Expanding role of percutaneous cholecystostomy and interventional radiology for the management of acute cholecystitis: An analysis of 144 patients.

PURPOSE: To investigate the rates of interval cholecystectomy and recurrent cholecystitis after initial percutaneous cholecystostomy (PC) and identify predictors of patient outcome after PC. MATERIALS AND METHODS: A total of 144 patients with acute cholecystitis who were treated with PC were included. There were 96 men and 48 women, with a mean age of 71±13 (SD) years (range: 25-100 years). Patient characteristics, diagnostic imaging studies and results of laboratory tests at initial presentation, clinical outcomes after the initial PC treatment were reviewed. RESULTS: Among the 144 patients, 56 patients were referred for acute acalculous and 88 patients for calculus cholecystitis. Five procedure-related major complications (3.6%) were observed including bile peritonitis (n=3), hematoma (n=1) and abscess formation (n=1). Recurrent acute cholecystitis after initial clinical resolution and PC tube removal was observed in 8 patients (6.0%). The rate of interval cholecystectomy was 33.6% (47/140) with an average interval period of 100±482 (SD) days (range: 3-1017 days). PC was a definitive treatment in 85 patients (60.7%) whereas 39 patients (27.9%) had elective interval cholecystectomy without having recurrent cholecystitis. The clinical outcomes after PC did not significantly differ between patients with calculous cholecystitis and those with acalculous cholecystitis. Multiple prior abdominal operations were associated with higher rates of recurrent cholecystitis. CONCLUSION: For both acute acalculous and calculous cholecystitis, PC is an effective and definitive treatment modality for more than two thirds of our study patients over 3.5-year study period with low rates of recurrent disease and interval cholecystectomy.

Unilateral absence of right-lung perfusion with normal ventilation on radionuclide lung scan as a sign of aortic dissection.

A case of aortic dissection with unilateral absence of right-lung perfusion and normal ventilation on radionuclide ventilation/perfusion (V/Q) lung scan is presented with a review of the literature. Anticoagulation or thrombolytic therapy for presumed pulmonary embolism may be catastrophic if the clinical syndrome and V/Q scan appearance are instead due to aortic dissection. With this V/Q scan appearance, these therapies should not be instituted unless pulmonary embolism is diagnosed by pulmonary arteriography.

Access-site thrombosis after placement of inferior vena cava filters with 12-14-F delivery sheaths.

Inferior vena cava filters were placed in 60 patients. Ultrasound (US) of the venous access site was performed before and 3-5 days after filter placement to determine the prevalence of occlusive and nonocclusive access-site thrombosis (AST). Prevalence of symptoms attributable to AST was also evaluated at 1-month clinical follow-up in 58 of the 60 patients. All filters were placed with delivery sheaths with outer diameters of 12-14 F. US depicted development of occlusive AST in six of the 60 patients (10%). Nonocclusive AST developed in 15 (25%). Symptoms related to AST occurred in two of 58 patients (3%). There was a substantially increased prevalence of occlusive thrombus in patients in whom partially occluding thrombus or extrinsic compression in the inferior vena cava or ipsilateral iliofemoral veins was demonstrated on vena cavograms obtained before filter placement. The prevalence of both symptoms attributable to AST and US-detected occlusive thrombus in this series with smaller delivery systems is lower than that reported after percutaneous placement of stainless steel Greenfield filters via 29.5-F (outer diameter) sheaths.

Color Doppler flow imaging appearance of a popliteal venous aneurysm.

Popliteal venous aneurysms are rare lesions that usually become evident when thrombus from within the aneurysm embolizes to the lungs. The authors report an unusual case in which the patient presented without thromboembolic complications. The appearance of a popliteal venous aneurysm at color Doppler flow imaging is described.

Fine needle aspiration of pancreatic fluid collections.

The complications of pancreatitis remain diagnostic and therapeutic challenges. Patients with simple pancreatitis, pancreatic necrosis, pseudocyst, noninfected fluid collection or abscess may all have similar clinical pictures. During the last decade computerized tomography (CT)-guided needle aspiration of peripancreatic fluid collections has been increasingly used as a diagnostic tool for pancreatic abscesses. This study reviewed the effectiveness of CT-guided needle aspiration of peripancreatic fluid collections at our institution in terms of diagnostic accuracy, correlation with eventual outcome, and safety. Charts of patients who underwent needle aspiration of de novo peripancreatic fluid collections over the past 2 years were reviewed. Thirty-five patients underwent 50 aspirations. Eleven patients (31%) had a positive aspirate culture; seven of these had a positive Gram's stain. There were no false positive Gram's stains but four false negatives. Twenty-four (69%) patients had negative aspirate Gram's stains and cultures. Patients with positive aspirate cultures were treated with antibiotics only (2), CT-guided drain placement (7), or surgical drainage (3). The mortality related to each of these therapeutic modalities was 50 per cent, 0 per cent, and 33 per cent, respectively. Of the 24 patients with negative aspirate cultures, five had no further treatment, 12 received antibiotics, and six underwent CT drain placement. All these patients survived. There was one false negative aspirate culture. This patient underwent delayed surgical drainage but expired. There were no major complications from CT-guided aspiration. CT-guided aspiration appears to be a safe and reliable method of diagnosing infection in peripancreatic fluid collections.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraarterial administration of lidocaine for analgesia in hepatic chemoembolization.

Hepatic chemoembolization (HCE) routinely results in severe pain requiring massive doses of intravenously administered narcotics. This study examines the efficacy and safety of lidocaine administered intraarterially for analgesia in HCE. In 45 HCE procedures, lidocaine was injected into hepatic arterial branches just prior to and during chemoembolization. Adjunctive analgesic doses given during the procedure and the need for a morphine sulfate drip infusion for postprocedural pain control were recorded and compared with those in 20 procedures performed previously without lidocaine. In procedures with lidocaine, an average of 0.13 mg of morphine sulfate and 1.3 mg of midazolam were required. This is significantly lower than the 11.7 mg of morphine sulfate and 3.7 mg of midazolam used during procedures without lidocaine. A postprocedural morphine drip infusion was required for control of severe pain in 16 of 20 (80%) procedures performed without lidocaine compared with nine of 45 (20%) of those performed with lidocaine. Peripheral blood levels of lidocaine were well below the toxic level, and no complications referable to lidocaine toxicity occurred. Marked reductions in the amount of narcotic analgesia in HCE procedures may be safely achieved with the administration of intraarterial lidocaine.