monooctanoin and Gallstones

Common duct calculi retained after gallbladder surgery continue to present a clinical challenge especially in the era of minimally invasive surgery. This review examines the strategy of dissolution therapy used throughout the history of biliary tract surgery and its use to the modern surgeon.. Original journal articles and reviews were identified using standard surgical textbooks and MEDLINE. Keywords for searching included choledocholithiasis, dissolution, mono-octanoin, common duct stones, MTBE, cholic acid, and gallstones.. Dissolution therapy used initially as an alternative to open surgery is now used more effectively as an adjunct to laparoscopic or endoscopic biliary tract surgery. The current review demonstrates a majority of patients with retained choledocholithiasis respond to dissolution and can be safely managed without choledochotomy.

Topics: Administration, Topical; Anesthetics, Local; Bile Acids and Salts; Calcium; Caprylates; Chelating Agents; Chloroform; Cholecystectomy, Laparoscopic; Expectorants; Gallstones; Glycerides; Heparin; Humans; Methyl Ethers; Sodium Chloride; Solubility; Solvents; Therapeutic Irrigation

Common bile duct stones are a common cause of morbidity and mortality in adults. An increasing number of surgical and medical therapies are available to manage them, with different success rates reported. The various medical treatment strategies were developed during the last decade, but these medical modalities should not be contemplated as a first-line alternative of treatment. A consensus from experts is that there is no primary indication to use solvents on common bile duct stones because they have a relatively high rate of adverse effects and their success is limited compared with lithotripsy. However, there is a subgroup of patients in whom invasive or surgical treatment is risky or may fail. In these patients stone dissolution by solvent may constitute a plausible therapeutic alternative or may help reduce the size of the stones sufficiently to facilitate subsequent endoscopic extraction. Solvents may also be indicated in settings where endoscopic techniques or lithotripsy are not available and the patient has a T-tube in the common bile duct. Even in this condition, however, it is probably quicker and more effective to refer the patient to a center with expertise and technologic support to practice stone removal.

Topics: Caprylates; Gallstones; Gastrointestinal Agents; Glycerides; Humans; Methyl Ethers; Solvents; Ursodeoxycholic Acid

Topics: Adult; Aged; Animals; Calcium; Caprylates; Cattle; Chenodeoxycholic Acid; Cholelithiasis; Cholesterol; Clinical Trials as Topic; Common Bile Duct; Drug Evaluation, Preclinical; Female; Gallstones; Glycerides; Humans; In Vitro Techniques; Infusions, Parenteral; Male; Middle Aged; Particle Size; Solubility; Ursodeoxycholic Acid

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

Management of choledocholithiasis requires several strategies to solve the various clinical problems encountered. A maximal effort during cholecystectomy at discovery of the duct stones in almost one of every six patients should, of course, be continued. Cystic duct cholangiography should routinely be used in deciding whether to explore the common duct. Postexploratory choledochoscopy has demonstrated discovery value and will hopefully be increasingly used. More training and sharing of technical details is indicated. When a retained stone is discovered on T tube cholangiogram, several options are available with no one clearly superior. Waiting for the T tube tract to mature and attempting extraction via flexible endoscopes or Burhenne technique is probably most cost effective if appropriate skills are available, especially for small calculi. Calculi greater than 8 mm in diameter with some probability of having high cholesterol content may be best managed with monooctanoin infusion. Parenthetically, monooctanoin dissolution may reduce morbidity of ERS, since large stones that would require large, more risky sphincterotomies can in some instances be reduced to passable size by monooctanoin infusion via an endoscopically placed nasobiliary tube. Endoscopic sphincterotomy for retained stones is ordinarily reserved for patients in whom nonoperative retrieval has failed or the T tube has fallen out. When common duct obstruction due to stones occurs prior to or remote from cholecystectomy, ERS is the preferred method of management when available, under conditions previously noted. With improved discovery methods and less morbid therapeutic options, consequences of choledocholithiasis will be less formidable.

Topics: Age Factors; Aged; Caprylates; Cholangiography; Cholangiopancreatography, Endoscopic Retrograde; Cholangitis; Cholecystectomy; Cholelithiasis; Cholestasis, Extrahepatic; Endoscopy; Excipients; Gallstones; Glycerides; Humans; Middle Aged; Pancreatitis; Recurrence; Tomography, X-Ray Computed; Ultrasonography

Topics: Animals; Bile; Bile Acids and Salts; Caprylates; Chenodeoxycholic Acid; Cholelithiasis; Cholic Acid; Cholic Acids; Common Bile Duct; Cyclohexenes; Drug Therapy, Combination; Edetic Acid; Gallstones; Glycerides; Heparin; Humans; Intubation; Limonene; Lipid Metabolism; Recurrence; Solvents; Terpenes; Ursodeoxycholic Acid

Major advances in gastroenterology are due in part to the rapid development of fiberendoscopes. Originally intended to improve gastroenterological diagnostics, the field of application was broadened by a variety of therapeutic procedures which now concur with the corresponding surgical approach. Endoscopic electro- and photocoagulation has considerably improved the outcome of acute gastrointestinal hemorrhage: endoscopic polypectomy is the procedure of choice today in benign and occasionally in malignant bowel tumors. Biliary tract surgery was revolutionized by endoscopic sphincterotomy, offering a low-risk procedure in high-risk patients with common bile duct stones. Endoscopic treatment of chronic pancreatitis by duct occlusion is just the beginning, and the old dream of dissolving gallstones rapidly by perfusing the biliary system with litholytic agents is now reality. Finally, the transhepatic or internal drainage in obstructive jaundice leads to transitory preoperative or permanent relief in malignant blockade of bile flow.

Topics: Ampulla of Vater; Animals; Caprylates; Catheterization; Cholestasis; Dogs; Drainage; Electrocoagulation; Endoscopes; Gallstones; Gastroenterology; Gastrointestinal Hemorrhage; Glycerides; Humans; Infusions, Parenteral; Intestinal Polyps; Laser Therapy; Methods; Tissue Adhesives

Topics: Adult; Aged; Animals; Calcium; Caprylates; Cattle; Chenodeoxycholic Acid; Cholelithiasis; Cholesterol; Clinical Trials as Topic; Common Bile Duct; Drug Evaluation, Preclinical; Female; Gallstones; Glycerides; Humans; In Vitro Techniques; Infusions, Parenteral; Male; Middle Aged; Particle Size; Solubility; Ursodeoxycholic Acid

Topics: Adolescent; Adult; Aged; Caprylates; Female; Gallstones; Glycerides; Heparin; Humans; Intubation; Male; Middle Aged; Postoperative Complications; Prospective Studies; Sodium Chloride

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

A retrospective analysis of 48 patients undergoing mono-octanoin infusion via nasobiliary catheter following failure of endoscopic extraction of common bile duct stones is reported. Among 35 patients who received a complete course of treatment, nine (26 per cent) had duct clearance by the completion of the infusion and a further eight on subsequent endoscopic retrograde cholangiopancreatography (ERCP) (total 49 per cent). Two patients had a successful stone extraction after enlargement of the sphincterotomy (total non-surgical clearance rate 54 per cent). None of five patients with stones greater than 2 cm in diameter had stone clearance at the completion of the infusion and only one at subsequent ERCP. Among 13 patients receiving an incomplete course of treatment seven had clear ducts on repeat ERCP (54 per cent). Mono-octanoin infusion via a nasobiliary catheter is of limited value in the management of this difficult group of patients, although it may be successful in some.

Topics: Aged; Aged, 80 and over; Caprylates; Cholangiopancreatography, Endoscopic Retrograde; Female; Gallstones; Glycerides; Humans; Male; Middle Aged; Retrospective Studies; Solvents; Sphincterotomy, Endoscopic

The clinical suitability of conventional glyceromonooctanoin (GMOC) and ethylenediaminetetraacetic acid (EDTA) containing solvents for the dissolution of common bile duct stones is questionable. To improve the solvent-stone contact and the miscibility with bile, GMOC was hydrophilized by the addition of polyethyleneglycol-caprylglyceride, polyethyleneglycol-sorbitan-etheroleyl-ester, and polyethyleneglycol-sorbitanlauryl-ester (PEG-GMOC). This product was mixed with a bile acid-EDTA (BA-EDTA) solution in a ratio of 1:2 (v/v) for cholesterol solubilizing and calcium complexing capacities. To determine clinical efficiency, the new solvent was infused via a nasobiliary tube in 16 patients with endoscopically nonextractable common bile duct stones and compared with a group of 16 patients treated with an alternating GMOC/BA-EDTA regimen. Continuous perfusion with PEG-GMOC-BA-EDTA led to a total (12 patients) or partial (3 patients) disappearance of the stones within 2-15 days. Similarly, alternating GMOC and BA-EDTA treatment dissolved the stones in 12 patients. The average volume of PEG-GMOC-BA-EDTA infused contained only 27% of the GMOC applied during the alternating therapeutic regime. This reduction of the GMOC dose was associated with a significant reduction of adverse effects such as emesis, diarrhea and biliary pain. We concluded that GMOC is equally efficient in the new hydrophilized form but it is clearly superior as far as side effects are concerned. In all, this supports its clinical suitability for the dissolution treatment of common bile duct stones.

Topics: Aged; Aged, 80 and over; Bile Acids and Salts; Caprylates; Cholangiography; Drug Administration Schedule; Edetic Acid; Emulsions; Female; Gallstones; Glycerides; Humans; Male; Perfusion; Solvents

Retained common bile duct stones in postcholecystectomy patients who have a T-tube in situ should be treated, preferably, by nonoperative means. Thus, we treated seven such patients with common bile duct perfusion (through T-tube) of methyl tertiary butyl ether, and 10 patients with perfusion of monooctanoin. However, successful dissolution was achieved in only one and three patients, respectively. Hence, endoscopic sphincterotomy (ES) was performed in the patients in whom solvent perfusion had failed, and in other subsequent patients with T-tube in situ. Of 28 patients thus treated, bile duct clearance could be achieved in 27 (96.5%) patients; minor bleeding occurred in only three patients. After sphincterotomy, the stones passed out spontaneously in 20 patients while the T-tube was still in situ, but in two patients, only after the T-tube was removed. Similarly, basketing of the stones could be done in four patients with the T-tube in position, but in one patient whose ductal stones were above the T-tube, the tube had to be removed to make basketing successful. Endoscopic sphincterotomy is an efficient method of treating retained common bile duct stones in patients with T-tube in situ. However, in those patients whose ductal stones are above or astride the T-tube, the T-tube may have to be removed to attain bile duct clearance.

Topics: Adolescent; Adult; Caprylates; Child; Cholangiopancreatography, Endoscopic Retrograde; Ethers; Female; Gallstones; Glycerides; Humans; Intubation; Male; Methyl Ethers; Middle Aged; Solvents; Sphincterotomy, Transduodenal; Therapeutic Irrigation

The agent Octaglin was used for dissolving residual stones found in 5 patients in the early periods after operations on the biliary tract. It was administered through a drain left in the choledochus or cystic duct during the surgical intervention. The composition of the concrements was determined from examination of the biliary crystal structures by the method of polarizing light microscopy. The stones were dissolved completely in all cases so that 4 of the 5 patients did not need to be operated on for a second time.

Topics: Adult; Aged; Caprylates; Cholecystectomy; Cholelithiasis; Drainage; Female; Gallstones; Glycerides; Humans; Middle Aged; Solvents

Percutaneous transhepatic removal of common bile duct stones was performed 54 times in 50 patients with a success rate of 93%. In all patients, a modified Dormia basket was inserted through a percutaneous transhepatic catheter, and the stones or fragments were advanced into the duodenum. All patients had contraindications to surgery or had undergone unsuccessful attempts at endoscopic retrograde cholangiopancreatography and sphincterotomy. Monooctanoin (25 patients) or methyl tertiary-butyl ether (four patients) was infused to reduce stone size or remove residual debris. The average time for complete stone removal was 8.6 days. Morbidity was 13% and mortality was 4%, results which compare favorably with those of surgery.

Topics: Aged; Caprylates; Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Ethers; Gallstones; Glycerides; Humans; Methyl Ethers; Sphincterotomy, Transduodenal

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

The combination of ceruletide-induced relaxation of the sphincter of Oddi plus flushing with saline has recently been proposed as a novel procedure for the treatment of residual common bile duct (CBD) stones. In this study we have administered intravenous ceruletide (2 ng kg-1 body weight min-1 for 1 h) plus intraductal saline (800-3000 ml, infused at a rate that kept biliary pressure below 30 cmH2O) to a group of 14 patients. The treatment induced the passage of residual stones in 11 subjects (79 per cent) with complete clearance in 7 (50 per cent). The majority of the cleared concretions (11/15) had a diameter less than 10 mm. No severe side-effects were recorded during the treatment. Four of the seven subjects who exhibited incomplete CBD clearance underwent a short cycle of mono-octanoin administration in order to reduce the size of residual radiolucent stones. This course of treatment was followed by another attempt with intravenous ceruletide and saline washout which gave a successful response in an additional three cases. These data indicate that the combination of ceruletide and flushing is a safe and inexpensive method for treatment of residual stones. The procedure is feasible for both radiolucent and radio-opaque stones and is mainly eligible for small concretions of diameter less than 10 mm. Larger (greater than 10 mm) radiolucent stones may be partially dissolved with mono-octanoin and then eliminated by the washout technique.

Topics: Adult; Aged; Caprylates; Ceruletide; Female; Gallstones; Glycerides; Humans; Injections, Intravenous; Intubation; Male; Middle Aged; Sodium Chloride; Solvents; Sphincter of Oddi; Therapeutic Irrigation

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.

Topics: Adult; Aged; Aged, 80 and over; Caprylates; Catheterization; Drainage; Gallstones; Glycerides; Humans; Length of Stay; Middle Aged

Topics: Caprylates; Cholagogues and Choleretics; Cyclohexanecarboxylic Acids; Drug Evaluation; Drug Therapy, Combination; Gallstones; Glycerides; Humans; Solvents; Time Factors

The efficacy and safety of mono-octanoin, a cholesterol solvent for the direct dissolution of stones in the biliary tract, was assessed by collating case reports on 343 patients provided by 222 physicians who used the material between 1977 and 1983. Most patients had previously undergone cholecystectomy, with common duct exploration, the majority within the preceding six weeks. In most, sphincterotomy was impossible or if carried out, had not induced stone passage. Stone dissolution was considered preferable to surgery, especially in patients who were frail, elderly, or had multiple medical problems. Treatment was unequivocally successful in 88 patients (26%) and was a valuable adjunct to interventional treatment in another 29 subjects (8%). In 70 patients (20%), calculi became smaller, but remained within the biliary tree. Thus, mono-octanoin was judged to have been useful in 54% of patients. Treatment was ineffective in 124 cases (36%). In the remaining 32 patients (9%), treatment was aborted because of side effects. Such side effects were common, occurring in 67% of cases, and in 41% of patients they were multiple. Abdominal pain was the most common complication. Other side effects reported were nausea, vomiting, and diarrhoea. Side effects were usually dose related and responded to reduction in infusion rate. Side effects were life threatening in 12 patients (5%), but there were no permanent sequelae and no deaths occurred. These data indicate that mono-octanoin is moderately effective, generally second line, but sometimes first line, treatment for retained biliary duct calculi.

Topics: Adolescent; Adult; Aged; Caprylates; Female; Gallstones; Glycerides; Humans; Liver Function Tests; Male; Middle Aged; Solvents

Topics: Caprylates; Carnosine; Catheterization; Edetic Acid; Endoscopy; Female; Gallstones; Glycerides; Humans; Middle Aged; Therapeutic Irrigation

A prospective study of 53 consecutive patients with retained common bile duct stones, treated with monooctanoin infusion is presented. Overall good results were obtained in 58.6% of cases and poor in 41.4%. No abnormal levels of hepatic and pancreatic enzymes were observed. The main cause of failures was due to stones located in the intrahepatic tree. In the presence of pigmented stones or when their size exceeds 30 mm, monooctanoin infusion should be associated to other instrumental procedures. It is concluded that when intrabiliary infusion of monooctanoin is well tolerated, it is an effective alternative for treatment of retained common bile duct stones.

Topics: Adult; Aged; Caprylates; Cholangiography; Female; Follow-Up Studies; Gallstones; Glycerides; Humans; Male; Middle Aged; Prospective Studies

Seventeen patients with bile duct calculi were treated alternately with a preparation of glycerol octanoate and a bile salt-EDTA solution via a nasobiliary tube. Of 14 patients (group I), it was necessary to operate on four immediately after irrigation therapy, success resulted from this conservative therapy in eight (57%) cases and two were unchanged. Laboratory investigations showed a decrease in zinc and copper concentrations in the serum. Of the patients 50-60% suffered from vomiting and diarrhea. For three patients (group II), there was an interval of 6-26 days between the end of the therapy and operation. Histological findings in the patients in group I and II subjected to operation included acute ulcerative and chronic inflammation in gallbladder and common bile duct walls. Since the alterations were of minor degree in four of the seven patients who subsequently underwent surgery the risk of irrigation therapy seems to be acceptable.

Topics: Aged; Bile Acids and Salts; Caprylates; Cholangitis; Diarrhea; Edetic Acid; Female; Gallbladder Diseases; Gallstones; Glycerides; Hemorrhage; Humans; Male; Middle Aged; Nausea; Ulcer

Alternating fluid rinsing with a modified glyceromono-octanoate (GMOC) and bile salt-EDTA (BA-EDTA) solution via an endoscopically placed indwelling nasal biliary catheter was performed on 15 patients (13 women, 2 men) with recurrent stones in the choledochal duct after cholecystectomy. Of 12 radiotranslucent and three radioopaque concrements with a mean diameter of 1.72 X 2.05 cm (largest concrement: 3.0 X 3.5, smallest 1.0 X 2.1 cm) 13 were dissolved (87% success rate). In one patient chemolitholysis had to be stopped because of electrolyte abnormalities, before treatment had been completed. After the end of treatment all patients were free of symptoms and during a fairly long follow-up period no stone recurrences were observed.

Topics: Aged; Bile Acids and Salts; Caprylates; Catheters, Indwelling; Cholecystectomy; Common Bile Duct; Drug Combinations; Edetic Acid; Female; Gallstones; Glycerides; Humans; Male; Middle Aged; Nose; Postoperative Complications; Recurrence; Solutions; Therapeutic Irrigation; Time Factors

The following perfusion media for dissolving bile duct calculi were infused via a cutaneobiliary tube into the biliary tract of 12 mongrel dogs: 4.3% cholate solution, 0.34% chenodeoxycholate solution, Capmul, GMOC (special formulation of Capmul), BA-EDTA and 0.9% saline. Infusion lasted 50 h. Postmortem examination revealed hemorrhagic, partly phlegmonous cholangitis, acute duodenitis, necrosis and abscesses in the liver. The lesions were most pronounced after the cholate solution and with Capmul and GMOC, but were only detected to a slight extent after BA-EDTA and the chenodeoxycholate solution. 0.9% saline had no side effects. The investigations could demonstrate that it is the very irrigation media that today are recommended for treatment of bile duct stones in patients, that cause considerable morphologic side effects. The alternating administration of an EDTA solution with a Capmul preparation may diminish local toxicity of the latter.

Topics: Animals; Bile Acids and Salts; Biliary Tract; Caprylates; Chenodeoxycholic Acid; Cholic Acid; Cholic Acids; Common Bile Duct; Dogs; Duodenum; Edetic Acid; Female; Gallstones; Glycerides; Jejunum; Male; Perfusion; Solutions; Solvents

The aim of this study was to estimate efficacy, safety, and tolerance of monooctanoin in 16 patients with retained radiolucent biliary stones and indwelling biliary drainage. Monooctanoin was infused continuously at a rate of 3-4 ml/h. Monitoring of pressure with a manometer broken off at 20 cm prevented the development of excessive pressure in the common bile duct. The mean volume of the compound instilled (+/- SD) was 848 +/- 393 ml (range 80-1450) and the mean duration of treatment was 13 +/- 6 days (range 2-23). Monooctanoin induced disappearance of stones in 11 of 16 patients giving a success rate of 69%. Three patients exhibited a partial dissolution of stones which were then successfully removed through the postoperative T-tube. The two failures can be attributed to the type of stones mainly composed of bile pigments. Side effects from the infusion of monooctanoin were only minor and easily controlled by reducing the infusion rate of the solution. Laboratory tests, including hepatic and pancreatic enzymes, remained stable. In one subject endoscopic and histological evidence of mild duodenitis was found when pre- and posttreatment features were compared. On the basis of these data, we recommend monooctanoin to treat biliary-retained cholesterol stones.

Topics: Adult; Aged; Caprylates; Catheters, Indwelling; Cholecystectomy; Drainage; Drug Evaluation; Female; Gallstones; Glycerides; Humans; Male; Manometry; Middle Aged; Postoperative Complications

Several nonsurgical methods of therapy are available for treatment of retained common bile duct calculi. These include percutaneous extraction, endoscopic extraction, dissolution, and endoscopic sphincterotomy. The method chosen depends on location and size of calculi, size of sinus tract, patient age, surgical risks, and other factors. In most cases, procedures can be carried out safely and successfully with few or no complications.

Topics: Aged; Caprylates; Cholangiography; Endoscopes; Endoscopy; Gallstones; Glycerides; Humans; Methods; Sphincter of Oddi

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.

Topics: Aged; Caprylates; Catheterization; Cholangiography; Gallstones; Glycerides; Humans; Male; Punctures

Topics: Caprylates; Duodenal Ulcer; Gallstones; Glycerides; Humans; Infusions, Parenteral; Male; Middle Aged

Topics: Adolescent; Adult; Aged; Caprylates; Female; Gallstones; Glycerides; Humans; Isotonic Solutions; Male; Middle Aged; Postoperative Complications

Topics: Caprylates; Gallstones; Glycerides; Humans; Postoperative Complications

Topics: Caprylates; Cholangiopancreatography, Endoscopic Retrograde; Female; Gallstones; Glycerides; Humans; Liver Abscess; Middle Aged; Solvents; Sphincter of Oddi

Topics: Caprylates; Cholangiography; Gallstones; Glycerides; Humans; Male; Middle Aged

Topics: Administration, Oral; Caprylates; Chenodeoxycholic Acid; Cholelithiasis; Cholesterol; Cholic Acids; Endoscopy; Female; Gallstones; Glycerides; Humans; Intubation, Gastrointestinal; Liver

Endoscopic sphincterotomy is widely being used for the treatment of common bile duct stones. In a small group of patients the gallstones are large in size and, hence, difficult to be extracted after a successful endoscopic sphincterotomy. We used a constant infusion of mono-octanoin through a nasobiliary catheter in nine such patients. This method was successful in partial or complete dissolution of the stones in 74% of the patients. In the remaining 36% of the patients, the stones were noted to be soft allowing easy extraction by crushing.

Topics: Caprylates; Catheterization; Endoscopy; Gallstones; Glycerides; Humans; Infusions, Parenteral; Solubility

Mono-octanoin is effective in the dissolution of retained common duct stones. Some of the failures of this solution to dissolve retained common duct stones are attributed to the low cholesterol content of the stones. This assumption was evaluated by analyzing gallbladder stones from 58 patients following cholecystectomy. Each stone was also incubated in mono-octanoin, and the composition of the stone was compared with the rate of dissolution. Stones containing 10% or less cholesterol did not appreciably dissolve in mono-octanoin. Stones 40% or greater in cholesterol content dissolved within an average of 3.3 days, which was significantly faster than those low in cholesterol (p less than 0.001). Following common duct exploration, stones should be saved for analysis or in vitro determination of the rate of dissolution in mono-octanoin. The use of mono-octanoin is recommended only for retained stones that are high in cholesterol or dissolve rapidly when incubated in mono-octanoin and should be effective in 91% of the cases.

Topics: Caprylates; Cholesterol; Gallstones; Glycerides; Humans

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

Mono-octanoin (glyceryl-l-mono-octanoate), 2-4 ml/h, was instilled into the bile or hepatic ducts of twenty-four patients with retained gallstones after cholecystectomy and choledochotomy. After treatment, fifteen patients no longer had stones. In five the stones were smaller or reduced in number; and in four of these the stones were extracted mechanically via the T-tube tract. Mechanical extraction was also possible in one of the four patients with unaltered stones. With a battery-operated pump or hand injection, mono-octanoin can be safely infused as early as the 8th postoperative day and some patients can continue the treatment outside hospital.

Topics: Adolescent; Adult; Aged; Bile Ducts, Intrahepatic; Caprylates; Cholesterol; Female; Gallstones; Glycerides; Humans; Male; Middle Aged; Postoperative Care; Solvents

Topics: Caprylates; Cholesterol; Gallstones; Glycerides; Humans; Solvents

Topics: Caprylates; Gallstones; Glycerides; Humans; Methods; Solvents

Topics: Caprylates; Catheterization; Gallstones; Glycerides; Humans; Intubation; Solvents

Twenty patients with bile duct stones were treated via an indwelling nasobiliary tube with a modified Capmul 8210 preparation (GMOC) and alternating with a bile salt-EDTA (BA-EDTA) solution for an average of 12 days. In vitro the dissolution capacity of GMOC and BA-EDTA for cholesterol stones was higher than that of Capmul 8210. The nasobiliary tube was tolerated well for a maximum of 84 days; this renders us independent of the T-tube. The therapeutic success rate of GMOC was 64%, even though we treated mostly old and large concrements. Side effects occurred markedly less than with Capmul 8210. In patients with acute cholecystitis or cholangitis the clinical course improved under therapy, and there was no deterioration of a chronic condition.

Topics: Aged; Caprylates; Cholic Acids; Common Bile Duct; Deoxycholic Acid; Drug Combinations; Edetic Acid; Female; Gallstones; Glycerides; Humans; In Vitro Techniques; Infusions, Parenteral; Intubation; Male; Middle Aged; Nose; Solutions; Solvents; Ursodeoxycholic Acid

Monooctanoin is a medium-chain diglyceride that is effective in dissolving cholesterol gallstones in vitro. The in vivo efficacy of monooctanoin was evaluated in eight patients who had monooctanoin infused through the T tube to dissolve retained common duct stones. Five of eight (62%) experienced success. Abdominal cramps and diarrhea were the only side effects, and these resolved by temporarily stopping the infusion or decreasing the rate of the infusion. Since bilirubinate stones accounted for the three failures, the composition of the stone is the determining factor in selecting a treatment plan for retained common duct stones. Retained cholesterol stones can be successfully treated within 4 to 7 days by T-tube infusion of monooctanoin. Pigment stones should be removed by extraction through the T-tube tract or by endoscopic papillotomy.

Topics: Adult; Aged; Caprylates; Drug Evaluation; Female; Gallstones; Glycerides; Humans; Male; Middle Aged

Topics: Adult; Aged; Caprylates; Catheterization; Female; Gallstones; Glycerides; Humans; Liver; Male; Radiography; Solvents

Cholesterol stones in the bile duct may be resolved by applying Capmul 8210 (Cholesterol-caprylic acid ester) by way of T-drain or through a gastro-biliary tube. Results of in vitro experiments and a case reported do show, that an alternating irrigation with a specially prepared solution of glycerooctonate with bile salt-EDTA-solution will yield better results than Capmul 8210 alone. The advantage of this alternating therapy results from the fact, that calcium bilirubinate may be resolved in addition to the other components of the gallstones, and that side effects are rarer and less disturbing than side effects caused by Capmul 8210.

Topics: Anticholesteremic Agents; Bile Acids and Salts; Caprylates; Cholesterol; Drug Therapy, Combination; Edetic Acid; Emulsions; Esters; Gallstones; Glycerides; Glycerol; Humans; In Vitro Techniques; Intubation; Therapeutic Irrigation

Topics: Adult; Aged; Caprylates; Female; Gallstones; Glycerides; Humans; Male; Middle Aged

A commercial emulsifying agent consisting largely of glyceryl-l-monooctanoate (monooctanoin) was found to be an excellent cholesterol solvent. In vitro, the agent dissolved mixed cholesterol gallstones more than twice as fast as sodium cholate solutions, which have been previously used for dissolution of retained cholesterol bile duct stones by T-tube infusion. To test clinical efficacy, the solvent was infused, via T-tube, into 12 patients with retained bile duct stones. Some or all of the stones disappeared in 10 patients during biliary tract infusion of monooctanoin for 4--21 days. Stones from the 2 patients whose stones did not disappear were removed surgically and in vitro were found to be insoluble in monooctanoin. Monooctanoin infusions were well tolerated. This digestible solvent appears to be a useful substance for direct physical dissolution of retained bile duct stones by T-tube infusion.

Topics: Adult; Aged; Anorexia; Caprylates; Cholesterol; Cholic Acids; Female; Gallstones; Glycerides; Humans; Male; Middle Aged; Nausea; Perfusion; Solubility; Solvents

In 5 patients with common bile duct stones a dissolution therapy with the octanoate mixture Capmul 8210 was performed using the transpapillary perfusion technique. In 3 out of the 5 cases a passage of the stones without further endoscopic operative procedures could be achieved. Complaints were endurable except in one case. Further studies to dissolve common bile duct stones with a modified Capmul solution via a transpapillary tube seem justified.

Topics: Adult; Aged; Caprylates; Female; Gallstones; Glycerides; Humans; Intubation; Male; Middle Aged; Perfusion