Choledochoscopic stone removal through a T-tube tract: experience in 75 consecutive patients.

Retained biliary stones remain a common clinical problem in patients after surgery. Since 1984, the authors have used choledochoscopy in the treatment of suspected retained biliary stones in 75 patients. These procedures were performed in the radiology department with use of local anesthesia supplemented by an intravenously administered sedative and analgesic. A 15-F flexible fiberoptic choledochoscope was used. Fifty-one of the 75 patients were treated as outpatients. Treatment was successful in 74 of 75 patients; in one patient, intrahepatic stones were not completely removed. Electrohydraulic lithotripsy was used to fragment calculi in 11 patients (15%). Biopsies were performed in four patients (5%). Five minor complications occurred; three required overnight admission. Choledochoscopic-assisted removal of retained biliary calculi is a highly effective and safe procedure. Advantages over standard fluoroscopic stone removal include the ability to directly visualize and fragment adherent or impacted stones and visualize noncalculous filling defects, such as air bubbles, mucus, and biliary tumors.

Detection of focal hepatic masses: prospective evaluation with CT, delayed CT, CT during arterial portography, and MR imaging.

The sensitivities of contrast medium-enhanced computed tomography (CT), delayed CT (DCT), CT during arterial portography (CTAP), and magnetic resonance (MR) imaging for detecting focal liver lesions were prospectively evaluated in eight patients who subsequently underwent hepatic lobectomy or transplantation. Pathologic evaluation of the resected liver specimens demonstrated 37 lesions. The sensitivities were 81% (30 of 37 lesions) for CTAP, 57% (21 of 37 lesions) for MR imaging, 52% (12 of 23 lesions) for DCT, and 38% (14 of 37 lesions) for contrast-enhanced CT. The difference between the sensitivity of CTAP and the sensitivities of the other imaging tests was statistically significant (P less than .004). Of the lesions smaller than 1 cm in diameter, CTAP depicted 61% (11 of 18 lesions), MR imaging 17% (three of 18 lesions), CT 0% (zero of 18 lesions), and DCT 0% (zero of nine lesions). It is concluded that for preoperative detection of focal hepatic masses, CTAP is the most accurate technique available to most radiologists. Patients with primary or secondary hepatic neoplasms who are being considered for hepatic resection should undergo CTAP as part of their preoperative examination.

Role of percutaneous intracorporeal electrohydraulic lithotripsy in the treatment of biliary tract calculi. Work in progress.

Although surgery is the treatment of choice for symptomatic gallstones, most bile duct calculi can be successfully treated with the use of routine percutaneous or endoscopic methods. Failure of these methods is most often associated with stones larger than 1.5 cm. The authors used percutaneous intracorporeal electrohydraulic lithotripsy (EHL) to treat 11 patients with calculi in the bile ducts (n = 10) or gallbladder (n = 1) in whom the use of other percutaneous or endoscopic methods failed. The stones in all 11 patients were successfully fragmented and removed. There were no complications. Intracorporeal EHL is an effective alternative therapy for the treatment of biliary tract calculi when standard methods fail.

Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair.

The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.

Chronic intestinal obstruction: value of percutaneous gastrostomy tube placement.

Percutaneous gastrostomy tubes were placed in six patients for treatment of nausea and vomiting associated with chronic intestinal obstruction. There were no complications related to the tubes, and in all patient, symptoms were relieved. For the patient, the advantages of gastrostomy over nasogastric drainage include improved comfort, increased mobility, and a decreased risk of pulmonary aspiration. Percutaneous gastrostomy is a safe procedure and provides excellent palliation for intractable nausea and vomiting in patients with chronic intestinal obstruction.

Suprapancreatic biliary obstruction: CT evaluation.

In a 5-year period, 92 patients with biliary obstruction proximal to the pancreatic segment were evaluated with computed tomography (CT). Seventy-three were judged to have technically optimal studies. Observations of the level of obstruction were compared with data from 50 percutaneous transhepatic cholangiograms; CT data enabled the level of obstruction to be correctly predicted in 46. CT enabled correct prediction of the distribution of obstructing lesions in all 18 patients with intrahepatic obstruction. Forty-four of the 73 patients had pathologic examination of the porta hepatitis. CT findings of obstructing mass and lesser omental nodes resulted in correct prediction of malignancy in 25 (92%) of 27 patients; the absence of such findings enabled correct prediction of benign disease in 13 (77%) of 17 individuals. CT is most valuable as a noninvasive means of planning surgical or radiologic drainage procedures in patients with biliary obstruction.

CT and MR imaging of radiation hepatitis.

The authors describe two cases of radiation hepatitis evaluated by magnetic resonance imaging and CT with CT angiography (CTA) additionally performed in one patient. On CT the radiation hepatitis appeared as sharply demarcated region of lower attenuation than the adjacent normal liver. The region of radiation hepatitis demonstrated decreased perfusion in the portal venous phase of CTA, and 4 min delayed images following CTA showed increased density or relative increased accumulation of contrast. Magnetic resonance in both cases showed that the area of low density on CT had high signal on the T2-weighted image and had increased water content as determined by proton spectroscopic imaging method.

Endourological management of ureteroileal anastomotic strictures: is it effective?

Ureteroileal stenosis represents a serious postoperative threat to the obstructed kidney and open revision in these patients often is difficult. We evaluated 9 patients with 10 ureteroileal strictures who were treated with semirigid fascial dilators (1), balloon dilation (4) or a combination of balloon dilation and percutaneous intraureteral surgery (4). All 5 patients who had semirigid fascial or balloon dilation alone had early recurrence of the strictures. However, in 4 patients dilation in conjunction with percutaneous intraureteral incision of the stricture through a flexible choledochonephroscope resulted in short-term resolution of each ureteroileal stricture. However, by 6 months these strictures had recurred in 50 per cent of the patients.

Emphysematous pyelonephritis: successful management by percutaneous drainage.

Emphysematous pyelonephritis is a life-threatening infection that usually requires open surgical drainage. We report a case of emphysematous pyelonephritis treated successfully with percutaneous drainage.

Intercostal-space nephrostomy for percutaneous stone removal.

Intercostal-space nephrostomies were created in 50 kidneys for removal of 17 staghorn, 9 calyceal, and 24 ureteral calculi. Complications were encountered in six [12%] of 50 patients. These included large pleural effusions in four patients and hydropneumothoraces in two patients. Four patients (8%) had chest tubes placed. The intercostal approach provides direct, straight access to both upper-pole and ureteral calculi as well as to the major portion of most staghorn calculi. Although the morbidity rate is slightly higher than for the more traditional approach via the subcostal lower pole or middle calyx complications generally can be avoided by using a working sheath and placing a large nephrostomy tube after the procedure.

Biliary stricture dilatation: multicenter review of clinical management in 73 patients.

Eighty-nine biliary strictures in 73 patients who had undergone percutaneous balloon dilatation were reviewed to determine long-term patency rates and clinical management problems. The majority of dilatations were performed in patients with anastomotic strictures (n = 44), iatrogenic strictures (n = 28), and strictures associated with sclerosing cholangitis (n = 17). Patency rates after 36 months or more were 67%, 76%, and 42%, respectively. Complications, mostly minor, occurred in less than 7% of patients. Of patients with significant biliary obstruction, 15% had little or no intrahepatic biliary duct dilatation demonstrated by cross-sectional imaging and/or direct cholangiography. No definite conclusions could be drawn about the utility of long-term internal/external stenting.

High resolution CT of the porta hepatis and hepatoduodenal ligament.

The authors present a detailed analysis of the sectional anatomy of the porta hepatis and hepatoduodenal ligament, and illustrate the use of high resolution CT in the clinical evaluation of the area.

Intraarterial digital subtraction angiography of renal transplants.

Twenty-four intraarterial digital subtraction angiography (IA-DSA) studies were performed in 23 renal transplant recipients for evaluation of possible postoperative complications. Ten patients had normal studies. Five patients had minimal (less than 50%) narrowing at the renal artery anastomosis and five had more severe stenoses. Three patients had vascular occlusions. IA-DSA results correlated well with findings at surgery and/or conventional angiography. The major advantage of IA-DSA is the small amount of contrast material needed to perform the study. IA-DSA is particularly well suited to the evaluation of vascular problems in renal transplant patients.

Barium pharyngography: comparison of single and double contrast.

In 119 patients referred for barium pharyngography, both single- and double-contrast examinations were performed. The air-contrast examinations were easier to perform and yielded fewer suboptimal studies than the single-contrast examinations. Neither technique proved to be sensitive in the detection of lesions in the oral cavity, but for lesions in the pharynx, the air-contrast technique had a higher sensitivity (87% vs. 33%) and overall accuracy (94% vs. 84%) than the combination of single-contrast radiography and videotaped fluoroscopy. Single-contrast films provided no further information than the combination of the air-contrast views and the videotaped fluoroscopy. The air-contrast examination was clinically helpful in those patients in whom indirect laryngoscopy was difficult.

Papillary renal cell carcinoma: CT and sonographic evaluation.

The CT, sonographic, and pathologic appearances of 13 surgically confirmed cases of papillary renal cell carcinoma were reviewed. CT-pathologic correlation was available in all 13 cases. Sonography was performed in eight patients (10 distinct renal masses). CT features closely correlated with the previously established clinicopathologic and angiographic appearances. Papillary renal cell carcinoma demonstrated low stage at presentation in most cases (10 of 13 had stage I or II), had a high frequency of calcification (seven), and had less enhancement (diminished vascularity) than typical hypernephroma on CT scans. No consistent sonographic pattern existed; one of 10 masses was hyperechoic, five were hypoechoic, and four were isoechoic compared with normal kidney cortex. On the basis of these observations, a prospective CT diagnosis of papillary renal cell carcinoma can be confidently made in many circumstances. This is particularly important when renal-sparing surgery is a clinical consideration.

Gastrohepatic ligament: normal and pathologic CT anatomy.

In a review of 200 consecutive CT scans of the upper abdomen, the structures within the gastrohepatic ligament (GHL) were well seen in 182 (91%). In 85% of these 182 patients, the largest structure visible within the GHL was 6 mm or smaller. A total of 27 patients had a structure larger than 6 mm within the GHL; this finding could be explained in 13 by the presence of a normal anatomic variant. Of the 14 others, 12 had known tumor arising in or known to have spread to the upper abdomen. Two patients had no obvious explanation. Fourteen patients with cancers of the stomach (9 patients), pancreas (3 patients), and esophagus (2 patients) had 57 intact nodes that were evaluated pathologically. Of these 40/40 benign nodes and 10/17 malignant nodes were less than or equal to 8 mm in size. When anatomic variants are excluded, the finding of rounded structures greater than 8 mm in the GHL is a reliable indicator of left gastric node involvement by carcinoma or lymphoma or of coronary venous dilatation.

CT appearance of sclerosing cholangitis.

Ten cases of sclerosing cholangitis, both primary and secondary forms, were found to have similar abnormalities within the liver on CT examinations. These changes are different from those seen in cases of biliary obstruction due to tumor, stone, inflammatory mass, or other focal process. The finding of focal, discontinuous areas of minimal intrahepatic biliary dilatation without associated mass lesion seems to be highly suggestive of sclerosing cholangitis. Only the rare, diffuse form of cholangiocarcinoma would be likely to produce a similar CT appearance.