Four hundred fifty-three consecutive pancreaticoduodenectomies with pancreaticogastrostomy

BACKGROUND

Patients who undergo pancreaticoduodenectomy (PD) have the pancreatic remnant (PR) anastomosed to the jejunum. In this study, all patients had the PR anastomosed to the stomach. Our aims are to evaluate postoperative outcomes of patients undergoing PD with pancreaticogastrostomy (PG).

METHODS

There was 453 patients who underwent PD with PG. Preoperative characteristics, intraoperative data, and postoperative outcomes were analyzed using univariate and multivariate models.

RESULTS

The patient cohort had a median age of 67 years and underwent resection for pancreatic (40.8%), ampullary (15.9%), duodenal (6.6%), distal bile duct (6.4%) cancers. Multivariate analysis revealed poor prognosis was related to age, tumor diameter, lymph node ratio, perineural invasion, and tumor differentiation in patients with periampullary adenocarcinoma.

CONCLUSIONS

This series of patients undergoing PD with PG shows that the operation can be performed safely with excellent outcomes for a variety of malignant and benign conditions.

Embolization of a traumatic uterine arteriovenous malformation

Uterine arteriovenous malformation (AVM) is a rare but potentially life-threatening source of bleeding. A high index of suspicion and accurate diagnosis of the condition in a timely manor are essential because instrumentation that is often used for other sources of uterine bleeding can lead to massive hemorrhage. Although angiography remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the modalities of choice for the evaluation of a suspected AVM. US and MRI cannot only accurately define a uterine AVM, but they also have the ability to assess the extent of pelvic involvement noninvasively. The definitive treatment of uterine AVM is hysterectomy. However, most women diagnosed with the condition are of childbearing age. Transcatheter uterine artery embolization offers a safe and effective alternative to surgery, with the major advantage of retaining childbearing capacity.

Treatment of hemodialysis graft pseudoaneurysms with stent grafts: institutional experience and review of the literature

Hemodialysis access grafts are an important component of the treatment of patients with renal failure. Because access sites are limited, maximizing graft lifespan is of major importance to dialysis patients. Pseudoaneurysm formation is a rare, but important complication potentially limiting the longevity of dialysis grafts. With rapidly advancing technology, placement of stent grafts in patients with end-stage renal disease is an important step in prolonging the life of the graft. We conducted a review of the literature regarding stent-graft use for hemodialysis access. In addition, we looked at our experience utilizing the Viabahn(®) (W. L. Gore & Associates, Newark, DE) stent graft in pseudoaneurysm repair. Our patients achieved primary patency of their grafts for 1, 5, and 9 months, respectively. No complications related to stent-graft implementation have been encountered in six stent-graft implants over the course of 29 months.

Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment

Pulmonary artery pseudoaneurysms (PAPs) are uncommon but associated with high mortality. Left untreated, lesions can enlarge, rupture, and lead to exsanguination and death. Presentations range from life-threatening hemorrhage to silent lesions that enlarge for days, months, or years. Because abnormalities on imaging studies can lead to early diagnosis and treatment and embolization is the treatment of choice, the radiologist can contribute to both timely diagnosis and treatment of PAPs. Pseudoaneurysms due to penetrating trauma, blunt trauma, bacterial endocarditis, and complications related to pulmonary artery catheters and right heart catheterization are presented. Three were treated by embolization.

Saline Mobilization of the Colon during Percutaneous Renal Cryoablation

A 62-year-old woman with a history of multiple abdominal surgeries underwent computed tomography-guided percutaneous renal cryoablation for a 1.5-cm enhancing left renal mass. We describe the technique of salinoma formation to displace the colon away from the tumor to avoid colonic injury during cryoablation.

Chronic Mesenteric Ischemia Resulting from Isolated Lesions of the Superior Mesenteric Artery

Atherosclerosis is a common cause of chronic mesenteric ischemia, generally affecting 2 or more arterial branches supplying the gut. The authors present a case in which symptomatic mesenteric ischemia was the result of 2 tandem atherosclerotic lesions in the superior mesenteric artery. Both the celiac axis and inferior mesenteric arteries were fully patent. The patient experienced complete relief of symptoms after percutaneous deployment of an intravascular stent across the proximal arterial narrowing. The case also documents the existence of an atheroma in a distal mesenteric artery.

Post-transplant IVC occlusion and thrombosis treated with tPA, heparin, and sharp recanalization

Complete inferior vena cava (IVC) thrombosis can be a lethal complication in a liver transplant recipient. The case of a 52-year-old liver transplant recipient, who developed complete IVC as well as left iliofemoral thrombosis, is reported. After treatment with combined tissue plasminogen activator (tPA) and heparin, the IVC was successfully recanalized with sharp dissection, balloon dilatation, and stent placement.

Simultaneous transjugular renal biopsy and hemodialysis catheter placement in patients with ARF

BACKGROUND

Previous studies have evaluated transjugular renal biopsy in patients with contraindications to percutaneous renal biopsy or those undergoing simultaneous renal and hepatic biopsies. We sought to evaluate transjugular renal biopsy in patients with acute renal failure (ARF) or ARF in the presence of chronic renal insufficiency (CRI) who required venous catheter placement for hemodialysis (HD).

METHODS

Ten consecutive patients (6 patients, ARF; 4 patients, ARF on CRI) at a single tertiary-care medical center, while undergoing placement of HD access through the internal jugular route, also underwent transjugular renal biopsy using the Quick-Core (Cook, Bloomington, IN) system to delineate the cause of ARF. Transjugular renal biopsy was performed because it was the opinion of the attending nephrologist that a histological diagnosis might alter management.

RESULTS

Renal biopsy findings were diabetic nephropathy (3 patients), acute tubular necrosis (ATN; 2 patients), nephrosclerosis (2 patients), immunoglobulin A nephropathy (1 patient), lupus nephritis with focal crescents and ATN (1 patient), and pauci-immune necrotizing glomerulonephritis (1 patient). There were no major complications from the procedures. Among the 6 patients with ARF, management was directly affected in 3 patients (either initiation of appropriate immunosuppressive therapy or withholding of such therapy). In the remaining 3 patients with ARF and in patients with ARF on CRI, performing transjugular renal biopsy at the time of HD access placement obviated additional testing and/or unnecessary therapy. Four patients recovered renal function and HD therapy was discontinued, 2 patients died, and 1 patient was lost to follow-up.

CONCLUSION

Simultaneous transjugular renal biopsy/HD catheter placement should be considered in patients with ARF requiring HD therapy for whom knowledge of the renal histological diagnosis may alter patient management.

Pelvic lymphocele following motor vehicle collision

The development of lymphocele has been described in the mediastinum following thoracic duct injury from blunt trauma or surgery, in lower extremity surgery or trauma, and in the pelvis following renal transplant or staging lymphadenectomy. We describe a case of pelvic lymphocele following blunt trauma from a motor vehicle collision in which the patient did not sustain any fractures. The patient subsequently experienced right lower extremity pain and swelling thought to result from a deep venous thrombosis. Venogram demonstrated external compression of the right iliac vein, and computed tomography revealed a pelvic fluid collection. The patient underwent successful pigtail catheter placement under ultrasound guidance, and his symptoms resolved completely following 4 weeks of external drainage. A brief review of the diagnosis and management of lymphocele follows.

Hepatic rupture caused by peliosis hepatis

Peliosis hepatis is a rare entity that can affect children and cause fatal hepatic hemorrhage or hepatic failure. Radiographic findings are nonspecific and can resemble other hepatic pathologies such as cysts, abscesses, metastases, and hemangiomatosis. Peliosis hepatis can resolve spontaneously or by withdrawal of inciting medications. Certain cases may require surgical resection of the involved portions of the liver. Recently, fatal liver hemorrhage was reported in 2 pediatric patients with a rare congenital muscle disorder known as myotubular (centronuclear) myopathy. One of these patients was found at autopsy to have peliosis hepatis. The authors report the first successful treatment of life-threatening liver hemorrhage caused by peliosis hepatis in a child with myotubular myopathy. Awareness of this condition may reduce the catastrophic complications seen with peliosis hepatis.

Transjugular renal biopsy in patients with liver disease

Although transjugular renal biopsy has been used extensively in Europe, experience with its use in the United States has been limited. We report 25 patients who underwent both transjugular liver and renal biopsies in the same sitting and 4 patients who underwent only a transjugular renal biopsy. All 29 patients had both liver disease and renal abnormalities. Each patient was also believed to have a relative or absolute contraindication to a percutaneous renal biopsy (usually in the form of a bleeding abnormality). Transjugular renal biopsy yielded a quantity of tissue sufficient for diagnosis in all but 1 patient. The mean number of glomeruli obtained per biopsy was 19.4 +/- 12.2 (SD). Pathological diagnoses found were tubular injury in 5 patients, membranoproliferative glomerulonephritis in 5 patients, nephrosclerosis in 3 patients, diabetic nephropathy in 2 patients, immunoglobulin A (IgA) nephropathy in 2 patients, minimal change disease in 2 patients, end-stage renal disease in 2 patients, nonspecific changes in 1 patient, early glomerulosclerosis in 1 patient, tubular atrophy only in 1 patient, and normal renal histological characteristics in 4 patients. One patient with suspected IgA nephropathy had no histological diagnosis established because of a lack of glomeruli in the biopsy specimen. There were no instances of major bleeding from the perirenal area; however, a small perirenal hematoma was identified in 3 patients by postbiopsy computed tomography or sonography. Thus, based on our experience, transjugular renal biopsy appears to be a safe and effective procedure for establishing a histological diagnosis and is an attractive alternative biopsy method for patients with advanced liver disease and contraindications to conventional percutaneous renal biopsy.

Traumatic pseudoaneurysm of the brachial artery

Detection and treatment of vascular injuries in extremity and pelvic trauma can be challenging. Angiography, while no longer routinely used in asymptomatic patients, is still a primary means of diagnosis. Appropriate patient selection based on physical examination, along with other less invasive imaging modalities, can decrease the need for angiography while still detecting the vast majority of clinically significant injuries. Angiography also plays a definitive therapeutic role in most cases of significant hemorrhage in the pelvis through precise identification and selective embolization of bleeding vessels.

Successful nonoperative management of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy

BACKGROUND/AIMS

To report the management of a hepatic artery pseudoaneurysm presenting 35 days following a Whipple procedure.

METHODS

The case study of a patient with a bleeding pseudoaneurysm is presented.

RESULTS

Computed tomography demonstrated a pseudoaneurysm which was successfully embolized.

CONCLUSIONS

Acute gastrointestinal bleeding from a pseudoaneurysm in the hepatic artery following Whipple procedure can be successfully managed with transcatheter embolization.

Splenosis as a cause of testicular pain: laparoscopic management

This is a case report of a 37-year-old man with severe testicular pain unresolved after conventional investigative and therapeutic methods. On the basis of his history of abdominal trauma followed by emergency splenectomy and evidence of functioning splenic tissue on a radionuclide scan, the diagnosis of splenosis was established. Laparoscopic exploration was done, and the initial diagnosis confirmed. Splenic tissue located at the right inguinal ring was removed. Testicular pain abated after the procedure.

Penile arteriography

Vasculogenic impotence can be due to multiple different causes, many of which can be diagnosed by noninvasive studies. Once an arterial etiology for impotence is suspected, penile arteriography may be necessary to define arterial pathology and to plan potential surgical intervention. The quality of arterial imaging is highly dependent on attention to the technical aspects of the examination, which include a thorough understanding of the arterial anatomy of the pelvis. In addition, patient preparation, arterial catheterization techniques, and pharmacological adjuncts can be helpful to improve image quality. The technique of image acquisition also can affect the quality of the images obtained. This article discusses the technical issues involved in penile arteriography.

Limb-threatening lower extremity ischemia successfully treated with intra-arterial infusion--case reports

The authors present two patients with acute arterial vasospasm of the lower extremities causing marked ischemia. One patient had a history of Raynaud's disease, the second had been taking Cafergot for migraine headaches. Both patients's were given a test dose of intra-arterial tolazoline (50 mg). The patient with Raynaud's disease demonstrated marked improvement diffusely and was successfully treated with overnight infusion of papaverine. The second patient, taking Cafergot, demonstrated no angiographic response to tolazoline. It was speculated that the arteries of this patient were thrombosed. The patient was successfully treated with urokinase and remained free of pain at the 15-month follow-up.

Gastrostomy button placement through percutaneous gastrostomy tracts created with fluoroscopic guidance: experience in 27 children

PURPOSE

The authors report their experience with skin level (button) gastrostomy placement through radiologically created gastrostomy tracts.

PATIENTS AND METHODS

Fifty-two gastrostomy buttons have been placed in 27 children (average age, 73 months; range, 9-235 months). All buttons were placed through tracts created during earlier fluoroscopically guided percutaneous gastrostomy. Fifteen Bard mushroom-type buttons and 12 MIC-Key balloon-type buttons were initially placed. Patients have been followed up for an average of 13.4 months.

RESULTS

Button placement was successful at the initial attempt in 25 of 27 patients (93%). Tract age at button placement averaged 18.5 weeks. The average tract length measured 3.5 cm (1.7-6.0 cm). Tract rupture and peritoneal leakage occurred in three patients; one patient had the button immediately repositioned without sequela, and the remaining two patients underwent replacement of the gastrostomy tube into the stomach and successful button placement approximately 1 week later. There were no major complications. Minor problems (leak, granulation tissue, valve malfunction, balloon breakage) occurred in 19 patients.

CONCLUSION

Button gastrostomy is a useful alternative to the traditional gastrostomy tube for the pediatric population. Conversion with use of existing radiologically created tracts is possible and safe. Attention to tract integrity and proper button position is required to avoid complications.

Amyloidosis: CT appearance of calcified, enlarged periaortic lymph nodes

The radiographic demonstration of lymph node involvement in amyloidosis is rare. We report a case of calcified, enlarged perioartic and mediastinal lymph nodes detected by CT.

Decompression of acute urinary tract obstruction by extravasation into a large simple renal cyst

We report a case of pelvocaliceal decompression by extravasation into a preexisting simple renal cyst. This is a rare complication of acute urinary obstruction. The findings and the prognostic implications are discussed.