Presacral masses after abdominoperineal resection for colorectal carcinoma: the need for needle biopsy

Computed tomographic(CT)-guided biopsy of presacral masses after abdominoperineal resection for colorectal carcinoma was performed in 28 patients, using a transgluteal approach. The masses were divided into three groups according to their morphologic appearance: solid mass, mass with central low-density area, and gas-containing mass. Of 19 patients with a homogeneous solid mass, 15 had biopsy-proven recurrent adenocarcinoma. In the other nine patients, who had low-density masses with or without gas, it was not possible to offer a diagnosis on the basis of the CT appearance alone. In these cases, needle biopsy disclosed various entities, including recurrent tumor, abscess, and posttreatment necrosis. There was only one complication, transient hematuria. CT-guided needle biopsy of presacral masses after abdominoperineal resection is a simple, relatively safe, and valuable diagnostic technique.

Comparison of sonography and plain films in evaluation of the acute abdomen

In 95 patients with acute abdominal pain seen in the emergency ward of a large urban teaching hospital, real-time sonography was performed in conjunction with a plain film of the abdomen in order to detect what, if any, added information was provided by the sonographic examination. In 20 patients (21%) the sonogram contributed important diagnostic information not provided by the plain film of the abdomen. Most of these patients had pathology referable to the biliary tract (14 of 20). In 28 patients (30%), the sonogram confirmed the diagnosis by abdominal film. In 39 (41%) the sonogram added no relevant information, and in three (3%) it was deleterious. In five (5%) the plain film provided more information than the sonogram.

Severe esophageal strictures: indications for balloon catheter dilatation

Bougienage of esophageal strictures is a traditional method of therapy for patients who present with a stricture sufficiently large to permit passage of a mercury-weighted rubber bougie. However, when the residual lumen is smaller than 12 mm diameter, bougie dilatation acquires a prohibitively high risk of esophageal perforation. Twenty patients who had severe esophageal strictures have undergone surgical repair or Eder-Puestow dilatation assisted by guidewire. Fluoroscopic balloon catheter dilatation obviated surgery and allowed subsequent standard bougienage both in hospital and at home performed by the patient. We discuss indications, technique, results, and complications.

Monooctanoin perfusion treatment of intrahepatic calculi

Seventeen patients who had intrahepatic calculi underwent perfusion with monooctanoin. While five patients responded with a decrease in size or number of calculi, only one had a complete response; 12 showed no response; and one died during the perfusion (however, the perfusion was not believed to have contributed to the death). Fifteen of the 17 patients required further treatment by a combination of basket extraction, oral administration of chenodeoxycholic acid, or surgery. The lack of response to monooctanoin perfusion was in part due to calculus composition. Because of the poor response to this treatment and the prolonged hospitalization generally required, monooctanoin is not recommended for dissolution of intrahepatic calculi.

Abscess-fistula association: radiologic recognition and percutaneous management

Thirty-five patients with postoperative enteric and/or biliary fistulae were diagnosed and treated by percutaneous catheter drainage. All were initially considered to have postoperative abdominal abscesses, and the enteric or biliary communications were unrecognized before radiologic intervention. In addition, at the time of initial catheter insertion, only six of the 35 abscesses were recognized as being associated with an underlying fistula. In the other 29 patients the fistulae were found either by clinical follow-up or contrast sinogram after 24-72 hr of catheter drainage. Percutaneous catheter drainage was the definitive treatment in 28 (80%) of the 35 patients. The seven failures were either from inadequate catheter positioning or inability to treat the primary cause of the fistula (e.g., radiation enteritis, perforated cancer). These data suggest that even abscesses with underlying fistulae, traditionally an indication for surgical intervention, may be successfully managed by percutaneous methods.

Serious complications following transgression of the pleural space in drainage procedures

Transgression of the parietal pleura may occur during placement of interventional drainage catheters into the liver and upper abdomen, and occasionally results in lethal complications. In a review of nearly 2,000 such procedures, four deaths were found to be related directly to pleural transgression from biliary drainage. Therefore, the anatomy of the pleura pertinent to abdominal needle or catheter insertion was analyzed. In 14 cadavers examined after intercostal needle insertion into the liver, needles inserted through the 9th intercostal space or higher punctured the pleura in all but one cadaver. Radiologic studies of 15 clinical cases revealed that elderly patients rarely depressed the diaphragm below the 9th intercostal space, which increases the risk of unsuspected puncture of the pleura. Review of clinical material revealed that diagnostic needle puncture through the parietal pleura carries far less risk than placement of a long-term drainage catheter. Methods to avoid puncture of the pleura, as well as the technical problems involved in such maneuvers, are given.

The uses of diagnostic ultrasound in the thorax

Modern real-time gray scale ultrasonography has contributed new diagnostic and therapeutic information in patients with diseases of the lungs and pleura. This article will discuss the ways in which ultrasound is most clinically useful in patients with thoracic disease.

CT- and ultrasound-guided catheter drainage of empyemas after chest-tube failure

CT- and ultrasound-guided catheters were used to locate and drain empyemas in 17 patients, most of whom had failed to improve with conventional chest-tube drainage due to a poorly positioned tube. Fifteen patients (88.2%) were treated successfully, averting surgery or further drainage, and bacteremia in 1 patient was the only complication. Previously unrecognized communications with the bronchi, esophagus, and subphrenic space were demonstrated, and intracavitary tumor biopsy and instillation of a sclerosing agent were performed in several patients. Compared to the tubes used to drain abdominal abscesses, empyema catheters need less irrigation; dionosil is often the preferred contrast agent, the catheter can be withdrawn in one step, and a residual fibrotic or tumor cavity may persist after pus has been evacuated.

Temporizing effect of percutaneous drainage of complicated abscesses in critically ill patients

Fifteen patients who would not have been candidates for percutaneous abscess drainage previously, and who were exceedingly high-risk for surgery, underwent initial catheter drainage. The patients were critically ill and had complicated abscesses, which were poorly defined, multiloculated, phlegmonous, and had associated fistulas. The percutaneous drainages were not curative. However, the patients dramatically improved and became fit for surgery (13 patients) or another interventional procedure (three patients). Five hypotensive patients were stabilized by the catheter drainage; mean white blood cell count in the 15 patients decreased by 14,000/mm3; mean temperature decreased from 40 degrees C to 38.1 degrees C; and anemia, coagulation factors, and overall condition improved. Eventual surgery was more limited (directed to the cause of the abscess) and less time-consuming. All these high-risk patients survived with this combined radiologic-surgical approach. Temporizing percutaneous abscess drainage in gravely ill patients with complex abscesses offers significant therapeutic benefit, although it may not be curative. With realistic expectations for partial success rather than cure, the scope of candidates for percutaneous drainage has broadened.

Iliopsoas abscess: treatment by CT-guided percutaneous catheter drainage

Eight cases of iliopsoas abscess were diagnosed and treated by computed tomographic (CT)-guided needle aspiration and percutaneous catheter drainage. The etiology varied but was definitely established in only four of eight cases. Seven of eight were successfully drained and surgery avoided. The eighth patient defervesced satisfactorily but ultimately required surgical debridement of a sacral osteomyelitis. Clinical, anatomic, and technical considerations for percutaneous drainage of iliopsoas abscesses are discussed. CT was essential both in early diagnosis and in guiding diagnostic needle aspiration and catheter placement. Image-guided percutaneous drainage appears to be the treatment of choice for iliopsoas abscess.

Inflammatory pancreatic masses. Problems in differentiating focal pancreatitis from carcinoma

The authors studied 19 patients with focal inflammatory masses of the pancreas over an 18-month period. In 13 cases, transhepatic cholangiography and/or endoscopic retrograde cholangiopancreatography were unsuccessful in differentiating pancreatitis from carcinoma. Eighteen patients had a history of alcohol abuse, and 12 had had pancreatitis previously. Pre-existing glandular injury appears to be a prerequisite to formation of focal inflammatory pancreatic masses.

The clinical value of body computed tomography over time and technologic change

A clinical study of body computed tomography (CT) at Massachusetts General Hospital evaluated 2,619 patients who were prospectively assigned to one of 12 examination protocols. Data obtained from referring physicians and patient records just before CT examination and later in the course of care served as a basis for judging the contribution of CT to diagnostic understanding, use of other tests, and choice of therapy. Fifty-three percent of examinations produced a substantial or unique contribution to diagnostic understanding, and 15% contributed to a change in treatment. Performance in different protocols varied greatly: lymphoma, pancreas, retroperitoneum, lung, and liver ranked in the top half for both diagnostic and therapeutic efficacy; pelvis, urology, and colon fell in the bottom third. Overall, CT reduced surgery by an estimated 14% and angiography by an estimated 11% in the study population. Availability of CT was also associated over time with significant declines in the frequency of sonographic examinations and of lymphangiography, though not of endoscopic retrograde cholangiopancreatography. Compared with an 18-sec scanner, examinations on a 3-sec unit more frequently contributed to improved diagnostic understanding (p less than 0.05) and to increased physician confidence in previously chosen treatment (p less than 0.001). Studies of the diagnostic and therapeutic efficacy of devices like CT can guide clinical expectations and provide a basis for evaluating new imaging methods.

Percutaneous aspiration of hepatic cysts does not provide definitive therapy

Follow-up of 13 patients who underwent radiologically guided percutaneous needle aspiration of simple liver cysts revealed cyst recurrence in all patients within 2 years. While still effective as a primary diagnostic maneuver, percutaneous aspiration seems to lack permanent therapeutic benefit. However, it may be used as a therapeutic trial to confirm the origin of the patient's symptoms. The possible role of intracystic instillation of sclerosing agents was not studied in this series.

Biliary pressure: manometric and perfusion studies at percutaneous transhepatic cholangiography and percutaneous biliary drainage

Manometric pressure recordings were attempted during percutaneous transhepatic cholangiography (PTC) and after percutaneous biliary drainage (PBD) in 203 cases. Successful readings were achieved at PTC in 85% (104/122) of patients. Pressure measurements were also obtained through 56 biliary drainage catheters, and controlled perfusion challenges were performed in 12 patients (on 18 occasions). Documentation of the occasionally poor correlation between the caliber of ducts and the degree of obstruction (i.e., pressure) was shown, and it was suggested that very high pressures may be predictive of a bile leak after PTC. Adequacy of percutaneous drainage and stricture dilatation were further assessed with these manometric techniques. Pressure and perfusion data aided in detecting and determining the significance of the nondilated obstructed duct, the dilated nonobstructed ductal system, and subtle distal ductal strictures. The knowledge obtained from percutaneous pressure recordings may help to determine appropriate therapy.

Ultrasound in obstructive jaundice: prospective evaluation of site and cause

A prospective study of the ability of ultrasound to accurately determine the site and etiology of biliary obstruction in 62 patients is reported. The site of obstruction was predicted in 27% of the patients, but was indeterminate in 73% because of the inability to visualize the complete biliary tract. The cause of obstruction was correctly predicted in 23% of the patients and was indeterminate in 76%. While sonography is an excellent screening method for distinguishing dilated ducts from nondilated ducts, the authors believe that direct cholangiography, or possibly computed tomography, is necessary if stringent criteria are applied to the determination of the site and cause of biliary obstruction.

Sonographic appearance of hematoma in liver, spleen, and kidney: a clinical, pathologic, and animal study

Following the observation of several cases of localized echogenic foci in abdominal parenchymal organs in patients with acute bleeding due to trauma, an experimental study was designed to define the sonographic appearance of fresh, nonhemolyzed blood. Ultrasound scanning performed before and after the injection of blood or air into the parenchyma of cadaveric organs (liver, spleen, and kidney) resulted in consistent ultrasonic patterns. Linear echogenic foci resulted from the injection of 0.5 to 2.0 ml of blood, rounded echogenic foci were seen with air or 3- to 10-ml injections of blood, and the injection of contrast material (into the liver only) caused poorly defined hypoechoic areas. To determine if the ultrasound appearance of the cadaveric organs could have been caused mainly by air, an in vivo experiment was performed in which computed tomograms of the liver of a dog that had been injected with autologous blood were obtained. It is concluded that CT confirmed the ultrasound findings, and that ultrasound is useful for the investigation of hematoma following blunt, and possibly penetrating, trauma.

Detection and drainage of bilomas: special considerations

Localized collections of bile within the peritoneal cavity, "biloma," may occur after surgery or trauma and are readily detected by sonography and computed tomography. Eleven cases in which the diagnosis was confirmed by percutaneous needle aspiration and treatment carried out by radiologic catheter drainage are reported. Specific identification of bile was made by visual inspection, initial rapid dip-stick (Multistix) technique, and formal chemical analysis. Evidence of continued free bile leak included a positive technetium HIDA scintigram and copious amounts of bilious catheter drainage over a prolonged period. Unexpected clinical features of biloma included presentation as a pyogenic subhepatic abscess in four (36%) of 11 cases, localization of the biloma collection in the left upper abdomen despite surgery on the right side in four (36%) cases, and the presence of an active bile fistula in five (45%) cases. Percutaneous radiologic catheter drainage provided adequate therapeutic drainage in all but two patients in whom a continuing active bile leak eventually required surgical correction.

Air within a pancreatic inflammatory mass: not necessarily a sign of abscess

Intrapancreatic air is considered to be a reliable if not a diagnostic sign of pancreatic abscess. The presence of extraluminal air within the pancreatic bed may also result from perforation of a pseudocyst into adjacent bowel. We describe a patient believed to have a pancreatic phlegmon both clinically and radiographically, in whom intrapancreatic air could be demonstrated on multiple abdominal CT scans over several months. The relatively unremarkable clinical course of this patient during an 11-month interval is incompatible with the usual rapid deterioration and high mortality rate of untreated pancreatic abscess.

Prospective diagnosis of choledocholithiasis

Choledocholithiasis was detected by ultrasound in 11 of 87 patients (13%) overall, including 11 of 56 patients (20%) who had dilated ducts. Choledocholithiasis occurred with a normal caliber common bile duct in 31 of 87 patients (36%), and choledocholithiasis occurred without stones in the gallbladder in seven of 66 patients (11%). Biliary ultrasound plays a limited role in the exclusion of choledocholithiasis.

The occurrence of fluid collections following routine abdominal surgical procedures: sonographic survey in asymptomatic postoperative patients

To investigate the frequency and appearance of reactive effusions following abdominal surgery, a prospective real-time sonographic survey of 80 asymptomatic postoperative patients was conducted. Serial scans on the 4th, 8th, and 12th postoperative days disclosed localized abdominal fluid collections in 19% (15/80), 6% (5/80), and 2.5% (2/80) of cases, respectively. The only collection that enlarged was an abscess. Knowledge of the natural history of reactive postoperative effusions should help the ultrasonographer to detect pathologic fluid collections and abscesses in postsurgical patients.