H B D'Agostino

Laparoscopic injuries to the bile duct. A cause for concern.

The authors report six patients who had injuries to their common hepatic bile duct at laparoscopie cholecystectomy over a 16-month period. Five of the six complications could be attributed to laser injuries during dissection in the region of Calots triangle. The authors discuss the possible mechanism of these injuries, their perioperative management, and the methods of surgical reconstruction. The follow-up period ranges from 3 months to 21 months. Liver function parameters and isotope biliary excretion scans are back to normal in all six patients. The potential hazards of laparoscopie surgery demand that extraordinary care be used not only during the actual surgical procedure, but also in the preoperative decision concerning the dissection method to be employed.

CT-guided transthoracic needle biopsy

CT-guided biopsy of pulmonary and mediastinal lesions is safe and effective. It is most valuable in those cases in which fluoroscopic guidance is not possible due to resolution or anatomic consideration. CT guidance permits puncture of lesions as small as 0.5 cm, typically not seen fluoroscopically. Sensitivity of biopsy in malignant lung lesions in our series of 83 cases was 92%. Pneumothorax is the most frequent complication (10–60%) and requires chest tube insertion in 5–15% of patients.

Percutaneous tissue ablation by radiofrequency thermal energy as a prelim to tumour ablation

Porcine hepatic tissue was ablated in vitro and in vivo with radiofrequency (RF) energy applied through various percutaneous probes. Ultrasound was used for guidance. The technique was assessed for potential use to ablate tumours percutaneously. Tissue ablation was performed in two porcine cadaver and six live piglet livers in various experiments, three RF generators with either bipolar gold probes, 18–22 gauge modified angiocath needles, titanium curved and spiral 0.018″ guidewires, three-pronged grabber baskets, and/or a thermistor (temperature-controlled) probe were used to induce the RF effect with simultaneous assessment by real-time ultrasound. Gross and microscopic analysis of the liver was undertaken after acute sacrifice of the animals. The hepatic tissue that surrounded the probe after RF energy application became increasingly echogenic sonographically. The size of the echogenic area on ultrasound corresponded to the size of the thermal lesion on gross and microscopic examination. Thermal lesion...

Successful topical dissolution of cholesterol gallbladder stones using ethyl propionate.

Topical dissolution of cholesterol gallbladderstones using methyl tert-butyl ether (MTBE) is useful insymptomatic patients judged too ill for surgery.Previous studies showed that ethyl propionate (EP), a C5 ester, dissolves cholesterolgallstones rapidly in vitro, but differs from MTBE inbeing eliminated so rapidly by the liver that bloodlevels remain undetectable. Our aim was to test EP as atopical dissolution agent for cholesterol gallbladderstones. Five high-risk patients underwent topicaldissolution of gallbladder stones by EP. In threepatients, the solvent was instilled via acholecystostomy tube placed previously to treat acutecholecystitis; in two patients, a percutaneoustranshepatic catheter was placed in the gallbladderelectively. Gallstone dissolution was assessed bychromatography, by gravimetry, and by cathetercholecystography. Total dissolution of gallstones wasobtained in four patients after 6-10 hr of lavage; inthe fifth patient, partial gallstone dissolutionfacilitated basketing of the stones. In two patients, cholesteroldissolution was measured and averaged 30 mg/min. Sideeffects were limited to one episode of transienthypotension and pain at the infusion site; no patientdeveloped somnolence or nausea. Gallstone elimination wasassociated with relief of symptoms. EP is an acceptablealternative to MTBE for topical dissolution ofcholesterol gallbladder stones in high-risk patients. The lower volatility and rapid hepaticextraction of EP suggest that it may be preferable toMTBE in this investigational procedure.

Laboratory analysis of catheters for percutaneous abscess drainage

SummaryA laboratory model was designed to evaluate factors contributing to catheter efficacy as they pertain to percutaneous abscess drainage (PAD). Sixteen commercially available and commonly used catheters were studied, with controlled pressure gradients and fluid viscosities as predicted by Poiseuilles law. Factors that influenced flow through these catheters included catheter length, inner lumen diameter, applied pressure gradient and fluid viscosity. The type of suction (continuous v. intermittent) and surface area available for fluid entry also affected the overall drainage efficiency. The catheters with the largest inner lumen diameter (the 16 F Medi-tech sump and 14 F Malecot catheters) demonstrated the best drainage characteristics, especially when draining a viscous solution. When PAD is to be used, the efficacy of drainage is influenced in large part by the physical characteristics of the catheter used.

Percutaneous radiologic and endoscopic gastrostomy: A two-year evaluation

SummaryThere are two methods of minimally invasive gastrostomy placement: radiologic (RG) and endoscopic (PEG). In order to investigate the effectiveness of these two methods, this study examined those patients undergoing percutaneous gastrostomy at our institution from 1 July 1993 to 30 June 1995 (44 RG, 69 PEG). Compared to PEG, RG was a shorter procedure (33.5 min vs 41.2 min) and required less conscious sedation. RG also had a higher rate of technical success (100% vs 95.7%) and a lower rate of major complications (11.4% vs 16.7%). Thirty-day mortality was similar after both procedures. These results are consistent with those from a recent meta-analysis of the literature and suggest that radiologic gastrostomy may have advantages over PEG.

Percutaneous abscess drainage: current applications for critically ill patients.

Radiologically guided percutaneous abscess drainage (PAD) was first reported in 1977. Since this time, technological advances in imaging, improved catheter technology, and increased experience with the procedure have resulted in a tremendous expansion of the indications for PAD. This procedure currently has applications in nearly every organ system of the body. These changes have also contributed to improved success rates, with concurrent minimization of procedure-related complications. The advantages of PAD include simple, rapid performance; feasibility of bedside intensive care unit (ICU) performance; safety; avoidance of general anesthesia; and well-documented efficacy. This procedure has now become well entrenched in clinical medicine and probably ranks with the development of effective antibiotics as the most significant improvement in the treatment of abscesses in the past century. PAD is ideally suited for the treatment of critically ill ICU patients. We discuss technical developments over the past 15 years; general principles of patient preparation and catheters are also reviewed. Current applications of PAD in each organ system are discussed.

Percutaneous management of hepatocellular carcinoma: Patient selection for percutaneous alcohol injection alone or combined with arterial chemoembolization

SummaryThe purpose of our study was to assess the efficacy of percutaneous ethanol injection (PEI) alone or in combination with transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) not eligible for surgery. From January 1989 to December 1993, 46 patients (40 men, 6 women) with cirrhosis and histologically proven HCC were treated percutaneously. Twenty-six patients (56.5%) with single tumours smaller than 5 cm were treated with PEI alone. Twenty patients (43.5%) with multiple tumours or a single HCC 5cm or larger were treated with both PEI and TACE. Treatment results were evaluated by length of survival and findings on follow-up imaging studies. Survival rates in the group treated with PEI were 81% at 1 year, 70% at 2 years, and 56% at 3 years. In the group treated with PEI and TACE, survival was 79% at 1 year, 55% at 2 years, and 46% at 3 years. Treatment failed to control HCC in 16 patients (34.8%). There were no treatment-related major complications or deaths. As a mea...

Percutaneous dissolution of gallstones

Contact dissolution with MTBE is an effective and safe method to treat symptomatic patients with cholesterol gallstones. Personnel, time, and safety factors have limited widespread use of the procedure. With current competing methods to treat gallstones, it is likely that MTBE use will be reserved for those patients who elect percutaneous therapy due to fear of surgery or anesthesia and in those elderly patients who are compromised by underlying medical conditions.

Large bore transhepatic tract dilatation in pigs: Results and implications for human procedures

SummaryLarge bore transhepatic tracts were created in six anesthetised pigs. A peripheral tract (entering the gall-bladder bed) and a central tract were created in each pig. After balloon dilatation to 30 F and passage of a 30 F inner diameter sheath, bleeding was monitored with the sheath in place and after sheath removal. Blood loss was quantified and tracts were examined microscopically. Peripheral tracts were shorter than central tracts (mean 1.9 versus 3.6 cm). Bleeding occurred more frequently and to a greater degree from central tracts. Injury to small arteries and veins was identified microscopically in two tracts that bled heavily. Although significant bleeding, or lack thereof after dilatation of large transhepatic tracts, was variable, recommendations for large tract dilatation include: selection of a peripheral tract route, use of a working sheath with an outside diameter not exceeding that of the inflated balloon, particular care to avoid loss of access and not removing sheaths prematurely.