Robert N. Gibson

Liver atrophy complicating benign bile duct strictures. Surgical and interventional radiologic approaches.

The hepatic atrophy and hypertrophy complex has been described in a selected group of nine patients with benign bile duct stricture. The clinical features common to this group were a high biliary stricture and a long-standing history of cholangitis and intermittent jaundice. A history of multiple surgical procedures and associated vascular damage or portal hypertension is strongly suggestive of the atrophy and hypertrophy complex. The radiologic criteria for the diagnosis of this condition are presented. Computerized tomography and HIDA scintigraphy were valuable as noninvasive means to diagnose lobar liver atrophy. The atrophy and hypertrophy complex described herein poses significant therapeutic problems and demands approaches other than those normally applicable for high biliary strictures. A combined surgical and radiologic approach with additional interventional radiologic procedures may be appropriate in patients in whom hilar anastomosis is difficult or impossible.

Nonoperative approach to hilar cancer determined by the atrophy-hypertrophy complex

Twenty-seven of 135 patients with malignant hilar stricture who had associated liver atrophy or hypertrophy or both were treated by the percutaneous insertion of an endoprosthesis in the hypertrophied lobe only. The procedure was successful in 25 patients. Three patients died within 30 days of drainage. Procedure-related nonfatal complications occurred in seven patients. Effective decompression was accomplished in 21 patients, with complete relief of jaundice in 15. Late complications were experienced by 10 patients. The median total hospital stay was 22 days. Thirteen patients survived from 6 weeks to 12 months (median 5 months), 8 were alive from 3 to 18 months (median 8 months), and 1 patient was lost to follow-up. On the available evidence, we suggest that the preoperative demonstration of the atrophy-hypertrophy complex in jaundiced patients with irresectable hilar cancer is an indication for nonoperative therapy. Patients without the atrophy-hypertrophy complex and those with the complex but associated nonneoplastic disease are likely to fare better with surgical decompression and direct mucosa-to-mucosa anastomosis.

Real-time ultrasound measurement of bladder volume: a comparative study of three methods

The accuracy of different ultrasound methods for determining the volume of urine in the bladder was compared using three methods in current use. Each method was applied to the same ultrasound images from 16 patients with prostatic hypertrophy. The calculated volumes were compared with the true volumes derived by measurement of voided and catheter-drained urine. All methods showed similar degrees of accuracy in quantifying bladder volumes. The range of errors of the best method tested was +/- 35% of true volume and this suggests that ultrasound measurement of bladder volume is not sufficiently accurate for many clinical and research applications.

Percutaneous transhepatic endoprostheses for hilar cholangiocarcinoma

In patients with unresectable hilar cholangiocarcinoma, percutaneous transhepatic endoprosthesis insertion is one of the available methods of palliation. We reviewed our experience with it in 35 consecutive patients with hilar cholangiocarcinoma who were judged on clinical or radiologic evidence to be unsuitable for resective or palliative surgery. The 30-day mortality rate was 14 percent (5 of 35 patients). Of the remaining 30 patients, endoprosthesis placement was successful in 28, with 2 patients discharged with a permanent external drainage catheter. Twenty-four patients survived a median of 3 months (range 1 to 17 months), and 2 were lost to follow-up. Good or fair palliation of symptoms was achieved in 50 percent of the discharged patients and in 66 percent of those living longer than 3 months. We believe that percutaneous transhepatic endoprostheses can provide useful palliation in patients with hilar cholangiocarcinoma, even in the presence of advanced disease.

The radiology of fibrolamellar hepatoma

Seven patients with fibrolamellar hepatoma were examined with computed tomography (CT), ultrasonography and angiography. On CT the tumours were large, of low attenuation, had a well-defined edge and some contained areas of calcification or necrosis. Ultrasonography revealed well-defined masses of mixed echogenicity, occasionally involving the portal vein. In one patient there was dilatation of the intrahepatic biliary tree. Arteriography showed vascular tumours with involvement of the portal vein in five cases and compression of the inferior vena cava in five cases. CT and ultrasonography are the most useful radiological investigations for suggesting the diagnosis of fibrolamellar hepatoma which should be considered in the case of any large solitary well-defined hepatic tumour in the noncirrhotic liver of a young person.

Use of giant steel coils in the therapeutic embolization of a superior mesenteric artery-portal vein fistula

The use of a series of giant steel coils is described for the therapeutic embolization of a posttraumatic arteriovenous fistula between the superior mesenteric artery and the portal vein.

Doppler Ultrasound in the Diagnosis of Intestinal Ischemia

Conventional ultrasound is unreliable in detecting narrowing of the visceral arteries. Two cases are reported in which duplex Doppler ultrasound correctly identified severe narrowing of the celiac artery. Doppler ultrasound promises to be more accurate than conventional ultrasound in the diagnosis of visceral ischemia and may help to identify those patients who may require angiography.

Duplex ultrasound in the evaluation of portacaval shunts.

The results of ultrasound imaging combined with Doppler studies of blood flow are presented in two patients with surgical portacaval shunts performed for portal hypertension. Duplex scanning proved a quick and noninvasive method of confirming the patency of the anastomoses. The demonstration of appropriate Doppler flow signals across the shunt is the most convincing ultrasound evidence of patency. Portacaval shunts are more amenable to study by ultrasound than more peripheral shunts because the liver can be used as an acoustic window.

Therapeutic ureteric embolisation

Vesico-vaginal fistula with its associated incontinence is an unpleasant and distressing condition and when it occurs as a result of pelvic malignant disease, surgical management can be very difficult. We describe a case in which percutaneous transrenal embolisation of the ureter abolished the incontinence and obviated the need for further surgery. The technique has been used successfully in a previous similar case (Gunther et al, 1979). A 68-year-old woman was found to have an endometrial carcinoma in 1980. The tumour had already invaded locally into the pelvis and the initial treatment consisted of surgical removal of as much malignant tissue as possible. One year later she returned with evidence of extensive local recurrence for which she received pelvic radiotherapy. She remained symptom-free until 1983 when she presented with incontinence due to a vesico-vaginal fistula. There was clinical evidence of further pelvic tumour and an intravenous urogram showed no function in the right kidney, a normal le...

Carotid artery stenosis - reassessment of the Doppler criteria

Few previous studies of the accuracy of duplex Doppler in the assessment of carotid artery stenosis have looked at the accuracy in excluding disease in populations with a significant number of normal arteries. In addition, few studies have compared different criteria for stenosis. Duplex Doppler was used to evaluate the carotid arteries in 80 patients. Two well-described methods for analysing Doppler traces were used and the results were compared with those obtained from non-selective digital subtraction angiography. On the basis of these findings, the Doppler criteria used for carotid stenosis were redefined in terms of changes in peak velocity rather than Doppler frequency shift. Using these criteria, the sensitivity of Doppler in identifying carotid stenosis was 97% (98% sensitivity for greater than 50% stenosis) and specificity was increased from 84% to 93%.