Madhu Gulati

Image-guided percutaneous drainage of thoracic empyema: Can sonography predict the outcome?

Abstract. The aim of this study was to assess the safety and efficacy of image-guided percutaneous catheter drainage (IGPCD) of thoracic empyemas, and to correlate the outcome of IGPCD with the pre-procedural sonographic appearance. One hundred three patients (74 males and 29 females) with thoracic empyema (age range 1 month to 70 years, median age 28 years) underwent IGPCD. In 63 (61.17 %) patients, IGPCD was the primary treatment modality; in 40 (38.84 %) patients it was used after unsuccessful intercostal chest tube drainage (ICTD). Ultrasound was the main modality used for guidance; CT guidance was used in only 7 patients (6.8 %). Eight- to 12-F pigtail catheters or 10- to 14-F Malecot catheters were used. The outcome was correlated with the pre-procedural US appearance (anechoic, complex non-septated or complex septated) of the empyema. The IGPCD technique was successful in 80 of 102 patients. Based on the US appearance, IGPCD was successful in 12 of 13 (92.3 %) patients with anechoic empyemas; 53 of 65 (81.54 %) patients with complex non-septated empyemas, and in 15 of 24 (62.5 %) patients with complex septated empyemas. A statistically significant difference (p < 0.01) was seen in the outcome of IGPCD in the three categories. Twenty-two patients required further treatment: ICTD (n = 9; 2 of them later also underwent surgery); and surgery (n = 15). The duration of catheter drainage ranged from 2–60 days. No major complications were encountered. Percutaneous catheter drainage of thoracic empyemas with imaging guidance ensures accurate catheter placement with a high success and a low complication rate. Pre-procedural US can predict the likelihood of success of IGPCD.

CT-guided fine-needle aspiration biopsy of spinal lesions.

Purpose: A retrospective study of CT-guided fine-needle aspiration biopsies (FNABs) of spinal lesions performed over a period of 6 years was carried out with the aim of assessing the safety and efficacy of the procedure and to analyse the various approaches used. Material and Methods: Ninety-three FNABs were performed in 87 patients, 4–70 years of age, under CT guidance. Lytic or mixed vertebral lesions with or without a paraspinal soft tissue component were included in the study. the approach depended on the anatomic region and part of the vertebra involved. Results: A definite cytological diagnosis was obtained in 77 patients (88.5%); of these, 47 patients had benign lesions and 30 patients had neoplasms. the most common pathologies encountered were tuberculosis (n=33) and metastases (n=17). There were 10 inconclusive FNABs; these showed blood only, necrotic material or scanty material insufficient for diagnosis. There were no procedure-related complications. Conclusion: CT-guided FNAB is a safe and effective technique for the evaluation of spinal lesions and is helpful in planning therapy. Choosing the appropriate approach results in a low complication rate.

Percutaneous nephrostomy with real-time sonographic guidance

Purpose: Percutaneous nephrostomy (PCN) is an effective method for achieving temporary drainage of the obstructed urinary system and is usually performed under fluoroscopic guidance alone or more commonly under combined sonographic and fluoroscopic guidance. We undertook a retrospective analysis of 273 PCNs performed solely under ultrasound (US) guidance with the aim of evaluating the technique and the safety and efficacy of the procedure. Material and Methods: A total of 273 PCN procedures in 267 patients were performed under real-time US guidance using the Seldinger technique. the indications for PCNs comprised benign (n=215) and malignant (n=46) urinary obstruction, and urinary fistulae (n=6). Results: PCN was successful in 269 of the 273 attempts (98.5%). Satisfactory catheter placement was achieved in 245 of the 269 procedures (91.1%) under US guidance. Fluoroscopic assistance for catheter repositioning was required in 24 PCNs owing to the unsatisfactory position of the catheter tip. Major complications occurred in 15 patients (5.6%). Catheter dislodgement and catheter blockage was seen in respectively 12.6% and 3.3% of procedures. Conclusion: in most patients, PCN can be performed safely using real-time sonographic guidance.

Role of tissue harmonic imaging in focal hepatic lesions: comparison with conventional sonography.

Background: The purpose of the present study was to compare iissue harmonic imaging (THI) and conventional sonography in focal hepatic lesions.

Ultrasound‐guided percutaneous nephrostomy in non‐dilated pelvicaliceal system

Percutaneous placement of nephrostomy catheters in patients with non‐dilated pelvicaliceal systems remains problematic. We successfully performed ultrasound‐guided percutaneous nephrostomies in 5 such patients after intravenous administration of a diuretic agent. Diuresis resulted in transient dilatation of the calyces, facilitating the procedures, which were performed under real‐time sonographic guidance using the Seldinger technique. No complications were encountered.

Imaging of esophageal tuberculosis: A review of 23 cases:

Purpose: To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis. Material and Methods: The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment. Results: Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Emphysema in heavy smokers with normal chest radiography: Detection and quantification by HRCT

Purpose: To determine the severity and extent of emphysema in heavy smokers by high-resolution CT (HRCT) and to correlate the findings with spirometric tests (STs) and symptomatology. Material and Methods: Fifty adult smokers with a mean age of 53 years with a smoking history of more than 30 pack years and normal chest radiographs underwent HRCT of the chest and ST (FEV1, FEV1/FVC, PEFR). Among these, 22 had symptoms of pulmonary disease and 28 were asymptomatic. Quantification of emphysema was done using a density mask program and the visual scoring method. The results were correlated with ST and symptomatology. Results: 58% (29 out of 50) of the subjects had significant emphysema on HRCT. Eleven out of 15 with normal ST showed emphysema on HRCT while 2 with airflow obstruction on ST showed normal CT scores. 14% (4 out of 28) asymptomatic subjects had severe emphysema compared to 64% of symptomatic subjects. Emphysematous changes were predominantly seen in upper lung zones in 48% of the patients while in 52% it was distributed equally in both upper and lower zones. The number of pack years of smoking showed a positive correlation with CT scores. The correlation between HRCT scores and ST was statistically significant. Conclusion: A significant number of asymptomatic and clinically undiagnosed smokers tend to have significant emphysema. HRCT helps in early detection of disease and thus helps implementation of preventive measures.

Sonographically guided fine needle aspiration biopsy of abdominal lymph nodes: experience in 102 patients.

We present our experience with sonographically guided fine needle aspiration biopsy of abdominal and retroperitoneal lymph nodes in 102 patients. The biopsied lymph nodes measured 1 to 6 cm (mean, 2.3 cm) and were located at the porta hepatis (n = 23), in the peripancreatic (n = 31), paraaortic (n = 22), aortocaval (n = 1), common iliac (n = 3), or external iliac (n = 6) regions, or in the mesentery (n = 16). Material sufficient for cytologic analysis was obtained in 87 (85.2%) of the 102 patients. The cytologic diagnosis in these patients included malignancy in 47 patients, tuberculosis in 28 patients, reactive lymphoid hyperplasia in 10 patients, and aspergillosis in two patients. In the other 15 patients, fine needle aspiration biopsy could not provide a definitive diagnosis. No major or minor complications occurred in our study. Thus, sonographic guidance is an effective alternative to computed tomography for biopsy of abdominal and retroperitoneal lymph nodes.

Ilio-psoas abscess in the paediatric population : treatment by US-guided percutaneous drainage

Background. Image-guided percutaneous drainage has been shown to be a safe and effective alternative to surgery in the management of psoas abscess in adults and adolescents. There is little information on its use in children. Objective. To evaluate the safety and efficacy of US-guided percutaneous needle aspiration and catheter drainage of ilio-psoas abscesses. Materials and methods. A retrospective review of 14 children with 16 ilio-psoas abscesses (10 pyogenic and 4 tuberculous) who were treated by US-guided percutaneous needle aspiration (n = 5) or catheter drainage (n = 9) along with appropriate antimicrobial therapy. Results. Percutaneous treatment was successful in 10 of the 14 patients; all showed clinical improvement within 24–48 h of drainage and subsequent imaging demonstrated resolution of the abscess cavities. Surgery was avoided in all of these ten patients except one, who underwent open surgical drainage of ipsilateral hip joint pus. Of the other four patients, two had to undergo surgical drainage of the ilio-psoas abscesses after failure of percutaneous treatment, one improved with antibiotics after needle aspiration failed to yield any pus, and one died of continuing staphylococcal septicaemia within 24 h of the procedure. There were no procedural complications. Conclusions. Percutaneous drainage represents an effective alternative to surgical drainage as a supplement to medical therapy in the management of children with ilio-psoas abscesses.

Sonographically guided fine-needle aspiration biopsy of lytic lesions of the spine: Technique and indications

We report the use of sonography to guide fine‐needle aspiration biopsies (FNABs) of lytic lesions of the spine.