Myron Wojtowycz

Bleeding Stomal Varices: Case Series and Systematic Review of the Literature

BACKGROUND & AIMS Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. METHODS We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. RESULTS We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. CONCLUSIONS Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

The Bird's Nest Inferior Vena Caval Filter: Review of a Single-Center Experience

PURPOSE To examine a large single-center experience with Birds Nest vena caval filters for indications, clinically evident recurrent thromboembolic disease, and other filter-related complications. MATERIALS AND METHODS During a 6-year period, 308 patients underwent percutaneous placement of an inferior vena caval filter. The 267 patients who received a Birds Nest filter are the subject of this retrospective review. The series included 162 men and 105 women who ranged in age from 16 to 88 years (mean, 57.1 +/- 17.0 standard deviation). RESULTS Indications for filter placement included contraindication to anticoagulation (n = 141), complication of anticoagulation (n = 23), failure of anticoagulation (n = 30), failure of previously placed filter (n = 1), and prophylaxis (n = 82). Ten patients had more than one indication. Acute lower extremity deep venous thrombosis was confirmed in 133 patients, pulmonary embolism (PE) was found in 44 patients, and both were positively diagnosed in 37 other patients. Fifty-three patients had no documented acute thromboembolic disease at the time of insertion. Mean follow-up was 13 months. Thirty-day mortality was 9.7%, including one death from recurrent PE and one major puncture-site bleeding episode that may have contributed to death. Recurrent PE was found at radionuclide scanning or autopsy in three patients (1.1%), whereas another eight patients (3.0%) had suspected recurrent PE without confirmatory studies. Eight patients (3.0%) developed early venous access site thrombosis, including two who progressed to phlegmasia cerulea dolens with fatal complications. Significant nonthromboembolic problems were encountered in 1.9% of patients. CONCLUSIONS The Birds Nest filter is a safe and effective device for patients with complicated venous thromboembolic disease.

Abdominal abscesses associated with enteric fistulas: percutaneous management.

For many years, surgical dictum stated abdominal fistulas should be treated by means of surgical excision. Recent advances in percutaneous techniques have altered this. The authors reviewed 150 consecutive abdominal abscesses drained percutaneously over a 36-month period. Among these, 24 patients were found to have 26 fistulous communications to bowel, the pancreatic duct, or the biliary system. Initial drainage of their abscesses was performed in the hospital, but 17 of 24 patients were discharged with a tube in place and were followed up as outpatients. The duration of drainage ranged from 4 days to 3 months. Fistulas healed in 21 of 24 patients (88%) without surgical intervention. Complications were few and included inadvertent dislodgment requiring tube replacement (two patients) and inadvertent puncture of the transverse colon (one patient). Treatment of abdominal abscesses with fistulas by means of percutaneous methods is reliable and safe. Hospital stay may be minimized with outpatient management after drainage.

Pancreatic pseudocyst with fistula to the common bile duct: radiological diagnosis and management.

A patient was found to have fistulization of a pancreatic pseudocyst with the common bile duct. Resolution of the pseudocyst and the attendant biliary obstruction was achieved with percutaneous biliary drainage alone. The clinical and radiological features of this case are herein presented along with a brief review of the subject.

Cytologic diagnosis of true thymic hyperplasia by combined radiologic imaging and aspiration cytology: A case report including flow cytometric analysis

True thymic hyperplasia (TH) is an age‐dependent increase in size and weight of the thymus gland, which by definition maintains a normal histologic architecture. TH can mimic other important diseases, including lymphofollicular hyperplasia, thymoma, lymphoma, and germ‐cell tumors. Traditionally, separating these entities has required a formal surgical biopsy. Given that many of these conditions occur in children, this can be a traumatic experience for both the patient and family members. Fine‐needle aspiration biopsy has the distinct advantage of being able to obtain diagnostic material without requiring general anesthesia. We are aware of only one previously reported case of an enlarged thymus being subjected to aspiration cytology. We therefore present a case of thymic hyperplasia in a 5‐mo‐old child diagnosed by combined radiologic and cytologic parameters, including flow cytometric analysis. Diagn. Cytopathol. 2000;23:417–421.

A Safe Route for Deep Pelvic Biopsy with Distention of the Iliacus Muscle

To avoid bowel perforation during deep pelvic biopsy, the authors describe a technique in which the iliacus muscle is distended by injecting it with a solution of lidocaine and saline. This muscle distention causes sufficient bowel displacement to allow safe advancement of biopsy needles as large as 14 gauge through the distended muscle belly to the region of interest.

Detection of retroperitoneal hemorrhage after translumbar aortography by computerized tomography.

Thirty-seven patients were examined by CT scan within 24 hours of translumbar aortography. Eighteen of them had signs of hemorrhage, of which psoas asymmetry was the most common. Para-aortic densities and obliteration of the aorta were the next most frequent manifestations. CT scanning can be a useful tool in selected cases to detect or follow hemorrhage after aortography by the translumbar approach.

Calcified bronchopulmonary sequestration.

An unusual case of calcified sequestration in a 76-year-old female is presented.