Peripancreatic retroperitoneal gas mimicking necrotizing pancreatitis after laparoscopic cholecystectomy.

The computed tomographic image of gas in the pancreas and peripancreatic retroperitoneum is strongly suggestive of necrotizing pancreatitis. The authors describe an 81-year-old woman who, 7 days after laparoscopic cholecystectomy, presented with retroperitoneal gas but did not have the clinical or biochemical features of necrotizing pancreatitis. Resolution of her low-grade fever and of the radiologic findings with conservative treatment and the absence of other causes for pneumoretroperitoneum suggest that the gas observed was related to the laparoscopic cholecystectomy.

Periurethral injection of collagen in the treatment of urinary stress incontinence: ultrasonographic appearance.

OBJECTIVE: To describe the ultrasonographic appearance of collagen injected periurethrally to treat urinary stress incontinence. PATIENTS AND METHODS: Transvesical and transvaginal ultrasonography (US) was performed 26 times in 23 patients 3 to 36 months after periurethral injection of collagen to treat symptomatic urinary stress incontinence. The patients ranged in age from 23 to 86 (median 54) years. The appearance, location and volume of the collagen were recorded. Clinical data were also obtained. RESULTS: Transvesical US demonstrated the collagen in 17 of the patients, whereas transvaginal US demonstrated the collagen in all of them. The collagen collections appeared as circumscribed masses at the bladder base and showed various levels of echogenicity with both techniques. However, in patients with more than one deposit of collagen, the collections had similar echogenicity, and echogenicity increased over time in the two patients who underwent serial imaging. In 21 of the patients, the collagen collections were located posterior or lateral to the urethra, and these patients recorded complete or moderate resolution of incontinence. In two of the patients the collections were exophytic, projecting into the bladder lumen; these patients experienced little improvement in their continence. CONCLUSIONS: US provides a rapid, noninvasive method of assessing collagen after periurethral injection. Transvaginal US is the best method of visualizing such collections.

Needle size and sample adequacy in ultrasound-guided biopsy of thyroid nodules.

OBJECTIVES: To determine the optimal needle size (23-gauge or 27-gauge) for ultrasound-guided fine-needle aspiration biopsy of thyroid nodules and to compare the interoperator yield for this procedure. PATIENTS AND METHOD: Over an 11-month period, 123 patients underwent biopsy of a thyroid nodule. Three experienced radiologists were assigned at random to sample the nodules. For each nodule, four passes were performed in random order, two with 23-gauge needles and two with 27-gauge needles. If a specific pass yielded no tissue or blood, as determined by visual inspection (i.e., the sample was dry), the procedure was repeated until a satisfactory sample was obtained. After each patient had left the department, the aspirates were reviewed by a cytopathologist (who was not aware of needle size or operator identity) to determine diagnostic adequacy. RESULTS: Among the 123 nodules, 88 were solid, and 35 were complex cysts. There was no significant difference between the two sizes of needle in the adequacy of the samples obtained (102 nodules were adequately sampled with the 23-gauge needle and 95 with the 27-gauge needle; McNemar chi 2 test, p = 0.1456). However, there were significantly fewer dry passes with the larger needle (2 with the 23-gauge needle and 16 with the 27-gauge needle; chi 2 test, p = 0.0022). Sixteen nodules were inadequately sampled with both needles. Eight of these were less than 1 cm in greatest dimension. Only one solid nodule greater than 1 cm in greatest dimension was inadequately sampled. There was no difference in yield among the three radiologists (chi 2 test, p = 0.5192). No significant complications were encountered. CONCLUSIONS: Needles of both 23 and 27 gauge can be used to obtain fine-needle aspiration biopsy samples from thyroid nodules. Using both sizes is recommended, because the number of dry passes is lower with the larger needle, but the diagnostic quality of the aspirate may be better with the smaller one. Experienced physicians can perform fine-needle aspiration biopsy with equal proficiency.

Value of standardized gestational age charts for fetuses of first-generation Oriental immigrants to Canada.

OBJECTIVE: to ascertain if standard gestational age charts can be used to accurately predict the gestational age of fetuses of first-generation Oriental immigrants to Canada. PATIENTS AND METHODS: Over a 3-year period, all patients presenting for obstetric ultrasound examinations were invited to participate in the study. The authors recorded biparietal diameter, head circumference, femur length and abdominal circumference for 139 fetuses in the second and third trimesters. A study performed in the first trimester was used as the baseline for gestational age. The data for 126 of the fetuses were complete, and these data were used for the analysis. RESULTS: For 77 of the fetuses, both parents were Oriental, and for 49, one or both parents were not Oriental; the latter constituted the control group. A total of 1008 individual measurements were obtained, and of these, all but 14 fell within two standard deviations of the norm, according to standard gestational age charts. Of the abnormal measurements, seven were obtained from five fetuses with Oriental parents, and seven were obtained from six fetuses in the control group. The difference between the two groups in the proportion of measurements falling either above or below two standard deviations from the norm was not statistically significant (Fisher's exact test, p = 0.41694). CONCLUSION: The authors conclude that standard gestational age charts can be used to determine gestational age in first-generation Oriental immigrants to Canada.

Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases.

Role of intraoperative ultrasonography in hepatic surgery: a preliminary report.

Twenty-four patients who underwent ultrasonography during hepatic surgery in the 22 months from October 1989 to July 1991 were studied prospectively to determine the value, if any, of intraoperative ultrasonography. For 6 (25%) of the 24 patients the operative plan was altered because of the ultrasonographic findings. In one of them resection was extended from a left lateral segmentectomy or sectorectomy to a left hemihepatectomy. In the other five patients the planned liver procedure was abandoned. Two of these five patients were cirrhotic--in one of them an additional metastasis was seen, and in the other there was tumour invasion of the portal vein. Of the three noncirrhotic patients, one had tumour invasion of the right hepatic vein, and the other two patients had additional metastases in the caudate lobe (Couinaud segment 1). Ultrasonography was found to be useful in 25% of patients who underwent this investigation during hepatic surgery--it avoided liver resections that would have failed because of advanced malignant disease.

Ultrasound guided percutaneous renal biopsy.

We performed percutaneous ultrasound guided renal biopsy on 27 patients ages 16 to 76 years. A 14 gauge cutting needle was used. Twenty-six patients had medical renal disease; one patient had a renal mass. Patients were followed by sonograms performed immediately post procedure as well the following day. Serum hemoglobin was obtained prior to the procedure as well as one day post biopsy. Complications included five small hematomas and one transient mild hydronephrosis secondary to blood clots. The hematomas were all first noted on the scan one day post biopsy. We conclude that ultrasound guided percutaneous renal biopsy is a safe procedure which is easily performed by the radiologist.

Iliac artery aneurysms presenting as large pelvic masses.

Iliac artery aneurysms are rare but potentially lethal. Radiographic diagnosis is imperative as they can be asymptomatic. Five cases of iliac artery aneurysms are presented.

Observer error in the characterization of hepatic lesions in patients with neoplastic liver disease.

Sixteen patients with known neoplastic liver disease underwent 20 ultrasound examinations by two separate teams to determine the level of agreement in the measurement of lesion size and sonographic characteristics. The intraclass correlation coefficient for the observations on lesion size was r = 0.97 (95% lower confidence limit r = 0.96). We conclude that sonographic estimation of the size of neoplastic liver lesions in highly reproducible and that the measurements obtained may be safely incorporated into the criteria of response for cancer clinical trials.

Effect of steroid ingestion on pancreatic echogenicity.

Pancreatic and liver ultrasound examinations of twenty-five patients without evidence of liver or pancreatic disease and who had been on Prednisone (greater than 7.5 mg per day for longer than six months) were compared with corresponding age- and sex-matched normal controls. Statistical analysis enabled effects of known variables that determine pancreatic echogenicity to be taken into account and showed that steroid ingestion had a statistically significant effect on pancreatic echogenicity, a previous unreported observation.

Hypertrophied muscular bands in the region of the foramen of Bochdalek as a cause for an accessory fissure within the liver.

Within the right lobe of the liver a linear echogenic band with two parallel sonolucencies within it (accessory fissure) was noted on both real time and static scans of 11 patients over a one-year period. Examination of 27 cadavers was performed to ascertain the etiology of this band and demonstrated three with diaphragmatic bands. In two cadavers the band occurred in a location compatible with the echogenic line noted on ultrasound. The embryonic origin of the diaphragmatic band is presumed to be the anterior edge of the foramen of Bochdalek.