Controversial issues in the management of pancreatic cancer: Part one. A debate held at St Mary's Hospital, London on 18 November 1993.
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Biopsy, Needle↗
Biomedical subjects
W M Gedroyc
Publications and source records attributed to W M Gedroyc.
Controversial issues in the management of pancreatic cancer: Part Two. A debate held at St Mary's Hospital, London on 18 November 1993.
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Aged↗
Magnetic resonance angiography of renal arteries.
Magnetic resonance angiography has very exciting potential for the investigation of renal artery stenosis. This article discusses what exact techniques are optimal and current information suggests that 3-D phase contrast sequences are probably the best that are currently available for this role. Magnetic resonance imaging techniques provide instantly recognizable images and generally are more acceptable than other modalities. In addition, the current study suggests a very promising sensitivity and specificity for the determination of renal artery stenosis.
Humans↗
Surgical clip artefact mimicking arterial stenosis: a problem with magnetic resonance angiography.
In three patients undergoing three-dimensional phase contrast magnetic resonance angiography (MRA) for evaluation of renal transplant arteries, a convincing stenosis was demonstrated that was not present on conventional angiograms. In each patient there was a stainless steel surgical clip in the soft tissues adjacent to the renal artery. Although the clip artefact was easily recognized on the acquired tomographic magnetic resonance slices, it was completely indistinguishable from a true stenosis on the final projection images. This may limit the use of MRA in post-surgical vascular evaluation unless review is made of the phase contrast images.
Adult↗
Magnetic resonance angiography of renal transplants.
Stenosis of the artery of transplanted kidneys is an important cause of graft dysfunction. Diagnosis and follow-up of this condition normally requires intra-arterial digital-subtraction angiography (IADSA), which is invasive and may cause complications. A possible alternative to IADSA is magnetic resonance angiography (MRA), and we have assessed this technique in 50 renal transplant patients who were referred for investigation of possible renal arterial stenosis. In every patient, MRA was compared prospectively with conventional IADSA. Compared with IADSA, MRA had a sensitivity of 83% and a specificity of 97%, and when all images were graded retrospectively for severity of stenosis, the two techniques showed a significant correlation (r = 0.74, p less than 0.001). MRA can provide an accurate image of the renal transplant artery in a non-invasive manner with a high sensitivity and specificity.
Angiography, Digital Subtraction↗
Middle aortic syndrome: clinical and radiological findings.
Eight patients with the middle aortic syndrome are described. They were aged 2 months to 14 years at diagnosis; follow up was one to 11 years. Clinical presentations included asymptomatic hypertension (n = 5), severe headache, nose bleed, and chest pain (n = 1), and cardiac failure (n = 1). All had severe hypertension requiring multiple drug treatment. Diminished peripheral pulses were not helpful in the diagnosis, which is made on aortography. Associated clinical findings were Williams' syndrome (n = 3) and appreciable eosinophilia (n = 3). The differential diagnosis includes Takayasu's arteritis, fibromuscular dysplasia, and neurofibromatosis. Blood pressure was adequately controlled by medical treatment in six patients. Surgical angioplasty was performed in two. One patient remained normotensive without drug treatment 21 months after operation; the other died of sepsis and uncontrollable haemorrhage in the postoperative period. Medical treatment is satisfactory in most cases: surgery should be reserved for those in whom blood pressure cannot be controlled without unacceptable side effects of drug treatment. Although rare, the middle aortic syndrome should be considered in the differential diagnosis of hypertension when commoner causes have been excluded. Aortography is necessary for diagnosis.
Adolescent↗
Percutaneous stone and stent removal from renal transplants.
Techniques developed for removal of stones from normally sited kidneys can be safely employed in the transplanted kidney. We describe our experience in removing stones, stent material and organised blood clot from renal transplant collecting systems, using modified percutaneous techniques.
Adult↗
Normal and near normal caliceal patterns in reflux nephropathy.
Distorted, clubbed calices associated with focal renal scars or areas of more diffuse parenchymal loss make up the accepted urographic diagnostic criteria of chronic reflux nephropathy. It is widely believed that this diagnosis should not be suggested in the absence of the above findings and that scarring with normal calices indicates a vascular aetiology. This study describes five children with marked renal parenchymal loss all of whom have normal or near normal calices underlying the areas of parenchymal thinning and all of whom show severe vesico-ureteric reflux on micturating cystography. We suggest that these patients represent examples of true reflux nephropathy and that normal or near normal caliceal patterns may be seen underlying areas of renal parenchymal damage in this condition. No localised scars were seen in association with normal calices and we suggest that the marked tissue distortion caused by localised indented scars plays a significant part in producing the caliceal appearances more usually seen in reflux nephropathy. Other possible mechanisms responsible for the maintenance of relatively normal caliceal architecture are also discussed.
Child↗
More medullary sponge variants.
Sponge kidney has characteristic plain film and urographic findings which are generally regarded as being limited to the medullary pyramids. We describe two groups of patients with renal changes of medullary sponge kidney who show additional renal abnormalities. In the first group there were multiple cortical cysts; in the second there were cavities deep in the medulla, many of which communicated with the calices. Neither of these findings has been described before and we suggest that the spectrum of changes associated with this condition is wider than has previously been appreciated.
Humans↗
Ureteric obstruction in stented renal transplants.
The use of renal stents in renal transplants is becoming increasingly popular and has been routine practice at this institution for the past 4 years. Despite this procedure, however, obstruction of the transplant ureter still occurs and we describe 7 patients who developed renal obstruction in the presence of a stented transplant ureter. The underlying causes of these findings are discussed together with suggested recommendations for optimum radiological assessment of transplant ureteric stents. The implication of these observations is that urine may flow down stented ureters between the ureter and the stent rather than down the stent lumen.
Adolescent↗
CAPD fluid: a common cause of photon deficient lesions on 99mTc-D.T.P.A. scans in renal transplant patients.
Single or multiple transient photon deficient areas on 99mTc-DTPA scintigrams were found in 40% of a series of 34 patients who had undergone renal transplantion directly from CAPD maintenance. Ultrasound showed only loculated intraperitoneal CAPD fluid adjacent to the transplant with no evidence of local complications. We conclude that such collections are a common cause of photon deficient areas on 99mTc-DTPA transplantscintigrams and in the absence of ultrasound, these appearances should be interpreted with caution.
Humans↗
Arteriography of renal transplantation.
The arterial anatomy of renal transplants is often complex, with overlapping, tortuous vessels which prevent easy visualisation of the origins of the transplant artery. We have adopted a technique using smallbore catheters with non-selective 'flush' injections of contrast medium, high resolution magnification techniques and multiple oblique projections. A retrospective study over six years (1980 to 1985 inclusive) revealed 34 significant (greater than 50%) transplant artery stenoses (13 adults, 21 children) from 200 transplant arteriograms performed. During this period, 452 transplants were performed, 38% in children. The incidence of transplant artery stenosis was 7.5%. Percutaneous transluminal angioplasty was attempted in 11 patients (four adults, seven children), with technical success in only five (45.5%). The predominance of children in this group contributes to the poor success rate of percutaneous transluminal angioplasty in our hands, which we attribute to the small arteries involved, the acute vessel angulations seen and the tough undilatable stenoses which are encountered in transplants in paediatric patients. Fourteen patients with post biopsy arterio-venous fistulae are described and the role of embolisation in this condition is discussed. A simplified approach for the arteriography of live related donors is also described.
Adolescent↗
The early chest radiographic changes of Pneumocystis pneumonia.
In a retrospective 3-year survey, 14 immunosuppressed patients from a renal unit were diagnosed as having Pneumocystis pneumonia. All 14 patients had a chest radiograph taken within 48 h of the onset of the acute illness. In only three out of the 14 cases did the radiograph show 'classical' bilateral perihilar infiltration: In six the film was normal and in five there were minimal non-specific changes only. We conclude that normal radiographic appearances are common in the early stages of Pneumocystis pneumonia and 'classical' radiological features are rarely seen.
Humans↗
Management of ureteral strictures in renal transplants by antegrade balloon dilatation and temporary internal stenting.
PURPOSE: To evaluate the efficacy of percutaneous balloon dilatation and temporary internal stenting in the treatment of transplant ureteral strictures. METHODS: Nine patients presenting with obstructed renal transplants were treated by antegrade nephrostomy insertion, ureteroplasty, and temporary internal stenting. Following stent removal, patients were divided into two groups for analysis according to whether the obstruction occurred less than (group A) or more than (group B) 3 months following transplantation. RESULTS: All procedures were technically successful. In group A (n = 6), all patients were successfully treated by one or two dilatations with stenting. In group B (n = 3), two patients were successfully treated by one dilatation with stenting. Overall, eight patients (89%) have had their primary or secondary stent removed successfully at a mean interval of 97.5 days after insertion, and remain well at a mean follow-up interval of 22 months. CONCLUSION: Balloon dilatation and temporary internal stenting is a useful method for treating transplant ureteral strictures.
Catheterization↗