CT for Evaluation of Hemoptysis.

Hemoptysis, which is defined as expectoration of blood from the alveoli or airways of the lower respiratory tract, is an alarming clinical symptom with an extensive differential diagnosis. CT has emerged as an important noninvasive tool in the evaluation of patients with hemoptysis, and the authors present a systematic but flexible approach to CT interpretation. The first step in this approach involves identifying findings of parenchymal and airway hemorrhage. The second step is aimed at determining the mechanism of hemoptysis and whether a specific vascular supply can be implicated. Hemoptysis can have primary vascular and secondary vascular causes. Primary vascular mechanisms include chronic systemic vascular hypertrophy, focally damaged vessels, a dysplastic lung parenchyma with systemic arterial supply, arteriovenous malformations and fistulas, and bleeding at the capillary level. Evaluating vascular mechanisms of hemoptysis at CT also entails determining if a specific vascular source can be implicated. Although the bronchial arteries are responsible for most cases of hemoptysis, nonbronchial systemic arteries and the pulmonary arteries are important potential sources of hemoptysis that must be recognized. Secondary vascular mechanisms of hemoptysis include processes that directly destroy the lung parenchyma and processes that directly invade the airway. Understanding and employing this approach allow the diagnostic radiologist to interpret CT examinations accurately in patients with hemoptysis and provide information that is best suited to directing subsequent treatment. ©RSNA, 2021.

Management algorithm of acute cholecystitis after percutaneous cholecystostomy catheter placement based on outcomes from 377 patients.

PURPOSE: To report outcomes of percutaneous cholecystostomy (PC) catheter placement in patients with acute cholecystitis (AC) and propose management algorithm of AC after PC catheter placement based on the outcomes. METHOD AND MATERIALS: Retrospective study was performed. 419 patients who underwent PC between July 2010 and September 2016 were included. Patients who underwent PC for indication other than AC were excluded. The primary outcome was definitive treatment of AC following PC, including cholecystectomy or percutaneous cholecystolithotomy. Secondary outcomes include removal of drainage catheter without further management or death with catheter in place. Based on outcomes, we proposed management algorithm of AC after PC catheter placement. RESULTS: 377 of 419 patients underwent PC for treatment of AC (median age, 66 years; range 18-100 years). Technical success rate was 100% with 2.4% major complications rate and 1.6% minor complications rate. Following PC, 118 patients (31%) underwent definitive treatment with cholecystectomy. Sixty-one patients (16%) underwent definitive treatment with percutaneous cholecystolithotomy with removal of catheters. Seventy-four patients (20%) had their catheters removed upon resolution of cholecystitis without undergoing surgery or stone removal. Fifty patients (13%) died with catheters in place due to other comorbidities. Five patients (1%) still had their catheters in place at the end of the study. CONCLUSION: PC remains a viable option for treatment of AC with low complication rate and can be used as bridge to definitive therapy. Our proposed management algorithm can be a guideline for the management of AC after PC catheter placement.

Percutaneous Cholecystolithotomy Using Cholecystoscopy.

The morbidity and mortality of cholecystectomy can increase to 10% in high surgical risk patients. The technique for percutaneous cholecystolithotomy consists of 3 steps: (1) percutaneous cholecystostomy, (2) tract dilation and cholecystolithotomy, and (3) tract evaluation and catheter removal. Cholecystoscopy is critical in guiding the lithotripsy probe for fragmentation of large stones and is useful for locating small stone fragments not seen in cholangiography. Cholecystoscopy is also useful for assessing ambiguous lesions and in distinguishing between stone vs debris or mass. Technical success rate of percutaneous cholecystolithotomy using cholecystoscopy ranges from 93% to 100%. Procedure related complication rate has been reported as 4%-15%. The most common complication is bile leak during the procedure or after catheter removal. Although recurrence rate of gallstones has been reported up to 40%, the symptom recurrence rate is much lower. Therefore, percutaneous cholecystolithotomy using cholecystoscopy can be an alternative to cholecystectomy in high surgical risk patients with symptomatic gallstones.

Endovascular treatment of superior mesenteric artery pseudoaneurysms using covered stents in six patients.

OBJECTIVE: The objective of our study was to evaluate our experience with the use of endovascular treatments for superior mesenteric artery (SMA) pseudoaneurysms using covered stents. MATERIALS AND METHODS: Between 2002 and 2011, six patients (mean age, 41.7 years; range, 23-65 years) with SMA pseudoaneurysms were treated percutaneously with the placement of covered stents at our institution. The causes of SMA pseudoaneurysms were penetrating trauma (n = 2), blunt trauma (n = 1), and previous surgical procedures (n = 3). The mean diameter of the SMA pseudoaneurysms was 16 mm (range, 4-24 mm). Technical success and clinical success were retrospectively analyzed. RESULTS: Immediate technical success, defined as exclusion of the pseudoaneurysm and lack of active extravasation, was achieved in all six patients. Secondary balloon angioplasty was needed in one patient with residual narrowing. There was a small dissection of the proximal SMA necessitating placement of a second bare stent across the dissection. A second covered stent (Fluency stent, 8 mm) was placed in the same patient because of recurrent bleeding due to a type II endoleak 5 days after the first covered stent had been placed. This patient had no subsequent episodes of bleeding or bowel ischemia. Follow-up CT in the remaining five patients (mean, 21 months; range, 1-58 months) confirmed stent patency and preserved distal arterial flow to the bowel without episodes of bleeding or bowel ischemia during follow-up (mean, 27 months; range, 11-58 months). CONCLUSION: Percutaneous endovascular treatment using a covered stent may be a safe and feasible tool for SMA pseudoaneurysms.

Management of iatrogenic bile duct injuries: role of the interventional radiologist.

Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.

Common bile duct injury following laparoscopic cholecystectomy in the setting of sinistroposition of the galladder and biliary confluence: a case report.

INTRODUCTION: A bile duct injury occurred to a 64-year-old female with highly aberrant bile ducts due to sinistroposition. Methods of potential injury avoidance are discussed. MATERIALS AND METHODS: A patient underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. A left-sided gallbladder was diagnosed intraoperatively. Three days later, the patient presented with jaundice and rising liver function tests. The patient was referred to our institution for suspected bile duct injury. Endoscopic retrograde cholangiopancreatography showed complete occlusion of the common bile duct. A percutaneous transhepatic tube was placed in the bile ducts for decompression. During later operative exploration, a left-sided common hepatic duct was discovered. Review of preoperative imaging confirmed that the right hepatic duct crossed superior to the umbilical portion of the left portal vein and that segment 4 ducts drained into the right anterior sectional bile duct. CONCLUSION: This case describes an extremely rare anomaly associated with an injury to the common bile duct during laparoscopic cholecystectomy. Knowledge of the complex and unusual alterations in biliary anatomy, which may accompany sinistroposition of the gallbladder, should aid in avoidance of such injuries in the future.

"Sideways": results of repair of biliary injuries using a policy of side-to-side hepatico-jejunostomy.

BACKGROUND: The Hepp-Couinaud technique describes side-to-side HJ to the main left hepatic duct but a side-to-side approach is not consistently used when repairing other ducts. Compared with end-to-side repairs, side-to-side anastomoses require less dissection, theoretically preserving blood supply to the bile ducts, and usually permit wider anastomoses. METHODS: We report the treatment results of 113 consecutive biliary injuries, with intention to perform side-to side anastomosis in all. RESULTS: 113 biliary injuries, 109 associated with cholecystectomy, were treated from 1992-2006. Injury types were B (7 patients, 6%); C (11 patients, 10%); E1 (8 patients, 7%); E2 (37 patients, 33%); E3 (20 patients, 18%); E4 (24 patients, 21%); E5 (6 patients, 5%). 19% of repairs were early (within 1 week after cholecystectomy), 58% were delayed (at least 6 weeks after cholecystectomy), and 22% were reoperations for recurrent strictures. In 92% of cases, side-to-side repair was accomplished. 23/113 (20%) developed postoperative complications, with one postoperative death. Mean follow-up was 4.9 years. Excellent anastomotic function was achieved in 107/112 (95%). "Poor" anastomotic results occurred in 5 patients: 2 patients with E4 injuries had postoperative anastomotic stenting >3 months, and 3 developed strictures requiring percutaneous dilation. There have been no reoperations for biliary strictures. CONCLUSIONS: HJ using side-to-side anastomosis has theoretical advantages and is usually possible. In some high right-sided injuries it could not be achieved. 95% excellent anastomotic function without intervention attests to the benefit of the method, especially as postoperative stenting >3 months was considered to be a "poor" result.