Lymphangioma communicating with the excretory system.

Lymphangioma is a rare benign tumor caused by failure in the development of the lymphatic communicating system. The corresponding nomenclature is confusing. In recent years ''renal lymphangiectasia'' is the preferred name. Although this disease may occur in any site of the body, the neck (75%) and axillary area (20%) are the most common sites, and the kidney is occasionally involved. We report a case of lymphangioma communicating with the urinary system in a 61-year-old man diagnosed by CT scan treated with nephrectomy and histological confirmation.

Use of the ALN permanent/removable vena cava filter. A multi-centre experience.

AIM: Vena cava filters are used for the prevention of pulmonary embolism in cases of contraindication, failure or complications of the anticoagulant therapy. There are no certain data in the literature concerning the effectiveness of vena cava filters and, above all, the possible long-term complications are not known. For this reason increasing attention is paid to permanent/removable filters that permit exploitation of the short-term advantages of vena cava interruption, eliminating the possible long-term complications. We have reported the results of a multicentre experience concerning ALN permanent/removable vena cava filters in a total of 276 patients. METHODS: Vena cava filters were placed in 276 patients via the jugular, femoral and brachial vein. The filter was removed in 43 patients after 3 months and in 28 patients after 6 months. RESULTS: In 1 case, due to incomplete opening of the filter, immediate percutaneous removal was performed and another filter was positioned. In 5 cases it was not possible to remove the filter, in 1 case due to inexperience and in the remaining cases due to adhesion of the head or claws of the filter to the wall of the vein. No problems occurred in the other cases. CONCLUSIONS: The ALN vena cava filter is safe, easy to position and remove even a long time after placement. Currently permanent filters should be used only for patients with poor survival expectancy whereas in all other cases the use of removable filters is preferable.

[The treatment of iatrogenic pneumothorax with small-gauge catheters. The author's personal experience in 30 cases]. / Il trattamento dello pneumotorace iatrogeno con cateteri con piccolo calibro. Esperienza personale in 30 casi.

PURPOSE: Pneumothorax (PNX) is the most frequent complication in patients who have undergone lung biopsy. If PNX is asymptomatic and < 30%, it does not require treatment, while if it is > 30% and the patient is symptomatic treatment is needed. As a rule surgery is required and patients are hospitalized and undergo intrathoracic drainage with positioning of a large gauge catheter--i.e. over 15 French (F). In the last 10 years radiologists have begun treating PNX with much smaller catheters (7-10 F). We report the execution technique using 6.3 F catheters and the results obtained in 30 patients with symptomatic iatrogenic PNX and/or iatrogenic PNX > 30%. MATERIAL AND METHODS: All the patients underwent CT-guided lung biopsy. Immediately after the procedure some follow-up scans were performed and a further expiratory radiograph with the patient in upright position was carried out after at least 2 hours. If an asymptomatic PNX < 30% was found the patient was discharged and submitted to radiographic follow-up the following morning and every 24 hours thereafter for 2 days. If there was a symptomatic PNX and/or a PNX > 30% an intrathoracic drainage catheter was positioned. Under fluoroscopic or CT guidance we positioned a 5.7 F intrathoracic pig-tail catheter at a point corresponding to the 3rd or 4th intercostal space on the midclavear line. After manual suction of intrathoracic air we connected the catheter to a Hemlick valve and repeated the chest radiograph 4 hours later. If the PNX had not reformed the patient was discharged and submitted to radiographic follow-up every 24 hours for 3-5 days. On the contrary if the PNX had reformed, or if pain and/or dyspnea symptoms or signs persisted, the catheter was connected to a continuous-suction system and the patient rehospitalized for about 6 days. Oximetry was performed in all patients before biopsy, on PNX diagnosis, and after pulmonary re-expansion. RESULTS: All the cases were resolved and 9 patients were followed-up in the outpatients department. Drainage had to be repeated in 2 patients only and the 5.7 F catheters replaced with an 8 F and a 10 F catheters. Oximetric data were always correlated with the presence/absence of PNX. In particular, in PNX > 30% we found over 10% reduction relative to prebiopsy values. This datum was corrected and came to meet the prebiopsy value as soon as the lung was re-expanded. No significant changes were seen in PNX < 30%. CONCLUSIONS: Small gauge catheters provide the following advantages: the procedure presents a low risk of complications, is easy to carry out and much better tolerated by the patient; also in some cases the cost is lower because no hospitalization is required. The close correlation of oximetric values with the presence/absence of PNX < 30% could be considered to decrease follow-up radiographic examinations. Finally the possibility of treating iatrogenic PNX using radiological techniques further promotes the acceptability of lung biopsy by colleagues from other branches of medicine.

Diagnosis of Hill-Sachs lesion of the shoulder. Comparison between ultrasonography and arthro-CT.

AIM: The Hill-Sachs lesion is a compression fracture caused by impact on the trabeculae of the humeral head during anterior glenohumeral dislocation. The early and accurate identification of patients who risk recurrence of shoulder dislocation requires a suitable screening method. This should be characterized by high sensitivity and specificity, low cost, and repeatability. MATERIAL AND METHODS: The results of ultrasound examination as a screening method were evaluated, the indicator being the identification of the Hill-Sachs lesion. Using ultrasonography and conventional radiological techniques, and double contrast CT (arthro-CT), we studied 60 patients with posttraumatic instability of the shoulder. RESULTS: Against arthro-CT as the true standard, ultrasonography showed a sensitivity of 95.6%, specificity of 92.8%, and diagnostic accuracy of 95%. CONCLUSION: Ultrasonography is an acceptable screening examination for recurrent scapulohumeral dislocation and should be applied prior to other techniques of investigation such as arthro-CT or MR imaging.

[Role of computerized tomography in percutaneous drainage of acute infected necrotic-hemorrhagic pancreatitis]. / Ruolo della Tomografia Computerizzata e del drenaggio percutaneo nelle pancreatiti acute necrotico-emorragiche infette.

In the last few years, Computed Tomography (CT) has emerged as the most sensitive and reliable imaging technique to diagnose acute pancreatitis (AP). Besides assessing the extent of damage to the pancreas and to periglandular tissue. CT can recognize the major early and late complications of the disease promptly and with extreme accuracy. We investigated the diagnostic capabilities of CT in controlling AP development and tried to assess the role of interventional radiology as a therapeutic support after or instead of surgery in treating the necrotic forms of pancreatitis complicated by sepsis. From 1989 to 1995, acute pancreatitis mostly due to biliary tract disease and alcoholism was diagnosed in 228 patients. Necrotic processes were identified in 105 of them since disease onset; septic complications developed in 57 patients. Surgery was performed in 42 patients, but the result was poor in 11 of them (30%) and CT showed the persistence of some infectious pancreatic exudate which had been drained insufficiently. Since sepsis persisted in these patients, the exudate was aspirated percutaneously after positioning appropriate drainage means guided by abdominal CT. Sepsis resolved completely in 10 patients, while one required subsequent surgery. Percutaneous drainage catheters were positioned in 15 patients as the treatment of choice, under CT and US guidance. Sepsis resolved in 7 cases only (45%), while 3 of the extant patients died and 5 needed surgery. The results of our experience demonstrate the effectiveness of percutaneous drainage under CT guidance. However, this technique should be used after and as a support to surgery, the latter remaining the treatment of choice for infectious necrotic AP. Thus, in our experience, the use of percutaneous aspiration instead of surgery proved to be a less effective tool in curing this condition and its use should therefore be limited to high-risk surgical patients.

[Follow-up with Doppler color ultrasonography of patients treated with transjugular intrahepatic portosystemic diversion]. / Il follow-up con eco color Doppler dei pazienti sottoposti a derivazione intraepatica portosistemica per via transgiugulare (TIPS).

We investigated both reliability and limitations of color flow duplex US (CFDU) during the preoperative period and in the follow-up of the patients submitted to transjugular intrahepatic portosystemic shunt (TIPS). MATERIAL AND METHODS. Sixty-six patients suffering from cirrhosis underwent TIPS. Twenty-seven patients were excluded from the trial, as they were treated in other hospitals and submitted to different follow-up. Twenty-four hours before and 48 hours after TIPS, and at 3, 6 and 12 months' intervals during the follow-up, the mean flow rate was measured in the main portal vein and in the stent; the reappearance of ascitis was monitored by the same operator with CFDU. Six and 12 months after TIPS, all patients underwent venography and endoscopy. RESULTS. In 25 cases (64%), both CFDU and venography confirmed shunt patency. In these patients, the flow rate in the main portal vein and stent remained constantly high. In 9 patients (23%), CFDU diagnosed a stenosis on the basis of a marked reduction in the mean flow rate in the main portal vein (p < 0.001), which in 2 patients returned to pre-TIPS values, and in the stent proximal to the portal vein (p < 0.001). In 2 patients (5%), the obstruction was characterized by a return to pre-TIPS values in the portal vein and by the absence of any flow in the stent. Velocimetric sampling in the stent proximal to the vena cava had poor statistical significance. Venography confirmed the flowmetric results in all but 3 patients (7%). CONCLUSIONS. On the basis of our data, CFDU exhibited about 100% sensitivity, 89% specificity and 92% accuracy in the diagnosis of TIPS stenosis/obstruction. We therefore consider CFDU a useful tool in the follow-up of the patients submitted to TIPS, angiography being suggested only when needed on the basis of CFDU and/or endoscopic findings.

[Ultrasonography and retrograde transpapillary cholangiopancreatography combined with sphincterotomy in the diagnosis of choledochal lithiasis. Our experience with 87 patients]. / L'ecografia e la colangiopancreatografia transpapillare retrograda associata a sfinterotomia nella diagnosi di litiasi coledocica. Nostra esperienza in 87 pazienti.

We retrospectively reviewed the US findings of 87 patients to assess US sensitivity in the detection of choledochal (CBD) stones. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was used as the diagnostic standard, except for 1 patient who underwent surgical exploration. First, the distal CBD was studied with transverse and parasagittal US scans through the head and uncinate portions of the pancreas. CBD stones usually appeared as hyperechoic lesions, most of them with acoustic shadowing. In some cases, the stone moves during real-time scanning, which further confirms the diagnosis. Fifty-four of 87 patients had CBD stones and US detected them in 46 cases. The absence of a stone was diagnosed correctly in 28 of 33 patients. In our series, US sensitivity, specificity and accuracy were 85%, positive predictive value 88% and negative predictive value 78%. If the distal duct cannot be demonstrated adequately or if duct size is normal, US sensitivity in detecting stones decreases and other examinations, such as ERCP, should be performed. We conclude that US can be used as the diagnostic method of choice to examine the patients with suspected biliary tract disease. Although ERCP is the gold standard for diagnosis and therapeutic purposes in choledochal stones, it remains an invasive technique and must therefore be held in reserve.

Circadian variation in renal sodium and potassium handling in cirrhosis. The role of aldosterone, cortisol, sympathoadrenergic tone, and intratubular factors.

Renal sodium and potassium handling, plasma aldosterone and cortisol concentrations, and urine free norepinephrine excretion were determined every 4 h for 24 h in 15 cirrhotics (7 without ascites, group 1; 8 with ascites, group 2) and 7 healthy controls during controlled salt intake and recumbency. Renal sodium excretion was significantly reduced in group 2, whereas it exceeded threefold the salt intake in group 1. Its circadian rhythm was disrupted in both groups of patients. Significant inverse correlations with plasma aldosterone were found erratically in controls, never in group 1, and at every 4-h interval in group 2. In the latter, the indexes of tubular activity and effectiveness of aldosterone were also significantly increased. Urine norepinephrine excretion was never related to sodium excretion in either controls or patients; in group 2 it was directly correlated with glomerular filtration rate in many instances. The cortisol-related circadian rhythm of kaliuresis was retained only in group 1. The 24-h renal potassium excretion of controls and patients was comparable, in spite of the striking hyperaldosteronism, and the more than doubled contribution of aldosterone to kaliuresis shown in group 2. The influence of aldosterone on potassium excretion was also witnessed by the direct correlation between these variables found in group 1 and, when kaliuresis was corrected by the distal sodium delivery, group 2. Renal sodium handling in cirrhosis is altered even before ascites formation and compensated patients can undergo "spontaneous natriuresis." Aldosterone is the main cause of sodium retention in nonazotemic ascitic patients, while sympathoadrenergic hyperactivity may contribute to preserve renal perfusion. The influence of aldosterone on kaliuresis is enhanced, but renal potassium wasting in patients with ascites and hyperaldosteronism is prevented by reduced distal tubular availability of sodium.