Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management

OBJECTIVE

The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries.

METHODS

Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996.

RESULTS

Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation.

CONCLUSIONS

Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster

OBJECTIVE

This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries.

SUMMARY BACKGROUND DATA

The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully.

METHODS

The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns.

RESULTS

Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury.

CONCLUSIONS

Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Outcome of tunneled hemodialysis catheters placed by radiologists

PURPOSE

To compare the outcomes of hemodialysis catheters placed by interventional radiologists with those placed by surgeons.

MATERIALS AND METHODS

The outcomes were retrospectively analyzed of 237 hemodialysis catheters placed in 140 patients by a radiology service from January 1991 through December 1992. Follow-up data were available for 222 catheters (94%). Catheter secondary patency and freedom from infection were analyzed statistically and by means of life-table analysis.

RESULTS

Pneumothorax occurred after the placement of six catheters (2.5%); in two patients, a chest tube was required for decompression. Other short-term complications included air embolism with no clinical sequelae (two procedures) and prolonged oozing from the tunnel (two procedures). Long-term complications included infection and catheter failure. Infection occurred in 26 patients (18%) with 32 catheters (14%) and resulted in removal of 25 catheters. Ninety-three catheters (42%) failed, and 63 catheters (28%) were removed because of failure.

CONCLUSION

Hemodialysis catheters placed by radiologists do not have a higher rate of complications or failure than catheters placed by surgeons.

Subcutaneously tethered temporary filter: pathologic effects in swine

PURPOSE

To evaluate the histopathologic effects of the Tempo-filter, a temporary caval filter, on the caval wall and determine the feasibility of deployment and removal of the device in swine.

MATERIALS AND METHODS

Filters were placed in the infrarenal inferior vena cava of 11 swine. The tethering catheter was sutured in a subcutaneous pocket near the puncture site. The original tethering catheter used in humans and a stiffer catheter designed to prevent migration in swine were evaluated. Postplacement, mid-study, and preexplant vena cavography procedures were performed. Four swine underwent in situ dissection at 3-10 weeks. Filters were removed from seven animals just before they were killed at 1-6 weeks.

RESULTS

All filters were successfully placed. All seven filters were successfully removed at up to 6 weeks after placement. Cephalic migration of more than 1 cm was observed in 10 of 11 swine (100% of original catheters, 83% of stiff catheters). Other complications were more common with stiffer tethering catheters, including caval stenosis in 40% of original catheters and 100% of stiff catheters, filter cone thrombus in 0% and 67%, tethering catheter thrombus in 20% and 83%, pulmonary embolism in 0% and 50%, and death in 0% and 17%, respectively. There was mild vessel wall damage in the vena cava.

CONCLUSION

Placement of the Tempofilter and removal at up to 6 weeks after placement is feasible.

Identification of the aberrant hepatic artery with axial spiral CT

PURPOSE

To determine whether axial spiral computed tomography (CT) allows detection of the replaced hepatic artery as part of preoperative planning for pancreatic tumor resection.

MATERIALS AND METHODS

Axial spiral CT scans (8-mm section thickness, 4-mm overlapping reconstructions) were obtained in 50 patients with periampullary tumor and were examined by three radiologists. Readers' interpretations were compared with angiographic results.

RESULTS

Eight patients had an aberrant hepatic artery. Two of the three readers detected or suspected all of these abnormalities (100% sensitivity), and one reader identified seven of eight aberrant arteries (88% sensitivity). However, readers requested angiographic confirmation in 14 of 24 tests. Sensitivity, specificity, and accuracy were 96%, 87%, and 88%, respectively, for all readers.

CONCLUSION

Axial spiral CT may simplify preoperative evaluation of periampullary tumors. However, angiographic support was necessary in most cases in this study. Improvements in CT techniques may eventually allow spiral CT to replace angiography in the examination of these patients.

Percutaneous jejunostomy replacement in patients who have undergone esophagectomy

PURPOSE

The authors expand their experience with a technique for the percutaneous replacement of a feeding jejunostomy tube in patients who have undergone esophagectomy, in which markers placed during the initial surgical jejunostomy are used.

PATIENTS AND METHODS

During esophagectomy in eight patients, a loop of jejunum was intubated with a surgical jejunostomy tube. This loop was then fixed to the anterior abdominal wall and marked with metal clips. In eight patients who required late nutritional support, the surgically placed metal clips on the fixed jejunal loop were used as fluoroscopic guides to mark the site for percutaneous access into the jejunum. Once access was obtained and verified with use of the Seldinger technique, a feeding jejunostomy tube was placed percutaneously after tract dilation.

RESULTS

Percutaneous replacement of a feeding jejunostomy tube was successful in all eight patients; in one patient, two placement attempts on successive days were required. No immediate complications occurred. Only one replacement jejunostomy tube has required replacement due to leakage around the tube (mean follow-up, 3.1 months).

CONCLUSION

Percutaneous replacement of a feeding jejunostomy tube with use of surgically placed clips as guides for access is a safe and effective method for providing late nutritional support in the postesophagectomy patient.

Percutaneous transluminal atherectomy of the superficial femoral and popliteal arteries: long-term results in 48 patients

PURPOSE

Evaluate retrospectively the long-term primary patency of directional atherectomy (DA) in the femoropopliteal arteries.

MATERIALS AND METHODS

DA was used alone in 59 patients (47%) or in combination with predilatation to allow passage of the device (43%) or after thrombolysis (10%) to treat 127 (93%) excentric atherosclerotic stenoses and nine (7%) occlusions of the femoropopliteal arteries. Forty-eight patients were followed by telephone interview, scheduled outpatient visits, color-flow Doppler evaluation, and angiography for 1-36 months (mean 16.9 months).

RESULTS

Technical success (reduction of the stenosis or occlusion to less than 30% luminal diameter) was achieved in 110 lesions (80.3%) during 48 procedures in 37 patients. Mean luminal diameter was increased 54% with a concomitant increase in mean ankle/brachial indices of 0.33. According to Kaplan-Meier survival curves, patency at 12 and 24 months was 88% and 75%, respectively. When patients who retained patency but developed restenosis were excluded, the probability of patency at 12, 24, and 36 months was 76%, 58%, and 32%, respectively. Major and minor complications occurred in 15 (21.4%) procedures each for a total complication rate of 42.8%.

CONCLUSION

Based on our results, DA is an effective method for percutaneous treatment of atherosclerotic disease involving the femoropopliteal arteries. It has similar patency but a relatively high complication rate compared with PTA.

Biliary manometry versus clinical trial: value as predictors of success after treatment of biliary tract strictures

PURPOSE

To evaluate the biliary manometric-perfusion test (BMPT) and clinical trial as predictors of long-term success after percutaneous and surgical treatment of biliary tract strictures.

PATIENTS AND METHODS

After percutaneous intervention or surgical repair of extrahepatic bile duct strictures, 43 patients underwent long-term biliary intubation (mean, 13 months) with 61 internal-external stents. Before removal of the stents, all 43 patients underwent a BMPT (n = 65) and 24 underwent a 2-3-week clinical trial (n = 27) with stents positioned above the treated region. Patients were followed up 1-46 months (mean, 16 months) after stent removal, with clinical outcome determined by means of physical examination, biochemical evaluation, chart review, and telephone interview.

RESULTS

With logistic regression analysis, the BMPT and clinical trial were shown to have equal predictive value in determining treatment success or failure. Eighty-four percent of the clinical outcomes were correctly predicted with BMPT, versus 88% for the clinical trial. Kaplan-Meier survival curve analysis demonstrated the probability of remaining stricture free at 1 year after passing a BMPT and after passing a clinical trial to be 90% and 86% (P = .55), respectively.

CONCLUSION

BMPT and clinical trial have similar capabilities in the prediction of long-term patency after treatment of benign biliary tract strictures, but the BMPT is less costly and time consuming for the patient.

Thrombosed dialysis access grafts: percutaneous mechanical declotting without urokinase

PURPOSE

To evaluate percutaneous declotting of dialysis access grafts with available catheters without urokinase.

MATERIALS AND METHODS

Thirty-four clotted grafts were treated in 24 patients. Clot was macerated and pushed into the central circulation with balloon catheters.

RESULTS

Successful mechanical declotting was performed in all but two patients (94%). The procedure was abandoned after successful declotting in four patients with poor venous outflow, resulting in a 24-hour success rate of 82%. Mean total procedure time was 116 minutes. Eight grafts clotted within 1 week. Using successful dialysis beyond 1 week as the measure of clinical success, the authors report a 59% clinical success rate with mean primary patency of 126 days (range, 16-322 days). Two complications, both emboli to the brachial artery, were successfully treated with urokinase. No symptomatic pulmonary emboli occurred.

CONCLUSION

Mechanical thrombolysis of clotted grafts with currently available catheters yields results similar to those reported with mechanical devices and urokinase. The procedure is relatively inexpensive, safe, and well tolerated.

Intrahepatic stones. The transhepatic team approach

OBJECTIVE

The authors reviewed the combined interventional radiologic and surgical management of 54 patients with intrahepatic stones at the Johns Hopkins Hospital. The team approach used large-bore transhepatic stents to access the intrahepatic ducts until they were stone free.

SUMMARY BACKGROUND DATA

Intrahepatic stones are uncommon in western countries. As a result, few American institutions have had much experience, and multiple management algorithms have been suggested. Nonoperative, operative, and combination surgical and nonoperative approaches have been advocated. At Johns Hopkins, combined surgical and percutaneous management has been used for 18 years.

METHODS

This team approach includes (1) percutaneous placement of transhepatic access catheters, (2) surgery for underlying biliary disease and stone removal, and, when necessary (3) postoperative percutaneous choledochoscopy and stone removal through the transhepatic stents.

RESULTS

The median age of the 54 patients was 50 years, and 32 were men. Biliary disease included 27 benign strictures, 7 sclerosing cholangitis, 5 choledochal cysts, 5 parasitic infections, 5 choledocholithiasis, and 5 biliary tumors. Fourteen patients (26%) were treated exclusively with percutaneous techniques. Forty patients (74%) had surgery, including 36 Roux-en-Y hepatico- or choledochojejunostomies with large-bore transhepatic stents. Eighteen of these 40 patients (45%) with multiple intrahepatic stones, strictures, or both required additional procedures after operation. No hospital deaths occurred after any of the percutaneous or surgical procedures. With a mean follow-up of 60 months, 94% of patients were stone free, 87% of patients were symptom free, and 73% have had their transhepatic stents removed.

CONCLUSIONS

A combined radiologic and surgical approach with transhepatic stents is a safe and effective method for managing intrahepatic stones.

Unresectable hilar cholangiocarcinoma: percutaneous versus operative palliation

BACKGROUND

Several nonoperative and operative options are available for palliation of patients with unresectable hilar cholangiocarcinoma. This retrospective analysis compares the results of nonoperative percutaneous stenting and operative palliation in 65 patients.

METHODS

Twenty-one patients were managed with percutaneous biliary stents (group A), and 44 patients underwent laparotomy (group B) with placement of large-bore silicone rubber transhepatic stents in 33. The two groups were similar with respect to age, gender, mean laboratory data, and cholangiographic extent of tumor.

RESULTS

Group A and group B patients were comparable in hospital morbidity (67% vs 61%), hospital mortality (14% vs 7%), and mean initial hospital stay (27 vs 31 days). Survival was greater in group B laparotomy patients at 1, 3, and 6 months (p < 0.01), and median survival was 5 months for group A compared with 8 months for group B patients (p = 0.06). Group A patients who were managed with percutaneous stents required more stent changes per month of survival (0.5 vs 0.3, p = 0.06). However, group B patients who underwent operative palliation were more likely to undergo a second operation (0% vs 21%, p = 0.05), most often for duodenal or small-bowel obstruction.

CONCLUSIONS

Operative placement of large-bore transhepatic stents may reduce cholangitis, delay hepatic failure, and prolong survival. We conclude that patients with unresectable hilar cholangiocarcinoma who are fit for surgery may benefit from operative palliation.

Percutaneous varicocele occlusion: long-term follow-up

PURPOSE

The authors summarize their 11-year experience with percutaneous varicocele occlusion at the Johns Hopkins Hospital.

PATIENTS AND METHODS

Data were obtained from the patients' medical records and from a mailed questionnaire. Most of the data analysis is based on the 182 patients who responded to the questionnaire.

RESULTS

Most of the occlusions were performed for infertility. The mean length of time couples had been attempting to conceive was approximately 44 months. Occlusion was technically successful in 95.7% of cases. Patients were followed up for a mean period of 59 months. Success is difficult to define because many patients and/or their wives received additional infertility treatment. Fifty-seven percent of all couples and 60% of a subgroup of couples who received no other treatment eventually conceived.

CONCLUSION

Percutaneous occlusion is a well-established treatment for varicoceles. Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. It is unlikely that resultant pregnancies occur from random chance alone.

Percutaneous embolotherapy of adolescent varicocele: results and long-term follow-up

PURPOSE

The authors evaluated the technical success and immediate and long-term results of percutaneous varicocele embolotherapy in the adolescent population.

PATIENTS AND METHODS

Fifty-nine adolescent patients were referred for outpatient spermatic venography and possible varicocele embolotherapy. Embolization was attempted with use of detachable balloons, coils, "sandwiched" dextrose, or a combination of these techniques. Data regarding follow-up were obtained through telephone interviews or mailed questionnaires.

RESULTS

The technical success rate for spermatic vein occlusion was 90%. Follow-up, obtained in 79% of the patients, ranged from 6 months to 8.75 years (mean, 4 years). Thirty-nine of 42 patients (93%) reported disappearance (n = 31) or only a slight, asymptomatic residual varicocele (n = 8). Three patients reported a recurrence of their varicocele. Complications occurred in three of 59 cases (5%), none had any long-term sequelae. In six cases, embolization was not feasible because of multiple collateral vessels or venous spasm.

CONCLUSIONS

Given the convenience of performing the procedure on an outpatient basis, the rapid recovery time, and long-term success and complication rates comparable to those with surgical ligation, we believe spermatic venography and percutaneous embolization is the treatment modality of choice for adolescent varicocele.

Preoperative spinal artery localization and its relationship to postoperative neurologic complications

PURPOSE

To evaluate the risk of spinal cord revascularization and ascertain the relationship between preoperative spinal arteriography and the frequency of postoperative neurologic injury and overall morbidity and mortality in patients who require surgical repair of thoracoabdominal aortic aneurysms.

MATERIALS AND METHODS

Fifty patients scheduled for surgical repair of a thoracoabdominal aortic aneurysm underwent spinal arteriography. All patients were divided into a positive spinal artery group (in which the spinal artery was identified) or negative spinal artery group (in which the spinal artery was not identified) and further divided based on extent of disease.

RESULTS

The complication rate of spinal arteriography was 4.6%; no patient had a permanent neurologic injury. No significant difference existed between the positive and negative spinal artery groups in occurrence of neurologic injury (P = .88) or combined morbidity and mortality (P = 51).

CONCLUSION

Patients who require spinal cord revascularization do not have greater frequency of neurologic injury or overall morbidity and mortality than those without this requirement. Spinal arteriography enables definitive spinal cord revascularization and thereby reduces the risk of neurologic injury.

Complications of interventional radiology: an imaging overview

The growth of interventional radiology has contributed to the development of more complex procedures applicable to an increasing patient population, with maintenance of low complication rates. However, due to its invasive nature, potential complications will always be associated with each procedure. Prompt recognition of these complications allows for rapid treatment with decreased patient morbidity and mortality. This overview provides detailed statistics and diagnostic imaging for evaluation of a wide spectrum of complications from hepatobiliary, renal, and vascular interventional procedures.

Randomized double-blind clinical trial of celiac plexus block for percutaneous biliary drainage

PURPOSE

This study was undertaken to determine the efficacy of celiac plexus block (CPB) as a method of providing analgesia for percutaneous biliary drainage (PBD).

PATIENTS AND METHODS

Thirty-two patients scheduled to undergo PBD were prospectively assigned randomly into placebo (30 mL of normal saline) and treatment (30 mL of 0.25% bupivacaine) CPB groups. Each patient received .03 mg/kg of midazolam for premedication before PBD and had access to a patient-controlled analgesia pump during the procedure. The pump was set to deliver 0.2 mg of midazolam and 25 micrograms of fentanyl per dose with a 3-minute lockout time. Vital signs, including heart rate and blood pressure, were continuously monitored during the procedure and recorded for comparison with baseline values. Patients completed a 10-point visual analogue pain scale following completion of their procedure.

RESULTS

Patients in the placebo and treatment groups self-administered a mean of 2.0 and 1.85 mg of midazolam, respectively (P = .40), and a mean of 247 and 231 micrograms of fentanyl, respectively (P = .40). On a 10-point pain scale, the mean postprocedure versus preprocedure elevation in pain was 2.1 points in the placebo group versus 1.6 points in the treatment group (P = .60). Overall, the degree of satisfaction with the analgesia was equal in both groups.

CONCLUSION

This study indicates that CPB is not an effective means of providing additional visceral pain relief over and above that which can be accomplished with self-administered intravenous medication for patients who undergo PBD.

Giant pseudoaneurysm of the hepatic artery--CT demonstration. Case report

Noninvasive imaging studies, particularly computed tomography (CT), are the first step in evaluation of patients with suspected hepatic trauma. Iatrogenic injury, accounting for up to one-third of cases, may commonly result in hepatic artery pseudoaneurysm formation. We present a case in which a giant hepatic artery pseudoaneurysm was misinterpreted as an intrahepatic hematoma on sequential CT scans due to the failure to employ dynamic contrast-enhanced scan techniques.

Biliary tract complications following laparoscopic cholecystectomy: imaging and intervention

Radiologic studies and interventional procedures were performed in a series of 13 patients with biliary complications following laparoscopic cholecystectomy, and the results were evaluated. Two categories of ductal complication--minor and major--were found. Minor complications (n = 6) included bile leaks and bilomas; these were managed with percutaneous techniques or simple surgical repair. Major complications (n = 8), consisting primarily of common hepatic duct injuries or strictures, were markedly resistant to percutaneous therapy, requiring major surgical repair (hepaticojejunostomy). Percutaneous treatment of recurrent strictures after primary repair was undertaken in three patients. Diagnostically, radionuclide imaging appeared most helpful in screening for biliary complications of laparoscopic cholecystectomy, supplemented by endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography for definitive diagnosis.

Interventional radiology in the biliary tract

Numerous papers have appeared in the past year outlining the expanded role of the radiologist in the treatment of patients with biliary disease, including papers describing palliative treatment of patients with obstructive jaundice due to malignant disease using self-expanding metallic biliary endoprostheses placed percutaneously, extracorporeal shock-wave lithotripsy used to treat patients with gallstones and intrahepatic stones, percutaneous rotational contact biliary lithotripsy, pulsed dye laser biliary lithotripsy, percutaneous biliary intervention via a minicholecystotomy, conventional percutaneous fluoroscopic management of bile duct stones, and percutaneous management of biliary strictures including transluminal biopsy. Percutaneous evaluation and treatment of patients with biliary disease using cholangioscopy as an adjuvant to biliary intervention, radionuclide imaging for improved evaluation of suspected biliary injury after laparoscopic cholecystectomy, and percutaneous treatment of the critically ill patient with cholecystitis or the patient with a perforated gallbladder are also discussed. Diagnostic and therapeutic options available to radiologists for treating patients with biliary disease are summarized.

Interventional radiology in the liver and pancreas

The application of interventional radiographic procedures in the management of patients with liver and pancreatic pathology continues to expand. Percutaneous hepatobiliary interventional procedures that have received considerable attention in the past year include technical refinements of the transjugular intrahepatic portosystemic shunt procedure used in patients with portal hypertension and esophageal varices, transshunt embolotherapy of persistent varices in patients with small-caliber mesocaval shunts, percutaneous and transcatheter embolotherapy of hepatic malignancies in patients with primary or metastatic lesions, and MR angiography in the preoperative evaluation of patients awaiting liver transplantation. Other topics reviewed include percutaneous and transvenous biopsy of orthotopic liver transplants, management of bile leaks and strictures after liver transplantation, use of a biopsy gun and larger gauge needles to obtain specimens for histologic analysis in patients with orthotopic liver and pancreatic transplants, percutaneous treatment of caval and hepatic venous stenoses in patients with Budd-Chiari syndrome using self-expanding stainless steel stents, percutaneous treatment of patients with hepatic Echinococcus granulosus cysts, and percutaneous managements of iatrogenic hepatic vascular injuries. General diagnostic evaluation and interventional procedures highlighted include using selective intra-arterial injection of calcium to localize small insulinomas. Recent review papers describing complications of percutaneous transabdominal fine-needle biopsy are analyzed. The diagnostic and therapeutic options available for treating patients with hepatic and pancreatic diseases are summarized in greater detail.