Percutaneous Management of Biliary Stones.

Bile duct stone disease is the most common causes of nonmalignant bile duct obstructions. The range of common bile duct stone formation in patients with cholecystectomy is 3 to 14.7%. Hepatolithiasis, although endemic in some parts of the world, is a rare disease that is difficult to manage. Endoscopic intervention is accepted as the first-line management of common bile duct stones. However, when the bile duct cannot be cannulated for various reasons, the endoscopic procedure fails. In this circumstance, percutaneous approach is an alternative technique for the nonsurgical treatment of bile duct stones. This article reviews the indications, technique, outcomes, and complications of the percutaneous treatment of bile duct stone disease.

Percutaneous antegrade ureteral stent placement: single center experience.

PURPOSE: We aimed to present our clinical experience with percutaneous antegrade ureteral stent placement in a single center. METHODS: Electronic records of patients who underwent percutaneous image-guided ureteral stent placement between September 2005 and April 2017 were reviewed. A total of 461 patients (322 males, 139 females; age range, 19-94 years; mean age, 61.4±15 years) were included in the study. Patients were classified into two main groups: those with neoplastic disease and those with non-neoplastic disease. Failure was defined as persistence of high level of serum creatinine or an inability to place stents percutaneously. Postprocedural complications were grouped as percutaneous nephrostomy and stent placement related complications. RESULTS: A total of 727 procedures in 461 patients were included in the study: 654 procedures (90%) in 407 patients (88.3%) were in the neoplastic group and 73 procedures (10%) in 54 patients (11.7%) were in the non-neoplastic group. Our technical success rates were 97.7% and 100% and complication rates were 3.1% and 4.1% in neoplastic and non-neoplastic groups, respectively. Seven stents retrievals and 112 balloon dilatations were performed successfully. CONCLUSION: Percutaneous antegrade ureteral stent placement is a safe and effective method for management of ureteral injuries and obstructions due to both malignant and benign causes when the retrograde approach has failed.

Percutaneous management of bile duct stones in children: results of 12 cases.

PURPOSE: We aimed to evaluate the effectiveness of percutaneous transhepatic removal of bile duct stones in children. METHODS: The study included 12 pediatric patients (4 males, 8 females; age range, 1-16 years; mean age, 6.6 years) who underwent percutaneous transhepatic removal of bile duct stones between September 2007 and December 2015. Demographic data, patient symptoms, indications for interventions, technical and clinical outcomes of the procedure, and complications were retrospectively evaluated. RESULTS: Of 12 children, five children with cholelithiasis underwent cholecystectomy subsequently. The overall technical and clinical success rate was 100%. One patient had cholangitis as a complication during the follow-up and was treated medically. CONCLUSION: Percutaneous transhepatic removal of bile duct stones is a safe and effective method for the treatment of children with biliary stone disease. It is a feasible alternative when the endoscopic procedure is unavailable or fails.

Percutaneous treatment of liver hydatid cysts in 190 patients: a retrospective study.

Background Hydatid liver disease (HLD) is a significant health problem, especially in endemic areas worldwide. Percutaneous treatment is an effective alternative therapeutic option. Purpose To present the clinical and radiological results of percutaneous treatment of HLD in 190 patients. Material and Methods Percutaneous treatment of HLD between April 2005 and March 2015 was analyzed retrospectively. The demographic data, numbers and types of cysts, initial and final volumes of the cysts, types of percutaneous treatment, and procedure-related complications were determined. Results A total of 190 patients (95 male patients and 95 female patients; age range, 5-82 years) with 283 liver hydatid cysts who underwent percutaneous treatment were included in the study. Of the 283 cysts, 234 (83%) were cystic echinococcosis CE1, 31 (11%) were CE3a, and 18 (6%) were CE2 cysts, according to the World Health Organization (WHO) classification. The percutaneous procedure was successful in all patients. A total of 12 (6.3%) major complications, including anaphylaxis, allergic skin reaction, perihepatic hemorrhage, and cavity infection, were seen. No mortality was noted. Recurrence in one patient and an additional cyst in one patient were seen. All patients were asymptomatic during the follow-up period. Mean volume reduction was 77.5%, with a mean follow-up period of 18 months. Conclusion Percutaneous treatment is an effective and safe method for the treatment of HLD. It should be regarded as a first-line treatment method for uncomplicated hydatid cysts.

Imaging findings and management of diaphragmatic mesothelial cysts in children.

BACKGROUND: Diaphragmatic mesothelial cysts are rare benign congenital lesions with typical imaging findings. OBJECTIVE: To present imaging and treatment outcomes in 30 children with diaphragmatic mesothelial cyst. MATERIALS AND METHODS: We conducted a retrospective chart review and recorded demographic data, imaging findings, treatment and US follow-up results, initial and final volume of the cysts and length of follow-up period for each case of diaphragmatic mesothelial cyst in a specialist hospital. RESULTS: The study included 30 children (16 girls, age range 1-17 years, mean age 7.9 years) diagnosed with diaphragmatic mesothelial cyst between January 2010 and December 2015. Imaging findings included thin-walled bilobulated or oval-shape cysts located between the diaphragm and right lobe of the liver. Treatment consisted of percutaneous drainage in 17 children and was successful in all. Cysts disappeared completely in 12 of these 17 children (70.5%, 95% confidence interval [CI] 44-90%). Mean volume reduction was 98%. No complication or mortality was seen. The other 13 children were followed with US without treatment. In 4 of these 13 children (30.8%, 95% CI 9-61%), cysts spontaneously decreased in size. No cyst increased in size. CONCLUSION: In children with typical imaging findings, percutaneous drainage appears safe and effective when treatment is deemed necessary.

Percutaneous ultrasound-guided core needle biopsy of solid pancreatic masses: Results in 250 patients.

BACKGROUND: To determine the diagnostic accuracy and complications of percutaneous sonographic (US)-guided core needle-needle biopsy in the diagnosis of solid pancreatic masses. METHODS: Cases of US-guided percutaneous core needle biopsy of solid pancreatic masses performed in our department between July 2009 and June 2015 were analyzed retrospectively. The demographic data, lesions' size and location, pathology results, accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and complications of the biopsies were determined. RESULTS: A total of 250 patients (150 males, 100 females; age range, 16-88 years; mean age, 64.3 ± 12.1 years) were included in the study. The overall diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of all 250 biopsies were 94.8%, 94.3%, 97.2%, 99.5%, and 75%, respectively, and changed to 98.4%, 99%, 94.7%, 99%, and 94.7%, respectively, after the biopsy was repeated in 12 patients. Four (1.6%) major complications, including a pseudoaneurysm of the gastroduodenal artery, and three cases of acute pancreatitis, and one (0.4%) minor complication (a vaso-vagal syncope), were observed. There was no biopsy-related death. CONCLUSIONS: US-guided percutaneous core needle biopsy is a safe and highly effective method with acceptable complication rates in the diagnosis of solid pancreatic masses. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:470-473, 2016.

Percutaneous transhepatic removal of bile duct stones: results of 261 patients.

PURPOSE: To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient. METHODS: Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14-92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones = 248 patients and hepatolithiasis = 13 patients) were included in the study. Percutaneous transhepatic cholangiography was performed, and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stones were pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation. RESULTS: Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 major complications (6.8%), including cholangitis (n = 7), subcapsular biloma (n = 4), subcapsular hematoma (n = 1), subcapsular abscess (n = 1), bile peritonitis (n = 1), duodenal perforation (n = 1), CBD perforation (n = 1), gastroduodenal artery pseudoaneurysm (n = 1), and right hepatic artery transection (n = 1), were observed after the procedure. There was no mortality. CONCLUSION: Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.

Percutaneous transhepatic removal of bile duct stones: results of 261 patients.

PURPOSE: To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient. METHODS: Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14-92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones=248 patients and hepatolithiasis=13 patients) were included in the study. First, percutaneous transhepatic cholangiography was performed and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stones were pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation. RESULTS: Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 (6.8%) major complications, including cholangitis (n=7), subcapsular biloma (n=4), subcapsular hematoma (n=1), subcapsular abscess (n=1), bile peritonitis (n=1), duodenal perforation (n=1), CBD perforation (n=1), gastroduodenal artery pseudoaneurysm (n=1), and right hepatic artery transection (n=1), were seen after the procedure. There was no mortality. CONCLUSION: Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.

Transjugular liver biopsy: results of 97 patients.

OBJECTIVE: To evaluate the feasibility and efficacy of transjugular liver biopsy in patients with contraindicated percutaneous biopsy. MATERIALS AND METHODS: Between June 2005 and April 2010, 97 patients who were admitted for transjugular liver biopsy were enrolled in this retrospective study. All liver biopsies were obtained using an 18 gauge Quick-Core liver biopsy set through the right hepatic vein via the internal jugular vein. Clinical indication, histopathological diagnosis, and complications were noted. RESULTS: Primary technical success was achieved in 93 (95.8%) patients. Hepatic veins could not be catheterized and opacified in two patients and in the remaining two patients the veins could be opacified and catheterized but we were not able to pass the biopsy needle into the hepatic vein because of the acute angle between the inferior vena cava and hepatic veins. At least two specimens were obtained from each patient. The most frequent histopathological diagnosis was cirrhosis. A subcutaneous hematoma around the puncture side was encountered in one patient. CONCLUSION: Transjugular liver biopsy is a feasible and effective alternative in patients with contraindication for percutaneous biopsy.

Transrectal ultrasound guided multi-core prostate biopsy: pain control: results of 106 patients.

PURPOSE: To determine the efficacy of periprostatic nerve block (PPNB) for control of transrectal ultrasound (TRUS)-guided multicore prostate biopsy-related pain. METHODS: A total of 106 cases with suspicion of prostate cancer underwent TRUS-guided multicore prostate biopsy under local anesthesia using a total of 10 ml of 1% lidocaine for each patient. Lidocaine was injected around the neurovascular bundle at the base of the prostate just lateral to the seminal vesicle-prostate junction. The pain score was assessed using visual analog pain score from 0 to 10. All patients were questioned for whether they would accept repeat biopsy or not, if necessary. RESULTS: Pain score ranged from 0 to 5 (mean: 1.4). Thirty-five percent (37/106) of patients reported a score of 0, whereas 17% (18/106), 32% (34/106), 8.4% (9/106), 6.7% (7/106), 0.9% (1/106) reported pain scores of 1, 2, 3, 4, and 5, respectively. There were no pain scores of 6-10. Answers for the question "would you accept repeat biopsy or not, if necessary?" was "yes" for 82% (87/106) of the patients. CONCLUSIONS: PPNB prior to multi-core TRUS-guided prostate biopsy is an easy, safe, and effective technique for the control of procedure-related pain.

Hydatid cysts of the liver in children: percutaneous treatment with ultrasound follow-up.

BACKGROUND: Hydatid disease is a serious public health problem in endemic areas. Percutaneous treatment is an effective alternative to surgical and medical therapy in hydatid liver disease (HLD). OBJECTIVE: To present clinical and radiological results of percutaneous treatment of HLD in children. MATERIALS AND METHODS: Twenty-five children (16 males; age range, 5-15 years; mean age, 9.6 years) with a total of 30 hydatid cysts of the liver underwent ultrasound US guided percutaneous treatment using hypertonic saline as the scolicidal agent. RESULTS: The percutaneous procedure was successful in all patients. All children were asymptomatic at follow-up. A hypersensitivity reaction occurred in one child (4%) during the procedure. No other complications occurred. The reduction in cyst volume was 14-100% (mean, 64%) at follow-up (mean 13.8 months). On US at follow-up, the treated cysts were semisolid with a heterogeneous echo pattern (n = 17), solid hypoechoic (n = 10) or solid with calcification (n = 2). One treated cyst disappeared sonographically. CONCLUSION: Percutaneous treatment of HLD is effective, safe and well-tolerated in children.

Popliteal artery branching patterns detected by digital subtraction angiography.

PURPOSE: To describe the popliteal and distal branching patterns detected by digital subtraction angiography. MATERIALS AND METHODS: The popliteal branching patterns were analyzed in 535 extremities (270 right, 265 left). Of these, 226 limbs were evaluated bilaterally, while 83 were evaluated unilaterally. The branching patterns were classified according to the level of branching and the presence of hypoplasia or aplasia of the distal branches. RESULTS: Four hundred and seventy-two (88.1%) limbs had a normal level of popliteal artery branching. Type IA was the most frequently encountered pattern. High division of the popliteal artery was seen in 30 (5.6%) limbs. Type IIA was the most frequently encountered pattern among these limbs. Type IIC was not seen. We encountered a new pattern characterized by high division of the peroneal artery with a trifurcation pattern and an anterior tibial artery with a proximal medial course and a distal lateral course. We called this pattern Type IID. Thirty-three (6.1%) limbs exhibited hypoplasia/aplasia of the distal branches. Type IIIA was the most frequently encountered pattern among these limbs. CONCLUSION: Variations that occur in nearly 10% of patients should be understood because they may affect the choice of management strategy.

Bilateral round ligament varicosities mimicking an inguinal hernia in pregnancy: case report.

A 22-year-old pregnant woman presented with a painful swelling in the right groin. Sonography was performed to confirm a presumptive diagnosis of inguinal hernia based on physical examination. Gray-scale sonography examination revealed bilateral inguinal cystic lesion expanding with the Valsalva maneuver. Color Doppler imaging demonstrated multiple prominent vessels with retrograde venous flow during Valsalva maneuver. Bilateral round ligament varicosities were diagnosed and inguinal hernia was excluded by sonographic findings. Round ligament varicosities should be considered in the differential diagnosis of groin swelling during pregnancy.

Transarterial embolization for renal arterial bleeding.

PURPOSE: To evaluate the effectiveness of percutaneous transarterial embolization for the treatment of renal arterial bleeding in patients with renovascular injury. MATERIALS AND METHODS: The archives of our angiography suite were retrospectively reviewed, and 15 patients who had undergone renal embolization due to renal artery bleeding were included in the study. The site, number, and type of bleeding lesions, and the result of the embolization procedure were recorded. The technical and medical success, and technical and medical complications of the procedure were noted. RESULTS: On renal digital subtraction angiography (DSA) 18 lesions were detected in 15 patients. In 13 cases bleeding was effectively controlled with embolization in a single session. In one case bleeding was controlled on the second attempt. One case underwent nephrectomy. Nontarget embolization was seen in two patients, one treated with polyvinyl alcohol (PVA), the other with n-butyl cyanoacrylate (NBCA) mixture. Iatrogenic dissection of the segmental branch was seen in one patient. Puncture-site bleeding, postembolization syndrome, perirenal abscess or renal abscess, and arterial hypertension were not detected in any of the patients. CONCLUSION: Percutaneous transarterial embolization is an effective, minimally invasive, and a tissue preserving treatment method for renovascular injuries. Therefore, endovascular embolization should be the first preferred treatment modality.

Direct CT venography for evaluation of the lower extremity venous anomalies of Klippel-Trenaunay Syndrome.

OBJECTIVE: Our aim was to describe the technique of direct CT venography and to describe various forms of venous anomalies detected with CT venography in patients with Klippel-Trénaunay syndrome. CONCLUSION: MDCT is helpful for visualizing the full length of extremities and for evaluating length and thickness on one image.

Isolated penetrating gluteal injuries.

In the authors' institution, 27 patients with gluteal injuries were treated surgically during the past 17 years. All patients were males, and the mean age was 32.4 years. Most patients (89%) had stab wounds. The lesion was on the right buttock in 16 (59%) patients and on the left buttock in 11 (41%) patients. Bleeding was the most common presenting sign. The superior gluteal artery and its branches were the most commonly injured arteries (89%). Surgical procedure was arterial ligation alone in all but one case, whereas one patient underwent coil embolization. Mortality was 11% and included 1 death on arrival to the medical center and 2 intraoperative deaths. To achieve a low rate of morbidity and mortality with such injuries, careful physical examination and immediate surgical or endovascular treatment is needed.

Endovascular treatment of lower limb penetrating arterial traumas.

PURPOSE: The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma. MATERIALS AND METHODS: Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients. RESULTS: On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient. CONCLUSIONS: We conclude that embolization-particularly n-butyl cyanoacrylate embolization-is technically feasible in patients with penetrating peripheral arterial trauma.

Modified pudendal thigh flap for perineoscrotal reconstruction: a case of Leriche syndrome with rapidly progressing Fournier's gangrene.

We present the first report of Leriche syndrome associated with Fournier's gangrene. We used a modified pudendal thigh flap in the treatment of an extensive perineoscrotal soft-tissue defect successfully. We propose this new robust flap as an addition to the existing reconstructive armamentarium and draw attention to the coexistence of Leriche syndrome and Fournier's gangrene.