Gerhard R. Wittich

Percutaneous Abscess Drainage: Update

During the approximately 20 years that percutaneous abscess drainage (PAD) has been an extant procedure and as the millennium begins, PAD has become, by consensus, the treatment of choice for abscesses. Indications for PAD continue to expand, and currently almost all abscesses are considered amenable. On occasion, PAD is an adjunctive procedure that provides a beneficial temporizing effect for the surgeon who eventually must operate for a coexisting problem such as a bowel leak. Simple unilocular abscesses are cured almost uniformly by PAD; more complicated abscesses, such as those with enteric fistulas (e.g., diverticular abscess) or pancreatic abscesses, have cure rates ranging from 65% to 90%. Various catheters and insertion techniques have proven effective. Ultrasonography, computed tomography, and fluoroscopy are the staple modalities that guide PAD. PAD is the prototype interventional radiology procedure, providing detection of the abscess by imaging, needling for diagnosis, and catheterization for therapy.

Hemoptysis secondary to pulmonary pseudoaneurysm 30 years after a gunshot wound

A 49-year-old man presented with intermittent hemoptysis from a traumatic pulmonary artery pseudoaneurysm 30 years following a thoracic gunshot wound. The patient was asymptomatic for 28.5 years, when he began experiencing recurrent hemoptysis, chest pain, and a cough. A left lower lobe mass on chest x-ray film was investigated with contrast-enhanced computed tomography and pulmonary angiogram confirming a 1.5-cm pseudoaneurysm. Intraluminal coil embolization was attempted, but a left lower lobectomy was ultimately necessary to treat persistent hemoptysis.

Anchoring a migrating inferior vena cava stent with use of a T-fastener.

An attempt to treat symptomatic stenosis of the inferior vena cava in a patient with metastatic liver disease was complicated by migration of a Wallstent into the right atrium. Effective palliation was achieved by insertion of a second stent, which was anchored by transhepatic insertion of a T-fastener into the intracaval stent. This anchoring maneuver was performed safely under sonographic and fluoroscopic guidance.

Interventional Radiology Strategies in the Treatment of Pseudomyxoma Peritonei

PurposeTo describe percutaneous maneuvers to treat the unusual entity symptomatic pseudomyxoma peritonei (PMP).MethodsFour patients with PMP were treated by interventional radiology techniques that included large catheters (20–30 Fr) alone (n = 3), multiple catheters (n = 4), and dextran sulfate as a catalytic agent through smaller catheters (n = 1). The causes of the PMP were tumors in the ovary (2 patients), appendix (1 patient), and colon (1 patient). Each patient previously had undergone at least two operations to remove the PMP, and all patients had symptomatic recurrence. An in vitro analysis of catalytic agents also was performed.ResultsAll four patients improved symptomatically. Follow-up CT scans demonstrated marked reduction of PMP material in all cases. One patient underwent another interventional radiology session 5 months after the first; the other three patients had no recurrence of symptoms. One patient had reversible hypotension 2 hr after the procedure. The amount of material removed varied from 3 to 6 L.ConclusionThese interventional radiology techniques were effective and safe for PMP and suggest options for this difficult medical and surgical problem.

Transosseous Access for Decompression of an Obstructed Pelvic Kidney

Abstract We report a case of an obstructed pelvic kidney which was decompressed using a transosseous access route. The patient presented with obstructive uropathy and fever, necessitating decompression. Initial access was gained to the kidney by traversing the ilium, allowing subsequent retrograde placement of a double-J ureteric catheter.

Removal of a Trapped Endoscopic Catheter from the Gallbladder via Percutaneous Transhepatic Cholecystostomy: Technical Innovation

BackgroundPercutaneous cholecystostomy is used for a variety of clinical problems.MethodsPercutaneous cholecystostomy was utilized in a novel setting to resolve a problematic endoscopic situation.ObservationsPercutaneous cholecystostomy permitted successful removal of a broken and trapped endoscopic biliary catheter, in addition to helping treat cholecystitis.ConclusionAnother valuable use of percutaneous cholecystostomy is demonstrated, as well as emphasizing the importance of the interplay between endoscopists and interventional radiologists.

Surgically transplanted ovary simulating a hepatic metastasis

BACKGROUND Surgical procedures may alter normal anatomy, confounding the interpretation of cross-sectional imaging studies. This problem is greater if neither a relevant history nor previous comparison studies are available. CASE OUTLINE In a 29-year-old woman submitted to radical hysterectomy for cervical carcinoma, one ovary was surgically repositioned into the right paracolic gutter out of the radiation field. This ovary simulated a hepatic metastasis on subsequent CT examinations. History was obscure, adding to the interpretive challenge. DISCUSSION Clues to establishing the correct diagnosis are presented. The availability of an adequate history and previous radiological images are important to prevent diagnostic error.

Antegrade balloon dilation of postoperative ureterovesical junction obstruction in children

Obstruction of the ureterovesical junction is an uncommon but well-recognized complication of ureteral reimplantation that traditionally has been treated by surgical correction [1, 5–9]. We report our experience with antegrade balloon dilation (ABD) of these strictures in two children. Obstruction was confirmed by diuretic renogram and pressure perfusion studies prior to ABD. Clinical follow-up was done at 3 months and 14 months, and ultrasonographic studies revealed resolution of the hydronephrosis. In addition, diuretic renograms showed complete washout of radiotracer. Morbidity was limited to episodes of pyelonephritis that readily responded to medical management. ABD of ureteral strictures is a relatively simple procedure with a potential for a high success rate and low morbidity. This modality should be considered as the first line of treatment in patients with distal ureteral obstruction after reimplantation.

Management of Common Bile Duct Stones

Courvoisier reported the first successful choledocholithotomy (CL) before the turn of the century.1 A few years later, in 1912, the father of biliary surgery, Hans Kehr, published his landmark textbook based on 2,000 cases including patients with CBD stones. He invented T-tube drainage after surgical exploration of the CBD.2 It is ironic that the great American surgeon, William Halstead, a few years after a cholecystectomy, died of complications from a choledocholithotomy for retained stones.

Symptomatic Renal Obstruction or Urosepsis During Pregnancy: Treatment by Sonographically Guided Percutaneous Nephrostomy

Seven pregnant women with symptomatic hydronephrosis had sonographically guided percutaneous nephrostomy for pyosepsis (five patients) or for pain with azotemia (two patients with renal transplants). Antibiotics had been ineffective in controlling pyosepsis in each patient; retrograde ureteral catheterization via cystoscopy was unsuccessful in one patient. After percutaneous nephrostomy, prompt clinical improvement was observed in all patients (i.e., sepsis was relieved and pain abated). Labor was not induced in any of the patients, and no adverse effects occurred to any fetus or mother. Eleven (eight percutaneous nephrostomy, three catheter exchanges) of the 12 procedures were done without conventional radiography and with sonographic guidance alone. After percutaneous nephrostomy, maneuvers to obtain a diagnosis and to treat the obstruction (if necessary) were delayed until after delivery. The causes of ureteral obstruction were calculi (four patients) and a gravid uterus (three patients). After delivery, stones were removed either percutaneously (one patient) or cystoscopically (two patients) or passed spontaneously (one patient); resolution of obstruction by the gravid uterus was proved by Whitaker test after delivery. Sonographically guided percutaneous nephrostomy is an effective and safe method to treat pregnant women who have symptomatic obstructive hydronephrosis associated with either pyosepsis or azotemia. The procedure is rapid, requires minimal anesthesia, has no radiation, and is safe for the fetus. The technique is a useful and perhaps preferable alternative to more invasive surgical therapy or retrograde stenting.