Edward Russell

Percutaneous Catheter-directed Debridement of Infected Pancreatic Necrosis: Results in 20 Patients

PURPOSE To evaluate the usefulness of transcatheter debridement of infected pancreatic necrosis. MATERIALS AND METHODS Transcatheter debridement was performed on 20 patients who ranged in age from 20 to 78 years during the 8-year study period. All patients had infected pancreatic necrosis and were hemodynamically stable. Necrosis was defined as nonenhancing pancreatic tissue, as seen on contrast-enhanced computed tomography (CT). Infection was suspected clinically and documented by cultures of the pancreatic fluid at its initial drainage. Debridement was performed in multiple sessions in close succession (duration, 30-120 minutes; mean, 60 minutes) via large-bore catheters with enlarged side holes. Debris was removed with use of suction catheters, stone baskets, and copious amounts of lavage fluid. RESULTS All patients underwent successful catheter debridement. Success was determined by clinical course, as well as lesion appearance, at fluoroscopy and CT. Patients underwent 7-32 (average, 17) episodes of debridement and stayed 0-36 days (average, 9 days) in the intensive care unit, 13-118 days (average, 42 days) on the regular floor, and spent 0-98 days (average, 32 days) with the catheters as an outpatient. No deaths occurred. CONCLUSION Percutaneous catheter-directed debridement is a safe and effective treatment and it can be used as the primary means of treatment for the hemodynamically stable patient with infected pancreatic necrosis.

Portosystemic Communications Studied by Transhepatic Portography

The experience of collecting 120 transhepatic portograms, performed in patients with different degrees of portal hypertension, affords the opportunity for discussing the anatomical and hemodynamic features of portosystemic communications. Multiple pathways of decompression were found. The coronary-gastroesophageal collateral formed pathways in 108 cases, other major collaterals in 41, and minor collaterals in 2. This multiplicity of communications suggests that no one vessel is indispensable as a collateral pathway.

Balloon dilatation of biliary strictures through a choledochojejuno-cutaneous fistula

The problem of recurrent strictures following repair for bile duct injuries or in patients with sclerosing cholangitis is well recognized. For the most part, the recurrent problems have required repeated operations. The possibility of controlling the recurrent strictures by dilatation has been postulated, but repeated dilatations obviously require simple access to the entire biliary tree. We have found that stomatization of the afferent limb of a choledochojejunostomy or hepaticojejunostomy provides ready access to the biliary tree through which strictures can be readily traversed and dilated. Our early results with this procedure suggest that long-term patency can be expected following dilatation of these strictures.

Selective catheterization of the portal vein and its tributaries. Preliminary report.

The portal vein and its tributaries were selectively catheterized in 90 patients. Only one complication required surgery. This technique not only provides information about the status of the portal circulation and liver parenchyma but can also be used in the treatment of bleeding esophageal varices by selective embolization of autologous clots or inert material.

Suspected vascular trauma of the extremities: The role of arteriography in proximity injuries

We reviewed 72 patients with penetrating trauma to the extremities who underwent arteriography for proximity injury only. None of the patients had clinical evidence of vascular trauma. There were 62 males and ten females, with a mean age of 29.9 years. Gunshot wounds were the most common cause of injury (91.7%) and the thigh was the most common site of injury (47.2%). A normal arteriogram was found in 55 of 72 patients (76.4%). The remaining 17 patients (23.6%) had arteriographic abnormalities that did not warrant surgery. Only one patient was explored (1.4%) for spasm of the popliteal artery. No vascular injury was found at surgery. This study suggests that routine arteriography in proximity injury only may be unnecessary and that these patients could safely be admitted to the hospital for a 24-hour period of observation.

New techniques for interruption of gastroesophageal venous blood flow.

Enlarged gastroesophageal veins were successfully obliterated in 41 patients using embolization with modified autogenous clots and/or Gelfoam, balloon occlusion, iatrogenic perivenous hematoma, sclerosing agents (Sotradecol and Keflin), or a combination of these methods. Thirteen patients were actively bleeding when studied, and the site of bleeding was detected in 4. Surgical exploration of 16 patients and autopsy study of 5 showed persistent obliteration ranging between three weeks and seven months. No major complications requiring reparative surgery were encountered. Gelfoam soaked with Sotradecol is the preferred agent because it provides persistent obliteration of the embolized veins. Patients who are acutely bleeding or have done so previously are candidates for selective obliteration of the gastroesophageal veins.

Percutaneous dilatation of biliary strictures through the afferent limb of a modified roux-en-y choledochojejunostomy or hepaticojejunostomy

BACKGROUND This report is a 13-year prospective evaluation of percutaneous balloon dilatation of benign biliary strictures through the subcutaneous or subfascially positioned afferent limb of a choledocho or hepaticojejunostomy in 30 patients. DATA SOURCE Twenty-seven strictures developed after a common duct injury sustained at the time of cholecystectomy, two after hepatectomy reconstruction for trauma and one following a gastrectomy. Twelve injuries (40%) were recognized at operation. Of the 18 patients where the injury was unrecognized at the time of operation, 8 had not been reoperated at the time of referral, 7 had late repairs by the referring physician, and 3 had late repairs at our institution. The follow-up is 1 to 13 years. RESULTS There has been 1 late death and 6 patients are lost alive. The jejunal-limb was accessed 50 times with two minor and no major complications. There have been two parajejunal hernia repairs, but there have not been any reoperations for recurrent biliary strictures. CONCLUSIONS Benign biliary strictures can be effectively managed by repeat balloon dilatations thru the afferent limb of a choledocho or hepaticojejunostomy, thus eliminating the need for repeat surgical interventions.

Why Every Renal Mass is Not Always a Surgical Lesion. The Need for an Orderly, Logical, Diagnostic Approach

The fact that approximately 95 per cent of asymptomatic renal masses are benign is a compelling reason for the streamlined diagnostic approach which is described herein. Within the confines of these guidelines for the study of renal masses, when proceeding from simple to complex methods of evaluation, one should always consider the age of the patient, the status of the cardiovascular system, the radiologic appearance of the mass on drip infusion nephrotomography and the results of renal echography as qualifying determinants and then propose the logical sequence of individualized studies under the best possible circumstances.

Pitfalls in transhepatic portography.

Difficulties commonly encountered in transhepatic catheterization of the portal vein and interpretation of portograms are discussed. A long-sleeved trocar is recommended. Curved guide wires and deflector assemblies may assist in superselective catheterization of the tributaries of the portal vein. The judicious use of embolic material (small volumes, slowly injected) should guarantee the success and safety of this technique. Transhepatic obliteration of the gastroesophageal veins is a relatively simple and usually successful form of palliative treatment for actively bleeding and stable gastroesophageal varices. Thoroughness of the embolization procedure and of interruption of blood flow in the gastroesophageal veins is necessary to prevent early recurrence of bleeding.

Ultrasound Guidance in Accessing the Afferent Limb of a Modified Roux-en-Y Choledochojejunostomy for Percutaneous Dilation of Biliary Strictures

Percutaneous retrograde biliary dilation via the afferent limb of a modified Roux-en-Y choledochojejunostomy is used in the management of chronic biliary strictures. Access to the afferent loop may be challenging in the absence of surgically placed radiopaque markers. Ultrasound (US) guidance was used to access the loop in 10 patients with subcutaneous afferent loops and three patients with subfascial afferent loops. Successful puncture was made in all 10 patients with subcutaneous loops and in one patient with a subfascial loop. Initial fluoroscopically guided attempts failed in five loops, which were then successfully accessed with use of US guidance. US is useful in accessing subcutaneous afferent loops.