Radiologic placement of a low profile implantable venous access port in a pediatric population

PURPOSE

To evaluate the feasibility and complications of placement of a low-profile venous access port in the chest in children requiring long-term venous access.

METHOD

A low-profile peripheral arm port (PAS port; Sims Deltec, St. Paul, MN, USA) was implanted in the chest in 22 children over a 4-year period. The mean age of the study group was 6 years (range: 9 months to 20 years). Ports were placed for the administration of chemotherapy, hyperalimentation and frequent blood sampling. Sonographic guidance was used to access the internal jugular or subclavian vein in each case. A review of all inpatient and outpatient charts was undertaken to assess catheter performance and complications.

RESULTS

Access to the central venous circulation was successfully achieved in each case without complication. Ports remained implanted for 6579 catheter-days (mean: 299 days). Ten ports have been removed. Of three patients (13%) experiencing device-related infections (0.45 infections/1000 catheter days), two (9.1%) were unresponsive to antibiotics and removed (0.3 infections/1000 catheter days). One port was removed because of pain in the shoulder adjacent to the port implantation site. One port was removed because of difficult access. The final port was removed in order to place a dual-lumen catheter prior to bone marrow transplant. Twelve ports remain implanted. Aspiration occlusion occurred in four patients (18%). Deep venous thrombosis did not occur in any patient.

CONCLUSION

Low-profile chest ports placed by interventional radiologists in the interventional radiology suite can be placed in children as safely as traditional chest ports placed in the operating room. The incidence of infection, venous thrombosis and aspiration occlusion is comparable to that of ports placed operatively.

Characterization of radial forces in Z stents

RATIONAL AND OBJECTIVES

The purpose of this study was to evaluate the effects of variation in design parameters on the resultant radial force. We evaluated the influence of wire gauge, leg length, and number of bends on the radial force produced by z stents and compared these with radial forces produced by commercial stents. A second goal was to develop an engineering model for predicting radial forces generated by z stents.

METHODS

Z stents were fashioned by hand using stainless steel wire and solder that connected the ends. The radial force was measured as a function of wire gauge, vessel diameter, leg length, and number of bends and compared with the theoretical values of radial force calculated by combining Castigliano's theorem and the law of Laplace.

RESULTS

Theoretically predicted radial forces were within 8% of each observed value of radial force up to 70% spring compression.

CONCLUSIONS

These results suggest that the z-stent model can be used to build custom stents with preselected values of radial force for clinical use. In addition, they can be used to design model investigational stents made of similar materials and surface areas to test the effects of radial force on biological response.

Peripheral venous access ports: outcomes analysis in 109 patients

PURPOSE

To perform a retrospective outcomes analysis of central venous catheters with peripheral venous access ports, with comparison to published data.

METHODS

One hundred and twelve central venous catheters with peripherally placed access ports were placed under sonographic guidance in 109 patients over a 4-year period. Ports were placed for the administration of chemotherapy, hyperalimentation, long-term antibiotic therapy, gamma-globulin therapy, and frequent blood sampling. A vein in the upper arm was accessed in each case and the catheter was passed to the superior vena cava or right atrium. Povidone iodine skin preparation was used in the first 65 port insertions. A combination of Iodophor solution and povidone iodine solution was used in the last 47 port insertions. Forty patients received low-dose (1 mg) warfarin sodium beginning the day after port insertion. Three patients received higher doses of warfarin sodium for preexistent venous thrombosis. Catheter performance and complications were assessed and compared with published data.

RESULTS

Access into the basilic or brachial veins was obtained in all cases. Ports remained functional for a total of 28,936 patient days. The port functioned in 50% of patients until completion of therapy, or the patient's expiration. Ports were removed prior to completion of therapy in 18% of patients. Eleven patients (9.9% of ports placed) suffered an infectious complication (0.38 per thousand catheter-days)-in nine, at the port implantation site, in two along the catheter. In all 11 instances the port was removed. Port pocket infection in the early postoperative period occurred in three patients (4.7%) receiving a Betadine prep vs two patients (4.2%) receiving a standard O.R. prep. This difference was not statistically significant (p = 0.9). Venous thrombosis occurred in three patients (6.8%) receiving warfarin sodium and in two patients (3%) not receiving warfarin sodium. This difference was not statistically significant (p = 0.6). Aspiration occlusion occurred in 13 patients (11.7%). Intracatheter urokinase was infused in eight of these patients and successfully restored catheter function in all but two instances. These complication rates are comparable to or better than those reported with chest ports.

CONCLUSION

Peripheral ports for long-term central venous access placed by interventional radiologists in the interventional radiology suite are as safe and as effective as chest ports.

Translumbar placement of paired hemodialysis catheters (Tesio catheters) and follow-up in 10 patients

For lack of other suitable access, 10 consecutive patients received paired hemodialysis catheters for long-term hemodialysis using a translumbar approach to the inferior vena cava (IVC). All attempts were successful. Five paired catheters were placed using the single-puncture technique, and five using the dual-puncture technique. Catheters were in place for a total of 2252 catheter days. The average duration of catheter placement was 250 days (range 30-580 days). All catheters were functioning up to the time the study was completed or the patient died. The most common complication was partial dislodgment of the catheter in 3 of 23 catheters (13%), all occurring in obese patients. One episode of retroperitoneal hemorrhage was noted in a patient having the single-access technique. There were no episodes of infection or IVC thrombosis.

Endovascular stent graft for management of ureteroarterial fistula after orthotopic bladder substitution

We describe the first case of an ureteroarterial fistula developing after orthotopic neobladder substitution and its minimally invasive management using endovascular stent grafting. We outline the risk factors for the development of ureteroarterial fistulae and trace the evolution of diagnostic and therapeutic modalities used in the management of these life-threatening complications. Minimally invasive management with endovascular stent grafting and exclusion of two pseudoaneurysms in the iliac artery system was performed successfully. After successful endovascular exclusion of two pseudoaneurysms, the patient's hematuria resolved and he recovered fully. Three-dimensional computed tomography performed 3 months later documented a patent aortoiliac arterial system without evidence of pseudoaneurysm or endovascular leak. Ureteroarterial fistula after orthotopic bladder substitution was managed with an endovascular stent graft without the need for extra-anatomical vascular bypass. Early recognition, stabilization, and angiographic evaluation followed by this minimally invasive technique may avoid open operative repair and attendant morbidity.

Access to occluded infrainguinal bypass grafts with a loopsnare

Thrombolysis for the treatment of occluded bypass grafts is used in selected clinical circumstances. Unfortunately, a minority of these procedures are technical failures because of the inability to access the occluded graft. We describe a technique that greatly increases the chances of technical success.

Ultrasound characteristics of subdermally implanted Implanon contraceptive rods

This study was designed to define sonographic characteristics and the optimal sonographic technique for localization of the single rod Implanon system. Diagnostic ultrasonography was performed in eight women who had the Implanon rod implanted in the medial aspect of the upper arm. All implants were scanned in the longitudinal and transverse direction using 3.5 MHz, 5 MHz, and 7.5 MHz linear array transducers. Scanning was performed both directly against the skin and with 2 and 4 cm Kiteco ultrasound stand-off pads. Each image obtained was evaluated for detectability of the Implanon rod and the grade of acoustic shadowing produced by the Implanon rod by two independent observers. Discrepancies in evaluation were adjudicated by a third observer. The Implanon rod implant was not directly identified using the transducer and standoff pad combinations. Implanon rods were indirectly identified as a result of the posterior acoustic shadow cast by the Implanon. Best demonstration was achieved with the 5 or 7.5 MHz transducer and a 2 cm stand-off pad in the transverse direction. Appropriate ultrasonographic technique and familiarity with posterior acoustic shadowing patterns generated by the implant provide a noninvasive method for localization of nonpalpable, single rod implants prior to removal.

The role of interventional radiology in the management of intra- and extra-peritoneal leakage in patients who have undergone continent urinary diversion

PURPOSE

To assess how radiologic intervention altered the hospital course of patients undergoing continent urinary diversion.

METHODS

Thirty-seven consecutive patients with bladder cancer invading the muscular layer were treated with total cystectomy and construction of a continent urinary reservoir. Eleven of 37 patients suffered early and late anastomotic leakage; six had prolonged extraperitoneal leakage at the urethroenteric anastomosis, three had prolonged intraperitoneal pouch leaks, and two had delayed ureteroenteric leaks. Seven of these patients required radiologic intervention.

RESULTS

Intervention in the form of drainage catheter manipulation (n = 4), percutaneous nephrostomy (n = 4), or ureteral stent placement (n = 2) resulted in cessation of leakage without surgical intervention in all seven patients. Intraperitoneal pouch leaks were more difficult to control than extraperitoneal leakage and required longer drainage intervals.

CONCLUSION

Interventional radiologic procedures played a key role in the management of continent urinary diversion complications, obviating the need for repeat surgical intervention in all instances.

Use of a snare wire to perform nephrostomy access in the presence of obstructive staghorn calculi

We describe a technique for gaining access to the central collecting system via a chosen calyx, utilizing an alternative entry point to that calyx. An Amplatz nitinol loop snare is then used to convert this access to a traditional approach.

Radiology/pathology conference at Robert Wood Johnson Medical School

A healthy female was noted to have an enlarging mass in the suprasternal fossa. The clinical diagnosis of post-traumatic arteriovenous fistula led to diagnostic arteriography and radiologic evaluation.

Radiology-pathology conference: Robert Wood Johnson Medical School. Eosinophilic granuloma of the lung

Eosinophilic granuloma of the lung is a nodular infiltration of the interstitium of the lung by histiocytes, plasma cells, lymphocytes, and eosinophils. While radiologic findings of nodules and small cystic spaces of the upper lung zones are present, surgical biopsy is required for diagnosis.

Radiology-pathology conference at Robert Wood Johnson Medical School. Benign renal angiomyolipoma

Angiomyolipoma is a benign tumor of the kidney. Conservative management of this tumor requires its differentiation from hypernephroma. This can be accomplished by identification of the fat within the tumor with CT scanning. The authors present a case report.

Radiology/pathology conference at Robert Wood Johnson Medical School. Benign mediastinal teratoma

The authors review the findings for a 15-month-old female after a left thoracotomy was performed. Radiographs demonstrated a large mass involving the majority of the left hemithorax. Pathologic findings yielded a well-encapsulated, red and white, soft tissue mass.

Radiologic diagnosis of cystic fibrosis in adults and children

RATIONALE AND OBJECTIVES

Most radiologists are familiar with the classic chest radiographic findings of cystic fibrosis (CF) when these occur in children. We hypothesized that given the same findings, a diagnosis of CF would be less likely to be considered in an adult than in a child.

METHODS

We compiled 30 pediatric and 28 adult CF chest radiographs and obtained two independent readings on each by different general radiologists among the eight who volunteered to participate as they performed their daily clinical work. The cases were presented to the readers so that they did not know which radiographs were part of the study. The association between the correct diagnosis of CF and whether the patient was an adult or a child was assessed using odds ratios and logistic regression, so that Brasfield score, Schwachman-Kulczycki score, and the patient's sex could also be considered as predictive of correct diagnosis.

RESULTS

In 67% of the pediatric cases, at least one of the radiologists considered CF as a possible diagnosis, whereas they considered CF a possibility in only 50% of the adults. Both radiologists suggested the correct diagnosis in 40% of pediatric cases and only 14% of adult cases (p < .05).

CONCLUSION

Because the radiographic findings were similar in the two groups of patients according to severity groupings, we believe CF was less commonly considered in the adult patient because of the traditional belief that CF is a childhood disease.

Tunneled central venous access catheter placement in the pediatric population: comparison of radiologic and surgical results

PURPOSE

To compare the success and infection rates of radiologic placement with those of surgical placement of tunneled central venous access catheters (TCVACs) in infants and small children.

MATERIALS AND METHODS

In 17 pediatric patients, TCVACs were placed with vascular access under ultrasound or fluoroscopic guidance in the radiology department. In 29 other patients, TCVACs were placed with percutaneous puncture or surgical cutdown in the surgery department.

RESULTS

Two (11%) of 18 attempts at radiologic placement were unsuccessful; six (38%) of the 16 radiologically placed catheters necessitated removal because of dislodgment, malfunction, or infection; six (38%) were electively removed; and four (25%) still function. Eight (23%) of 35 attempts at surgical placement were unsuccessful; 17 (63%) of the 27 surgically placed catheters required removal because of dislodgment, malfunction, or infection; nine (33%) were electively removed; and one (4%) still functions.

CONCLUSION

The success and infection rates of radiologic placement of TCVACs were similar to those of surgical placement. Radiologic placement required fewer attempts and was slightly less expensive.

Peritoneal dialysis catheters: repositioning with new fluoroscopic technique

From April 1990 to December 1992, the authors evaluated a new technique for radiologic manipulation of malfunctioning peritoneal dialysis catheters (PDCs). In 25 patients (16 male and nine female patients, aged 15-81 years), 25 PDCs were fluoroscopically manipulated 38 times for failure to drain (n = 22) or painful dialysis (n = 3). The PDC was backed out of its initial position with use of a wire and stiffener. Immediate success was obtained in 34 of 38 manipulations (89%), 21 manipulations (55%) were successful at 1 week, and durable success (function for more than 1 month or until the catheter was no longer needed) was achieved in 16 manipulations (42%). This is an effective alternative procedure to surgical catheter replacement or hemodialysis.

Elective one-stage abdominal operations after percutaneous catheter drainage of pyogenic liver abscess

During the past 10 years, 15 patients have had percutaneous catheter drainage (PCD) of pyogenic liver abscesses (PLA) at a major teaching hospital. Five PLA were related to biliary tract disease, two were secondary to colonic diverticulitis, two developed after abdominal surgery, and the remaining were associated with hepatic trauma, gastric ulcer, Crohn's ileitis, and colon cancer. Two abscesses were cryptogenic. Mean diameter of PLA was 8 cm and ranged from 2-14 cm. Three patients had multiple PLA. All patients were initially treated by PCD without major complications. However, one patient required a second PCD after developing a recurrent abscess. Fever and leukocytosis defervesced at a mean 3.6 days and 7 days, respectively, after PCD. Seven of the 15 patients subsequently had one-stage elective abdominal operations for treatment of diseases underlying PLA including two cholecystectomies, two colon resections, one gastrectomy, one ileostomy closure, and one laparotomy for unresectable gall bladder cancer. There were no postoperative complications. These results demonstrate that PLA are best treated by using PCD as primary treatment with surgical drainage reserved for patients who do not respond clinically to PCD. The need for operative treatment in diseases underlying PLA should not deter use of PCD as primary treatment.

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.

Percutaneous retrieval of nonvascular foreign bodies

Although intravascular foreign bodies are routinely removed with percutaneous extraction, surgical retrieval is performed of most nonvascular foreign bodies. The authors describe six cases in which percutaneous extraction was performed for removal of nonvascular foreign bodies. These foreign bodies included an intraabdominal laparotomy towel, two pelvic drains, an angiographic guidewire fragment in a pelvic abscess cavity, and a superficially located sewing needle and bullet fragment. Computed tomography or plain radiography was performed to define the safest track for percutaneous removal. Fluoroscopy was performed to direct foreign body removal; the major challenge of the procedure was precise localization of the foreign body to minimize dissection. Although a surgeon and operating suite were available for backup care if necessary, all six foreign bodies were removed successfully without complication by the interventional radiologist in the radiology suite. Percutaneous retrieval of nonvascular foreign bodies, while not frequently performed, can in many cases obviate surgical incisions, extensive dissection, and the cost and risk of administration of general anesthesia.

Over-the-wire placement of large bore thoracostomy tubes

A simple method is described for placement of large caliber thoracostomy tubes utilizing an over-the-wire (Seldinger) technique. The method employs an angioplasty balloon catheter on which a renal fascial dilator and sheath are mounted. Through the sheath a large caliber thoracostomy tube is placed into the pleural space.

Bilateral adrenal hemorrhage after an open heart operation

Bilateral adrenal hemorrhage and acute adrenal insufficiency were diagnosed after coronary bypass grafting in a 65-year-old man. The symptoms were nonspecific and easily mistaken for other postoperative complications. Diagnosis was based on finding of adrenal hemorrhage on computed tomogram and confirmed biochemically with an adrenal stimulation test. Corticosteroid therapy was curative.

Value of clinical screening for detection of asymptomatic hemodialysis vascular access stenoses

Measurement of recirculation and intradialytic venous line pressures may aid in the detection of hemodialysis vascular access stenoses. The authors screened 29 consecutive asymptomatic patients for recirculation values exceeding 15% or venous pressures greater than 150 mmHg. All 13 patients requiring and agreeing to angiography on the basis of the screening protocol proved to have high-grade stenoses of their vascular access outflow or inflow. Asymptomatic vascular access pathology is common. High-risk asymptomatic populations may be detected by simple screening procedures.

Bronchiectasis in children with lymphocytic interstitial pneumonia and acquired immune deficiency syndrome. Plain film and CT observations

In a review of 77 HIV positive children seen between 1981 and 1990, 32 were diagnosed as having lymphocytic interstitial pneumonitis). Four of the LIP group developed bronchiectasis, a finding not previously reported. The precise factors leading to the bronchiectasis are unclear. All patients had chronically consolidated lung with volume loss. A history of recurrent bacterial superinfection was not noted in any of the cases. With more cases of HIV positive children living longer, bronchiectasis, long known to occur in primary immunologic disorders, will probably be more frequently noted.

Limitations of percutaneous catheter drainage of abdominal abscesses

During the past eight years, 119 patients with abdominal abscesses underwent percutaneous catheter drainage (PCD), including 76 who had successful treatment by the initial PCD, 19 who had recurrent abscesses after removal of drainage catheters and 24 who were outright failures and either died of sepsis or required surgical drainage. This study was designed to identify outcome variables that might be used prospectively to assess the therapeutic efficacy of PCD. Outcome variables included abscess size, daily drainage volume and location, presence of a gastrointestinal fistula, age, bacteriologic factors and response of the pulse rate, body temperature and leukocyte count of the patient to PCD. Ninety of 119 patients (76 per cent) ultimately had successful drainage of abscesses by PCD alone. The over-all mortality rate was 16 per cent (19 of 119), with a 75 per cent mortality rate in the failure group. Neither abscess size, bacteriologic findings nor pulse rate correlated with outcome. PCD failure was significantly greater in patients greater than or equal to 60 years (p less than or equal to 0.01) and in patients with pancreatic abscesses versus other locations (p less than or equal to 0.04). Drainage volume was significantly greater in PCD failures than among PCD successes at greater than or equal to 3 days after PCD (p less than or equal to 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Radiologic distinction of pyogenic pulmonary infection from Pneumocystis carinii pneumonia in AIDS patients

Thirty-four episodes of pyogenic pulmonary infection in 30 patients infected with human immunodeficiency virus (HIV) and 30 episodes of Pneumocystis carinii pneumonia (PCP) in 30 AIDS patients were reviewed to determine if the radiologic features were more helpful than clinical and laboratory findings in the differential diagnosis. The radiologic features of pyogenic pulmonary infection included lobar consolidation, nodules, infiltrates with pleural effusions, round infiltrates, and pleural effusions alone. These features are uncommon in PCP. The chest radiograph may be highly suggestive of a pyogenic process, especially when it shows local consolidation or nodules. Since bacterial pneumonias have a more favorable outcome, it is concluded that the radiologic features should be the primary guide to prompt diagnosis and treatment.

Antibiotic bonded nephrostomy catheters for percutaneous nephrostomies

A prospective controlled trial of the effectiveness of a cefoxitin-bonded nephrostomy catheter was undertaken to determine the effectiveness of an antibiotic bonded catheter in decreasing the infectious complications of percutaneous nephrostomy. The study concludes that bonding of the antibiotic cefoxitin to percutaneous nephrostomy catheters did not influence the incidence of bacteriuria or urinary tract infection. In addition, observations on the overall incidence of complications from percutaneous nephrostomy are made.

The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs

Portable resuscitation-area cervical-spine radiographs (PCS) frequently constitute a routine part of the emergency evaluation of patients suffering from blunt trauma. Their adequacy and cost were evaluated by reviewing the records of 92 consecutive trauma patients. Forty-seven of 74 patients (63.5%) had adequate PCS in that all seven cervical vertebrae were visualized. In 27 patients (36.5), all seven cervical vertebrae were not adequately visualized. Inadequate studies were most likely to occur in patients with abnormal vital signs on admission (56%) (P less than .01) and in those subsequently requiring general anesthesia (34.5%). Fifteen patients were intubated without difficulty by maintaining neck immobilization because of uncertainty regarding cervical-spine injuries. The annual cost of inadequate cervical-spine studies was estimated to be $31,000.00. Although the four cervical-spine injuries were diagnosed by the portable technique, routine PCS were frequently inadequate in visualizing all seven cervical vertebrae. Major decisions concerning intubation and surgery frequently had to be made before adequate radiographic evaluation could be completed. It is suggested that time and money are lost by routinely doing a single lateral portable cervical radiograph. It is more appropriate to obtain complete radiographic studies after life-threatening injuries are addressed while patients are treated using the standard techniques of neck immobilization.

Percutaneous catheter drainage of abdominal abscesses associated with perforated viscus

Improvements in radiologic localization have made percutaneous catheter drainage (PCD) the initial procedure of choice for many intra-abdominal abscesses (IAA). During the past seven years 154 patients underwent PCD for treatment of abdominal abscesses. Fourteen of these patients had PCD as the initial treatment for IAA secondary to a perforated viscus and subsequently underwent an elective one-stage operation to treat the underlying disease. Etiologies of the abscesses included perforated appendicitis in six patients, sigmoid diverticulitis in three patients, Crohn's ileitis in two patients, and one case each of perforated gastric ulcer, perforated sigmoid carcinoma, and perforated gallbladder. Initial localization of the abscess was achieved by either CT or ultrasound. Seven abscesses were localized in the right lower quadrant, four were localized in the liver, and one was localized each in the left flank, right flank, subhepatic space, and pelvis. All patients subsequently underwent a definitive elective operation for their primary disease including six interval appendectomies, four sigmoid colectomies, two small-bowel resections, one subtotal gastrectomy and one cholecystectomy. There were no complications due to PCD and no deaths occurred. We conclude that PCD can be successfully performed as the initial treatment for IAA associated with a perforated viscus, obviating the first stage of the traditional two-stage surgical approach.

Use of gastrointestinal contrast studies in obstruction of the small and large bowel

Gastrointestinal contrast studies were performed in 96 (27 percent) of 342 patients with small-bowel obstruction including 57 upper gastrointestinal and 39 barium-enema examinations. In 34 patients, upper gastrointestinal examination disclosed either obstruction or failure of contrast to reach the cecum in 24 hours; all 34 patients required surgery. The remaining 23 patients who had upper gastrointestinal studies recovered with tube decompression. Barium enema demonstrated obstruction in 13 (33 percent) of 39 cases of suspected small-bowel obstruction and localized obstruction in the colon rather than small bowel in 9 of 13 cases. Barium enema was 100 percent predictive of surgery when obstruction was shown, but was not helpful in predicting surgery when obstruction was not demonstrated. Surgery was required in 42 percent of patients whose barium enema did not show obstruction. Barium enema also was performed in 19 of 23 patients with large-bowel obstruction and showed the level of obstruction in all cases. All patients with large-bowel obstruction required surgery except for three who recovered after barium-enema reduction of intussusception or volvulus. Barium upper gastrointestinal examination is recommended in small-bowel obstruction when plain films are nondiagnostic, and in selected cases of small-bowel obstruction that do not resolve with a short trial of tube decompression. Barium enema is not recommended in suspected small-bowel obstruction but should be performed in all cases of large-bowel obstruction, except when perforation is a possibility or when the cecum measures 10 cm or larger in diameter.

Catheter occlusion of a mycotic renal artery aneurysm with cure of associated renovascular hypertension

We describe successful transcatheter occlusion of a mycotic renal artery aneurysm. The patient's hypertension resolved following occlusion of the aneurysm and infarction of the renal parenchyma in the distribution of the aneurysmal vessel.

Percutaneous catheter drainage of abscesses associated with enteric fistulae

In the past six years, percutaneous catheter drainage (PCD) has been performed in the treatment of 99 patients with abdominal and retroperitoneal abscesses. Of these 99 patients, 15 had abscesses associated with an enteric fistula. Fistula sites included small bowel (five), colon (three), complex (three), duodenum (two) and one each for the stomach and common duct. Two of these 15 patients had an initially successful PCD, ten developed recurrent abscesses after the first PCD and the procedure failed in the remaining three patients. Of the ten patients with recurrent abscesses, eight were successfully treated by a second PCD while two required small-bowel resection. Of the three failures, all three required operation and eventually died of septic complications. The diagnosis of fistula was made at the initial PCD in only six of 15 cases. There was a significant correlation between PCD failure and presence of an enteric fistula (P less than 0.001 by chi-square test). These data suggest that the diagnosis of fistula associated with abdominal abscess is elusive, but once established, most recurrent abscesses can be successfully treated by a second PCD. Operative treatment of recurrent fistula-related abscesses should be reserved for persistent fistula drainage after a second PCD or for unresolved sepsis following the initial PCD.

Acute focal bacterial nephritis

Clinical and radiographic characteristics of 12 patients with acute focal bacterial nephritis (AFBN) are presented along with review of the literature. Most patients presented with symptoms of an inflammatory or infectious process. Fever and pyuria were the most frequently encountered clinical characteristics. Imaging modalities that were used to establish a definitive diagnosis of focal bacterial nephritis included ultrasound, computed tomography, and intravenous urography with nephrotomography. Ultrasound was found to be the most effective and least costly method of diagnosis. Misdiagnosis of AFBN as abscess or tumor, which it may stimulate, could lead to inappropriate surgical therapy.

Combined hepatic and gastric artery aneurysms: a case report and review of the literature

A patient is presented who was successfully managed with metasynchronous rupture of a hepatic and a left gastric artery aneurysm. The subject of visceral artery, hepatic artery, and gastric artery aneurysms is reviewed. The role and limitations of modern interventional radiologic procedures in treating this entity is illustrated.

Transvaginal pelvic abscess drainage with US guidance

Transvaginal catheter drainage of pelvic and intraabdominal abscesses with the use of real-time ultrasound guidance is described. The technique was successfully used in two patients to drain abscesses in the cul-de-sac. Transvaginal drainage is a safe, simple alternative to transabdominal, transgluteal, and transrectal drainage of these abscesses.

Occlusion of a hepatic arterial aneurysm with gianturco coils in a patient with the Ehlers-Danlos syndrome

Successful transcatheter occlusion of a proper hepatic arterial aneurysm in a patient with type IV Ehlers-Danlos syndrome is reported. This patient also had multiple, small intrahepatic arterial aneurysms, stenosis, and vascular occlusions. A spontaneous colonic perforation brought this patient to medical attention.

Salmonella mediastinitis--a rare disease

A case report is presented of a young man who was seen because of pleuritic chest pain and fever. CT cross sectional imaging defined a mediastinal mass. Diagnosis of acute mediastinitis due to Salmonella java was made from culturing material at mediastonotomy.

Percutaneous catheter versus open surgical drainage in the treatment of abdominal abscesses

In the past 3 years, percutaneous catheter drainage (PCD) was performed for 24 abdominal and retroperitoneal abscesses while open surgical drainage (OSD) was used for treatment of 24 similar abscesses at the affiliated hospitals of UMDNJ-Rutgers Medical School. Although the method of treatment was arbitrarily selected by the attending physician, the two groups were similar with respect to abscess location, underlying illnesses, and previous operations. In the PCD group, 17 of 24 abscesses developed after operations versus 16 of 24 in the OSD group. Location of abscesses were: PCD group: abdominal (9), renal (5), pelvic (4), subphrenic (3), hepatic (2), pancreatic (1); OSD group: abdominal (10), renal (4), subphrenic (4), pelvic (3), hepatic (2), pancreatic (1). With PCD, the abscesses were localized by ultrasound or computerized tomography scan; a 20- or 22-gauge needle passed into the cavity, followed by progressively larger guide wires, dilators, and catheters; the pus evacuated; and abscess cavity thoroughly irrigated with sterile saline. Percutaneous catheter drainage was successful in 22 of 24 cases. There were two inconsequential complications. The mean post-PCD hospital stay was 11.7 days. With OSD, five patients developed major complications, including three deaths from sepsis. The mean post-OSD stay for surviving patients was 21.2 days. The advantages of PCD versus OSD are: 1) precise noninvasive localization of abscesses, 2) avoidance of general anesthesia, 3) avoidance of major complications, and 4) shorter postdrainage hospital stay. Open surgical drainage should be reserved for cases where PCD fails to control sepsis, close fistulae, or when noninvasive scanning either fails to demonstrate a discrete abscess in the face of intra-abdominal sepsis or identifies an abscess that cannot be percutaneously drained without traversing the bowel.

The initial experience with the use of a portable infusion pump in the delivery of human menopausal gonadotropins

The initial experience with the use of a portable infusion pump for the delivery of human menopausal gonadotropins (hMG) in the therapy of ovulation dysfunction of women who failed to conceive following (1) either clomiphene citrate (five patients with polycystic ovary syndrome) or danazol (three patients with mild endometriosis) and (2) standard intramuscular hMG-human chorionic gonadotropin therapy is reported. In six of these patients this approach was used because of suboptimal response of serum estradiol levels to standard hMG therapy, and all six patients had an increase in estradiol response with infusion therapy; therapy duration and total dosage of hMG were similar in both treatment modalities. Sonography suggested stimulation of several follicles with infusion therapy. Advantages and disadvantages of the use of the infusion pump for hMG therapy are discussed. In conclusion, hMG therapy via the infusion pump is feasible. This mode of administration appears to lead to more satisfactory follicular development in selected patients. Multiple follicular stimulation is to be expected. Self-administration of medication is readily achieved by the educated patient. Further consideration and exploration of hMG infusion therapy is suggested.