Mary C. Foshager

Laparoscopic drainage of lymphoceles after kidney transplantation: Indications and limitations

BACKGROUND Symptomatic lymphoceles are not uncommon after kidney transplantations. Surgical marsupialization with internal drainage is the treatment of choice. However, laparoscopic drainage is reportedly as effective, with only minimal trauma. METHODS We attempted 14 laparoscopic lymphocele drainages during a 3-year period and studied the indications and limitations, using intraoperative ultrasonography in all cases. RESULTS Laparoscopic drainage was successful in only 9 (64%) of 14 patients. A conversion to open laparotomy was necessary in five patients; their lymphoceles were lateral and either posterior or inferior to the kidney. Two patients with initially successful laparoscopic drainage required conversion to open laparotomy 21 and 83 days later; their lymphoceles were inferior to the kidney. Laparoscopic drainage shortened the median hospital stay by 4 days versus open surgical drainage and by 7 days versus conversion. Hospital costs for laparoscopic drainage averaged

Diagnosis of pancreas rejection : cystoscopic transduodenal versus percutaneous computed tomography scan-guided biopsy

7400 less versus open drainage and

Early sonographic evaluation of the transjugular intrahepatic portosystemic shunt (TIPS)

10,300 less versus conversion. CONCLUSIONS In patients with symptomatic lymphoceles medial and either superior or anterior to the kidney, laparoscopic drainage under intraoperative ultrasonographic guidance is easy, safe, and effective. It decreases hospitalization, convalescence, and costs. In patients with symptomatic lymphoceles lateral and either posterior or inferior to the kidney, laparoscopic drainage may fail because of anatomic inaccessibility and technical impracticability.

Renal pedicle torsion after simultaneous kidney-pancreas transplantation.

BACKGROUND The most common cause of graft failure after technically successful pancreas transplants is rejection. Laboratory parameters for detecting pancreas graft rejection are not consistently reliable and can lead to unnecessary antirejection treatment. Histopathologic evaluation is the gold standard in the differential diagnosis of pancreas graft dysfunction. Four biopsy techniques have been described: cystoscopic transduodenal (CB), percutaneous computed tomography scan-guided (PB), open, and laparoscopic biopsy. METHODS We studied the two most common techniques, CB and PB, in pancreas transplant recipients with presumed rejection. Group 1 comprised 103 attempts at CB in 82 recipients (53 men, 29 women) with bladder-drained (BD) pancreas transplants, at 1 to 80 (median, 14) months after transplant. Group 2 comprised 93 attempts at PB in 68 recipients (41 men, 27 women), at 0.5 to 64 (median, 14) months after transplant. RESULTS In group 1, of 103 attempts at CB, adequate tissue was obtained in 90 (87%): pancreas alone in 23 (22%), pancreas + duodenum in 35 (34%), duodenum alone in 32 (31%). Of the 58 pancreas biopsies, 23 (40%) showed acute rejection. Of the 67 duodenal biopsies, 16 (24%) showed acute rejection. Complications of CB included macrohematuria in 4 recipients (4%) and microhematuria in 32 (31%). We noted no biopsy-related pancreatitis. The mean cost of CB was

Sonographic findings in bone marrow transplant patients with symptomatic hepatic venoocclusive disease.

2561+/-246. In group 2, of 93 attempts at PB, adequate tissue (all pancreas) was obtained in 67 (72%); of these, 29 (43%) showed acute rejection. Of 23 inaccessible pancreases, 9 (39%) underwent CB; pancreatic tissue was obtained in four (45%), and results were consistent with rejection in all four. Complications of PB included biopsy-related pancreatitis (serum amylase > or = 25%) in five (7%) recipients, macrohematuria in one (1%), and abdominal hemorrhage in two (3%). The mean cost of PB was

Effects of capsular contracture on ultrasonic screening for silicone gel breast implant rupture.

1038+/-78. (1) CB and PB prevented unnecessary antirejection treatment in 44% of our recipients with successful biopsies; (2) CB had a higher success rate for obtaining tissue (including duodenal specimens) and a lower rate of major complications; (3) PB was easier and cheaper, did not require general anesthesia, and was performed as an outpatient procedure. CONCLUSIONS We conclude that PB should become the biopsy technique of choice in recipients with presumed pancreas graft rejection. If PB fails, recipients with bladder-drained pancreas transplants should undergo CB. If CB fails, or in recipients with enteric-drained or duct-injected pancreas transplants, a laparoscopic or open biopsy should be considered.

Duplex sonography after transjugular intrahepatic portosystemic shunts (TIPS): normal hemodynamic findings and efficacy in predicting shunt patency and stenosis.

The purpose of this study was to evaluate duplex and color Doppler findings in patients before and within 24 h after transjugular intrahepatic porto-systemic shunts (TIPS). Conventional duplex and color Doppler were used in the assessment of 19 patients who underwent TIPS as part of a prospective protocol. Patients were examined within 24 h before and after the procedure. Before TIPS, patency, flow direction, and peak flow velocity in the main portal vein and hepatic artery were studied, as well as patency and flow direction in hepatic veins, splenic vein, and inferior vena cava (IVC). Immediately after the procedure, sonographic identification of stent position, shunt patency, and flow dynamics were evaluated and patency and flow direction of hepatic veins, splenic vein, and IVC were determined. The portogram performed at the end of the procedure was compared with the 24-h sonographic studies after TIPS to determined sonographic/angiographic correlation. No intraparenchymal abnormalities or perihepatic fluid collections were detected after the procedure. The metallic stent was clearly seen in all patients. Mean peak shunt flow velocities were 139±50 cm/sec within 24 h after TIPS. Absence of flow through the shunt was correctly identified in one case and confirmed angiographically. Mean peak flow velocity in the portal vein before TIPS was 22±13.6 cm/sec and increased to 43.6±9.1 cm/sec after TIPS (p<0.05). The hepatic artery peak systolic velocity increased from 77±51 cm/sec before TIPS to 119±53 cm/sec after the procedure (p=0.029). Conventional duplex and color Doppler ultrasound proved to be a useful non-invasive diagnostic method to assess patients who have undergone TIPS. We propose its use as the primary diagnostic modality in these patients.

Diagnosis of breast implant rupture : imaging findings and relative efficacies of imaging techniques

BACKGROUND Simultaneous kidney-pancreas transplantation has become a recognized therapy for type I diabetes mellitus patients with diabetic nephropathy, neuropathy, and retinopathy. In the vast majority of these procedures, both grafts are placed intraperitoneally, which reduces posttransplant morbidity. Recently, in some of our recipients, we noted renal dysfunction related to complications of the renal pedicle. Our objectives in this study were to identify the cause of this renal dysfunction and to prevent its occurrence in future recipients. STUDY DESIGN We undertook a retrospective chart review of simultaneous kidney-pancreas recipients who experienced renal dysfunction related to renal pedicle complications. RESULTS We found four recipients with renal dysfunction related to renal pedicle torsion, diagnosed by serial ultrasound scans and kidney graft biopsies. Early diagnosis allowed salvage of three kidney grafts, but one was lost after late diagnosis. CONCLUSIONS A high level of suspicion is needed to diagnose renal pedicle torsion. If simultaneous kidney-pancreas recipients have recurrent renal dysfunction, and rejection has been excluded, serial ultrasound scans with color flow Doppler examinations are needed. Once the diagnosis is made, a nephropexy to the anterior abdominal wall is indicated to prevent further torsion and save the kidney graft. We recommend prophylactic nephropexy of left renal grafts if the renal pedicle is > or = 5 cm long and if there is a 2 cm or more discrepancy between the length of the artery and the vein.

Duplex and color Doppler sonography of hemodialysis arteriovenous fistulas and grafts.

Sonographic findings were retrospectively compared between 19 patients with hepatic venoocclusive disease and 23 patients with other common causes of symptomatic liver dysfunction after bone marrow transplantation (14 grafts versus host disease and nine hepatitis). Doppler sonographic examination was available in all patients with venoocclusive disease, in nine of the patients with graft versus host disease, and in three of the patients with hepatitis. The hepatic artery resistive index and the overall flow direction, peak forward and retrograde velocities, and time‐averaged mean velocities in the hepatic veins and main portal vein were compared. The portal vein waveform was arbitrarily considered abnormal in the presence of any of the following: highly pulsatile waveform, very low mean velocity, biphasic flow, or flow reversal. Ascites was the most predictive gray scale sonographic finding for venoocclusive disease. Doppler sonographic findings of potential value in the diagnosis of hepatic venoocclusive disease include an abnormal portal vein waveform, resistive index of greater than 0.75, and marked thickening and edema of the gallbladder wall. However, the study is limited by its retrospective nature and reliance primarily on clinical criteria for the diagnosis of venoocclusive disease. Therefore, our findings will need to be verified in a large prospective study.

Development of stenoses in transjugular intrahepatic portosystemic shunts.

Unlike computed tomography and magnetic resonance imaging, ultrasound is an inexpensive test of postential use in detecting silicone gel breast implant (SBI) rupture. However, Periprosthetic capsular contractre can make ultrasonic diagnosis of rupture difficult because the contacture-related radial folds inside the SBI can lead to a false-positive diagtnosis of rupture. This study was conducted to determine the effects of capsular contracture on the ability of ultrasound to diagnose SBI rupture. Preoperative ultrasonic results of 122 SBIs were compared with surgical findings at the time of implant removal. The sensitivity and negative predictive values of ultrasound were lower in the presence of a contracted capsule (41.2% vs. 68.7%, P = 0.062; and 58.3% vs. 79.6%, p = 0.056 respectively). Ultrasound should be considered reliable in diagnosing SBI rupture only in the absence of a contracted capsule.Medot M, Landis GH, McGregor CE, Gutowski KA, Foshager MC, Griffiths HJ, Cunningham BL. Effects of capsular contracture on ultrasonic screening for sillicone gel breast implant rupture.