Percutaneous biliary stone clearance: is there still a need? A 10-year single-centre experience.

AIM: To evaluate the safety and efficacy of percutaneous biliary stone clearance in a single hepatopancreaticobiliary (HPB) centre. MATERIALS AND METHODS: All patients who underwent percutaneous biliary stone clearance between 2010 and 2020 at a HPB centre were identified from the radiology information system. Their demographic data, presentation, previous surgery, number/size of biliary calculi, success and complications were collected from patient records. Unpaired student's t-test was used to compare numerical variables and the Chi-square test was used to compare categorical data. RESULTS: Sixty-eight patients aged between 58.5-91.1 years underwent the procedure, and 42.6% (29/68) had the procedure due to surgically altered anatomy precluding endoscopic retrograde cholangiopancreatography (ERCP). The most common presentation was cholangitis (62%). The success rate of percutaneous stone clearance was 92.7%. The average number of calculi was two (range 1-12). Of the patients included, 4.4% developed pancreatitis, 4.4% developed cholangitis, and 1.5% had hepatic artery branch pseudoaneurysm successfully treated with transarterial embolisation. There was no significant difference in success or complication rates between the different access sites (right lobe, left lobe, roux-loop, T-tube, p=0.7767). CONCLUSION: Percutaneous biliary stone clearance is safe and effective and will continue to play an important role where ERCP fails or is impossible due surgically altered anatomy.

Respiratory-aspirated 35-mm hairpin successfully retrieved with a Teflon® snare system under fluoroscopic guidance via a split endotracheal tube: a useful technique in cases of failed extraction by bronchoscopy and avoiding the need for a thoracotomy.

Respiratory foreign body aspiration (FBA) is a common global health problem requiring prompt recognition and early treatment to prevent potentially fatal complications. The majority of FBAs are due to organic objects and treatment is usually via either endoscopic or surgical extraction. FBA of a straight hairpin has been described as a unique entity in the literature, occurring most commonly in females, particularly during adolescence. In the process of inserting hairpins, the pins will typically be between the teeth with the head tilted backwards, while tying their hair with both hands. This position increases the risk of aspiration, particularly if there is any sudden coughing or laughing. To our knowledge, this is the first case report of a 35-mm straight metallic hairpin foreign body that has been successfully retrieved by a radiological snare system under fluoroscopic guidance. This was achieved with the use of a split endotracheal tube, and therefore avoided the need for a thoracotomy in an adolescent female patient.

Evaluation of hepatic angiography procedures and bremsstrahlung imaging in selective internal radiation therapy: a two-year single-center experience.

The imaging of Bremsstrahlung radiation is performed after hepatic radioembolization to assess the distribution of the injected radioactive material. This review assesses the role of Bremsstrahlung imaging and its relation to the angiographic procedure and technique in hepatic selective internal radiation therapy on 21 patients undergoing this procedure at a single center.

Patterns of lung disease in a "normal" smoking population: are emphysema and airflow obstruction found together?

STUDY OBJECTIVES: We determined whether emphysema demonstrated on high-resolution CT (HRCT) scanning in apparently well smokers is associated with airflow obstruction. INTERVENTIONS: Lung function testing and limited HRCT scanning. DESIGN: Lung function measurements and scans were analyzed independently of each other. We used analysis of covariance to compare FEV(1) and maximum expiratory flow at 50% of vital capacity (MEF(50)) values after suitable corrections, between subjects with and without parenchymal damage (emphysema and/or reduced carbon monoxide transfer coefficient [KCO]), and to compare indexes of parenchymal damage between subjects with and without airflow obstruction. SETTING: Radiology and lung function departments of a district general hospital. PARTICIPANTS: Eighty current cigarette smokers and 20 lifetime nonsmoking control subjects (aged 35 to 65 years) who volunteered following publicity in local media. In all subjects, FEV(1) was > 1.5 L; no subjects were known to have lung disease. MEASUREMENTS AND RESULTS: FEV(1) and MEF(50) were measured spirometrically; static lung volumes were measured by helium dilution and body plethysmography; KCO was measured by a single-breath technique. HRCT scans were analyzed for emphysema by two radiologists. Of smokers, 25% had HRCT emphysema, generally mild; 16.3% and 25% had reduced FEV(1) and MEF(50), respectively; 12.5% had reduced KCO. Smokers with airflow obstruction were not more likely to have parenchymal damage. Smokers with parenchymal damage did not have reduced airway function. Nonsmokers generally had normal airways and parenchyma. CONCLUSIONS: "Normal" smokers with lung damage had either airflow obstruction or parenchymal damage, but not generally both.

The potential impact of high-quality MRI of the biliary tree on ERCP workload.

BACKGROUND: Magnetic resonance cholangiography (MRC) is a non-invasive method of imaging the biliary tree with virtually no morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) has a significant morbidity, mortality and failed imaging rate. Unlike MRC, ERCP is highly dependent on the clinical team for high-quality results and minimal morbidity. MRC requires high-quality image acquisition and appropriate reconstructions, with skilled reading of the images. OBJECTIVES: To assess the impact on ERCP workload of using MRC as the initial imaging modality for the biliary tree in selected patient groups, and to assess procedure-related morbidity and mortality. METHODS: An analysis of 1078 consecutive ERCP examinations performed at our institution over the six years to 1996 has been undertaken. Complications, imaging failure rates and ERCP findings have been analysed in the different referral categories to assess the potential impact of MRC on future ERCP workload and patient outcomes. RESULTS: At our institution, if MRC had been used as the first imaging investigation in patients with abdominal pain (n = 336, with or without abnormal liver function tests but without clinical jaundice) and those with present or past acute pancreatitis (n = 101), we estimate that 83 (19%) would have needed to go on to ERCP, but 354 (81%) would not have required further invasive investigation. In these categories, this would have resulted in five patients with stones missed at MRC, but 14 extra patients with stones would have been identified whose stones would have been missed at ERCP (failed examinations). There would be an overall 33% reduction in ERCP workload and 20 serious complications related to ERCP would have been avoided. Overall 7% of patients would be subjected to both investigations. CONCLUSIONS: In the interests of efficient use of resources, minimization of patient complications and accurate identification of those requiring therapeutic ERCP, MRC should be the preferred initial investigation in selected groups of patients presently being subjected to ERCP.

Cigarette smoke inhalation and lung damage in smoking volunteers.

Cigarette smoking is the dominant risk factor for chronic obstructive pulmonary disease (COPD) but only 10-15% of smokers develop the condition. Risk does not relate closely to cumulative cigarette consumption, perhaps because smokers vary in the degree and depth of smoke inhalation. This study examined the role of smoke inhalation in the development of COPD. Eighty current smokers and 20 lifetime nonsmoking volunteers (aged 35-65 yrs) were recruited. Lung function variables were measured and high-resolution computed tomography (HRCT) scans performed. Smoke inhalation was assessed by CO boost (the increment of expired carbon monoxide 5 min after smoking a cigarette) and serum cotinine. Mean CO boost was 6.3 parts per million (ppm) in smokers with low CO transfer coefficients (KCO) and 2.9 ppm in those with normal KCO (p=0.006); 7.2 ppm in smokers with both HRCT-defined emphysema and a low KCO and 2.6 ppm in those with neither abnormality (p=0.002); 4.5 ppm in smokers with HRCT-defined emphysema alone and 2.8 ppm in those without (p=0.08). Mean serum cotinine was 328 ng x mL(-1) in smokers with chronic productive cough and 243 ng x mL(-1) in those without (p=0.005). Lifetime nonsmokers had normal HRCT scans, lung function and serum cotinine. Emphysema is associated with high alveolar smoke exposure as measured by CO boost. Productive coughing is associated with high nicotine uptake, probably from airway smoke particle deposition.

Case report: chronic mesenteric ischaemia as a cause of abnormal bowel uptake of labelled leucocytes.

Chronic mesenteric ischaemia is often difficult to diagnose. A high level of clinical suspicion is needed and further investigation requires invasive procedures. We present a case where weight loss and abdominal pain were dominant features and initial interpretation of a labelled leucocyte scan suggested inflammatory bowel disease. Subsequent investigations excluded this possibility and chronic ischaemia was confirmed at autopsy. Positive small bowel images using 99Tcm-HMPAO labelled leucocytes may indicate chronic ischaemia.

Case report: rectal infarction after abdominal aortic surgery.

Full thickness ischaemic colitis complicates approximately 1-2% of abdominal aortic procedures. Ligation of the inferior mesenteric artery and hypotension are recognized as causative factors. It is not, however, widely appreciated that ischaemic proctitis may also rarely complicate aortic surgery, especially after complex procedures or if there has been additional interruption to the internal iliac circulation. We report a case of rectal necrosis following repair of a thrombosed aortic aneurysm in which plain X-ray appearances aided the diagnosis.

Case report: biliary peritonitis following Wallstent insertion.

A case is described of biliary peritonitis following insertion of a Wallstent endoprosthesis. Features of the case that may have contributed to this complication are described and methods of preventing such an outcome discussed.

A randomised, prospective study comparing two contrast media in ERCP.

A randomised, prospective, stratified, double blind study comparing two contrast media in endoscopic retrograde cholangio-pancreatography (ERCP) was undertaken. Forty-six patients received Meglumine/Sodium Ioxaglate (Hexabrix 320) and forty-eight received Meglumine/Sodium Diatrizoate (Urografin 310). The two groups were evenly matched for age, sex and diagnosis. Radiographs were examined independently by two radiologists. There were no differences in radiograph quality with either type of contrast medium. More patients developed pancreatitis following Urografin, suggesting that Hexabrix is a safer contrast medium for ERCP.

Demonstration of pancreatic parenchyma by digital subtraction techniques during endoscopic retrograde cholangiopancreatography.

This paper reports the feasibility of using digital subtraction angiography techniques during endoscopic retrograde cholangiopancreatography to obtain greater detail of pancreatic structure. The pancreatic duct was filled in 23 of 27 cases attempted and in 17 cases parenchymal detail was obtained. Filling defects due to neoplasm were clearly defined and the changes of chronic pancreatitis visualised. The technique seems valuable for small lesions but may carry a higher risk of producing pancreatitis.