The role of interventional radiology for complications of cholecystectomy.

This report summarizes diagnostic and therapeutic radiologic procedures in 45 patients who suffered major complications from cholecystectomy. Complications were divided into (1) bile duct injury or ligation and (2) a variety of pathologic fluid collections. Specific lesions were bile duct injury (n = 6), accidental bile duct ligation (n = 12), ductal stricture (n = 12), abscess (n = 11), biloma (n = 7), hematoma (n = 5), infected pancreatic pseudocyst (n = 3), and stones (n = 2). Presenting problems were sepsis, jaundice, and intermittent cholangitis. The patients underwent 104 interventional radiologic procedures including 29 percutaneous transhepatic cholangiograms, 21 percutaneous biliary drainages, 12 balloon dilatations of strictures, drainage of 11 abscesses, 8 bilomas, 5 hematomas, and 3 pancreatic pseudocysts. Stones were removed by baskets in 2 patients; 12 pressure and perfusion studies were performed. One hundred of 104 procedures were successful; there was one failed biliary drainage, one unsuccessful stricture dilatation, one unsuccessful hematoma drainage, and one recurrent biloma. Thirty patients were spared another operation. The percutaneous procedures were beneficial although not curative in 14 of 15 patients who underwent reoperation; in those patients the procedures helped to establish a diagnosis, improve the patient's preoperative status, or serve as a landmark for the surgeon to locate and repair the ligated or injured duct. One patient died after reoperation, a 2.2% mortality rate. Sectional imaging studies combined with interventional radiologic procedures help to diagnose promptly and effectively treat major complications of cholecystectomy. These interventional procedures either cure the complication and obviate reoperation or aid the surgeon by relieving sepsis and jaundice before reoperation and providing an intraoperative guide for bile duct reconstruction.

Hemoptysis secondary to pulmonary pseudoaneurysm 30 years after a gunshot wound.

A 49-year-old man presented with intermittent hemoptysis from a traumatic pulmonary artery pseudoaneurysm 30 years following a thoracic gunshot wound. The patient was asymptomatic for 28.5 years, when he began experiencing recurrent hemoptysis, chest pain, and a cough. A left lower lobe mass on chest x-ray film was investigated with contrast-enhanced computed tomography and pulmonary angiogram confirming a 1.5-cm pseudoaneurysm. Intraluminal coil embolization was attempted, but a left lower lobectomy was ultimately necessary to treat persistent hemoptysis.

Airway simulation to guide stent placement for tracheobronchial obstruction in lung cancer.

BACKGROUND: To effectively palliate large airway obstruction in advanced unresectable lung cancer (stage IIIB or IV), we developed an airway imaging technique to guide selective endobronchial metallic stent placement. METHODS: Fourteen consecutive patients with severe dyspnea (American Thoracic Society grade 4) had a combination of fiberoptic bronchoscopy, chest roentgenography, computed tomographic scanning, helical computed tomography with three-dimensional reconstruction, and intraluminal bronchography with selective bronchial guidewire placement under fluoroscopy to visually reconstruct and simulate the abnormal airway before and during stent placement. Wallstent or Gianturco intraluminal stents were used alone or in combination (up to five stents) to establish patency of the distal trachea and the major bronchi. RESULTS: All 14 patients had successful deployment with initial relief of airway stenosis (>75% predicted diameter). No procedural complications were noted. However, technical problems included stent foreshortening and imprecision of placement, misinterpretation of bronchography (mucous versus tumor), and airway maintenance during manipulation. Length of stay attributable to the procedure averaged 4 days. Stent placement initially improved the dyspnea score in 7 of 14 patients. Five of 14 died in less than 1 month, with the remainder alive at up to 8 months' follow-up. Of those surviving more than 1 month, the Karnofsky score improved in 4 and was unchanged in 5, with 2 dependent (Karnofsky score <50), 3 functional (Karnofsky score, 50 to 70), and 4 active (Karnofsky score >70). CONCLUSIONS: A protocol combining helical computed tomography with three-dimensional reconstruction, bronchography, and bronchoscopy allows accurate assessment of malignant airway obstruction to facilitate intralumenal stent placement for relief of stenosis. Patient selection to favor effective palliation and cost effectiveness has yet to be defined.

Ultrasonography of the salivary glands.

Sonography and computed tomography play complementary roles in imaging mass lesions in the salivary glands and their surroundings. Ninety per cent of parotid tumors originate from the superficial lobe, and we consider sonography to be the method of choice for imaging these lesions. The sensitivity of high-resolution sonography in detecting intraparotid tumors approaches 100 per cent, and ultrasound is therefore an excellent method to evaluate patients with parotid swelling. It may provide clinically useful information by precisely outlining the tumor borders or by detecting multiple or bilateral lesions. We restrict our use of CT to tumors that appear to extend beyond the borders of the parotid gland with possible invasion of surrounding soft tissues or bone. CT is also the method of choice for differentiating lesions of the deep lobe from parapharyngeal tumors and for staging carcinomas. Although ultrasound supplemented with computed tomography should replace conventional sialography in the work-up of parotid neoplasms, sialography remains the method of choice for evaluating patients with chronic sialadenitis, autoimmune diseases, and sialolithiasis. The role of sonography in these conditions is limited to ruling out a parotid neoplasm, assessing the extent of abscess formation, or assisting in localizing calculi in selected patients.

Imaging and interventional radiology for pancreatitis and its complications.

Complications of pancreatitis are common, protean in their manifestations, and can be catastrophic. When complications occur, the morbidity and mortality are high. Expeditious radiologic detection of the complication, together with the plethora of nonoperative interventional techniques, offers new and improved methods for diagnosis and treatment. This article focuses on the essential role of radiology and the natural integration of imaging and interventional radiology for pancreatitis and its complications.

Interventional ultrasound in the musculoskeletal system.

This article highlights the multiple applications of ultrasound as a guidance modality for interventional procedures in the musculoskeletal system. The percutaneous aspiration, drainage, and biopsy of musculoskeletal abscesses, masses, and focal muscular pathology in the extremities, trunk, and neck using ultrasound as the guidance system is described. Techniques for biopsy, fluid aspiration, catheter insertion, and needle visualization by ultrasound are discussed.

Acute renal failure in children. An ultrasonographic-clinical study.

Acute renal failure (ARF) may be due to obstructive uropathy or renal parenchymal disease. Twenty-five children with acute renal failure secondary to renal parenchymal disease underwent ultrasonographic examination of the kidneys. Changes of renal size and cortical echogenicity were correlated with renal function. All patients presented with bilaterally enlarged kidneys with the exception of those in the neonatal age group (12%). Improvement in renal function resulted in normalization of renal size. With regard to cortical echogenicity two groups were formed. Group A comprised 11 patients whose kidneys had the same echogenicity as the liver, while in group B the kidneys were more echogenic (14 patients). Cortical echogenicity was always increased. Determination of creatinine levels showed a statistically significant difference between group A (3.32 mg% +/- 1.40 S.D.) and group B (5.95 mg% +/- 1.96 S.D.), p less than 0.001. Changes in renal function were paralleled by rapid changes in renal size and cortical echogenicity.

Computed tomography of peripancreatic fat planes.

Obliteration of peripancreatic fat planes usually is considered an indicator of peripancreatic tumour infiltration in the presence of a malignant mass, or of inflammation of peripancreatic tissues in patients with pancreatitis. However, absence of peripancreatic fat planes also may be found in patients without evidence of pancreatic disease. Hence, CT scans of 125 patients without clinical or computed tomographic evidence of pancreatic disease were evaluated to assess normal variations in the anatomy of the pancreas and its relation to surrounding vessels and bowel loops. The fat plane separating the superior mesenteric artery from the pancreas was preserved in 100% of patients. Conversely, fat planes between the pancreas and the superior mesenteric vein, inferior vena cava, and adjacent bowel loops were partially or totally obliterated in 13% to 50% of patients. It is concluded that the absence of fat around the superior mesenteric artery is highly suggestive of pathologic changes of the pancreas, while the lack of fat planes between the pancreas and other splanchnic vessels or bowel loops frequently is normal, and therefore, is an unreliable sign of pancreatic disease. The applications of these findings to the assessment of tumour resectability by CT, and to CT scanning techniques, are discussed.

Sonography of gallstones and biliary dilatation without a visible aetiology: the infrequency of obstructing choledocholithiasis.

This paper describes 50 consecutive patients who sonographically had gallbladder stones and dilated bile ducts, but no visible aetiology for the dilatation. We reviewed these cases to determine the frequency of choledocholithiasis in this setting. Common duct stones caused obstruction in only 36% of these patients. Other aetiologies included strictures due to chronic pancreatitis or prior stone passage in 24% of the patients, and malignant obstruction in 16%. In 24% of the patients, no cause was found for biliary dilatation; common duct stones or obstructing tumours were excluded in the group. Since aetiologies other than stones are likely in a majority of cases, further preoperative workup (CT, percutaneous transhepatic cholangiography, ERCP) or intraoperative cholangiography (if the patient requires urgent cholecystectomy) is indicated. The additional studies should provide a diagnosis, help determine whether or not the common duct should be explored, or avoid unnecessary operation in case of incurable malignancy.

[Quality criteria in pancreatic sonography ]. / Qualitätskriterien der Pankreassonographie.

The quality of pancreatic sonography is determined not only by the technical equipment used and by the experience of the interpreter but also by the variable anatomical and nutritional status of the patients examined. The sonograms obtained from 211 consecutively examined patients were analyzed with regard to the quality of pancreatic imaging. Direct visualization of the parenchyma of the pancreatic head and body was found in 47%. In an additional 36%, unequivocal localization of the pancreatic area was possible by delineating the peripancreatic vessels. 17% of the studies were non-diagnostic due to over-lying intestinal gas in obese patients and cases of extensive scarring. This percentage can be reduced by a modified examination technique. The use of alternative radiological methods is, therefore, obligatory in less than 10%.

[Radiologic and endoscopic correlation in Crohn's disease of the colon]. / Radiologisch-endoskopische Korrelation bei Crohnscher Erkrankung des Kolons.

A comparative assessment was carried out in 47 patients with double-contrast irrigoscopy (DCI), colonoscopy and endoscopy, the confirmed diagnosis being Crohn's disease in each of the patients. However, the histological finding of Crohn's disease was established in 19% only of the endoscopic biopsies. DCI enabled a more comprehensive assessment of the entire colon than was possible via endoscopy, since the right half of the colon could be visualized in less than 50% of the patients by the endoscopic method, whereas roentgenologic visualization of this part of the colon was possible in more than 90% of the patients. There was good agreement in respect of parts of the colon visualized both via endoscopy and via x-ray examination. As far as the assessment of deeper mucosal lesions was concerned, radiology proved superior, whereas endoscopy offered advantages in respect of changes on the level of the mucosa.

[Differential diagnostic problems of subtotal hepatic steatosis in the sonogram]. / Differentialdiagnostische Probleme der subtotalen Steatotis hepatis im Sonogramm.

The authors describe the appearance of focal sparing in otherwise diffuse fatty infiltration of the liver found in 35 patients. These are pseudotumours which are less echogenic than the surrounding abnormal parenchyma. They are sharply marginated, of triangular shape and show no mass effect--neither by displacement of vessels nor by deformity of the contour of the liver. These characteristic morphologic features allowed a differentiation from neoplasms or abscesses in 80% of our cases. Hence, biopsies are rarely indicated in these patients.

[Sonography of the upper abdomen in cystic fibrosis (author's transl)]. / Oberbauchsonographie bei zystischer Fibrose (CF).

Ultrasound scans of the upper abdomen were carried out in fifty patients with cystic fibrosis (age 2 to 26 years). 38% showed an abnormal hepatic sonogram. On eight occasions it was possible to confirm these changes by a liver biopsy. In 14% there was homogenous increase in liver echoes. 22% showed an non-homogeneous liver structure due to fibrotic and cirrhotic changes and cholangitis. Four of these patients had splenomegaly due to portal hypertension. 85% of the pancreatic scans which could be evaluated showed small pancreases with high echoes. Cholelithiasis was not present in any. Sonography of the upper abdomen is the method of choice for evaluating the liver, biliary system, pancreas and spleen.

[High-resolution sonography after surgery of cystadenoma lymphomatosum of the parotid gland]. / Hochauflösende Sonographie nach Operation von Zystadenolymphomen der Glandula parotis.

Clinical and sonographic examinations were carried out on 38 patients who had undergone excision of a parotid gland for adenolymphomas and the results were compared. In 23 of these patients (60%) sonography showed further tumours on the same or opposite side, or bilaterally. The incidence of multiple tumours is therefore significantly higher than has been assumed so far. In 76% of patients, sonography showed clinically occult cystadenoma lymphomatosum. Only 14% of tumours smaller than 12 mm were detected clinically. In four patients, tumours larger than 12 mm, but lying deep in the gland were missed on palpation. In view of the frequency of multi-local or bilateral tumours, sonography of both parotids should be performed if there is clinical suspicion of a parotid tumour.

[Diagnostic imaging of hemangiopericytomas]. / Bildgebende Diagnostik bei Hämangioperizytomen.

Eight patients with histologically verified hemangiopericytomas were examined by conventional radiographic techniques (plain films, angiography including cavography) as well as by duplex sonography, CT and MRI. These imaging techniques detected solid tumors with cystic compartments. A typical computed tomographic finding was intensive contrast enhancement within the tumor. Duplex sonography revealed blood flow in the periphery of the tumor. In contrast to reports by other authors no tumor calcification was found by plain film radiography.

[The technic of adrenal biopsy. Ultrasound versus CT as the guidance method]. / Technik der Nebennierenbiopsie. Ultraschall versus CT als Zielmethode.

Forty-seven needle biopsies of the adrenal glands have been performed under ultrasound or CT guidance. The aim was to clarify the best guidance method, the best approach, the choice of biopsy needle and possible complications. Analysis of the results provided the following answers: 1. A mass in the right adrenal can be biopsied under ultrasound control by a transhepatic approach. Small lesions of the left adrenal are best approached under CT guidance. In these cases a subcostal angled approach is advised. 2. Cutting biopsy needles provide better results than aspiration biopsy needles. 3. The complication rate of adrenal biopsies is very low if thin cutting needles are used.

[Mirizzi syndrome: a sonographic diagnosis?]. / Mirizzi-Syndrom: Eine sonographische Diagnose?

The ultrasound appearances of 11 patients with operatively confirmed Mirizzi syndrome have been analysed. The trio 'dilated intrahepatic bile ducts, concretions in the neighbourhood of the dilated common hepatic duct with a normal distal duct' permit the diagnosis of the Mirizzi syndrome with considerable certainty. In five patients these features were found by sonography and no other diagnostic procedure was necessary. In six patients, ERC was carried out in order to evaluate the distal common bile duct. In one case PTC was carried out, since the liver hilum could not be seen on sonography.

[The percutaneous ultrasonic-guided fluoroscopy-controlled drainage of pericardial fluids]. / Perkutane ultraschallgezielte und durchleuchtungskontrollierte Drainage perikardialer Flüssigkeiten.

The results of 25 ultrasonographically guided percutaneous pericardial drainage procedures and of one pericardiocentesis performed in 25 patients with pericardial fluid collections are reported. After initial puncture of the pericardial cavity under sonographic guidance, dilatation and placement of 5F to 8.3F catheters in Seldinger technique was controlled fluoroscopically in 22 procedures. Clinical indications were emergency treatment of tamponade (n = 6) or urgent treatment of large (n = 14) pericardial effusions. The remaining 6 procedures were performed to establish specific diagnoses of small effusions. Puncture sites were subxiphoid in 23 and left parasternal in 3 cases. The volume of aspirated fluid ranged from 20 to 1710 ml (median: 615 ml). Median duration of pericardial drainage was 3 days (range less than 1 day to 21 days). A specific diagnosis was obtained in 48% of patients. 4 patients had subsequent elective surgical intervention for recurrent effusion or for pericardial biopsy. Three minor complications included one vasovagal reaction and two asymptomatic pneumothoraces. Percutaneous ultrasonically guided and fluoroscopically controlled placement of a pericardial catheter is safe and effective for treatment and diagnosis of pericardial effusions.

Percutaneous drainage of thoracic collections.

Various infected and noninfected thoracic fluid collections may be diagnosed and treated by interventional radiologic techniques. The core procedure of ultrasound-guided thoracentesis has been expanded to allow catheter drainage of empyema, bronchopleural fistula, abscesses in the lung, mediastinum, pericardium, and infected tumors. Tailored use of guidance methods permits effective evacuation of most of these abscesses and noninfected collections. This paper details the authors' approach to each of these entities while highlighting the results and expected pitfalls of these techniques.

Percutaneous drainage of infected and noninfected thoracic fluid collections.

Radiologically guided aspiration and drainage of thoracic fluid collections is an improvement on standard "blind" techniques for chest-tube insertion. Specific indications for radiologic drainage are broadening, and instead of failed surgical cases only, patients now are commonly referred for drainage. Most of these procedures are effective and the complication rate vis-à-vis alternatives is acceptable. Soft 12-F catheters suffice in most cases and are relatively comfortable to large-bore tubes.