Bob W. Gayler

The use of silastic transhepatic stents in benign and malignant biliary strictures.

Between 1969 and 1978, 45 patients with biliary strictures have been managed surgically utilizing silastic transhepatic stents. In 25 patients the strictures were benign. After resection or dilatation of the benign stricture, an hepaticojejunostomy was performed to a Roux-en-Y loop. The anastomosis was stented with a large bore silastic tube with multiple side holes passed through the biliary tree, out the anterior surface of the liver, and then out through the abdominal wall. There was one hospital death. Most stents were left in place for one year. Of the 15 patients with long-term follow-up, all have had excellent results. In 20 patients the strictures were malignant and involved the common hepatic duct in 10 patients or its bifuraction in 10 patients. In 14 patients the tumor was thought to be primary in the biliary tree, and in six patients the tumor was felt to represent a metastasis or direct extension from another site. In three patients the tumors were resected, and in the remaining they were dilated or bypassed. After positioning a silastic transhepatic stent, a hepaticojejunostomy was carried out. There were two hospital deaths. Serum bilirubin on admission average 17.1 mg%, and after decompression 1.8 mg%. Five patients have survived over one year, and two over two years. Postoperative radiotherapy and a primary biliary tumor favored longer survival.

Sclerosing cholangitis. Anatomical distribution of obstructive lesions.

The cholangiograms of 36 patients with sclerosing cholangitis were reviewed. The mean age of the patient group was 43 years, and the mean disease duration was 4.5 years. Seventeen of the patients had associated inflammatory bowel disease. The mean serum billrubin was 6.8 mg/dl, the mean SGOT was 105 IU/L, the mean SGPT was 108 IU/L, and the mean serum alkaline phosphatase was 534 IU/L. The cholangiograms demonstrated involvement of the extrahepatic bile ducts in 33 patients, involvement of the hepatic duct bifurcation in 33 patients, and involvement of the intrahepatic bile ducts in 35 patients. The cholangiograms were graded as to the areas of the most severe obstructive involvement. In 24 patients the area of most severe involvement was the hepatic duct bifurcation. In eight additional patients the hepatic duct bifurcation, along with the extrahepatic ducts and/or the intrahepatic ducts, were felt to be the areas most severely affected. This predilection for severe obstructive disease at the hepatic duct bifurcation in sclerosing cholangitis held for both patients with and without inflammatory bowel disease. Thus, most patients with sclerosing cholangitis have cholangiographic evidence of diffuse extrahepatic and intrahepatic biliary tract disease, with the hepatic duct bifurcation being the area generally most severely affected.

Jugular venous thrombosis: Diagnosis by computed tomography

Thrombosis of the internal jugular vein (TIJV) was diagnosed by CT in five patients. Clinical presentations included unexplained fever (four patients), swollen neck (three patients), and mediastinal widening (one patient). Factors contributing to TIJV included placement of a central venous catheter (three patients) and neck surgery (two patients). In two patients left TIJV occurred after right sided venous catheterization. The CT findings consisted of enlargement of the thrombosed vein, a nonenhancing filling defect in the lumen of the affected vessel, an enhancing vessel wall, and opacification of collateral venous channels.

Image quality and radiation levels in videofluoroscopy for swallowing studies: A review

Inexpensive video recording equipment coupled to conventional x-ray fluoroscopes is now in widespread use by clinicians for the evaluation of patients with swallowing disorders. The prevalence and simplicity of this apparatus have encouraged its use by clinical specialists who are often not specifically trained in the safe use of x-ray equipment, and this may not be in the best interest of either the patient or the examiner. This has prompted an overview of the operating principles of videofluorescopy equipment. The factors governing image quality are discussed as well as potential hazards and protective measures for both patients and operator. A method of estimating the radiation dose to sensitive tissues from a typical swallowing study is included.

A case‐control comparison of lingual tonsillar size in children with and without down syndrome

Lingual tonsillar hypertrophy is a common cause of persistent obstructive sleep apnea following adenotonsillectomy in the pediatric population and may be more prevalent in patients with Down syndrome (DS). We sought to quantify lingual tonsil size in pediatric DS patients and compare these findings to those of nonsyndromic children using cervical spine (c‐spine) radiographs.

The use of iohexol as oral contrast for computed tomography of the abdomen and pelvis.

Positive oral contrast agents (high-osmolar iodinated solutions [high-osmolar contrast medium] or barium sulfate suspensions) are used routinely for abdominal computed tomography. However, these agents are not ideal. Patients complain about the taste and, sometimes, refuse to drink the required quantity. Nausea, vomiting, and diarrhea are frequent. In certain clinical indications, either barium suspensions or high-osmolar contrast mediums may be contraindicated. This technical note describes the potential advantages of using low-osmolar iodinated solutions as an oral contrast agent for computed tomography.

The CT Scout View: Does It Need to Be Routinely Reviewed as Part of the CT Interpretation?

OBJECTIVE The objective of our study was to determine whether the CT scout view should be routinely reviewed by comparing diagnostic information on the scout view with that provided by the correlative CT study. MATERIALS AND METHODS Two radiologists blinded to history and CT findings reviewed retrospectively 2032 scout views. All cases with major findings (defined as any abnormality that would prompt additional diagnostic tests or require management) were correlated with the CT study, other imaging study, or medical record when necessary by a third radiologist to determine the validity of the scout view finding and whether the finding was identifiable on the current CT study. RESULTS Major findings were identified in 257 (13%, reader 1) and 436 (23%, reader 2) of cases. Most major findings were confirmed (69-78%) or refuted (13-16%) by the CT study. However, 15 (6%, reader 1) and 48 (11%, reader 2) of the major findings were not included in the CT FOV, of which five (2%, reader 1) and 21 (5%, reader 2) constituted a missed pathologic finding. The most common one was cardiomegaly detected on a nonchest CT scout view. Additional pathologic findings included fracture, metastasis, avascular necrosis or subluxation of the humeral head, dilated bowel, and thoracic aortic dilatation. The most common false-positive finding was cardiomegaly. CONCLUSION In a small percentage of cases, review of the CT scout view will disclose significant pathologic findings not included in the CT FOV. The results of this study support the routine inspection of the scout view, especially for the detection of pathologic findings in anatomic regions not imaged by CT.

Enlargement of the pancreatic head in patients with pancreas divisum

Pancreas divisum (PD) is a congenital anomaly present in 6-10% of the population. Computed tomography (CT) examinations in eight of 15 patients (53%) with endoscopic retrograde pancreatography (ERCP)-proven PD were interpreted as showing enlargement of the pancreatic head. Two of these had carcinoma, three had pancreatitis limited to the ventral pancreas, and three were normal. Criteria to distinguish nonpathologic enlargement of the pancreatic head due to PD alone from pathologic causes may include homogeneous parenchyma and an absence of other abnormal signs on CT. Because PD may simulate a pancreatic head mass, the radiologist should be familiar with this variant, and ERCP should precede biopsy unless other evidence of malignancy is present.

Radiation in Video-Recorded Fluoroscopy

Most swallowing specialists are aware that swallowing disorders are often best appreciated with the use of dynamically recorded fluoroscopic images. In the past, specialized cinefluorography systems were the dynamic recording method of choice. More recently, dynamic recording capability has become much more widely available with the use of inexpensive videotape recorders, easily connected to existing videofluoroscopy systems. Despite some loss of image quality, videotape-recorded fluoroscopy, or videofluorography (hereafter referred to as VTF) has many advantages over conventional cinefluorography systems in that it does not require specially designed x-ray equipment, and lacks the difficulties associated with handling, processing, and viewing of cine (movie) film. VTF, however, does involve radiation exposure to both patient and practitioner, and thus incorporates some risk.

Modification of the Longmire procedure.

Two modifications of the Longmire procedure of intrahepatic cholangiojejunostomy are reported. The first involves the preoperative placement under fluoroscopic control of a large Teflon catheler in the distal left hepatic duct to facilitate the identification and isolation of the duct at the time of surgery. The second modification is the use of a transhepatic silastic biliary stent positioned by utilizing the Teflon® catheter. These modifications make the Longmire procedure technically much easier, and should help insure long-term success in both benign and malignant strictures. A successful case utilizing these modifications is reported.