cholecystitis in animals. EDTA solutions bring about lesser changes. In humans, it has not been possible to distinguish these inflammatory changes unambiguously from those found in untreated gallstone patients.

Topics: Aged; Amides; Animals; Bile Acids and Salts; Bile Duct Diseases; Bile Pigments; Caprylates; Chelating Agents; Cholesterol; Dogs; Drug Combinations; Drug Therapy, Combination; Edetic Acid; Endocannabinoids; Ethanolamines; Gallstones; Glycerides; Humans; Middle Aged; Palmitic Acids; Rabbits; Solubility; Therapeutic Irrigation

A new litholytic mixture of mono-octanoin (MO) and methyl tert-butyl ether (MTBE) in a ratio of 2:1 (v/v) was employed in 42 patients with bile duct stones, 29 of them failures after papillotomy. Twenty-two of these patients had complicated stones. The new solvent mixture was given for 4-6 h/day and 2-3 ml were instilled every 30 min. Gentle aspiration and instillation were alternated so as to "stir" the preparation around the stones. Perfusion was given for up to six days. The mixture contributed to success in 37 cases (88%), 19 of them with complicated stones. Total dissolution was attained in 18 cases, and in the other 19 cases clearance was achieved after partial lysis followed by easy crushing with a basket. The mean volume of solvent perfused (+/- SD) was 84.9 +/- 39 ml (range 25-150), the mean duration of treatment was 16.5 +/- 7.4 h (range 5-30). Hospital stay averaged 4.6 +/- 1.6 days (range 2-7). There were five failures: in one patient eight large concretions were eliminated only after extracorporeal shock wave lithotripsy (ESWL). Two were re-operated and pigment stones were found. The last two refused alternative treatments. Side effects were minimal and easily managed by withdrawal of a few ml of bile. Treatment with the new solvent may be indicated as first-instance therapy in place of ESWL, laser endoscopy, electrohydraulic or mechanical lithotripsy for patients with complicated biliary stones, or in cases in which endoscopic papillotomy has failed.

Topics: Adult; Aged; Aged, 80 and over; Bile Duct Diseases; Caprylates; Cholelithiasis; Drug Combinations; Ethers; Female; Follow-Up Studies; Glycerides; Humans; Male; Methyl Ethers; Middle Aged; Solvents

Despite advances in intraoperative choledochoscopy and cholangiography, it is still common for bile duct stones to remain after common bile duct (CBD) exploration. The incidence of bile duct calculi in those undergoing cholecystectomy ranges from 7-15%, and that of retained stones immediately after CBD exploration, from 10-13%. Re-exploration carries a postoperative mortality varying from 3-28%. Treatment by T-tube flushing with heparinized saline, cholate or mono-octanoin is of limited value. Flushing with methyltertiarybutyl ether via a nasobiliary drain was recently reported to be successful in 80%, but confirmation of its efficacy and lack of toxicity is still pending. Continuous infusion via a nasobiliary tube of modified mono-octanoin alternating with EDTA solution may dissolve calcium bilirubin stones. Endoscopic sphincterotomy is successful in 95%. Extraction of CBD stones by either basket or balloon catheter is possible in 85-90% of cases at the time of endoscopic sphincterotomy. Large stones remaining are treated by mechanical lithotripsy with a success rate of 82%, which raises the overall success rate of endoscopic CBD stone extraction after endoscopic sphincterotomy to 97%. However, when stones exceed 25 mm in diameter, the success rate is lower. Electrohydraulic lithotripsy (EHL) may damage the CBD wall because the exact site of spark discharge is under fluoroscopic, not direct endoscopic control. In the near future, applying EHL under direct vision via peroral cholangioscopy should decrease the hazards of this method.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Bile Duct Diseases; Caprylates; Cholecystectomy; Cholelithiasis; Endoscopy; Glycerides; Humans; Lithotripsy; Postoperative Complications; Solvents; Sphincterotomy, Transduodenal; Therapeutic Irrigation

The authors describe percutaneous treatment of gallbladder or bile duct stones in 18 patients who were poor surgical candidates or in whom conventional therapy failed. Dissolution was performed in most cases with methyl tert-butyl ether (MTBE) because of its potent dissolution properties; other solvents used included monooctanoin or chelating solutions. Gallbladder stones were eliminated in 11 of 13 patients (six of seven with dissolution alone, four of four with dissolution and basket extraction, one with basket removal alone). In five patients with stones in the common bile duct (n = 3), cystic duct remnant (n = 1), and intrahepatic bile ducts (n = 1), stones were eliminated with dissolution alone in two and with dissolution plus basket extraction in one. In two patients percutaneous therapy failed due to complications (vagal hypotension with bile peritonitis and transient respiratory arrest) that occurred during catheter placement. Preliminary results suggest that MTBE is effective for dissolution of many gallbladder stones and some bile duct stones. Noncholesterol solvents and adjuvant mechanical maneuvers are valuable adjuncts to achieve complete stone elimination.

Topics: Bile Duct Diseases; Bile Ducts, Intrahepatic; Caprylates; Chelating Agents; Cholelithiasis; Ethers; Female; Gallstones; Glycerides; Humans; Male; Methyl Ethers; Solvents

Topics: Adult; Aged; Aged, 80 and over; Bile Duct Diseases; Caprylates; Cholelithiasis; Combined Modality Therapy; Endoscopy; Female; Glycerides; Humans; Male; Middle Aged; Reoperation

Mono-octanoin (glycerol-1-mono-octanoate) is a medium-chain diglyceride used to dissolve gallstones. We describe a patient in whom noncardiogenic pulmonary edema developed during intrabiliary infusion of monooctanoin. The temporal sequence suggests that the drug infusion initiated the lung injury.

Topics: Adult; Bile Duct Diseases; Caprylates; Cholelithiasis; Female; Glycerides; Humans; Pulmonary Edema; Radiography

Topics: Adult; Aged; Bile Duct Diseases; Caprylates; Cholecystectomy; Cholelithiasis; Female; Glycerides; Humans; Male; Middle Aged

Topics: Bile; Bile Duct Diseases; Bilirubin; Caprylates; Cholelithiasis; Cholesterol; Cholic Acid; Cholic Acids; Glycerides; Humans; Recurrence

Monooctanoin, a cholesterol solvent, was infused into the biliary system of 11 patients. Twenty-eight (74%) of 38 total stones responded to monooctanoin: 16 (42%) decreased in size, and 12 (32%) dissolved completely. Ten stones (26%) did not change in size. We attribute this to inadequate drug-stone contact, which was corrected by placement of the infusion catheter contiguous to the stone(s). The use of a second catheter for biliary drainage avoided the side effect of biliary colic and increased patient compliance. An infusion rate greater than 5 ml per hour invariably produced pain and diarrhea. There were no significant side effects from monooctanoin in any of our patients when a two catheter system and an infusion rate of 5 ml per hour or less were used. A major drawback to use of this still experimental agent is the prolonged hospital stay. This may be ameliorated when at home use of monooctanoin is approved.

Topics: Adult; Aged; Bile Duct Diseases; Caprylates; Cholelithiasis; Glycerides; Humans; Middle Aged; Perfusion

Topics: Bile Duct Diseases; Caprylates; Cholelithiasis; Drainage; Glycerides; Humans; Solvents

Topics: Bile Duct Diseases; Caprylates; Cholelithiasis; Glycerides; Humans