A Campatelli

Comparison between ethanol sclerotherapy and emptying with injection of saline in treatment of thyroid cysts

We compared the results of ethanol sclerotherapy in thyroid cysts with emptying of cysts and instillation of saline. Twenty-six patients with recurrent thyroid cysts were treated with cyst aspiration and subsequent ethanol sclerotherapy. A control group of 44 patients was submitted to cyst aspiration and subsequent injection with isotonic saline; among them 20 had previously been treated with repeated aspirations of the cyst fluid. The patients were followed up clinically and ultrasonically 1 and 12 months after treatment. Cure was defined as the absence of any residual cystic lesion or an ultrasonic cyst volume less than 50% of basal after 12 months from the start of treatment. Cytological study showed all of the lesions to be benign. Of the 44 patients in the saline group 16 (36%) were cured, among whom 6 of 20 had previously been submitted to repeated aspirations. Among the 26 patients treated with ethanol sclerotherapy 20 (77%) were cured. Statistical analysis revealed a significantly higher effectiveness of treatment with ethanol than that with emptying and saline instillation (chisquare,P = 0.002) or with repeated aspiration and saline instillation (chi-square,P = 0.003). Slight pain was observed in two patients treated with saline and five treated with ethanol sclerotherapy. Three patients treated with ethanol sclerotherapy presented severe pain and one transitory hyperthyroidism. We conclude that ethanol sclerotherapy is effective and safe in the treatment of thyroid cysts.

Endosonographic staging of rectal carcinoma.

Transrectal ultrasonography (US) scanning facilitates the ultrastructural differentiation of the various histologic layers of the rectal wall. In particular, the muscularis propria is represented by the 4th sonographic layer. Rectal carcinoma appears on US as a low echogenic area that suddenly interrupts the regular sequence of parietal layers.Sixty-five patients suffering with carcinoma of the lower two-thirds of the rectum underwent pre-operative linear endosonography for staging. The reliability of such a method in assessing the extra-rectal spread was evaluated in our study, at the end of which 55 sonographic/histologic correlations were obtained. Four false-negative and 1 false-positive determinations of the presence or absence of extrarectal spread proved that sonography has a sensitivity and specificity of 91%, with a positive predictive value of 97% and a negative predictive value of 71%. Lower results are obtained in lymph node staging: enlarged lymph nodes are seen in only 11/22 C1/C2 patients (11 false negatives) while we were aware of 3 false positives.

T-tube removal after liver transplantation: A new technique that reduces biliary complications

This article discusses a new simple, fast, and easily performed technique that allows reduction of morbidity and hospital stay after T-tube removal. A retrospective analysis was conducted of 145 recipients who underwent T-tube removal 3 months after orthotopic liver transplantation. Patients were divided in two groups: group 1 (n=93) underwent T-tube removal and contemporary placement under fluoroscopic guidance of a counter-drain. Group 2 (n=52) T-tubes were removed from the bile duct under fluoroscopy but were left in place as a counter-drain. Overall, there were 33 (22.7%) complications related to T-tube removal. Treatment was always conservative and no deaths were related to T-tube. In group 1, 29 (31.2%) complications occurred; and the mean hospital stay was 9.4±9.3 days. In group 2, four complications (7.7%) occurred (P =0.002); and the mean hospital stay was 5.8±5.5 days (P =0.012). The adoption of this new technique—under fluoroscopic guidance, using the T-tube itself as a counter-drain—for T-tube removal allowed us to significantly reduce biliary complications and hospital stay.

Incidentally discovered adrenal masses: evaluation with Gadolinium enhancement and fat-suppressed MR imaging at 0.5 T

The purpose of the study is to evaluate the ability of Gd-enhancement and fat-suppressed MR imaging operating at midfield strength to characterize incidentally discovered adrenal masses. Sixty patients with 72 adrenal masses incidentally discovered during US or CT exams were studied with a 0.51 MR unit following clinical and laboratory evaluation. After Gd-DTPA intravenous administration a modified three-point Dixon technique was performed in all patients. This technique provided three images sets: conventional T1-weighted SE images, fat-suppressed T1-weighted images and water-suppressed T1-weighted images. Diagnosis was established by means of surgery (11 lesions), fine-needle biopsy (21 lesions) and stability on ultrasonographic follow-up for at least 1 year (range, 12-87 months) from adrenal lesion discovery (40 masses). In most of adenomas (n = 55) an homogeneous enhancement was observed on postcontrast T1WI; however, 15 out of these lesions showed a small focal spot of high intensity in Gd-enhanced fat-suppressed images. On the contrary, malignant conditions (n = 6) and pheochromocytoma (n = 1), all had inhomogeneous signal intensities which were relatively higher after Gadolinium injection as compared with the liver. The fat suppression technique demonstrated areas of bright signal intensity related to high vascularity. The performance of three observers in order to differentiate malignant from benign conditions showed sensitivity, specificity, diagnostic accuracy, positive and negative predictive values of 100, 88.5, 90, 50 and 100% on the basis of gadolinium enhancement only, by utilizing the Dixon technique. In conclusion, although Gd-enhancement and fat-suppressed sequence helped correctly differentiate among the groups of incidentally discovered adrenal masses, the degree of overlap suggests that it is still difficult to characterize individual patients. However, the modified three-point Dixon technique after contrast material administration appears to be a further capability of midfield MRI in the characterization of adrenal tissue.

Ultrasound detection of unusual spontaneous portosystemic shunts associated with uncomplicated portal hypertension.

Seven cases of unusual spontaneous portosystemic shunts observed by ultrasonography in the last 8 months are reported, including cases of coronary vein varicocele and patent umbilical vein; two cases of spleno‐retroperitoneal anastomosis; omphalo‐ilio‐caval anastomosis; superior mesenteric vein‐inferior vena cava anastomosis; spleno‐renal anastomosis; and spleno‐portal anastomosis and anastomosis from the splenic vein to the abdominal wall. One of these collateral vessels was also analyzed by pulsed Doppler flowmetry. The patients were either cirrhotic or had pre‐hepatic portal hypertension (resulting from chronic pancreatitis) and gave no history of gastrointestinal bleeding or ascites. Two of these patients had previously undergone surgery for problems associated with cholestasis. In both cases, presurgical sonographic studies were used to guide the surgical procedures in the hope of preserving the anomalous connections. Furthermore, ultrasound detection of spontaneous portosystemic shunts was an important factor in interpreting the clinical symptoms of these patients.

Segmental organization of the pig liver: anatomical basis of controlled partition for experimental grafting.

Segmental anatomy has been investigated on 54 pig livers by bench-top radiology and ultrasonography of hepatic and portal vessels and bile ducts and dissection of suprahepatic veins. Eight segments were recognized, homologous to those of the human liver. Major variations were found only of arterial distribution. The inferior vena cava invariably ran within the parenchyma of the right lobe and close to the liver hilum; suprahepatic veins were also entirely intraparenchymal. Therefore, the pig liver can easily be divided into two halves, but only the right one can be used for reduced-size grafting into a recipient.

Diagnosis of adrenal adenoma: value of central spot of high-intensity hyperintense rim sign and homogeneous isointensity to liver on gadolinium-enhanced fat-suppressed spin-echo MR images.

Eighty‐nine patients with 108 adrenal masses, either adenomas (n = 88) or malignant lesions (n = 20), underwent magnetic resonance imaging (MRI) of the abdomen at 0.5 T for the purpose of determining whether adrenal adenomas could be differentiated from malignant lesions on gadolinium‐enhanced fat‐suppressed T1‐weighted spin‐echo (SE) images (Gd‐E FS T1WI) and on T2‐weighted SE images. The imaging protocol included conventional unenhanced SE T1‐ and T2‐weighted sequences and Gd‐E FS T1WI. Three observers independently evaluated signal intensity on unenhanced and enhanced images and also the presence of structures of high signal intensity in the outer margin [hyperintense rim sign (HRS)] or in the center [hyperintense central spot (HCS)] of the adrenal masses. Forty‐one (46.5%) of 88 adenomas were homogeneously isointense to liver in unenhanced and enhanced T1‐weighted sequences and in T2WI. HCS and HRS were observed in 33/88 (37.5%) and 15/88 (17%) adenomas, respectively, on Gd‐E FS T1WI; in contrast, these signs were never revealed in any case of malignant lesions. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy in classifying lesions as suggestive of adenoma were 93%, 90%, 98%, 75%, and 93%, respectively. Visual evaluation of details of tumor structures on Gd‐E FS T1WI allows good characterization of adrenal masses. HCS, HRS, and homogeneous isointensity to liver are characteristic signs of adrenal adenomas. J. Magn. Reson. Imaging 1999; 9:304–310.

Nonoperative management of pancreatic pseudocysts. Problems in differential diagnosis.

CONCLUSION The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. Awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively. BACKGROUND The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic errors occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature. METHODS Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo. RESULTS Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12-154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period.SummaryBackground. The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic error occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature.Methods. Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo.Results. Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12–154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period.Conclusion. The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. Awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively.

Renal hypertension due to giant perirenal haematoma: permanent resolution by percutaneous ultrasound-guided drainage.

We describe a case of renovascular hypertension accompanied by renal failure, arising in a young man with a solitary kidney 4 months after a blunt abdominal trauma. A giant haematoma was found around the right kidney and ultrasound-guided percutaneous drainage completely relieved the symptom complex. Nine years later, the patient is normotensive with normal renal function.

Role of color Doppler sonography in post-transplant surveillance of vascular complications involving pancreatic allografts

PURPOSE To evaluate the role of color Doppler ultrasonography in the postoperative surveillance of the vascular complications involving pancreas allografts. METHODS A retrospective analysis of a consecutive series of 223 pancreas transplantations was performed. All recipients received antithrombotic prophylaxis, which was tailored to the individuals estimated risk of thrombosis. All patients were monitored with daily color Doppler ultrasonography during the first post-transplant week and thereafter whenever clinically indicated. Vascular complications were defined as all thrombotic events requiring: increased anticoagulant therapy, angiography with fibrinolytic therapy, or repeat surgery. RESULTS The overall patient survival rates at one, three, and five years after transplantation were 94.7%, 93.3%, and 91%, respectively. The overall graft survival rates at the same time points were 87.4%, 79.6%, and 75.6%, respectively. In 28 of the 223 cases (12.5%) graft thromboses were diagnosed with Doppler ultrasound within the first 10 days after transplantation. In 3 cases, graft pancreatectomies were performed because of a complete loss of blood flow in the parenchyma. An attempt to rescue the graft was made in 18 patients. Fourteen of these grafts were saved and are still functioning (77.7%); and 4 rescue attempts failed and the grafts were subsequently explanted (32.3%). CONCLUSION Color Doppler ultrasound is a suitable tool for postoperative surveillance of pancreas transplant recipients. Its use can lead to early diagnosis and timely treatment of vascular complications.