Dilatation of biliary strictures through the afferent limb of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis.

Repeated dilatation of biliary strictures in patients with sclerosing cholangitis through a subcutaneously placed afferent limb of a choledochojejunostomy is technically feasible and safe. This study is a prospective 15-year evaluation of 36 patients treated by repeat dilatation through this jejunal limb. There was one operative death and one major complication of dilatation. The 5-year survival of all patients was 74%. If patients with cirrhosis or unproven cholangiocarcinoma at the time of operation are not included, the 5-year survival is 86%. The 15-year survival of all patients was 30%; it was 64% if those with cirrhosis and unproven cholangiocarcinoma at the time of operation are not included. Six patients are presently alive with an average survival of 159 months. The study suggests that a combination of repeated dilatations combined with transplantation is the approach of choice in selected patients.

A phase I study of chemoembolization with cisplatin, thiotepa, and lipiodol for primary and metastatic liver cancer.

Thirty patients with primary hepatocellular carcinoma or liver metastases were entered into a program of chemoembolization with cisplatin, lipiodol, and escalating doses of thiotepa. Doses of cisplatin were 100/m2, and thiotepa doses ranged from 9 mg/m2 to 24 mg/m2. Two of three patients with ocular melanoma had partial responses in the liver metastases for 3+ and 16 months. In patients with either hepatocellular carcinoma (15 patients) or primary cholangiocarcinoma of the liver (three patients), there were two partial responses, for 22 and 33 months. Five patients had minor responses: four with a 40% reduction in tumor and one with a mixed response. There were four early deaths, which involved sepsis in two patients, respiratory failure in one, and acute myocardial infarction in one. Otherwise, toxicity was tolerable and reversible and included abdominal pain and transient elevation of serum creatinine, bilirubin, and transaminases. Less common toxicities included ototoxicity and peripheral neuropathy. Chemoembolization of the liver with cisplatin, thiotepa, and lipiodol can produce responses, but toxicity can be significant. The recommended starting phase II dose for future studies is thiotepa 24 mg/m2 and cisplatin 100 mg/m2.

Percutaneous sclerotherapy of lymphoceles related to renal transplantation.

PURPOSE: To determine the advantages of using transcatheter sclerotherapy to treat renal allograft-related lymphoceles. MATERIALS AND METHODS: Eighteen patients first seen with symptomatic lymphoceles secondary to renal transplantation were treated with povidone-iodine percutaneous sclerotherapy. Percutaneous catheters were place by means of sonographic, computed tomographic, or combined fluoroscopic and sonographic guidance. Sclerotherapy was initiated while patients were in the hospital, and the patients then instilled povidone-iodine twice a day at home. RESULTS: One patient had an inadequate trial period of therapy and was not included in the analysis. Seventeen lymphoceles were adequately sclerosed. Average length of treatment was 35 days. Three lymphoceles recurred and were effectively treated percutaneously. Follow-up studies showed no recurrence 1 month to 2 years after completion of therapy. No patient needed surgery for lymphocele repair. CONCLUSION: Because of its safety and efficacy, percutaneous transcatheter sclerotherapy with povidone-iodine should be the treatment of choice in patients with lymphoceles that develop after renal transplantation.

Balloon dilatation through the subcutaneously placed afferent limb of a hepaticojejunostomy in patients with resected Klatskin tumors.

It is generally conceded that palliation for proximal bile duct tumors (Klatskin) is exceptional if obstruction and the resultant infections can be prevented. Our experience with balloon dilatations thru the subcutaneously placed afferent limb of a choledocho or hepatico jejunostomy in patients with benign strictures suggests that this approach will be effective in patients with malignancies and thus provide long-term control of the obstruction without the need for external tubes. This is a report on one patient who, following a resected Klatskin tumor with positive margins, was treated with transhepatic internal external stents and was converted to a subcutaneous limb following numerous bouts of cholangitis. A schedule for repeat dilatations thru the jejunal limb was established. The patient has remained afebrile with a normal bilirubin and a moderately elevated alkaline phosphatase. Recurrent tumors or postirradiation strictures in patients with resected Klatskin tumors can be effectively controlled by repeated balloon dilatation without the need for external stents.

A phase I study of chemoembolization with cisplatin and lipiodol for primary and metastatic liver cancer.

Twenty patients with either unresectable primary hepatocellular carcinoma or hepatic metastases were entered into a chemoembolization program with cisplatin and lipiodol; 19 patients were evaluable for response. Doses of cisplatin ranged from 40 to 100 mg/m2. Toxicity was tolerable and reversible and included abdominal pain, transient elevation in serum creatinine, serum bilirubin, and serum transaminases. Less common side effects include fever, ascites or pleural effusion, and hiccups. Two of four patients with ocular melanoma had partial responses. Duration of response was 10 and 11 months. Among 8 patients with unresectable hepatoma, 2 patients had partial response for 10+ and 13 months, 2 had minor response for 2 months and 4+ months, 1 patient had stable disease for 5+ months, and 3 patients failed to respond. Of the six colon cancer patients treated, one had a partial response in the liver, but developed progressive nodal disease, and another patient had a partial response for 3 months. Chemoembolization of the liver with cisplatin and lipiodol is feasible and doses of cisplatin at least 100 mg/m2 are tolerable. Antitumor activity in metastatic ocular melanoma is encouraging but requires further study.

A pilot clinical and pharmacological study of intra-arterial infusion of thiotepa.

Fourteen patients with progressive localized tumors were treated on a clinical and pharmacological study with intra-arterial Thiotepa. A transfemoral percutaneous catheter was inserted into the major artery supplying the tumor. A venous catheter was inserted into the vein draining the tumor area for blood sampling. Doses of Thiotepa ranged from 0.3 mg/kg to 1.0 mg/kg. Courses were repeated monthly and doses of drug escalated as tolerated. Toxicity was mild and doses of drug at least up to 0.9-1.0 mg/kg were tolerable. Pharmacokinetic parameters suggest increasing binding of Thiotepa to tissue when the drug is administered by the intra-arterial route. Clinical responses were observed in a patient with melanoma and in another patient with unknown primary cancer.

Lymphoceles: percutaneous treatment with povidone-iodine sclerosis.

Although percutaneous procedures have gained a degree of acceptance for treatment of lymphoceles, success rates for aspiration and drainage have been less than optimal. The authors investigated transcatheter sclerosis of pelvic lymphoceles with povidone-iodine as a method to increase the success rate of percutaneous management. Eight patients with a total of nine pelvic lymphoceles were treated with this method. Eight of the nine lymphoceles (89%) resolved without complications. Four patients had undergone lymphadenectomy and four, renal transplantation. The duration of catheter drainage ranged from 15 to 37 days. Four of the lymphoceles were found to be infected at initial drainage, but this did not alter the amount of time the catheter was left in place. One lymphocele failed to heal with sclerotherapy and required internal drainage. The early results with transcatheter povidone-iodine sclerosis of postoperative lymphoceles are encouraging and warrant further evaluation.

Hepaticodochojejunostomy with afferent limb: CT anatomy.

Hepaticodochojejunostomy with an afferent limb constructed to provide a permanent access route for retrograde biliary dilation has been described. The computed tomographic (CT) scans of 12 patients who had undergone this procedure were reviewed. The appearance of the afferent limb from its position within the subcutaneous tissues to its anastomosis with the biliary tree is described and illustrated. Recognition of the limb as a surgical pathway is important because familiarity with its anatomy will avoid errors in CT interpretation and aid in successful transjejunal catheterization of the bile ducts.

Traumatic adrenal hemorrhage: radiologic findings.

Four patients with traumatic hemorrhage in the right adrenal gland were examined with computed tomography (CT) and ultrasound (US) (initial US studies in three patients; follow-up study at least 1 month after the trauma in all patients). CT showed an enlarged inhomogeneous gland of normal to increased attenuation. This finding was associated with stranding of the periadrenal fat and stranding of the subcutaneous fat of the right flank, which corresponded to the site of trauma. US showed an enlarged, hyperechoic mass with a bright central echo that became cystic on follow-up examinations. Magnetic resonance imaging, performed in one patient, showed an enlarged gland that was isointense with liver on T1-weighted images and had increased signal intensity on T2-weighted images. Stranding of the periadrenal and subcutaneous fat of the right flank was present on T2-weighted images and appeared as streaky areas of increased signal intensity.

Evaluation of dry silver hard copies in digital radiography.

Diagnostic images produced by digital technologies are viewed on video terminals. Hard copies are subsequently made on film for use by radiologists and referring physicians. An alternative is to make prints on paper using "dry silver" technology. These prints are made by a camera that uses silver-coated paper. The paper is developed as it exits the camera and passes over a heating element. Thus dry silver paper is processed "dry," whereas standard film or print paper is processed in a chemical bath. The prints are viewed by reflected rather than transmitted light. We compared the diagnostic quality of the dry silver prints with that of conventional multiformat, transmitted-light images. Radiologists were asked to make diagnoses from both types of images. The results showed that the diagnoses made from the prints were identical to those made from the films. Furthermore, when the images were labeled with the diagnosis, there was no difference between the two formats in the information conveyed to the referring physician. We conclude that dry silver, reflection prints can provide an inexpensive, convenient method of making visual information available on patients' charts.

Percutaneous transjejunal biliary dilatation: alternate management for benign strictures.

Since 1980, 23 patients with diffuse benign biliary strictures underwent percutaneous retrograde biliary dilatation through a surgically created jejunal access route. Bile ducts of 15 patients with sclerosing cholangitis, five with traumatic strictures, and three with strictures of diverse etiology were dilated with 25-atm balloons during 88 separate sessions. Individual dilatation intervals ranged between 2 and 36 months. Three patients with sclerosing cholangitis died. One uncomplicated bile duct rupture occurred in the trauma group because of balloon oversizing. Our 5-year experience indicates that bile duct patency can be safely maintained by repeated retrograde dilatations without the need for biliary catheters or stents.

Nonsurgical drainage of appendiceal abscesses.

Five patients with abdominal abscesses complicating appendicitis were successfully treated by catheter drainage. In two patients, the percutaneous procedure was performed after incomplete surgical drainage; in three patients it was used as the only means of initial drainage. No interval appendectomy was required and no complications were associated with the procedure. Percutaneous management of appendiceal abscesses can be proposed as an alternative to surgical drainage.

Popliteal artery entrapment: importance of the stress runoff for diagnosis.

We review our experience with seven patients, (12 affected extremities) with popliteal artery entrapment. The classic angiographic finding of medial deviation of the popliteal artery was found in only three patients (four extremities). Four patients (eight extremities) had no medial deviation of their popliteal arteries and required a stress runoff examination to demonstrate arterial entrapment. Five patients had bilateral entrapment. This patient series underscores the need to consider possible arterial entrapment even when the popliteal arteries appear normal on the resting runoff examination as well as the importance of imaging both extremities since the incidence of bilateral entrapment may be higher than previously recognized.

Renal cell carcinoma complicating long-term dialysis: computed tomography-guided aspiration cytology.

The diagnosis of renal cell carcinoma was established by computed tomography-guided aspiration in two small solid lesions occurring in end-stage kidneys. This represents a safe means of providing more specific information about the various lesions that specific information about the various lesions that frequently develop in chronic hemodialysis patients: complex cysts, adenoma, and renal cell carcinoma. The proposed conservative approach of simple observation of these lesions may be altered if a precise diagnosis is obtained. Computed tomography is considered the most reliable imaging modality for evaluation and guided aspiration.

Statistical determinants of success and complications of thrombolytic therapy for arterial occlusion of lower extremity.

In this prospective study, we have documented the limited usefulness of thrombolytic therapy in the management of all patients with arterial occlusion of the lower extremities. We have also emphasized the significant rate of recurrent thrombosis unless an underlying obstructive lesion is corrected surgically after clot dissolution. Because thrombolytic drugs can lyse clots of a duration of several weeks, we recommend consideration of fibrinolytic therapy for subacute graft occlusions and segmental arterial thromboses. In such instances, thrombolysis is likely to reveal a focal underlying lesion that is correctable by a limited anastomotic revision or balloon angioplasty. Without fibrinolytic therapy, these older occlusions generally require more extensive bypass grafting or graft replacement. In contrast, we are less enthusiastic about thrombolytic therapy for distal small vessel thrombosis or embolism because complete clot lysis was achieved in only one of five patients. The primary problems with regional arterial low dosage thrombolytic infusions are bleeding at the angiographic catheter entry site and distal thromboemboli of the lysing clot. These difficulties may discourage wide acceptance of fibrinolytic therapy. However, they can be minimized by careful technique. Although its usefulness is limited and complications are common, catheter directed arterial low dosage thrombolytic therapy can be an important initial step in the diagnosis and treatment of selected arterial occlusion of the lower extremities.

Transgastric drainage of pancreatic fluid collections.

Eight pancreatic fluid collections in seven patients were successfully drained percutaneously through a transgastric approach. The drainage catheters were left in place for 3-6 weeks to promote the formation of a fistulous tract between the stomach and the pancreatic collection. Computed tomography (CT) was used for diagnosis and for planning of the access route. Combined sonography and fluoroscopy were used for guidance. Radiologic follow-up examinations (CT and sinograms) have shown no recurrences (3-12 months). No complications were encountered.

Dilatation of biliary strictures through a stomatized jejunal limb.

This preliminary report details the radiologists' contribution to the combined surgical-radiologic approach to maintaining patency of the biliary tree that may benefit certain categories of patients with biliary strictures. We have accessed the biliary tree through the stomatized afferent limb of a side to side biliary jejunal anastomosis in 18 patients. Our early experience with this technique suggests that we may be able to maintain patency of biliary strictures without the need for permanent indwelling catheters or stents.