monooctanoin and Common-Bile-Duct-Diseases

Retained gallstones in the biliary ducts have been therapeutically managed with monoctanoin (Moctanin; Ethitek Pharmaceuticals Company, Skokie, IL) since Food and Drug Administration approval in 1985. The clinical usefulness of monoctanoin therapy has previously been regarded by some investigators as limited because of the length of time required to achieve complete dissolution (2 to 10 days) and less than optimal results (50% to 86% efficacy). Here, the authors describe a safe technique for the rapid dissolution of retained stones that they have used successfully in four patients. This technique eliminates the need for pressure monitoring in the T-tube patient and is suitable for short-stay hospitalization. Representative case histories are presented.

Topics: Adult; Caprylates; Catheters, Indwelling; Cholestasis, Extrahepatic; Common Bile Duct Diseases; Female; Gallstones; Glycerides; Humans; Intubation; Male; Middle Aged; Solubility; Time Factors

Monooctanoin (MO), when infused into the common bile duct (CBD), is an effective agent in dissolving retained CBD stones. If the stone migrates and obstructs the distal CBD, the solution could be infused under pressure resulting in intrahepatic reflux. The relationship between the infusion pressure and the safety of monooctanoin has not been evaluated. To study the effects of intrahepatic reflux of MO, a canine model was used and solutions were infused into an obstructed CBD under controlled pressure. Solutions of normal saline (NS), 150 mM sodium cholate (Ch), or MO were infused under pressures of 30, 40, and 50 cm. All of eight dogs died when infused with MO at 50 cm pressure with a mean administered dose of 1.4 +/- 0.4 cc/kg within a mean time of 87 +/- 38 min. Three of four dogs died at 40 cm pressure (1.7 +/- 0.4 cc/kg; 133 +/- 95 min) and only one of three dogs died at 30 cm pressure (2.5 cc/kg; 335 min). These dogs died from progressive hypoxia, acidosis, hemolysis, and hemorrhagic pneumonitis. Four dogs each were administered Ch at 50 and 40 cm pressure and all died with an average absorption of 19 cc/kg. Six dogs were tested with NS at 50 cm and all survived despite absorbing 180 cc/kg in 6 hr. MO at 50 cm pressure and Ch at both 40 and 50 cm pressure were significantly more toxic than saline. It is concluded that MO and Ch infused under pressure into CBD carry a significant risk of serious side effects. The infusion pressure must be monitored to prevent increased biliary pressure which might lead to intrahepatic reflux.

Topics: Animals; Bile Reflux; Biliary Tract Diseases; Caprylates; Cholelithiasis; Cholestasis; Cholic Acid; Cholic Acids; Common Bile Duct Diseases; Dogs; Glycerides; Models, Biological; Pressure; Solvents

Topics: Bile; Bile Duct Neoplasms; Biliary Tract; Caprylates; Catheters, Indwelling; Cholangitis; Cholestasis; Common Bile Duct Diseases; Drainage; Endoscopes; Endoscopy; Gallstones; Glycerides; Hepatic Duct, Common; Humans; Prostheses and Implants; Radiography

A 72-year-old man with choledocholithiasis, demonstrated radiologically, was treated by constant perfusion through the gallbladder of monooctanoin (glyceryl-1-monooctanoate) following cholecystostomy for a perforated gallbladder. The monooctanoin was given at a rate of 7.5 ml/h and monitored to ensure that delivery pressure did not rise above 20 cm H2O. Perfusion was carried out for 60 hours, but could not be continued because of abdominal pain, nausea and vomiting. This was followed by progressive jaundice, anorexia and fever. The patient was treated with penicillin G and cefoxitin intravenously and metronidazole orally, but he died 5 weeks after the perfusion. Autopsy showed acute pancreatitis and cholangitis, and a biliary tree filled with pus and a black biliary cast. No calculi were present. The authors consider the possible causes for this patient's death.

Topics: Aged; Caprylates; Common Bile Duct Diseases; Gallstones; Glycerides; Humans; Male; Necrosis; Perfusion; Solvents