Gallstone recurrence and gallbladder function following percutaneous cholecystolithotomy

PURPOSE

To determine the frequency of recurrent symptoms and gallstones following successful percutaneous cholecystolithotomy (PCCL) and to evaluate the effect of the procedure on gallbladder function.

PATIENTS AND METHODS

Between 1988 and 1991, 32 patients underwent successful PCCL for the treatment of symptomatic gallstones. Outcome was assessed clinically (mean follow-up, 24 months) in 31 patients and by means of serial ultrasound examination (mean follow-up, 26 months) in 23 patients.

RESULTS

Symptomatic relief following the procedure was good, with only five of 31 patients (16%) experiencing recurrent symptoms during the follow-up period. Eight patients died of unrelated causes with no recurrence of symptoms. Nine (39%) of the remaining 23 patients have either retained gallstone fragments (four patients [16%]) or recurrent gallstones (five patients [22%]). Gallbladder motility was studied after PCCL in 10 patients, including four with retained or recurrent stones, and nine gallbladders were shown to be functioning well.

CONCLUSION

PCCL is a useful treatment for symptomatic gallstones in patients at high risk for surgery. It preserves gallbladder function, but recurrent gallstones are a significant problem.

Combined transhepatic and transvenous approach to hepatic vein stenosis after transjugular intrahepatic portosystemic shunt (TIPS)

We describe a simple technique for recatheterization of transjugular intrahepatic portosystemic shunts (TIPS) with severe hepatic vein ostial stenoses that are inaccessible to standard transvenous approaches. A small gauge needle is used to transhepatically introduce a guidewire into the shunt; the wire is passed through the hepatic vein stenosis, snared, and used to guide jugular or brachial catheters into the TIPS.

Intestinal varices: treatment with the transjugular intrahepatic portosystemic shunt

PURPOSE

To perform a retrospective evaluation of transjugular intrahepatic portosystemic shunt (TIPS) placement for treatment of intestinal varices.

MATERIALS AND METHODS

TIPS were placed in nine patients (six women and three men, aged 36-85 years [mean, 64 years]) with small- (n = 6) and large- (n = 3) intestinal varices. Six patients were actively bleeding at the time of shunt placement. One patient with colon cancer underwent prophylactic TIPS placement for variceal decompression before colectomy.

RESULTS

The mean preprocedure portosystemic gradient of 26.8 mm Hg +/- 5.1 was reduced to 8.8 mm Hg +/- 2.9. Bleeding was controlled in all but one case, in which supplemental variceal embolization was required. Two patients died within 5 days of TIPS placement of preexisting multisystem failure. Three patients died of unrelated causes at 2, 6, and 7 months. The remaining patients were alive an average of 15 months after TIPS placement. There was no recurrent bleeding in any case.

CONCLUSION

TIPS placement is an effective method of decompressing intestinal varices.

MR imaging with spatial modulation of magnetization in the evaluation of chronic central pulmonary thromboemboli

PURPOSE

To assess the diagnostic value of magnetic resonance (MR) imaging with SPAMM (spatial modulation of magnetization) in the identification of chronic central pulmonary thromboemboli.

MATERIALS AND METHODS

Twelve patients with pulmonary hypertension and five healthy volunteers were prospectively studied with a 1.5-T MR imaging system. The SPAMM technique was integrated into a conventional cardiac-synchronized spin-echo (SE) sequence. Six of the 12 patients had central thromboemboli.

RESULTS

In the healthy subjects, intravascular stripes in the central pulmonary arteries disappeared as a result of flow within 100 msec after the R wave. Areas of persistent stripes were identified in seven of eight central pulmonary arteries with thromboemboli. Conversely, in the 16 central pulmonary arteries without clot, intraluminal stripes disappeared despite the presence of flow-related signal (sensitivity = 88%, specificity = 100%, accuracy = 96%).

CONCLUSION

SPAMM appears to be a simple and effective technique for differentiating central pulmonary arterial thromboemboli from flow-related signal frequently observed with pulmonary hypertension.

Magnetic resonance venography for the detection of deep venous thrombosis: comparison with contrast venography and duplex Doppler ultrasonography

PURPOSE

Contrast venography is the gold standard for diagnosis in deep venous thrombosis (DVT); however, this technique is invasive and requires the use of potentially hazardous contrast agents. Although duplex Doppler ultrasonography is accurate in the evaluation of lower extremity DVT, it is less accurate in the assessment of the pelvic and intraabdominal veins. Magnetic resonance venography (MRV) has recently been developed, and our purpose was to determine whether MRV could accurately demonstrated DVT when compared with duplex scanning and contrast venography.

METHODS

Eighty-five patients underwent contrast venography and MRV from the inferior vena cava to the popliteal veins to rule out DVT. Thirty-three of these patients also underwent duplex scanning. Blinded readings of these studies were compared for the presence or absence and extent of venous thrombosis.

RESULTS

DVT was documented by contrast venography in 27 (27%) venous systems. Results of MRV and contrast venography were identical in 98 (97%) of 101 venous systems, whereas results of duplex scanning and contrast venography were identical in 40 (98%) of 41 venous systems. All DVTs identified by contrast venography were detected by MRV and duplex scanning. The discrepancies were due to false-positive MRV (3) and duplex scanning (1) results. When compared with contrast venography, MRV had a sensitivity of 100%, specificity of 96%, positive predictive value of 90%, and negative predictive value of 100%. For duplex scanning the sensitivity was 100%, specificity was 96%, positive predictive value was 94%, and negative predictive value was 100%.

CONCLUSIONS

It is concluded that MRV is an accurate noninvasive venographic technique for the detection of DVT.

Magnetic resonance arteriography of the pelvis and lower extremities

Reconstructive vascular surgery is the last resort for limb salvage in patients with vascular insufficiency. Planning the sites of arterial bypass grafts depends on an exact knowledge of the angiographic anatomy. Currently, conventional contrast angiography is the primary preoperative study for surgical planning. Recently, magnetic resonance (MR) arteriography has been shown to be an accurate technique for the evaluation of slow arterial flow in the lower extremities. The purpose of this review will be to show how MR arteriography can be used as both an adjunct to and in some cases instead of conventional angiography for the preoperative assessment of lower-extremity vascular reconstruction. The derivation of common artifacts, the many pitfalls of interpretation, and the evaluation of peripheral arterial occlusion and percentage stenosis will be discussed. MR arteriography of the lower extremities is an important advance for the noninvasive evaluation of disease of the peripheral vasculature.

Effectiveness of a prolapsed bird's nest filter

PURPOSE

The authors evaluated the variable deployment of the Bird's Nest filter, including frequency and extent of prolapse in clinical use, and analyzed the effects of this variability on clot-trapping efficiency with an in vitro model.

MATERIALS AND METHODS

In the clinical placement of 20 filters, the average length of cephalic filter wires from the center of the filter was measured from radiographs obtained immediately after placement. To analyze the effects of prolapse, a variable-rate pump was used to mimic the effects of respiration on IVC flow. Four clot sizes (5 x 20, 5 x 40, 10 x 20, and 10 x 40 mm) were evaluated with four filter configurations with wires stretched to different lengths in a cephalic direction from the center of the filter: 2 cm (normal-tight), 5 cm (normal-loose), 8 cm (moderate prolapse), and to a maximum of 12 cm (maximum prolapse). Ten passes for each clot size were performed with each filter configuration in both the horizontal and vertical positions. The smallest clots were also tested with a slower constant-rate pump.

RESULTS

In clinical use, the average length of the filter wire was 5.4 cm (range, 1.2-9.0 cm). With the variable flow pump, the in vitro degree of prolapse did not significantly decrease the trapping efficiency for any but the smallest (5 x 20-mm) clots, for the maximum prolapse configuration in the horizontal position (P = .01). In addition, for these clot sizes, the filter was more efficient with the slower constant rate compared with the faster variable rate; this difference was only statistically significant in the horizontal position for the maximum prolapse configuration (P = .007).

CONCLUSION

The results suggest that in clinical practice, a prolapsed Bird's Nest Filter remains effective for all but small clots.

Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt

Anorectal varices are portal-systemic collaterals commonly found in patients with portal hypertension. Although these varices rarely bleed, when bleeding does occur it may be massive and life threatening. Anorectal varices may be mistaken for hemorrhoids and there is no agreed upon method for their definitive diagnosis. Additionally, there is no standard therapy for bleeding anorectal varices, and when techniques designed for the control of hemorrhoidal bleeding are employed the results can be disastrous. We report here the first use of a transjugular intrahepatic portosystemic shunt (TIPS) for the permanent control of bleeding anorectal varices. Magnetic resonance imaging/magnetic resonance venography (MRI/V) was used as a non-invasive method for the identification of anorectal varices and to confirm the successful decompression of these varices with TIPS placement. MRI/V and TIPS may provide significant advances in the diagnosis and treatment of rectal variceal bleeding.

Symptomatic peripheral vascular disease: selection of imaging parameters and clinical evaluation with MR angiography

In the first phase of this study, seven healthy subjects underwent examination with two-dimensional time-of-flight (TOF) magnetic resonance (MR) angiography to develop a protocol for evaluation of peripheral arterial vasculature from the infrarenal aorta to the foot. In the second phase, 73 patients with symptomatic peripheral vascular disease underwent examination with both conventional contrast material-enhanced arteriography and two-dimensional TOF MR angiography to evaluate the clinical usefulness of MR angiography. Postinterventional and intraoperative angiography or direct surgical exploration was the standard of reference. In 32 patients, discrepancies occurred between findings on arteriograms and those on MR angiograms; most of these discrepancies were caused by improved depiction of runoff vessels on MR angiograms. The demonstration with MR angiography of blood vessels not seen on conventional arteriograms, unidentified stenoses, or misidentified blood vessels altered surgical management in 12 patients (16%). Metal-clip artifacts obscured clinically important disease on MR angiograms in two patients. It is concluded that two-dimensional TOF MR angiography is very useful in preoperative assessment of patients with severe peripheral vascular disease.

Lymphangiography as a staging tool for cervix cancer: limited value after hip arthroplasty

Lymphangiography (LAG) is often used in the work-up of cervical carcinoma. A patient with a history of bilateral hip arthroplasty, who presented with Stage IIIB squamous cell carcinoma of the cervix, was sent for lymphangiography. The LAG was deemed suboptimal, most likely because of altered lymphatic drainage engendered by the previous orthopaedic procedures. As the American population ages and hip arthroplasty becomes more common, the value of LAG in such patients will need to be reconsidered.

Magnetic resonance angiography of peripheral runoff vessels

Recent improvements in magnetic resonance imaging techniques have made magnetic resonance angiography (MRA) a very useful adjunct to invasive angiography. Fifty-five limbs in 51 patients with occlusive peripheral vascular disease were studied with both MRA and contrast arteriography. The magnetic resonance and contrast arteriograms were read by radiologists and surgeons and separate interventional plans were based on each study. The MRA findings differed significantly from those of conventional arteriography in 26 limbs (48%). In every case MRA visualized all of the same vessels and hemodynamic stenoses seen on the contrast arteriogram. In 48% of the cases, however, MRA revealed additional findings. Thus the discrepancies in the two studies were always the result of the failure of the arteriogram to reveal all of the patent vessels seen on MRA. The additional information provided by MRA resulted in alteration of the interventional plan in 11 cases (22%). In nine cases (18%) target vessels suitable for use in a limb-salvage procedure were identified by MRA, although they had been missed by conventional arteriography. In all of these cases, intraoperative arteriograms confirmed the suitability of these vessels for use in technically successful bypass procedures. In two cases (4%) additional information provided by MRA identified a target runoff vessel for bypass grafting that proved to be a better alternative than the one that would have been chosen on the basis of contrast arteriography.(ABSTRACT TRUNCATED AT 250 WORDS)

Expandable intravascular catheter: percutaneous use for endoluminal retrievals

Percutaneous use of an expandable vascular access catheter that can be deployed to temporarily occlude the entry vessel during retrieval of embolic material is described. The catheter was used to facilitate removal of two intraarterial objects, a postangioplasty free atheroma fragment and a displaced Gianturco coil. The expanded catheter end was equal to the arterial lumen, thus preventing distal embolization. The large distal lumen also facilitated plaque or foreign body removal by allowing deployment of various endovascular tools.

Magnetic resonance imaging of angiographically occult runoff vessels in peripheral arterial occlusive disease

BACKGROUND

Bypass grafting to arteries of the lower leg has become standard surgical management of advanced peripheral vascular disease. Its success depends on identifying suitable distal vessels. Preoperative preparation includes imaging of the arteries of the lower leg, usually by conventional contrast arteriography. An alternative procedure, magnetic resonance (MR) angiography, has been successfully employed in patients with various cardiovascular diseases, but its possible value in patients with peripheral vascular disease has received little attention.

METHODS

We used both conventional and MR angiography in preoperative studies of the lower-leg vessels of 23 patients (25 legs) with peripheral arteriosclerosis and arterial insufficiency, and developed independent therapeutic plans based on the information provided by each technique. When the plans differed, the interventional procedure judged more likely to save the limb was performed. The findings of conventional and MR angiography were verified by intraoperative arteriography, postinterventional arteriography, or direct operative exploration.

RESULTS

MR angiography detected all vessels identified by conventional angiography, whereas conventional arteriography failed to detect 22 percent of the runoff vessels identified by MR angiography. The detection by MR angiography of vessels not identified by conventional angiography altered the surgical management of the disorders of four patients (17 percent) and guided successful bypass procedures.

CONCLUSIONS

MR angiography is a noninvasive technique with greater sensitivity than conventional contrast arteriography for detecting distal runoff vessels in patients with peripheral arterial occlusive disease.

Prognostic significance of nuclear DNA content in phaeochromocytoma

Nuclear DNA content of 27 phaeochromocytomas was measured by image analysis of thin sections and monolayer smears of nuclei extracted from thick sections (cytospins) using archival paraffin-embedded tissue blocks. Recurrence was assessed on the basis of clinical follow-up or urinary catecholamine levels. The mean follow-up was 5.0 years, with a range of 4 months to 15 years. Although it is not possible to differentiate accurately malignant tumours using DNA analysis, prediction of benign tumours is possible. Using thin sections, all tumours were benign when the percentage of cells with a DNA content of 2.5 c (2 c = diploid) was less than 40% and the DNA content of 5 c was less than 4%. Using the cytospin preparation, all diploid tumours were benign. Thus, patients with diploid tumours may be saved intensive long-term follow-up. Aneuploid and tetraploid tumours, however, continue to require careful lifelong follow-up.

Comparison of image analysis and flow cytometric determination of cellular DNA content

A good correlation (r = 0.94) was obtained between the DNA indices (DI) using flow cytometry and image analysis of nuclei cytospins extracted from paraffin wax embedded tumour sections. Some of the limitations and problems associated with image analysis which came to light included an unacceptably high coefficient of variation (CV) and a "left-shift" in the DI in most DNA histograms obtained when using image analysis of 5 microns sections. In contrast, the DNA histograms generated using image analysis of cytospun nuclei from paraffin wax blocks were of good quality and similar to those obtained using flow cytometry. Variability in Feulgen staining was common and an important source of error despite rigorous control of the staining technique. This could be overcome by using internal controls such as fibroblasts rather than external controls (rat hepatocytes) to determine the diploid DI with image analysis. A thorough understanding and appreciation of the methodological problems associated with image analysis and flow cytometric determination of DNA content is required before these methods find widespread clinical application.

Drainage of bile ducts with an articulated T tube

An articulated T tube has been devised to simplify percutaneous replacement. Because the crosspiece and the stem are held together with sutures, they can be aligned over a catheter and guide wire for atraumatic insertion into the bile duct. By pulling the suture taut, the articulated T tube is easily reconstituted. A second suture can be attached to the proximal limb of the crosspiece to extract it end-on at a latter date without enlarging the tract. This articulated tube has been found very useful for safely replacing T tubes that have fallen out of immature tracts (n = 2) and inserting T tubes in tumor-encased bile ducts either via an existing T-tube tract (n = 1) or transhepatically (n = 1). This design extends the usefulness of T tubes for efficient intra- or extrahepatic bile duct drainage.

Percutaneous extraction of gallstones in 20 patients

Percutaneous cholecystolithotomy (PCL) was accomplished successfully without general anesthesia in 17 of 20 consecutive symptomatic patients from an outpatient gallstone center who were at risk for or had refused cholecystectomy. The other three patients underwent cholecystectomy because of a gallbladder collapse before admission, a tight stone-bearing phrygian cap, and a cannula slippage, respectively. A subhepatic approach was preferentially used after the fundus of the gallbladder was stabilized with a percutaneous anchor to prevent invagination and bile leakage. Retrograde slippage of the anchor into the tract in the first six patients was remedied by elongating the anchor from 2 to 3 cm. Calculi were removed in one session (11 patients) or two consecutive sessions (six patients). Morbidity included rehospitalization for stitch infection (n = 1) and dehydration (n = 1), cannula slippage (n = 1), broken guide wire (n = 1), vasovagal reaction (n = 1), and unextractable anchors (n = 3). Gallbladder endoscopy enabled identification of stones not visible at cholecystography. Hospitalization lasted 3-5 days; outpatient gallbladder drains were removed in 2-3 weeks in 10 patients and 4-6 weeks in seven (older) patients. No retained stones were seen at 6 months. The authors recommend PCL for patients at risk for surgery.

Method to control spraying of high-velocity infected blood droplets during arterial catheterization

Spurting of blood from standard arterial needles during guide-wire insertion can be controlled easily with a syringe and a simple needle inserted along the syringe plunger. With this method, blood droplets that may be infected with the hepatitis or human immunodeficiency virus will not come into contact with the head and neck of the angiographer or interventional radiologist.

Percutaneous enterostomy with the Cope suture anchor

Eighty-two percutaneous enterostomies were performed at three institutions with the Cope suture anchor for stomach or jejunal wall stabilization during alimentation tube placement. The anchors were successfully placed into the stomach or jejunum in 81 cases. Early in the series, two anchors were misplaced, with no sequelae. There were no other complications at the time of placement. In all successful cases, excellent immobilization of the viscus was achieved. Tract dilation and tube placement were easily performed, and there were no guidewire or tube dislodgments.