Tissue-independent MR tracking of invasive devices with an internal signal source

An improved MR tracking coil design is described that provides more robust tracking performance. It is shown theoretically and experimentally that a coil equipped with an internal spin source increases the signal-to-noise ratio in comparison to a coil system without internal source. The tracking behavior is stable even in air, which is important for laparoscopic work, in which the device has to be placed inside the inflated abdomen. Two types of coil windings were tested: one with the windings perpendicular to the coil axis and the other one with the windings tilted relative to this axis. The experiments showed no significant effect on the signal-to-noise ratio between the two types. The improved MR-tracking coil design with internal source was successfully used in cholecystostomies and in laparoscopic interventions; both procedures were performed on swine.

Gallbladder sepsis after stent insertion for bile duct obstruction: management by percutaneous cholecystostomy

Of 364 patients undergoing insertion of a biliary endoprosthesis in 1989, six (1.6 per cent) developed gallbladder sepsis. Three patients had cholangiocarcinoma, two had carcinoma of the pancreas and one had a benign biliary stricture. Two of the five patients with malignancy had gallbladder stones, and the patient with a benign stricture developed stones after 3 years of stenting. Three patients developed gallbladder sepsis early after endoprosthesis insertion (less than 6 days), while in the other three it occurred late (greater than 6 months). All six patients failed to respond to antibiotics and were successfully managed by percutaneous cholecystostomy; the patient with a benign biliary stricture also had cholecystolithotomy. The gallbladder drainage tubes were removed or became dislodged at intervals varying from 2 weeks to 6 months without complications. Percutaneous cholecystostomy is the treatment of choice for gallbladder sepsis unresponsive to antibiotics in patients with a biliary endoprosthesis in situ.

Percutaneous cholecystostomy: does transhepatic puncture preclude a transperitoneal catheter route?

Percutaneous cholecystostomy is now commonly performed for the diagnosis and treatment of gallbladder and biliary disorders. The optimal method and route of percutaneous cholecystostomy catheter placement, however, remain controversial and may depend on the indication for the procedure. The ability to predict traversal of the extraperitoneal plane of fixation ("bare area") between the liver and gallbladder with a transhepatic approach was investigated. With sonographic guidance, 21 transhepatic catheterizations were attempted: 19 in cadavers and two in patients who subsequently underwent cholecystectomy. In all cases, 8-F or 5-F self-retaining catheters were used. At autopsy or surgery, the catheter course and gallbladder puncture site were evaluated. Of 21 punctures, 19 (90%) were transhepatic and two (10%) were transperitoneal. Among the 19 transhepatic punctures, eight catheters (42%) traversed the bare area, while 11 (58%) entered the free gallbladder wall adjacent to the serosal attachment. There were four instances of guide-wire dislodgment during catheter placement; all occurred following puncture of the free wall of the gallbladder. No guide-wire dislodgment occurred when the bare area was transversed. Transhepatic gallbladder puncture does not prevent puncture of the free gallbladder surface. However, the liver and bare area do seem to provide guide-wire stability during catheter placement.

Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis

INTRODUCTION

Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management.

METHODS

A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates.

RESULTS

Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic.

CONCLUSIONS

Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.

Better treatment strategies for patients with acute cholecystitis and American Society of Anesthesiologists classification 3 or greater

PURPOSE

Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, it still carries high conversion and mortality rates. The purpose of this study was to find out better treatment strategies for high surgical risk patients with acute cholecystitis.

MATERIALS AND METHODS

Between January 2002 and June 2008, we performed percutaneous cholecystostomy instead of emergency cholecystectomy in 44 patients with acute cholecystitis and American Society of Anesthesiologists (ASA) classification 3 or greater. This was performed in 31 patients as a bridge procedure before elective cholecystectomy (bridge group) and as a palliative procedure in 11 patients (palliation group).

RESULTS

The mean age of patients was 71.6 years (range 52-86 years). The mean ASA classifications before and after percutaneous cholecystostomy were 3.3 +/- 0.5 and 2.5 +/- 0.6, respectively, in the bridge group, and 3.6 +/- 0.7 and 3.1 +/- 1.0, in the palliation group, respectively. Percutaneous cholecystostomy was technically successful in all patients. There were two deaths after percutaneous cholecystostomy in the palliation group due to underlying ischemic heart disease and multiple organ failure. Resumption of oral intake was possible 2.9 +/- 1.8 days in the bridge group and 3.9 +/- 3.5 days in the palliation group after percutaneous cholecystostomy. We attempted 17 laparoscopic cholecystectomies and experienced one failure due to bile duct injury (success rate: 94.1%). The postoperative course of all cholecystectomy patients was uneventful.

CONCLUSION

Percutaneous cholecystostomy is an effective bridge procedure before cholecystectomy in patients with acute cholecystitis and ASA classification 3 or greater.

Percutaneous cholecystostomy in critically ill patients

Sixteen critically ill patients underwent percutaneous cholecystostomy because of suspected acute cholecystitis. The procedure was technically successful, although 11 of 16 patients died subsequently because of various complications of their underlying primary disorders. We reviewed this series to reassess the value of percutaneous cholecystostomy. Four of 11 patients with definite acute cholecystitis (group 1) were cured by this technique, but three required surgery because of gallbladder wall necrosis. Two of these were among four cases which had demonstrated pericholecystic fluid collections on computed tomography (CT) or ultrasound of the abdomen. There were also five patients (group 2) in whom acute cholecystitis or its relationship to patients' symptoms were not fully determined, and four of them did not improve after percutaneous cholecystostomy. We conclude that this technique has a lower success rate in critically ill patients than reported previously.

[Percutaneous cholecystostomy for acute cholecystitis in high-risk patients]

AIM OF THE STUDY

The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia.

PATIENTS AND METHODS

From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases.

RESULTS

Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without).

CONCLUSION

Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Percutaneous cholecystostomy for high-risk patients with acute cholangitis

Percutaneous cholecystostomy (PC) is a well-established treatment for acute cholecystitis. We investigate the performance and role of PC in managing acute cholangitis.Retrospective review on all patients who underwent PC for acute cholangitis between January 2012 and June 2017 at a major regional hospital in Hong Kong.Thirty-two patients were included. The median age was 84 years and median American Society of Anaesthesiologists (ASA) physical status was Class III (severe systemic disease). All fulfilled Tokyo Guidelines 2013 (TG13) diagnostic criteria for moderate or severe cholangitis. Eighty-four percent of the patients were shown to have lower common bile duct stones on imaging. The majority had previously failed intervention by endoscopic retrograde cholangiopancreatography (38%), percutaneous transhepatic biliary drainage (38%), or both (13%)The technical success rate for PC was 100% with no procedure-related mortality. The overall 30-day mortality was 9%. Rest of the patients (91%) had significant improvement in clinical symptoms and could be discharged with median length of stay of 14 days. Significant postprocedural biochemical improvement was observed in terms of white cell count (P < .001), serum bilirubin (P < .001), alkaline phosphatase (P = .001), and alanine transaminase levels (P < .001). Time from admission to PC was associated with excess mortality (P = .002).PC is an effective treatment for acute cholangitis in high-risk elderly patients. Early intervention is associated with lower mortality. PC is particularly valuable as a temporising measure before definitive treatment in critical patients or as salvage therapy where other methods endoscopic retrograde cholangiopancreatography/percutaneous transhepatic biliary drainage (ERCP/PTBD) have failed.

A new biliodigestive anastomosis technique to prevent reflux and stasis

BACKGROUND

The Roux-en-Y procedure for biliodigestive drainage is most widely accepted, but 10% to 15% of patients postoperatively suffer from a blind-loop syndrome or cholangitis due to motility disorders. A new biliodigestive technique is evaluated in a rat model to prevent these complications.

METHODS

This experimental study in Wistar rats compares the Roux-en-Y technique with a new biliodigestive anastomosis creating a jejunal loop with luminal occlusion. Clinical parameters, small bowel motility, bacteriologic growth, and liver histopathology were evaluated in native and postoperative animals within a study period of 180 days.

RESULTS

Both operative procedures were well tolerated. After 6 months intense fibrosis of the liver and high-grade purulent cholangitis were observed in animals in the Roux-en-Y group. In these animals enterobacter and enterococci overgrowth was found. Myoelectric small bowel recordings revealed significant impairment of slow-wave frequency, aboral velocity, and action potentials (percentage of phase III) in Roux-en-Y animals.

CONCLUSIONS

Motility disorders after conventional Roux-en-Y biliodigestive anastomosis are pivotal for histomorphological damage and infectious findings and can be prevented by using the new technique to create a jejunal loop with luminal occlusion.

Laparoscopic tube cholecystostomy: still useful in the management of complicated acute cholecystitis

The preferred treatment for acute cholecystitis is laparoscopic cholecystectomy. Conversion to open operation may be necessary in cases where the anatomy is unclear or complications are encountered. Laparoscopic tube cholecystostomy remains an alternative to open surgery in cases where the gallbladder is judged too inflamed to allow for laparoscopic removal and in cases where the patient is too sick to tolerate a more extensive procedure. It also provides access for diagnostic cholangiography. We report three patients with acute cholecystitis who underwent laparoscopic cholecystostomy and interval laparoscopic cholecystectomy without complications. Laparoscopic tube cholecystostomy is safe and remains a useful option in select patients with complicated acute cholecystitis.

Operative tube versus percutaneous cholecystostomy for acute cholecystitis

The records of 26 patients who underwent cholecystostomy procedures for presumed acute cholecystitis during a 6-year period were reviewed. Nine patients had operative tube cholecystostomy (OC), and 17 patients had radiologic percutaneous cholecystostomy (PC). A correct diagnosis of acute cholecystitis was made in 22 of 26 patients (84%), including 14 of 17 PC patients and 8 of 9 in the OC group. The rate of resolution of cholecystitis was the same in each group (75% OC versus 78% PC). APACHE II scores prior to treatment were significantly higher in OC patients (20.9 OC versus 12.4 PC, p < 0.01). There were 5 deaths, including 3 in the OC groups and 2 in the PC group. Nonfatal complications were more frequent in the PC group. Two of the 14 correctly diagnosed PC patients (14%) subsequently required emergency cholecystectomy for persistent biliary sepsis, and 6 patients (43%) required at least 1 tube exchange for occlusion or dislodgement. Overall, only 5 of the 14 patients (36%) in the PC group were successfully treated without complications compared with 5 of 8 patients (63%) in the OC group. Despite its theoretical advantages, PC was no more effective than OC in the treatment of acute cholecystitis. These data suggest that OC remains a viable treatment option in critically ill patients with acute cholecystitis.

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.

Surgeon-performed ultrasound in the ICU setting

Evaluation of critically ill patients is often challenging due to altered sensorium, underlying disease, and the presence of multiple drains or monitoring devices. In such circumstances, the ability of physicians to perform ultrasound examinations in the intensive care unit provides a useful diagnostic and therapeutic adjunct. In this article,we review the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients.

Interventional radiology of the biliary tract

Interventional radiology provides a range of management options applicable to a broad spectrum of patients with biliary tract disorders. This review highlights the importance of these procedures, and illustrates their safety and effectiveness. Percutaneous transcatheter decompression has a well-established role in the management of patients with benign and malignant biliary obstruction. The advent of metallic stents has greatly increased the value of these techniques. Patients with biliary tract calculi can be successfully treated with a variety of percutaneous techniques, obviating surgery and providing a useful alternative to endoscopic methods. Finally, percutaneous cholecystostomy has evolved as a valuable adjunct in the treatment of calculous cholecystitis, as well as providing the definitive cure for many patients with acalculous cholecystitis.

EUS-guided endoscopic necrosectomy and temporary cystogastrostomy for infected pancreatic necrosis with self-expanding metallic stents

Pancreatic pseudocyst with infected necrotic tissue is associated with necrotizing pancreatitis and carries a high rate of complications and death. Open cystogastrostomy with removal of necrotic material and necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Endoscopic cyst drainage with necrosectomy is an alternative and less invasive technique. We report a case of endoscopic ultrasound-guided cystogastrostomy with a fully covered 15-mm-diameter self-expandable metal stent and staged endoscopic necrosectomy through the stent. This is the first case, so far, to use this technique with complete removal of necrotic material without any complications.

Laparoscopic cholecystojejunostomy: a technical application in unresectable biliary obstruction

Laparoscopic cholecystojejunostomy was accomplished utilizing an endoscopic gastrointestinal stapler in 2 patients with biliary obstruction and jaundice secondary to inoperable pancreatic carcinoma. This technique was performed on patients judged to be poor candidates for an open resection, due to medical conditions and associated comorbidities. The actual operating time, taking into account delays not related to the operation or technique, was 45-60 min. Both patients experienced immediate significant overall clinical improvement with minimal operative sequelae. The first patient was eating and ready for discharge in 4 days, and the second was prepared for discharge in less than 24 h. This operative procedure offers the patient excellent palliation with many advantages over traditional open surgery.

Predicting Infected Bile Among Patients Undergoing Percutaneous Cholecystostomy

PURPOSE

Patients may not achieve a clinical benefit after percutaneous cholecystostomy due to the inherent difficulty in identifying patients who truly have infected gallbladders. We attempted to identify imaging and biochemical parameters which would help to predict which patients have infected gallbladders.

METHODS

A retrospective review was performed of 52 patients undergoing percutaneous cholecystostomy for clinical suspicion of acute cholecystitis in whom bile culture results were available. Multiple imaging and biochemical variables were examined alone and in combination as predictors of infected bile, using logistic regression.

RESULTS

Of the 52 patients, 25 (48%) had infected bile. Organisms cultured included Enterococcus, Enterobacter, Klebsiella, Pseudomonas, E. coli, Citrobacter and Candida. No biochemical parameters were significantly predictive of infected bile; white blood cell count >15,000 was weakly associated with greater odds of infected bile (odds ratio 2.0, p = NS). The presence of gallstones, sludge, gallbladder wall thickening and pericholecystic fluid by ultrasound or CT were not predictive of infected bile, alone or in combination, although a trend was observed among patients with CT findings of acute cholecystitis toward a higher 30-day mortality. Radionuclide scans were performed in 31% of patients; all were positive and 66% of these patients had infected bile. Since no patient who underwent a radionuclide scan had a negative study, this variable could not be entered into the regression model due to collinearity.

CONCLUSION

No single CT or ultrasound imaging variable was predictive of infected bile, and only a weak association of white blood cell count with infected bile was seen. No other biochemical parameters had any association with infected bile. The ability of radionuclide scanning to predict infected bile was higher than that of ultrasound or CT. This study illustrates the continued challenge to identify bacterial cholecystitis among patients referred for percutaneous cholecystostomy.

Percutaneous cholecystocholedochostomy for cholecystitis and cystic duct obstruction in gallbladder carcinoma

Percutaneous cholecystocholedochostomy was performed in a patient with acute cholecystitis caused by cystic duct obstruction by gallbladder carcinoma, but removal of the percutaneous cholecystostomy catheter was unsuccessful because of continuing discharge. After creation of a cholecystocholedochostomy through the cholecystostomy tract with use of a transjugular liver access set and a 21-gauge needle, self-expandable metallic stents were placed in the narrowed common bile duct and the newly created tract between the gallbladder and the common hepatic duct. The external cholecystostomy catheter was successfully removed after the procedure. Jaundice occurred 70 days later as a result of tumor invasion above the segment with the stent, and an additional stent was placed. The patient died of diffuse metastasis 143 days after creation of the cholecystocholedochostomy without recurrence of cholecystitis.

Laparoscopic cholecyst-jejunostomy and gastroenterostomy for malignant disease

The technique of videolaparoscopic surgical bypass for malignant obstruction of the distal common bile duct and duodenum is described as it has evolved since 1991. The techniques available include anastomosis of jejunum to the gallbladder and stomach by suture, staples or a combination of the two techniques. The present criteria for patient selection for these palliative approaches, alone or in combination with ERCP stenting, are discussed. Early clinical experience in several small series of patients treated by this laparoscopic approach suggests rapid recovery will be added to the proven reliability of these open palliative bypass techniques.

Efficacy of preoperative percutaneous cholecystostomy in the management of acute cholecystitis according to severity grades

BACKGROUND/AIMS

The aim of this retrospective study was to assess the efficacy of percutaneous cholecystostomy (PC) for patients with acute cholecystitis (AC) according to severity.

METHODS

A total of 325 patients who underwent cholecystectomy between January 2008 and October 2010 were enrolled. Patients were classified into three groups based on severity grade according to the Tokyo guidelines for AC: grade I (mild), grade II (moderate), and grade III (severe). These groups were further classified into two subgroups based on whether or not they underwent preoperative PC.

RESULTS

A total of 184 patients were classified into the grade I group (57%), 135 patients were classified into the grade II group (42%), and five patients were classified into the grade III group (1%). In the grade I and II groups, the mean length of hospital stay was significantly shorter in the patients who did not undergo PC than in those who received PC (10.7 ± 4.4 vs. 13.7 ± 5.8, p < 0.001; 11.8 ± 6.5 vs. 16.9 ± 12.5, p = 0.003, respectively). The mean length of preoperative hospital stay was significantly shorter in the patients without PC than in those with PC in the grade I and II groups (5.8 ± 3.3 vs. 8.2 ± 4.6, p = 0.001; 6.0 ± 4.4 vs. 8.8 ± 5.2, p = 0.002). In addition, the operative time was shorter in patients without PC, especially in the grade I group (94.6 ± 36.4 vs. 107.3 ± 33.5, p = 0.034).

CONCLUSIONS

Preoperative PC should be reserved for only selected patients with mild or moderate AC. No significant benefit of preoperative PC was identified with respect to clinical outcome or complications.

Gallbladder aspiration for acute cholecystitis in average-surgical-risk patients

We conducted a retrospective case note review to assess whether or not gallbladder aspiration can be applied as a temporary measure for the treatment of acute cholecystitis in average-surgical-risk patients. Gallbladder aspiration was performed in 79 consecutive average-surgical-risk patients with acute cholecystitis, who had no indications of emergent surgery and who complained of severe colicky pain. Elective surgery became possible in 92% of patients by gallbladder aspiration. The percentage reached 97 when percutaneous cholecystostomy was added (four patients). Emergent surgery was needed in one patient suffering bile leakage following gallbladder aspiration. Colicky pain was controlled soon after the procedure in most cases. Neither major complications nor mortalities were observed in the following surgical therapies. It is suggested that gallbladder aspiration might be applied as a temporary measure for acute cholecystitis in average-surgical-risk patients, although early surgery should remain the primary choice of therapy in such patients.

Percutaneous cholecystostomy: a nonsurgical therapeutic option for acute cholecystitis in high-risk and critically ill patients

Percutaneous cholecystostomy offers a potentially important type of therapy for critically ill patients with acute cholecystitis who present high risk when undergoing laparotomy or laparoscopy under general anesthesia. It offers a distinct advantage for these kinds of patients by avoiding the risks of the surgical intervention. Percutaneous cholecystostomy is a safe and effective minimally invasive procedure with a high success rate and low procedure-related complications. It should be considered not only in temporary management of calculous cholecystitis, but also in definitive treatment in cases of acalculous cholecystitis.