R.Eugene Langevin

Early diagnosis of pancreatic infection by computed tomography-guided aspiration

We performed 92 computed tomography-guided percutaneous needle aspirations of pancreatic inflammatory masses in 60 patients suspected of harboring pancreatic infection. Thirty-six patients (60%) were found by Gram stain and culture to have a total of 41 separate episodes of pancreatic infection. Among 42 aspirates judged to be infected by computed tomography-guided aspiration, all but one were confirmed by surgery or indwelling catheter drainage. Among 50 aspirates judged to be sterile, no subsequent evidence of infection was found. All patients tolerated the procedure well and no complications were noted. As a result of this technique, we observed that pancreatic infection occurs earlier than has been previously appreciated (within 14 days of the onset of pancreatitis in 20 of the 36 patients) and that infection may recur during prolonged bouts of pancreatitis. We conclude that guided aspiration is a safe, accurate method for identifying infection of the pancreas at an early stage.

Prognostic factors in sterile pancreatic necrosis

Although the overall mortality in sterile pancreatic necrosis is low, patients who experience systemic complications may have a higher mortality. To study the impact of systemic complications and other factors on survival, possible prognostic factors were evaluated among 26 patients who experienced at least one systemic complication. Mortality was 38%. Factors that correlated with a fatal outcome were high Ransons scores during the first 48 hours (P = 0.01), high APACHE-II scores at admission (P = 0.04) and at 48 hours (P = 0.03), shock (P < 0.001), renal insufficiency (P < 0.05), multiple systemic complications (P < 0.001), and high body mass index (P = 0.01). Most systemic complications occurred during the first 2 weeks of illness. Logistic regression analysis showed that shock was the best predictor of a fatal outcome. Patients with favorable prognostic factors survived whether treated medically or surgically, whereas those with unfavorable factors had a fatal outcome whether treated medically or surgically. It is concluded that patients with severe sterile necrosis have a high mortality rate and that shock and other prognostic factors identify which patients are most likely to have a fatal outcome.

CT-guided aspiration of suspected pancreatic infection

SummaryWe have performed CT-guided percutaneous needle aspiration in 104 patients with severe pancreatitis strongly suspected of harboring pancreatic infection on the basis of systemic toxicity and CT findings (Balthazar CT grade D or E). Of these 104 patients, 51 (49%) were documented with pancreatic infection. Gram stain was positive in 54 of 58 infected aspirates, and culture was positive in all 58. Klebsiella,Escherichia coli, andStaphylococcus aureus were the most frequent organisms. Eighty-six percent of infected processes contained only one organism. Overall, pancreatic infection was documented by GPA within the first 2 wk in approx one-half of patients. There were no complications. The overall rate of infection decreased from 60 (1980–1987) to 34% (1988–1995) (p=0.01). This change was caused by a reduction in the rate of infected necrosis from 67 to 32% (p=0.015). The overall mortality rate remained at 20%. The mortality of sterile pancreatitis was not different from infected pancreatitis (p=0.14). We conclude that GPA is a safe, accurate method of diagnosis of pancreatic infection. The rate of pancreatic infectoon appears to be decreasing. The overall mortality of severe pancreatitis among patients suspected of harboring pancreatic infection has remained unchanged because of the high mortality associated with both infected necrosis and severe sterile necrosis.

Real-time three-dimensional reconstruction of intravascular ultrasound images of iliac arteries.

Abstract Intravascular ultrasound (IU) imaging provides detailed tomographic images of the vascular wall and lumen.1–3 One liability of this novel imaging modality, however, is the inability to view a given vascular segment in a composite format; detailed cross-sectional images are thus provided at the expense of a longitudinal perspective. The circumferential nature of a postangioplasty dissection may be well demonstrated by IU, for example, but the full longitudinal extent may not be readily apparent, even after repeated review of the videotaped images recorded over the length of the involved segment. Computer-based 3-dimensional (3-D) reconstruction (R) from serially recorded IU images offers a potential solution to this problem. By creating a longitudinal display of the entire vascular segment, 3-DR offers a composite format for presentation of detailed IU data, facilitating comparison of selected cross-sectional ullages with those that are proximal and distal. Previous studies from our laboratory have outlined the concepts, technique and instrumentation used for 3-DR, and demonstrated the feasibility and potential use of 3-DR.4–6 Whereas off-line analysis of such 3-DRs has provided insight into mechanisms of recanalization, to be clinically useful during interventional procedures, 3-D image generation must be rapid, if not instantaneous. We report here the use of real-time 3-DR from IU images recorded during percutaneous iliac artery revascularization in 2 patients.

Noninvasive assessment of peripheral vascular disease by color flow Doppler/two-dimensional ultrasound

Abstract The development, in 1985, of phased array scanning in a linear format 1 established the potential for acquiring high quality color flow Doppler (CFD) maps of the vasculature in the lower extremities. Subsequently, however, little information has been published 2,3 describing examination of the peripheral arteries by CFD, whether in linear, sector or anular format. Accordingly, the present study was undertaken to evaluate the utility of CFD in combination with 2-dimensional ultrasound (2DU) for the assessment of peripheral vascular disease.

Delayed common bile duct obstruction in acute pancreatitis

SummaryCommon bile duct obstruction during acute pancreatitis usually occurs in the early symptomatic phase of the illness, involves only the distal portion of the common bile duct, and subsides with clinical improvement. We present two cases of persistent common bile duct obstruction that developed 2–3 months after complete clinical subsidence of the initial episode of severe acute pancreatitis and involved a long segment of the common bile duct. After surgical decompression, there was no recurrence of common bile duct obstruction or pancreatitis.