Arthur R. Crampton

Percutaneous-Endoscopic Biliary Stent Placement: A Preliminary Report

The placement of large-bore endoprostheses for relief of biliary obstruction by the percutaneous-transhepatic route is painful, requires a large hepatic parenchymal tract, and has a fairly high complication rate. The alternative technique of endoscopically placing similar-sized stents requires special instruments and skills, and may fail in passing very tight stenoses. We report a simpler combined percutaneous-endoscopic biliary stent (PEBS) placement technique with a high placement rate used in 11 patients with advanced malignant obstruction. In all 11 patients, 10 and 11.5 French stents were easily placed. Three patients developed sepsis but responded to antibiotics. One clogged stent required replacement. Two stents needed later endoscopic adjustment. Results of liver function test improved in 10 patients, and 8 patients showed improved quality of life.

Accessory Hemiazygos Continuation of Left Inferior Vena Cava: Ct Demonstration

The first CT description of accessory hemiazygos continuation of a left-sided inferior vena cava is presented. This venous anomaly appears as a mediastinal mass on plain chest films and may simulate an aortic dissection on CT or angiography. Careful attention to the various abnormal vascular pathways will obviate the need for further invasive testing.

Percutaneous-endoscopic biliary stenting in patients with occluded surgical bypass

PURPOSE The purpose of this investigation was to test the feasibility of using a recently developed technique of placing internalized biliary stents into patients who have had reobstruction after initial surgical bypass. PATIENTS AND METHODS Seven men and three women, 46 to 85 years of age (eight with pancreatic carcinoma, one with metastatic colon, and one with metastatic ovarian carcinoma), all had reobstruction after initial surgical bypass palliation. Subsequent attempts to place stents via endoscope failed in five patients; a pair of 7-Fr stents placed in one patient failed to drain well. Endoscopic stenting in four patients was not even attempted because of severely distorted anatomy. Nine of the 10 patients then had successful internal stent placement by a combined percutaneous-transhepatic and peroral-endoscopically guided technique. RESULTS One of these nine placeable stents failed to drain well and the patient died 8 days later with massive tumor. Seven showed a significant decrease in bilirubin levels and improved quality of life. Two of these had sepsis that responded to antibiotics. Life span ranged between 11 days and 10 months, with one patient still alive; no deaths were directly due to stents. CONCLUSION A combined transhepatic-peroral technique of placing internalized biliary stents can be expected to result in repalliation in a majority of patients with reobstruction after earlier surgical bypass and in whom subsequent attempts at endoscopic placement of stents have failed or in whom tumor growth prevents undertaking the endoscopic approach.

Percutaneous-endoscopic biliary stent placement for Billroth II and total gastrectomy with Roux-en-Y enteroenterostomy

Some authors believe the endoscopic placement of large biliary prostheses has become the preferred palliative treatment for unresectable malignant obstruction of the biliary ducts.4 The success rate for inserting these stents endoscopically has approached 90%.3.5.6 In a collected series the mean survival of stented patients has ranged from 13 months for those with ampullary cancers to 5 months for patients with lesions above the midcommon bile duct. However, the presence of prior Billroth II partial gastrectomy with its attendant difficulty in ampullary access has been cited for causing failures of endoscopic approach to prosthetic placement.• Other methods of combined percutaneous-endoscopic biliary stenting (PEBS) that achieve placement of 10-11.5 F internal biliary stents with relative ease have recently been described.4.8·9 Our recently described techniqueS appears to be particularly suited to patients with prior gastric resection. We present two examples, one patient having had prior Billroth II and another with prior total gastrectomy and Roux-en-Y enteroenterostomy.

Calcification of the Abdominal Aorta as an Aid in Diagnosis of Gastric Carcinoma vs. Benign Ulcer

The stomach is an organ commonly affected by both cancer and benign ulceration. Benign, chronic ulcers in the elderly person can be large and for other reasons not easily differentiated from malignant tumor. That a negative cancer-atherosclerosis relationship exists has been suggested by many pathologists in the past (12, 18, 19). Grosse (12) has compiled the observations of 15 authors in 36,757 postmortem examinations, 11,094 of which were cancer cases. All of these authors agree that the incidence and the severity of atherosclerotic lesions are significantly less pronounced in cancer patients than in controls of the corresponding age groups. Beebe (1) showed that cancer tissue contained a low amount of calcium salts. The calcium in human tumors was found to be decreased and the potassium increased in proportion to the degree of malignancy. Eggers (5) states, in respect to the relation of cancerous growth to mineral elements, that the evidence of the action of potassium salts in facilitating, and of calc...

Arteriographic evaluation of postsurgical stomach

Visceral arteriography was performed in 35 adult patients who had undergone various types of gastric surgery. Nineteen of these patients had presented with gastrointestinal hemorrhage at different postoperative intervals (4 days–23 years). Arteriography showed the bleeding site in 14 (74%) and permitted its nonoperative control in 8 cases. Diffuse hemorrhage from the gastric pouch as well as localized bleeding from suture line, marginal or stress ulcers, and other sources were recognized. Arteriography was also crucial in the diagnosis of iatrogenic arteriovenous fistulas, telangiectasia in the anastomotic regions, inadvertently ligated arteries, and postoperative changes in the vascular architecture. Value and limitations of arteriography of the postsurgical stomach are presented together with a review of the pertinent literature.

Cavernous hepatic hemangioma simulating metastatic renal cell carcinoma

A case of cavernous hemangioma of the liver resembling a metastatic deposit is reported in a patient with renal cell carcinoma. The clinical and angiographic features that distinguish hepatic hemangiomas from metastatic renal cell carcinoma are discussed. The importance of this distinction in patient management is emphasized.