Self-expanding metallic stents for large bowel obstruction.

BACKGROUND: Self-expanding metallic stents (SEMS) may relieve colonic obstruction as definitive therapy or as a bridge to elective surgery. METHODS: This was a retrospective longitudinal cohort study of patients undergoing insertion of SEMS for large bowel obstruction at one institution. Scrutiny of the radiology department's coding system allowed identification of all patients undergoing colonic stent insertion between 2002 and 2008. Data were extracted from patient case notes and investigation reports. RESULTS: Eighty-two patients with a median age of 75 (interquartile range (i.q.r.) 43-94) years underwent stent insertion, 71 for palliation and 11 as a bridge to surgery. Obstruction was due to malignant disease in 67 patients and had a benign cause in 15. Median survival in the palliative setting was 103 (i.q.r. 44-317) days. Complications occurred in 43 patients, of whom 22 underwent unplanned surgery. High-grade obstruction (relative risk (RR) 2·05; P = 0·055) and benign disease (RR 3·45; P < 0·001) were associated with risk of adverse events. CONCLUSION: SEMS should not be used for large bowel obstruction with benign pathology.

The role of subintimal angioplasty in the management of arterial disease of the lower limb: the North-East of Scotland experience.

INTRODUCTION: The management of occlusive femoropopliteal disease continues to evolve and a definitive strategy remains to be defined. We examine the utility ofsubintimal angioplasty (SIA) in our institution. METHODS: A retrospective study with predefined end-points, including technical success and primary patency. RESULTS: 61 consecutive cases were identified (claudicants n=29 and critical ischaemia n=32). Sixty-four percent of occlusions were greater than 10 cm with poor run-off (60% with two vessels or less). Technical and physiological success was 95% and 79% respectively, with clinical improvement reported by 72%. At a mean follow-up of 20 months twelve-month primary patency (assessed clinically, with ABPI and selective duplex scanning) was 67% (subgroup analysis: claudicants 83%, criticals 53%, p=0.02) and morbidity 8% with no limb loss or procedure related mortality. CONCLUSION: SIA is an effective procedure for chronic lower limb ischaemia with acceptable outcome. Our experience correlates well with evidence in the current literature.

Does retrograde balloon dilation compromise outcome of secondary open pyeloplasty: 17 years' experience at a single center.

OBJECTIVES: To determine whether the outcome of secondary open pyeloplasty is compromised by previous retrograde balloon dilation. METHODS: Patients undergoing secondary open pyeloplasty after retrograde balloon dilation (n = 25) were compared with a similar group undergoing primary open pyeloplasty (n = 25) at the same institution. Patients were assessed by renography before and after surgery, and postoperative success was determined by the complete absence of pain. RESULTS: In the primary pyeloplasty group, the success rate was 96%, with a mean follow-up of 33 months (range 17 to 53). In the secondary pyeloplasty group, the success rate was 88%, with a mean follow-up of 20 months (range 9 to 32). No statistically significant difference was found in the success rates between the two groups (P = 0.6). CONCLUSIONS: Treatment failures after retrograde balloon dilation can be salvaged by secondary pyeloplasty with no detriment to the chance of long-term success compared with primary pyeloplasty.

Outcomes after placement of colorectal stents.

BACKGROUND: Colonic stents are increasingly used to palliate or alleviate large bowel obstruction in patients with colon cancer and other obstructing lesions in whom a definitive surgical procedure is inappropriate. We report on the outcomes of a large group of patients who underwent deployment of a colon stent in a single institution by a single operator. PATIENTS AND METHODS: This was a retrospective observational cohort study of all patients undergoing colonic stenting between September 1995 and May 2002. Data collected included nature of pathology, type of stent used, procedure morbidity, patient survival and details of any definitive procedures performed after stenting. RESULTS: One hundred and seven patients were evaluated (58 male) with a median age of 75 years (range 36-99 years). A total of 112 stents were successfully deployed (46 as an emergency). Twelve patients had double stents inserted coaxially and overlapping. In 7 patients the stent could not be safely deployed. Eighty-seven patients had colorectal cancer, 13 patients had an extra-luminal malignancy, 5 had diverticular strictures and in 2 patients the pathology was unknown. At last review (May 2002) 18 patients were alive, 82 patients had died and 7 patients had been lost to follow-up. Of those patients who died, the median survival after stenting alone was 6 weeks (range 4 days-36 weeks). Ten patients underwent subsequent definitive surgery. Stent complications included, 2 colonic perforations, 3 stent occlusions and 4 stent migrations. CONCLUSION: Colonic stenting can be used effectively, with acceptable morbidity, to manage patients presenting with large bowel obstruction. In a smaller number of patients colon stents may safely temporize symptoms while definitive surgery is planned.

Colonic pouchography is not routinely required prior to stoma closure.

BACKGROUND: Colonic pouch formation with pouch-anal anastomosis is now regarded as the procedure of choice for restoration of intestinal continuity following anterior resection for low rectal cancers. The aim of this study was to review the necessity for routine colonic pouchography prior to closure of a diverting loop stoma. METHODS: This was a prospective study of 52 consecutive patients who underwent colonic pouch formation between 1 June 1999 and 31 May 2002, four of whom have subsequently died. Each pouch was assessed clinically and radiologically prior to stoma closure. RESULTS: There were no clinical anastomotic leaks. Forty-six of 48 surviving patients have had a colonic pouchogram and in no case was either a pouch or pouch-anal anastomotic defect identified. To date 40 patients have undergone stoma closure without an anastomosis-related complication. CONCLUSION: Following successful colonic pouch formation, routine study of the pouch by contrast radiology does not add to clinical assessment. As a consequence radiological imaging is unnecessary and can be omitted.

Is there a role for balloon dilatation of pelvi-ureteric obstruction in children?

PURPOSE: The aim of this study was to examine the effectiveness of balloon dilatation with double J stenting in the management of children with pelvi-ureteric junction (PUJ) obstruction. METHODS: A retrospective study of a 4-year experience of PUJ balloon dilatation in children was conducted in a single unit. Information was collected on patient demographics, clinical presentation, the procedure of balloon dilatation, renal function, and antero-posterior renal pelvis diameter both pre- and postoperatively. RESULTS: There were 10 patients with a median age of 12.5 years (range, 21 months to 15 years). Four cases presented with ipsilateral flank pain, 3 with urinary tract infection, and 3 were discovered incidentally. Retrograde dilation was performed in all cases. Dilation was considered an initial success in 8 of 10 cases, and 1 patient deteriorated after 17 months. Double J stents were placed in all cases and remained in situ for a median of 7.5 weeks (range, 7 to 8.5). Median in-hospital stay was 2 days. Median follow-up was 34 months (range, 7 to 48). Ipsilateral renal excretion times (on MAG III isotope scanning) improved markedly from a median of 84 minutes (range 13 to 200) preoperatively to 7 minutes (range, 1 to 200) at 3 months and 7 minutes (range 1 to 113) at 12 months postoperatively. Median pelvic AP diameter reduced from 30 mm (range 22 to 74) to 16 mm (range, 8 to 36) at 2 months and 10 mm (range, 4 to 41) at 7 months. There were 2 immediate failed procedures, both occurred in patients who went on to open pyeloplasty and were found to have aberrant renal vessels causing extrinsic PUJ compression. One child deteriorated between 10 and 17 months and went on to open pyeloplasty. Twenty-two patients underwent open pyeloplasty in the unit during the same time period with a 95% success rate. Median stay was longer at 5 days and median age younger at 22 months (range, 6 weeks to 13 years). CONCLUSION: Balloon dilatation is a viable option in the management of PUJ obstruction, carrying minimal morbidity in experienced hands.

Self-expanding metal stents in the management of colorectal carcinoma--a preliminary report.

AIMS: The role of diagnostic imaging in colorectal carcinoma is in the initial diagnosis, staging and detection of complications of the disease. Seven cases of colorectal carcinoma are presented where expandable metallic stents were placed for the management of stenosing lesions in patients with advanced metastatic disease or with serious medical complications which prevented immediate surgery. RESULTS: Seven patients (five male, two female) with an age range of 51-76 years had expandable metallic stents placed over a 9-month period. All stents were placed successfully with no immediate complications. The stents remained in situ for a range of 7-210 days. CONCLUSION: Expandable metallic stents can be successfully and safely placed in the colon. These stents may be useful in the management of patients with advanced metastatic disease or in those presenting with large bowel obstruction in which decompression by a stent allows treatment of coexisting medical complications to enable surgery to be carried out at a later date.

Metallic ureteric stents: early experience.

OBJECTIVE: To report our experience with metallic self-expanding stents in the palliative care of patients with ureteric obstruction caused by advanced pelvic malignancy. PATIENTS AND METHODS: Seven patients (five men and two women, mean age 72.8 years, range 58-88) with ureteric obstruction caused by advanced pelvic malignancy were evaluated. Self-expanding metallic Memotherm stents (Angiomed, Karlsruhe, Germany) were deployed using an antegrade approach in all patients. Patients were followed for a mean (range) of 9 (4-13) months to assess renal function and survival. RESULTS: All seven patients had good palliation; their quality of life was improved and symptom such as loin pain were ameliorated. Renal function was preserved; the mean serum creatinine level before and after stenting was 636 and 263 mumol/L, respectively). The mean duration of stent patency was 9 months. Of the five patients who subsequently died, only two had recurrent renal failure, presumably caused by stent occlusion. CONCLUSIONS: The use of metallic stents in the palliative care of ureteric obstruction caused by advanced pelvic malignancy is a safe and effective treatment.

Expandable metal stent application in obstructing carcinoma of the proximal colon: report of a case.

PURPOSE: The increased mortality of emergency vs. elective colonic surgery applies equally to the right and left colon. Recent interest has surrounded the application of expandable metal stenting in acute obstruction but has been confined to the left colon. We describe successful application of stenting in the right colon, allowing postponement of a particularly high-risk laparotomy. METHODS: A patient with acute bilateral iliofemoral thromboses simultaneously developed complete obstruction of the proximal transverse colon. After heparinization and under fluoroscopic control, a 10-cm-long, self-expanding Wall-stent (Schneider, Bulach, Switzerland), 22 mm in diameter, was manipulated across the obstruction. RESULTS: Immediate decompression with symptomatic relief ensued. The stent prevented obstruction during a 10-week period of anticoagulation, and repeat duplex scanning showed resolution of iliac thrombus. An elective right hemicolectomy was then performed. Postoperative course was uncomplicated, and histopathology confirmed a Dukes B carcinoma. CONCLUSIONS: This case, in which a potentially hazardous laparotomy was delayed until the operative risk improved, defines a new role for stenting in colonic obstruction and demonstrates an extension of its applicability to the right colon. Literature review found no other report of stent application in the right colon.

Retrograde balloon dilatation for pelviureteric junction obstruction.

A total of 49 retrograde balloon dilatations for pelviureteric junction (PUJ) obstruction were carried out on 43 pelviureteric junctions in 42 patients from 1986 to 1991. The majority (34/43) were performed as primary treatment for PUJ obstruction, with 9 patients having a history of previous open pyeloplasty. Follow-up ranged from 3 months to 4 years (mean 18 months). Clinical improvement, as assessed by absence of symptoms, was seen in 34 cases (80%). There was either no change or an improvement in renographic findings (t1/2 time and/or split function) in 40 patients (93%). Of the 9 patients who were undergoing secondary treatment, 5 showed clinical improvement and 8 showed no change or renographic improvement. Nine patients required 12 further procedures, of which 5 were interval nephrectomy. Balloon pyelolysis is a simple procedure with good results over a 4-year follow-up period. It is less effective for the treatment of secondary pelviureteric junction obstruction. It has a low morbidity and no mortality, involves a short hospital stay and allows an immediate return to full activity. It is therefore an attractive alternative to open pyeloplasty as first-line treatment for PUJ obstruction.

Primary hepatocellular carcinoma in a patient with breast carcinoma.

We report the case of a patient who presented with a carcinoma of her right breast with ipsilateral axillary lymph node involvement whose staging investigations were otherwise normal. In addition to surgery she received a course of CMF chemotherapy and tamoxifen. Within six months of the diagnosis of breast carcinoma being made, the patient presented as an emergency with widespread intra-abdominal disease from a primary hepatocellular carcinoma. We have not previously witnessed the development of a second primary malignancy in a patient who has already received medication considered to be beneficial in the treatment of both types of malignancy. An extensive literature search has failed to reveal a similar case. The question of immunosuppression secondary to treatment with CMF chemotherapy is raised, and we suggest that perhaps a simple percutaneous biopsy of apparent liver metastases be performed under ultrasound control so as to determine the origin of liver disease in patients with breast carcinoma.

Low-field (0.08 T) magnetic resonance imaging of the pancreas: comparison with computed tomography and ultrasound.

Seventy-four patients referred for computed tomography (CT) and ultrasound examination with a presumptive diagnosis of pancreatic disease have been studied using a low-field (0.08 T) magnetic resonance (MR) imaging instrument. A further 50 patients being examined for non-pancreatic disease were also examined to assess the appearances of the normal pancreas. All the MR examinations were performed using an interleaved saturation-recovery/short inversion time (TI) inversion-recovery sequence. Part or all of the pancreas was seen in 96% of normal cases. In inflammatory disease, MR was more accurate than either CT or ultrasound for diagnosis, whilst for the demonstration of pancreatic tumours, MR was found to be no better or worse than either CT or ultrasound. The use of specific T1 measurement for soft-tissue characterization was not useful because of the large overlap in values between normal, inflamed and malignant pancreatic tissue. T1 measurement was found to be useful in differentiating different pathological fluids.

Ultrasound of the empty gestation sac in threatened abortion.

The major concern when an empty gestation sac is encountered during threatened abortion is whether or not the pregnancy is viable. Viable pregnancies are managed expectantly, whereas non-viable pregnancies are treated by evacuation of the uterus. Early evacuation of the non-viable pregnancy spares the patient considerable anxiety and discomfort. This study shows that a single ultrasound examination is useful in differentiating viable from non-viable empty gestation sacs. The size of the empty gestation sac was found to be the most useful criterion for determining non-viability. Empty gestation sacs with sizes greater than 26 mm were non-viable, a specificity of 100%, accounting for 43% (42 out of 102) of patients in our series. Other ultrasound criteria found to be useful were shape, position, wall and decidual reaction. The positive predictive value for a successful outcome to a pregnancy was low, being only 41% (9 out of 22).

Immune complex glomerulonephritis and chronic anaerobic urinary infection--complications of filariasis.

We describe a patient with chyluria due to abdominal Bancroftian filariasis. The patient showed two unusual complications, an immune complex glomerulonephritis and a chronic urinary infection. We also discuss the use of the CT whole body scanner in the diagnosis and delineation of the extent of the disease.

Central vein thrombosis associated with intravenous feeding--a prospective study.

Thirty consecutive patients receiving intravenous feeding according to a standard protocol were studied for possible central vein thrombosis by contrast venography. Twenty-two patients had contrast venograms and 6 venograms revealed significant thrombus. Only 1 patient had any clinical evidence of thrombosis. It is suggested that prophylaxis of central vein thrombosis should be standard with intravenous feeding.

Diagnosis of deep vein thrombosis using autologous indium-III-labelled platelets.

Forty-eight patients who had undergone surgical reduction of a fractured neck of femur or in whom deep vein thrombosis was suspected clinically were studied by ascending phlebography and imaging after injection of autologous indium-111-labelled platelets to assess the accuracy and value of the radioisotopic technique in diagnosing deep vein thrombosis. Imaging was performed with a wide-field gammacamera linked with data display facilities. Phlebography showed thrombi in 26 out of 54 limbs examined and a thrombus in the inferior vena cava of one patient; imaging the labelled platelets showed the thrombi in 24 of the 26 limbs and the thrombus in the inferior vena cava. The accumulation of indium-111 at sites corresponding to those at which venous thrombi have been shown phlebographically indicates that this radioisotopic technique is a useful addition to methods already available for the detection of deep vein thrombosis.

Indium-111 labelled platelets in diagnosis of leg-vein thrombosis: preliminary findings.

Platelets from eight patients thought clinically to have deep venous thrombosis were labbelled with indium-111 and reinjected. Subsequent scanning of the patients with a wholebody scanner and imaging with a gammacamera showed focal accumulation of the label at five sites in four legs, which correlated precisely with the sites of venous thrombi identified by ascending venography. This technique is a useful addition to methods for diagnosis venous thrombosis.