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Use of Methyl Tert-Butyl Ether for the Treatment of Refractory Intrahepatic Biliary Strictures and Bile Casts: A Modern Perspective.

Kim G, Malayaman SN, Green MS - Case Rep Surg (2015)

Bottom Line: We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction.The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy.However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine/Hahnemann University Hospital, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA 19102, USA.

ABSTRACT
Cholelithiasis is a prevalent problem in the United States with 14% or more adults affected. Definitive treatment of cholelithiasis is cholecystectomy. When cholecystectomy yields minimal resolution treatment options include expectant management of asymptomatic gallstones or endoscopic retrograde cholangiopancreatogram. We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction. Dissolution therapy of gallstones was first reported in 1722 when Vollisnieri used turpentine in vitro. While diethyl ether has excellent solubilizing capacity, its low boiling point limited its use surgically as it vaporizes immediately. Diethyl ether can expand 120-fold during warming to body temperature after injection into the biliary system making it impractical for routine use. The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy. Epidemiological studies have shown the general population should have minimal concerns from passive exposure. Dissolution using MTBE remains a viable option if surgical or endoscopic options are not available. However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient.

No MeSH data available.


Related in: MedlinePlus

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Mentions: Given the past procedural and surgical attempts to drain biliary casts, the decision was made to attempt to dissolve the casts using methyl tert-butyl ether (MTBE). The patient was brought into the operating room where she was given general anesthesia via an endotracheal tube. MTBE was directly injected into the biliary system with 30 mL ether injected in the right biliary system and 46 mL injected into the left biliary system. Following MTBE treatment, there was marked improvement of the right biliary duct system and modest improvement of the left biliary duct system (Figure 1). The patient's alkaline phosphatase decreased to 590 U/L, total bilirubin 14.44 mg/dL, and direct bilirubin 8.79 mg/dL, but WBC remained at 15.3 K/UL. She continued to have persistent Gram-negative rod infection for which she remained on long term antibiotics. Twenty days following MTBE injection, and a little over 2 months after being admitted to our institution, the patient was discharged to a rehabilitation center.


Use of Methyl Tert-Butyl Ether for the Treatment of Refractory Intrahepatic Biliary Strictures and Bile Casts: A Modern Perspective.

Kim G, Malayaman SN, Green MS - Case Rep Surg (2015)

© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4508463&req=5

Mentions: Given the past procedural and surgical attempts to drain biliary casts, the decision was made to attempt to dissolve the casts using methyl tert-butyl ether (MTBE). The patient was brought into the operating room where she was given general anesthesia via an endotracheal tube. MTBE was directly injected into the biliary system with 30 mL ether injected in the right biliary system and 46 mL injected into the left biliary system. Following MTBE treatment, there was marked improvement of the right biliary duct system and modest improvement of the left biliary duct system (Figure 1). The patient's alkaline phosphatase decreased to 590 U/L, total bilirubin 14.44 mg/dL, and direct bilirubin 8.79 mg/dL, but WBC remained at 15.3 K/UL. She continued to have persistent Gram-negative rod infection for which she remained on long term antibiotics. Twenty days following MTBE injection, and a little over 2 months after being admitted to our institution, the patient was discharged to a rehabilitation center.

Bottom Line: We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction.The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy.However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine/Hahnemann University Hospital, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA 19102, USA.

ABSTRACT
Cholelithiasis is a prevalent problem in the United States with 14% or more adults affected. Definitive treatment of cholelithiasis is cholecystectomy. When cholecystectomy yields minimal resolution treatment options include expectant management of asymptomatic gallstones or endoscopic retrograde cholangiopancreatogram. We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction. Dissolution therapy of gallstones was first reported in 1722 when Vollisnieri used turpentine in vitro. While diethyl ether has excellent solubilizing capacity, its low boiling point limited its use surgically as it vaporizes immediately. Diethyl ether can expand 120-fold during warming to body temperature after injection into the biliary system making it impractical for routine use. The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy. Epidemiological studies have shown the general population should have minimal concerns from passive exposure. Dissolution using MTBE remains a viable option if surgical or endoscopic options are not available. However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient.

No MeSH data available.


Related in: MedlinePlus