Biomedical subjects
Publications and source records attributed to C E Bender.
An easy, percutaneous technique for conversion of a needle catheter jejunostomy to a large bore jejunal feeding tube is described. There were no complications encountered in seven patients.
We treated 75 patients with symptomatic cholesterol gallstones by dissolving the stones with methyl tert-butyl ether (MTBE) instilled into the gallbladder through a percutaneous transhepatic catheter. The MTBE was continuously infused and aspirated manually four to six times a minute, for an average of five hours per day for one to three days; the treatment was monitored by fluoroscopy. The placement of the catheter and the administration of MTBE caused few side effects or complications, and treatment did not have to be stopped in any patient for this reason. In 72 patients there was complete dissolution of stones or more than 95 percent dissolution. Among 21 patients who were completely free of stones after treatment, 4 had recurrence of stone formation 6 to 16 months later. The other 51 patients had residual debris, which spontaneously cleared completely in 15 patients within 6 to 35 months; only 7 with persisting debris have had symptoms. Five of the initial 6 patients treated, but only 1 of the next 69 patients, have required surgery during follow-up periods of 6 to 42 months. We conclude that the dissolution of gallstones by MTBE delivered through a percutaneous transhepatic catheter is a useful alternative to surgery in selected patients with symptomatic cholesterol stones. Further study will be necessary to establish the long-term effectiveness of this treatment and its appropriate role in the management of the various types of gallstones.
To explore the possibility that gallbladder stone fragments might be able to be safely dissolved using methyl tert-butyl ether immediately after extracorporeal shock-wave lithotripsy (ESWL), a feasibility study in 8 patients with one to four partially calcified gallbladder stones was performed. The gallstones averaged 2.2 cm in diameter (range 1.3-3 cm) and contained layered or diffuse calcium detectable by computed tomography scan only (7 patients) or plain film (1 patient). After a 5F (1.7 mm) pigtail catheter was placed percutaneously into the gallbladder, ESWL fragmentation was performed using a renal stone lithotriptor. The patients were under general anesthesia and in the prone position on a support gantry designed for gallbladder stone ESWL. Following ESWL, methyl tert-butyl ether was infused and aspirated via the gallbladder catheter until no further stone material was radiologically detectable or could be dissolved. After 8-26 h (mean = 13 h) of methyl tert-butyl ether therapy, no radiologically detectable gallstones remained in 6 of 8 patients. Shell fragments of three peripherally calcified stones in 1 patient and the densely calcified, predominantly pigment stone in a second patient were refractory to combined therapy. Both ESWL and treatment with methyl tert-butyl ether were well tolerated in all patients, although bile leakage after catheter removal occurred in 3 patients, one of whom was treated by cholecystectomy. Additional measures to prevent bile leakage may be advisable if these two modalities are to be used in tandem. We found no evidence, however, that predissolution stone fragmentation with ESWL predisposed the gallbladder to either mucosal damage by methyl tert-butyl ether or increased absorption of it.
A familial asymptomatic os odontoideum with a Klippel-Feil type II fusion of C-2 and C-3 is reported. The pattern of inheritance within this family is consistent with that of autosomal dominance. The index case, a 16-year-old boy, was studied with plain cervical spine x-ray films, lateral cervical tomography in flexion and extension, fluoroscopic evaluation of the subluxation, and magnetic resonance (MR) imaging of the spine in flexion and extension. In spite of the subluxation noted on flexion and extension, there was no evidence of cord compression on MR imaging. The etiology and management of this condition are discussed.
An enteroscopic method that uses a pediatric colonoscope provides an alternative approach to the diagnostic and management problems arising in the setting of a Roux-en-Y limb hepaticojejunostomy or biliary diversion. Three patients with Roux-en-Y limb reconstructions who experienced recurrent cholangitis, recurrent pancreatitis, or choledocholithiasis in whom the technique was used are presented. The technique, which uses colonoscopic principles, is discussed along with the combined use of percutaneous transhepatic assistance. Enteroscopy of a Roux-en-Y limb is technically feasible and expands the diagnostic and management approach to biliary and pancreatic disease involving this postoperative anatomic condition.
The purpose of this study was to evaluate the usefulness of CT and sonography as procedures complementary to cholangiography in the detection and staging of cholangiocarcinoma. The studies of 42 patients with pathologically proved cholangiocarcinoma and preoperative CT (26 patients), sonography (30 patients), and cholangiography (31 patients) were reviewed blindly and retrospectively. The tumor was shown by CT in 69%, by sonography in 47%, and by cholangiography in 97% of patients. Three radiographic types of cholangiocarcinoma were identified: infiltrating stenotic (69%), bulky exophytic (19%), and polypoid intraluminal (12%). CT correctly staged 54%, sonography 50%, and cholangiography 58% of tumors as resectable (40%) or unresectable (60%). The sensitivities in detecting unresectability with CT, sonography, and cholangiography were 44%, 19%, and 43%, respectively; specificities were 78%, 100%, and 100%, respectively. CT and sonography combined with cholangiography increased the sensitivities to 64% and 50%, respectively. CT and sonography were complementary to cholangiography because they helped determine the extrabiliary extent of these tumors and therefore provided information on resectability.
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The criteria for a diagnosis of loosening or infection of hip arthroplasties on arthrographic study were further refined by a retrospective review of 178 arthrograms representing 170 patients. The 97 arthroplasties that were surgically evaluated form the basis of this report. With the refined criteria, subtraction arthrography had a sensitivity of 96% and specificity of 92% for demonstrating loosening of the femoral component and a sensitivity of 97% and a specificity of 68% for demonstrating loosening of the acetabular component. Pseudocapsule size and the presence of bursae were important factors influencing arthrographic interpretation. Arthrographic findings of pseudocapsule irregularity and the presence of nonbursal cavities were suggestive of infection but were not sensitive or specific. Laboratory evaluation of aspirated material was a more reliable predictor of infection, although its sensitivity was only 71%.
Benign postoperative biliary strictures in 74 patients were dilated percutaneously with balloon catheters. In all cases, dilation was performed with fluoroscopic guidance in a radiology suite. Lasting patency following removal of biliary stents occurred in 73% of 49 patients with biliary-enteric anastomotic strictures and in 88% of 25 patients with primary ductal strictures, for an overall success rate of 78%. A successful outcome was more likely if the interval between the last biliary tract surgery and balloon dilation exceeded 2 years. Stricture patency was more easily achieved in patients with primary ductal strictures than in those with biliary-enteric anastomotic strictures. Serious, procedure-related complications were encountered when strictures were dilated transhepatically; these included sepsis in 18 of 65 patients and bleeding due to arteriobiliary communications in seven. No serious complications occurred when strictures were dilated via a T tube track, making this the preferred route if available. Surgeons should be encouraged to leave T tubes in place if postoperative biliary stricture is suspected. Balloon dilation should be strongly considered in patients with benign postoperative strictures in whom surgical repair is difficult.
A retrospective review of 178 consecutive subtraction hip arthrograms (175 patients) was performed to evaluate the significance of cavities or bursal communications (or both) with the pseudocapsule in patients with painful hip arthroplasty. Bursae and/or communicating cavities were shown in 75 (43%) of the 175 patients. Communicating irregular cavities were noted in 12 patients (nine infected), and smooth bursae or bursalike structures were noted in 63 patients. The most frequent bursal locations were the greater trochanteric region (32/63), supraacetabular region (18/63), and iliopsoas (12/63). Three patients had multiple bursae. Six of the 18 acetabular bursae were associated with previous dislocations. Twenty-seven patients with bursae had no radiographic findings of loosening or infection. Of these 27, 12 (44%) responded to local injection of anesthetic into the bursa and were judged clinically to have bursitis. Arthrography, with aspiration from the bursae or cavities and injection of anesthetic, provides additional information regarding painful hip arthroplasty and may prevent unnecessary surgery.
Two patients with biliary cancer received radical radiation therapy. After treatment, both patients experienced episodes of biliary obstruction without definite evidence of progression of the tumor. These cases emphasize the importance of including radiation-induced biliary fibrosis in the differential diagnosis of hepatic duct stricture after radical radiation therapy.
Confirmation of tissue pathologic changes often is necessary before appropriate therapy can be instituted for lesions of the thoracic spine. Plain film roentgenography and computed tomography provide the key information needed for the percutaneous biopsy procedure. The location and type of bone involvement (lytic or sclerotic) and the presence or absence of a soft tissue mass determine the imaging technique and the choice of needle to use for safe and accurate performance of the procedure. In 26 patients with thoracic spinal or paraspinal lesions (or both), biopsy was done with use of fluoroscopic or computed tomographic guidance. The overall accuracy was 90%. Pneumothorax occurred in two patients. Percutaneous biopsy is a rapid, safe technique for diagnosis of lesions of the thoracic spine.
1. CT and sonography are helpful in distinguishing between an obstructing lesion and hepatocellular disease as the cause of jaundice. 2. CT and sonography can demonstrate the level and extent of an obstructing lesion, and can define its nature if a mass more than 1-2 cm is present; sonography is usually the preferred screening study because of its availability, relatively low cost and lack of radiation hazard. 3. PTC or ERCP is useful in the evaluation of jaundice when sonography and CT are equivocal, fail to provide information necessary to establish proper therapy, or are at variance with the clinical impression of obstructive jaundice; in addition to defining obstructions these techniques can detect atrophy, sequestra, stones, abscesses, fistulas, primary sclerosing cholangitis, etc. 4. PBD offers an expedient alternative to surgical decompression in patients with obstructive jaundice, since most cancers that cause biliary obstruction are not resectable for cure at the time of diagnosis.
We report the results of 1,000 consecutive patients who underwent percutaneous removal of renal and ureteral stones. Removal was successful for 98.3 per cent of the targeted renal stones and 88.2 per cent of the ureteral stones. Complications, evolution and technique are discussed. Percutaneous techniques are an effective way to handle the majority of renal calculi and these techniques will continue to be important as shock wave lithotripsy becomes more widespread in the United States.
Two patients had colonic perforation as a result of percutaneous nephrostomy placement followed by track dilatation and renal calculus removal. We present the technical aspects of nephrostomy placement and stone removal, as well as the clinical diagnosis and management of these cases. Both patients recovered well with conservative therapy and required no surgical intervention. This report reviews the anatomic considerations for percutaneous nephrostomy in patients undergoing renal stone removal.
Cholangiograms from 104 patients (and serial cholangiograms in 66 patients) with primary sclerosing cholangitis (PSC) were reviewed. In 13 patients the additional diagnosis of cholangiocarcinoma was made at biopsy or autopsy. Cholangiograms from patients with both PSC and carcinoma were compared with cholangiograms from patients with PSC alone. Marked dilatation of ducts or ductal segments (100% vs. 24%) and the appearance of a polypoid mass (46% vs. 7%) were common findings in the group of patients whose disease was complicated by malignancy. In the malignant group, polypoid masses were larger, measuring 1 cm or greater in diameter. On serial cholangiograms, four of 15 patients with progressive stricture formation and four of five with progressive ductal dilatation proved to have carcinomas. The frequent occurrence of bile duct carcinoma as a complication of PSC in this group of patients indicates that PSC has a strong tendency to undergo malignant degeneration. Cholangiographic findings which suggest malignant degeneration include markedly dilated ducts or ductal segments, presence of a polypoid mass 1 cm or greater in diameter, and progressive stricture formation or ductal dilatation.
Percutaneous renal and ureteral stone removal procedures are widely practiced. A new technique is described for removal of small symptomatic ureteral calculi using small (less than or equal to 14 French) tearable sheaths and standard stone retrieval baskets placed through acute percutaneous nephrostomy tracks. This fluoroscopically-guided technique was successful in 60 of 64 patients, who ranged from 16 to 88 years old. Subsequent endoscopic percutaneous calculus removal was successful in the four failures. The use of these small sheaths over previously described large tracks has produced no major complications, short hospital stays, and minimal patient disability.
While most cases of primary sclerosing cholangitis are characterized by multifocal bile duct strictures, a few have a localized high-grade stricture (dominant stricture) superimposed on diffuse disease. This dominant stricture may cause jaundice or bacterial cholangitis in some patients. Dominant strictures were percutaneously dilated in 14 patients with primary sclerosing cholangitis and jaundice or bacterial cholangitis. Stricture dilatation produced a significant decrease in the frequency of cholangitis and a significant decrease in serum bilirubin in those with recent onset of jaundice. The only complication was bacteremia or cholangitis in five patients. Three of nine patients with successful dilatations developed recurrent strictures at 6-18 months. Balloon dilatation should be considered the treatment of choice for dominant strictures in symptomatic patients with primary sclerosing cholangitis who have recent onset of jaundice (less than 6 months' duration) or recurrent episodes of bacterial cholangitis.