Asunto(s)
Recursos en Salud/organización & administración , Administración Hospitalaria , Servicio de Radiología en Hospital/organización & administración , Manejo de Caso , Ahorro de Costo , Técnicas de Apoyo para la Decisión , Prestación Integrada de Atención de Salud , Grupos Diagnósticos Relacionados , Eficiencia Organizacional , Recursos en Salud/economía , Administración Hospitalaria/economía , Administradores de Hospital , Humanos , Relaciones Interprofesionales , Tiempo de Internación , Imagen por Resonancia Magnética , Objetivos Organizacionales , Ejecutivos Médicos , Evaluación de Procesos, Atención de Salud , Servicio de Radiología en Hospital/economía , Gestión de Riesgos , Revisión de Utilización de RecursosRESUMEN
A significant risk of hepatic injury remains using reported methods of intraoperative retrograde transhepatic stenting (IRTS). Our hypothesis was that we could minimize this risk by: (1) using a pliable sheath to create a stent tract that follows the curve of the biliary tree, (2) decreasing the stent diameter, and (3) avoiding the hepatic hilum. We evaluated the safety of a novel technique of intraoperative stenting employing these three concepts. Twenty-four patients underwent IRTS between 1992 and 1995 at our institution after potentially curative resection (one bypass). Malignant disease was present in 22 of 24 patients. Bile ducts were normal caliber in all patients. There was no operative mortality and 38% operative morbidity, all readily treated. All complications were due to stent dislodgment. There were no deaths. This novel atraumatic method of IRTS has acceptable morbidity and mortality. Complications due to stent insertion are minimal. The technique compares favorably with previous methods of IRTS and offers a viable alternative to the surgeon when a transhepatic stent is required. Anchoring the stent securely to the skin is essential to prevent catheter dislodgement.
Asunto(s)
Conductos Biliares , Cuidados Intraoperatorios/métodos , Stents , Neoplasias de los Conductos Biliares/cirugía , Femenino , Humanos , Masculino , Neoplasias Pancreáticas/cirugía , Complicaciones Posoperatorias/prevención & controlRESUMEN
PURPOSE: Curative radiotherapy (RT) for carcinoma of the cervix requires adequate irradiation of regional lymph node groups. The best nonsurgical method of defining lymph node anatomy in the pelvis remains the lymphangiogram (LAG). This study was designed to determine if bony landmarks could accurately substitute for LAG as a means of determining lymph node position for the purpose of pelvic RT treatment planning. METHODS AND MATERIALS: The post-LAG simulation films of 22 patients treated at the Fox Chase Cancer Center for cervical cancer were examined. On anterior/posterior (A/P) simulation films, the distance of lymph nodes was determined from the top, middle, and bottom of the sacroiliac joint, and at the pelvic rim, 1 and 2 cm above the acetabulum. On lateral (LAT) simulation films, lymph node position was measured at points 0, 4, and 8 cm along a line from the bottom of L5 to the anterior aspect of the pubic symphysis. Positive values represent lateral and anterior distances relative to the reference point on A/P and LAT films, respectively. Negative values represent distances in the opposite direction. The adequacy of standard pelvic fields as defined by the Gynecologic Oncology Group (GOG) (A/P: 1.5 cm margin on the pelvic rim; LAT field edge is a vertical line anterior to the pubic symphysis) was also examined. Data are expressed as the mean +/- two standard deviations, (i.e. 95% confidence level). RESULTS: On A/P simulation films, the distance of visualized lymph nodes had mean values of -1.6 +/- 1.7 cm (range -4.1 to -0.4 cm), -1.3 +/- 1.5 cm (range -3.4 to 0.0 cm), and 1.2 +/- 1.8 cm (range -1.0 to 2.6 cm) from the sacro-iliac (SI) joint at the superior, middle, and inferior points, respectively. The mean distance of the nodes from the pelvic rim at points 1 and 2 cm above the acetabulum was 0.3 +/- 1.2 cm (range -0.6 to 1.8 cm) and 0.2 +/- 1.8 cm (range -1.6 to 2.1 cm), respectively. On LAT simulation films, the distance of lymph nodes from points 0, 4, and 8 cm from the previously described reference line had mean values of 2.0 +/- 1.0 cm (range 1.3 to 3.0 cm), 0.9 +/- 3.9 cm (range -1.9 to 5.1 cm), and 1.8 +/- 2.1 cm (range -0.8 to 3.5 cm), respectively. Ten of 22 (45%) patients would have had inadequate nodal irradiation if their fields had been designed according to standard GOG parameters. In all cases, these incompletely irradiated lymph nodes were from the lowest of the lateral external iliac group. CONCLUSION: Great variability in pelvic lymph node location is demonstrated when LAG is used to directly visualize their location. Bony structures are inaccurate landmarks for pelvic lymph node position. The GOG standard pelvic fields are not consistently adequate to cover all lateral external iliac lymph nodes, although the clinical significance of this subgroup of lymph nodes is not known. At this time, LAG remains the ideal radiographic modality to define anatomic location of regional lymph nodes for pelvic RT treatment planning. The clinical importance of the most lateral group of external iliac lymph nodes in various stages of cervical cancer represents a potential area of future research.
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Ganglios Linfáticos/patología , Linfografía , Neoplasias del Cuello Uterino/diagnóstico por imagen , Neoplasias del Cuello Uterino/radioterapia , Acetábulo/diagnóstico por imagen , Femenino , Humanos , Huesos Pélvicos/diagnóstico por imagen , Pelvis/diagnóstico por imagen , Estudios Retrospectivos , Articulación Sacroiliaca/diagnóstico por imagenRESUMEN
U.S. federally imposed efforts to regulate joint venturing are a result of certain physician strategies to circumvent anti-kickback statutes by investing in clinics, labs, and facilities for self-referral. This article addresses the ethical debate on physician ownership, MRI as an evolving modality, the 1989 Ethics in Patient Referrals Act and the subsequently released "safe harbors," and finally, describes an existing model for physician/hospital ownership in an outpatient MRI facility.
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Ética Médica , Convenios Médico-Hospital , Imagen por Resonancia Magnética , Servicio Ambulatorio en Hospital , Convenios Médico-Hospital/legislación & jurisprudencia , Humanos , Medicaid/economía , Medicare/economía , Servicio Ambulatorio en Hospital/legislación & jurisprudencia , Propiedad/legislación & jurisprudencia , Derivación y Consulta/legislación & jurisprudencia , Estados UnidosRESUMEN
An unusually large, noncalcified popliteal artery aneurysm causing cortical erosion was erroneously diagnosed as a soft-tissue sarcoma. The case stresses the importance of excluding a vascular cause of a mass whenever biopsy is considered. We review the clinical and radiological features of popliteal artery aneurysm and describe the appearance of the aneurysm on MR.
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Aneurisma , Arteria Poplítea , Anciano , Aneurisma/diagnóstico por imagen , Enfermedades Óseas/diagnóstico por imagen , Diagnóstico Diferencial , Fémur/diagnóstico por imagen , Humanos , Masculino , Arteria Poplítea/diagnóstico por imagen , RadiografíaRESUMEN
Ultrasound (US)-guided and fluoroscopically guided pericardial catheter placement was performed in 12 patients with known underlying malignancy who had clinical and radiographic evidence of a significant pericardial effusion. US guidance facilitated placement of a 22-gauge needle by means of a subxyphoid or transthoracic approach. The tract was subsequently dilated over a wire under fluoroscopic guidance with placement of either an 8.5- or 10-F catheter. This technique successfully established pericardial drainage in all patients with excellent symptomatic relief. Cytologic findings were positive for malignancy in 10 of the 12 patients. Radiologically guided pericardiocentesis allowed safe, rapid stabilization of the condition of patients with symptoms from pericardial effusion. This resulted in excellent palliation in patients with terminal disease and improvement in the clinical status of other patients so that additional therapies, such as sclerosis with tetracycline or surgical placement of a pericardial window, could be performed on an elective basis.
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Drenaje/métodos , Derrame Pericárdico/terapia , Adulto , Anciano , Cateterismo/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/complicaciones , Derrame Pericárdico/etiología , Técnicas de Ventana Pericárdica , PuncionesRESUMEN
The technique, results, and complications of 109 consecutive sonographically guided therapeutic paracenteses performed on 43 patients with malignant ascites are summarized. A 5.5-French Sacks One-Step Catheter was used in all cases but five in which tissue resistance prohibited passage of the catheter through the abdominal wall. The procedure was performed on an inpatient basis 70 times and in an outpatient setting 39 times. Colonic, ovarian, and breast carcinomas accounted for over 50% of the tumors resulting in malignant fluid collections. Three complications (hypotension, 2.6%) were directly related to the procedure; two of them were fatal (1.6%). The amount of ascitic fluid drained within the first 24 hr averaged 3.5 l at rates of 100-150 ml/sec. Ninety-five procedures (87%, in 39 patients) resulted in improvement of symptoms after drainage as manifested by decreased pain from abdominal distention, alleviation of nausea, improved appetite, or decreased dyspnea. The duration of symptomatic relief ranged from 4 days to 45 days (mean, 10.4 days). Sonographically guided paracentesis is an effective procedure that can be performed for short-term relief of symptoms caused by malignant ascites.
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Ascitis/terapia , Neoplasias/complicaciones , Cuidados Paliativos , Ultrasonografía , Adulto , Anciano , Anciano de 80 o más Años , Ascitis/diagnóstico , Ascitis/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Succión/instrumentación , Succión/métodosRESUMEN
Oxygen distribution was measured in 31 fixed lymph node metastases (mean diameter 4.4 cm +/- 0.8 cm) from squamous cell carcinoma of the head and neck by passing a needle electrode through each tumor under CT guidance. Thirteen tumors had uniform oxygen distribution with all measurements under 10 mm Hg. Six tumors had uniform oxygen distribution with all measurements above 10 mm Hg, and twelve tumors had variable oxygen distribution with measurements higher in the periphery than in the center. Response to radiation therapy was judged by changes in tumor volume 90 days following completion of therapy compared to pre-therapy volume. Eighteen tumors were considered complete responders (CR); eleven, non-responders (NR); two, partial responders (PR). No statistically significant difference in radiation dose or tumor size was seen in the PR and CR groups. Mean pO2 was 20.6 (+/- 4.4) mm Hg in the CR group and 4.7 (+/- 3.0) mm Hg in the NR group (p less than 0.001). Normalized pO2 content defined as the total tumor oxygen content normalized by dividing by the volume was 37.4 (+/- 8.2) mm Hg in the CR group and 8.2 (+/- 5.1) mm Hg in the NR group (p less than 0.001). The volume and oxygen levels of each tumor were tabulated and analyzed. Twelve tumors had greater than 26% of their volume containing a pO2 less than 8 mm Hg. Eleven of these were NR and one PR. Nineteen tumors had less than 26% of their volume containing a pO2 less than 8 mm Hg. Eighteen were CR and one PR (p less than 0.001). These data suggest that oxygen plays a significant role in human tumor response to radiation therapy. Oxygen measurements appear to allow separation of subgroups of patients with a poor prognosis who would most benefit from maneuvers to circumvent the hypoxic effect.
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Carcinoma de Células Escamosas/secundario , Metástasis Linfática/metabolismo , Oxígeno/metabolismo , Carcinoma de Células Escamosas/metabolismo , Carcinoma de Células Escamosas/radioterapia , Neoplasias de Cabeza y Cuello/patología , Neoplasias de Cabeza y Cuello/radioterapia , Presión ParcialRESUMEN
Balloon dilation catheters were used to treat 94 gastrointestinal strictures in 92 patients over a 6-year period. Long-term follow-up data were obtained for 80 of these patients, with a mean follow-up period of 389 days. Overall, of the patients who underwent a successful dilation procedure, 83% remained symptom free after 1 year, and 69% after 2 years. The location of the stricture did not significantly influence the long-term outcome, nor did procedure characteristics, aside from primary technical failure. Both patients with malignant strictures and those whose strictures were associated with an anastomosis were more likely than other patients to have recurrent symptoms.
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Sistema Digestivo/diagnóstico por imagen , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/terapia , Sistema Digestivo/patología , Dilatación/métodos , Estenosis Esofágica/diagnóstico por imagen , Estenosis Esofágica/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/terapia , Pronóstico , Estenosis Pilórica/diagnóstico por imagen , Estenosis Pilórica/terapia , Radiografía , Recurrencia , Factores de TiempoRESUMEN
Radiologically guided balloon catheters were used to dilate 94 gastrointestinal strictures in 92 patients over a 6-year period. Fifty strictures were esophageal and 44 nonesophageal (22 gastroenterostomies, 11 antral-pyloric strictures, four colorectal strictures, four enteroenterostomies, and three miscellaneous strictures). Factors influencing the success of stricture intubation included patient age, stricture location (esophageal vs. nonesophageal and proximal vs. distal esophageal), and association with a surgical anastomosis. Malignancy was associated with greater postdilation irregularity and a smaller increase in stricture diameter, as measured radiographically. Procedural failures occurred in 8% of cases (2% of esophageal and 30% of nonesophageal lesions). Two small, asymptomatic mucosal tears were seen after dilation (one esophageal and one colonic); no other procedural complications occurred. Following successful dilation, 16 patients (17%; six with esophageal and ten with non-esophageal strictures) had recurrence of symptoms during short-term (30-day) follow-up.
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Sistema Digestivo/diagnóstico por imagen , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/terapia , Sistema Digestivo/patología , Dilatación/métodos , Estenosis Esofágica/diagnóstico por imagen , Estenosis Esofágica/terapia , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/terapia , Pronóstico , Estenosis Pilórica/diagnóstico por imagen , Estenosis Pilórica/terapia , Radiografía , Recurrencia , Factores de TiempoRESUMEN
Photodynamic therapy was performed on ten tumors in patients who did not respond to initial therapy and for whom no additional conventional therapy was available. A sensitizing agent (hematoporphyrin derivative [HpD]) was injected directly into each tumor under computed tomographic (CT) guidance to deliver high concentrations to the tumor and to minimize systemic toxicity. Three to 6 days after the injection, a clear Teflon sheath catheter was placed into the tumor under CT guidance. The tumor was exposed to red light (630-nm wavelength) through laser fiberoptics inserted in the sheath. The initial investigation confirmed the technical feasibility of CT-guided photodynamic therapy by means of intratumoral HpD injections and laser exposure through fiberoptics inserted in sheath catheters. The toxicity from a single treatment was minor, and the tumor response was encouraging.
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Fotorradiación con Hematoporfirina , Neoplasias/tratamiento farmacológico , Fotoquimioterapia , Tomografía Computarizada por Rayos X , Cateterismo/métodos , Evaluación de Medicamentos , Tecnología de Fibra Óptica/instrumentación , HumanosAsunto(s)
Neoplasias/terapia , Cuidados Paliativos/métodos , Absceso/diagnóstico por imagen , Colestasis/diagnóstico por imagen , Drenaje , Embolización Terapéutica , Gastrostomía , Humanos , Neoplasias/diagnóstico por imagen , Nefrostomía Percutánea , Bloqueo Nervioso , Radiografía , Obstrucción Ureteral/diagnóstico por imagenAsunto(s)
Enfermedades de los Anexos/etiología , Artroplastia , Articulación de la Cadera/cirugía , Enfermedades Intestinales/etiología , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Adulto , Femenino , Hernia/etiología , Prótesis de Cadera , Humanos , Intestino Delgado , Complicaciones Posoperatorias , RadiografíaAsunto(s)
Embolización Terapéutica/métodos , Etanol/administración & dosificación , Hemorragia/terapia , Arterias Mamarias , Arterias Torácicas , Femenino , Hemorragia/diagnóstico por imagen , Humanos , Inyecciones Subcutáneas , Arterias Mamarias/diagnóstico por imagen , Persona de Mediana Edad , Radiografía , Arterias Torácicas/diagnóstico por imagenRESUMEN
Thrombocytopenic patients, who displayed hemostatic disorders and had been previously sensitized by repeated blood transfusions and/or pregnancies, were supported for surgical procedures by platelet transfusions obtained from a single ABO and HL-A matched donor by the use of continuous collection centrifugation. Because of the low incidence of HL-A identical donors, compatibility was assessed by known serological cross-reactivity of the HL-A determinants. In three cases repeated platelet transfusions had excellent in vivo survival, and sensitization could not be detected by a battery of immunological assays. In one case there was immune sensitization and refractoriness to repeated platelet transfusion, as documented by accelerated in vivo destruction of donor and third-party platelets bearing the disparate factor HL-A8. Although serologic tests for lymphocytotoxic and leukoagglutinating antibodies were negative, the patient displayed cellular immunity in leukocyte aggregation and cell-mediated plateletolysis tests. The single donor, continuous collection technique appears to have the technical advantage of rapid, efficient collection and the immunological benefit of a restricted spectrum of allosensitization.