Effects of angiographic needle size and subsequent catheter insertion on arterial walls. An in vitro experiment in human cadavers.

RATIONALE AND OBJECTIVES: It is widely believed that down-sizing catheters, and possibly needles, will decrease damage to the entry vessel in the performance of angiography. The purposes of this in vitro experiment are to determine if smaller needles produce less arterial wall damage than larger needles and to assess the influence of subsequent catheter insertion. METHODS: Each iliac artery pair from 35 fresh human cadavers was punctured three times with an 18-g needle and three times with a 21-g needle, for a total of 210 punctures. In two of each set of three, a 5- or 7-F dilator was passed. One hundred ninety-eight puncture tracts were usable and examined microscopically. They were graded on a scale of 1 to 3 in each of four categories: size of tract, margin irregularity, approximation of edges, and shape of tract. RESULTS: Chi-square analysis of the grading scores showed a significant shift of cases into lower damage grades when the smaller gauge needle was used for initial punctures (P < .0005). The subsequent insertion of a dilator, however, imposed further damage, such that the initial differences due to needle gauge were obliterated (P > .2). CONCLUSION: These data indicate that a 21-g needle produces less arterial wall damage than an 18-g needle, but that any safety conferred by the smaller needle is eliminated by the subsequent insertion of a 5- or 7-F catheter.

Combined fluoroendoscopic removal of retained biliary stones.

Sixty-one patients were referred in the postoperative period for stone extraction through the T-tube tract. In four patients the calculi passed spontaneously. One patient had a papilloma and another a blood clot mimicking a stone. Of the remaining 55 cases, all but three were successfully treated by removal of all calculi from the ductal system, a success rate of 94.5%. No major complications occurred in this series. We believe the combined fluoroendoscopic approach to be the preferred method of extracting stones through the T-tube tract because of the greater precision possible when manipulating under direct vision and the reduction in radiation exposure of patients and personnel.

Operative fluoroscopy and cholangiography. The use of modern radiologic technics during surgery.

Operative cholangiography as currently performed in many hospitals in the United States may be a cumbersome procedure yielding less than optimal information. For maximal accuracy and diagnostic yield, operative radiographic examination of the biliary tract should include fluoroscopic observation and aimed spot films. The advantages gained by using modern radiologic equipment and technics are increased image clarity, increased capability for functional assessment of a dynamic system, increased efficiency, and decreased radiation hazard. In a series of 100 patients undergoing operative cholangiography by our technic, only one retained stone was demonstrated by postoperative studies. Five anomalies of the ductal system were easily identified and possible injury to the anomalous ducts averted. Considering the morbidity and mortality attendant upon inadequate or inappropriate biliary tract operations, investment in the sophisticated equipment necessary for optimal operative radiography is small indeed.

Angiographic evaluation and management of nonvariceal upper gastrointestinal bleeding.

Endoscopy is the primary diagnostic and therapeutic tool used in the evaluation and treatment of patients with upper gastrointestinal bleeding. When endoscopy is unsuccessful in identifying or controlling GI hemorrhage, however, arteriography is useful in both the evaluation and treatment of upper GI hemorrhage.

Magnetic resonance imaging of the skull base.

Magnetic resonance (MR) imaging has made it possible to evaluate the skull base in one primary screening examination. In most cases, MR imaging also serves as the definitive imaging study. In some traumatic or congenital lesions or both, computed tomography (CT) and conventional radiographs may be preferred or may be needed to supplement the MR imaging examination. This article discusses the pathology of the skull base, particularly in the evaluation of suspected neoplasms. Optimal imaging of the skull base requires a minimum of two planes of section, typically with and without gadolinium contrast enhancement.

Herniography following indirect hernioplasty using the Marlex "mesh plug" technique.

In recent years, some surgeons have been performing indirect inguinal herniorrhaphies using a "mesh plug" technique without ligation or resection of the hernia sac. The authors have had an interest in herniography and questioned whether herniorrhaphy without ligation or resection of the indirect sac might result in a false positive herniogram or an abnormal filling defect within the peritoneal cavity. These questions were answered by the performance of herniography in five patients who had indirect hernias repaired by this method. No false positive herniograms were discovered, and the inverted sacs could not be identified within the peritoneal cavity. Therefore, herniography would still be a useful diagnostic tool in evaluating patients who have persistent or recurrent symptoms following operations wherein the hernia sac was left intact.

Herniography: a review of 333 herniograms.

We reviewed 333 consecutive herniographic studies in 306 patients for whom clinical data were available. Symptoms with either a negative or inconclusive physical examination (PE) were the most frequent reasons for requesting a herniogram. The herniogram was found to be more sensitive for the diagnosis of hernia, particularly inguinal, than PE. In 56 of 57 patients who came to operation the herniogram and the PE were concordant. In one patient, an incisional hernia was found at operation that had not been appreciated as such on the herniogram. We believe herniography should be used more frequently when the diagnosis of hernia is uncertain on PE, thereby reducing the incidence of unnecessary operative procedures.

The etiology of the adult indirect inguinal hernia: revisited.

It has generally been historically stated that indirect inguinal hernias develop only in patients who have a patient processus vaginalis that enlarges to become a hernia sac. Occasionally, this theory has been challenged but without any objective evidence. Herniography was performed by placing 50 mL of nonionic contrast material into the peritoneal cavity. The patient was then placed in a prone position with the head of the table elevated. Films of the inguinal fossae were obtained with the patient straining. The herniogram revealed a right indirect inguinal hernia. There was no left inguinal hernia, nor was there a patent processus vaginalis on the left side. Two years later, the patient developed left inguinal discomfort and swelling and was found to have a moderate-sized left inguinal hernia. At the time of operation, an indirect sac of moderate size was present. A mesh plug repair was performed. This case report is the first published objective evidence that, contrary to common thought, a patent processus vaginalis is not a necessary prerequisite to the development of an indirect inguinal hernia.

Herniography: analysis of its role and limitations.

INTRODUCTION: Herniography is a radiographic procedure shown to be valuable in the examination of groin symptoms. It is useful in clinical situations, including the detection of occult hernia, the investigation of groin hernia when physical findings are equivocal, and the assessment of pain after inguinal hernia repair. OBJECTIVE: To systematically review the current literature on the use of herniography and to evaluate its reliability, risk, and limitations. METHOD: The Medline database was searched for publications on herniography. RESULTS: Herniography has a low false-positive rate, ranging from 0 to 18.75%. The sensitivity rate ranges from 81 to 100%, and the specificity rate ranges from 92 to 98.4%. CONCLUSION: Herniography is a safe and effective diagnostic procedure for assessing obscure groin symptoms. It has the potential of reducing the incidence of unnecessary operations. It should be considered in the evaluation of patients where the etiology of inguinal pain is unclear.

Herniography in symptomatic patients following inguinal hernia repair.

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnostic dilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54 symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography, only 2 of which were definitely detected on physical examination. The herniogram was normal at 44 sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia. On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Of these hernias, 8 were not detected on physical examination. Herniography was found to be more sensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides corroborative evidence that hernia has not recurred, the need for reexploration may be eliminated.

Large melanoma metastases to the gastrointestinal tract.

It is well known that malignant melanoma can metastasize widely. Although these metastases in the gastrointestinal tract usually appear as small 'bull's-eye' or 'target' lesions, there are a few reports of relatively large melanoma metastases. We report five cases of large melanoma lesions metastatic to the alimentary canal. We also emphasise the consideration of a thorough gastrointestinal tract evaluation in patients with malignant melanoma especially if they are symptomatic.

A combined fluoroscopic and endoscopic approach for retrieval of retained stones through the T-tube tract.

Use of the flexible fiberoptic choledochoscope has been suggested as an alternate to the steerable catheter method for extracting retained biliary calculi through the T-tube tract. We found disadvantages to the use of this scope and describe the use of the smaller, more flexible fiberoptic bronchoscope which has facilitated the procedure. The ability to view the calculus through the endoscope while manipulating the stone basket obviates the necessity for fluoroscopic monitoring during this phase and, therefore, results in a significant reduction of radiation exposure to all concerned. In addition, an over-all reduction in procedure time has been achieved by this method.

Sclerotherapy induced pseudo-carcinoma.

Endoscopic sclerotherapy has been suggested as the therapy of choice for acute hemorrhage from esophageal varices. It not only controls such episodes, but also prevents rebleeding, and prolongs life. After treatment, patients may present with endoscopic and radiographic findings which mimic esophageal carcinoma including ulceration, non-pliable walls, irregular mucosal pattern and overhanging edges.

G-protein beta gamma subunit genes expressed in olfactory receptor neurons.

The expression of genes encoding G-protein beta gamma subunits was investigated in isolated olfactory receptor neurons from channel catfish. DNA sequencing of PCR products showed that the beta 1, beta 2, gamma 2 and gamma 3 genes were expressed in the neurons. Western blotting showed that at least three of these subunit proteins were expressed. This first analysis of the expression of beta gamma genes in olfactory receptor neurons suggests that these subunits may be involved in a variety of transduction events in these cells.

Percutaneous endoscopic laser lithotripsy of retained stones in the left hepatic duct. The role of the surgeon.

A 35-year-old woman with a retained stone in a branch of the left hepatic duct was referred to us. The stone was discovered on the postoperative T-tube cholangiogram. A flexible ureteroscope was introduced into the duct, under fluoroscopic and direct endoscopic vision and the pulse dye laser was used successfully to disintegrate the calculus. The postoperative course was uneventful. We suggest that in certain selected cases, the pulsed dye laser might be useful in disintegrating stones sited in difficult positions.

Modern operative fluorocholangiography: utopia or overlooked entity?

A system of image amplification with television fluoroscopy and 100 X 100 mm cut film technique is presented for use in the operating room. Biliary surgery has benefited from this equipment as operative cholangiography has been improved and unnecessary extension of operating time avoided. Applications of the equipment for other procedures are discussed.