Joel R. Bernstein

Diagnosis of inferior vena cava anomalies by computerized tomography

Abstract Knowledge of normal and variant vascular anatomy has become essential with increasing use of computerized tomography and ultrasound. We present three cases of IVC anomalies diagnosed by computerized tomography, including azygos continuation of the IVC and the first case of left IVC demonstrated on CT scan. The embryology of the normal and variant IVC is presented. The practical significance of these findings is discussed.

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.

Localized giant pseudopolyposis of the colon in ulcerative and granulomatous colitis.

The occurrence of localized large clusters of colonic pseudopolyps in 4 patients is described. The underlying disease was chronic ulcerative colitis in 2 cases and granulomatous colitis in 2 others. Each lesion presented as a bulky polypoid mass causing partial or total occlusion of the transverse segment or splenic flexure of the colon. The radiographic and pathologic features of this rare entity are illustrated, and the previously reported 10 cases are briefly reviewed.

Role of stereotactic breast biopsy.

Screening mammography can detect early, nonpalpable breast cancer, resulting in improved long-term survival and cure rates. However, greater compliance with screening guidelines has increased the number of mammographic abnormalities found. Since 75% of the surgical biopsies performed for nonpalpable lesions are benign, less expensive and invasive methods of diagnosis are evolving to reduce the cost of screening mammography programs and the number of women undergoing surgery for benign mammographic findings. Stereotactic needle core biopsy allows minimally invasive sampling of most breast lesions and generates tissue cores for histologic evaluation. A specific pathologic diagnosis, as well as determination of invasiveness, can be achieved for mass lesions. Microcalcification can also be sampled to diagnose in situ cancer, although the use of core biopsy for noncomedo intraductal cancer is still evolving. The procedure demands meticulous technique to assure accurate needle placement, and careful correlation of biopsy results and patient follow-up is mandatory. Accuracy relative to surgical biopsy of nonpalpable lesions has been excellent in published series. The role of this procedure in patients with low, intermediate, and high suspicion mammographic lesions is discussed.

Choledochocele presenting with jaundice. Diagnosis by percutaneous cholangiogram.

SummaryA case of choledochocele, a cystic dilatation of the common bile duct, is reported and relevant aspects of the literature are reviewed. This case is significant for the patients presentation with jaundice and for the preoperative demonstration and diagnosis by percutaneous transhepatic cholangiogram.

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.

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.