Sally E. Mitchell

Percutaneous Balloon Valvuloplasty: A New Method for Treating Congenital Pulmonary-Valve Stenosis

TRANSLUMINAL balloon angioplasty has been increasingly accepted as a nonsurgical technique for dilatation of stenotic arteries in the peripheral, renal, and coronary circulations.1 2 3 4 5 6 The ph...

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster.

OBJECTIVE This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries. SUMMARY BACKGROUND DATA The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully. METHODS The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns. RESULTS Patients with LC-related bile duct injuries were billed a mean of

Pancreaticoduodenectomy: Role of interventional radiologists in managing patients and complications

51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury. CONCLUSIONS Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Pulmonary Arteriovenous Malformations: Physiologic Observations and Results of Therapeutic Balloon Embolization

Although the mortality rate after pancreaticoduodenectomy has decreased, the morbidity rate remains high. Major morbidity is often managed with the aid of interventional radiologists. The objective of this study was to evaluate the cooperative roles of interventional radiologists and pancreatic surgeons in complex pancreatic surgery, specifically pancreaticoduodenectomy. Our pancreaticoduodenectomy database was reviewed for all patients undergoing pancreaticoduodenectomy between January 1, 1995 and December 31, 2000. The interventional radiologic procedures for each patient were evaluated. A total of 1061 patients underwent pancreaticoduodenectomy. The overall mortality and morbidity rates were 2.3% and 35%, respectively. Five hundred ninety patients (56%) had no interventional radiologic procedures, whereas 471 patients (44%) had interventional radiologic procedures. Of those, 342 (32%) had preoperative biliary drainage (PBD) and 129 (12%) required postoperative interventional radiologic procedures. Percutaneous aspiration/catheter drainage was required in 84 patients for intra-abdominal abscess, biloma, or lymphocele, with 24 requiring two or more abscess drains. Thirty-nine patients underwent postoperative PBD for bile leaks due to anastomotic disruption, undrained biliary segments, or T-tube/ bile stent dislodgment. Eighteen patients had hemobilia/gastrointestinal bleeding treated by angiography with embolization. The reoperation rate for the entire cohort of 1061 patients was 4.1% (n = 43). Nineteen of the 129 patients (15%) requiring postoperative radiologic intervention required reoperation. Although 4 of 18 patients who required embolization for bleeding subsequently required surgical intervention for the same reason, only 4 of 84 patients undergoing abscess drainage later required operation for anastomotic disruption or unsuccessful percutaneous drainage. As would be expected, the patients who required postoperative radiologic intervention (n = 129) had a higher incidence of postoperative complications including pancreatic fistula (20% vs. 6%, P <0.01), bile leakage (22% vs. 1%, P< 0.01), and wound infection (16% vs. 8%, P < 0.01). With the complications in these 129 patients, the postoperative mortality rate was only 6.2% compared to 1.7% in patients who did not require radiologic intervention (n = 932, P< 0.01). The median postoperative length of stay was 15 days in those patients requiring postoperative radiologic intervention, 10 days in those not requiring intervention (P< 0.01; postoperative interventional radiology vs. no postoperative interventional radiology), and 29.5 days for patients needing reoperation. Interventional radiologists play a critical role in the management of some patients undergoing pancreaticoduodenectomy. Although complications such as anastomotic leaks, abscess formation, and bleeding can result in increased mortality and a longer hospital stay, the skills of the interventional radiology team provide expert management of some life-threatening complications, thus avoiding reoperation, speeding recovery times, and minimizing morbidity.

An epistaxis severity score for hereditary hemorrhagic telangiectasia.

Pulmonary arteriovenous malformations can result in severe hypoxemia and dyspnea. We measured pulmonary function, arterial blood gases, and hemodynamics in 10 patients with such malformations. Pulmonary-function tests were normal, but hypoxemia was associated with chronic hyperventilation at rest (mean, 12 liters per minute; mean carbon dioxide tension, 28 mm Hg). With exercise, ventilation increased more than expected for the level of carbon dioxide production. Balloon embolization of 58 of the 71 visible vascular malformations in the 10 patients resulted in an increase in arterial oxygen tension (43 vs. 64 mm Hg; P less than 0.001) and hemoglobin saturation (79 vs. 92 per cent; P less than 0.001). Nine patients had improved exercise tolerance. Forty-eight to 72 hours after correction of the hypoxemia, resting ventilation had decreased but was still above normal (mean, 9.3 liters per minutes; mean carbon dioxide tension, 29 mm Hg). We conclude that ventilatory responses in these patients are similar to those of people from sea-level areas who are acclimated to high altitudes and that dyspnea is due to inappropriately high levels of ventilation for a given workload under hypoxic conditions.

Comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion

Hereditary hemorrhagic telangiectasia (HHT)‐related epistaxis leads to alterations in social functioning and quality of life. Although more than 95% experience epistaxis, there is considerable variability of severity. Because no standardized method exists to measure epistaxis severity, the purpose of this study was to determine factors associated with patient‐reported severity to develop a severity score.

Vascular malformations in the extremities: emphasis on MR imaging features that guide treatment options

Venography of 44 recurrent varicoceles in 37 patients demonstrated different anatomical patterns of recurrence in surgical patients (26) compared to those treated by percutaneous balloon occlusion (18). The 3 types of patterns identified included parallel, renal vein and transcrotal collateral pathways. Virtually all surgical recurrences were owing to mid retroperitoneal (27 per cent) or low (inguinal) parallel collaterals (58 per cent). The majority of post-balloon occlusion recurrences were due to either high retroperitoneal parallel (44 per cent) or renal vein collaterals (28 per cent). Surgical recurrences were treated easily with percutaneous balloon occlusion. However, 39 per cent of the patients with recurrences following balloon embolization were not anatomical candidates for repeat percutaneous occlusion. We conclude that venous collaterals are identified easily by renal venography, and knowledge of these collaterals is helpful in planning further surgical or radiological treatment.

Percutaneous Management of Benign Ureteral Strictures and Fistulas

Vascular malformations can be classified into high-flow arteriovenous malformations (AVM) and low-flow venous or lymphatic malformations (VM/LM). VMs and LMs have the ability to cross multiple tissue boundaries. Not only is subcutaneous tissue often involved, but multiple muscle groups, tendons, bone cortex and bone marrow are also not uncommonly violated. Magnetic resonance imaging (MRI) provides valuable information for the assessment and treatment of malformations. Firstly, MRI can characterize the flow pattern of these malformations to guide treatment towards trans-arterial embolization for AVMs and percutaneous embolization for low flow malformations. MRI is essential to define the anatomic extent and in-volvement of various tissue layers (a distinct advantage over ultrasound), and to correlate treatable components of the malformation with patient symptoms. Treatment is decided by the need to alleviate clinical symptoms, and is dependent on the extent of the malformation as defined by MRI. We present MRI features of vascular malformations to demonstrate the potential spectrum of in-volvement of these lesions, illustrating the value of MRI in treatment planning.

The Limitations of Gastro-Jejunal (G-J) Feeding Tubes in Children: A 9-Year Pediatric Hospital Database Analysis

The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5-year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The long strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas.

Segmental renal artery embolization for treatment of pediatric renovascular hypertension.

BACKGROUND:A gastro-jejunal (G-J) feeding tube is a safe and useful temporizing method of providing enteral access in children. Although G-J tubes are often used to obviate the need for a surgical jejunostomy, their long-term use is often associated with mechanical failure.AIM:To review the clinically effective durability of G-J feeding tubes in providing enteral access in children.METHODS:We performed a retrospective review of 102 patients at the Johns Hopkins Childrens Center from 1994–2003 whose underlying diagnosis necessitated the need for postpyloric enteral access.RESULTS:Long-term follow-up was obtained in 85 (48 M; 37 F) patients with a median (range) age of 2.0 (0.1–18.0) yr. The most common indication for G-J tube placement was gastroesophageal reflux with aspiration in 51 patients and feeding intolerance and vomiting in 19 patients. The mean (range) number of tube replacements was 2.2 (1–14) over a median (range) duration of follow-up of 39 (2–474) days. The indication for G-J tube replacement included: tube displacement (58), a clogged tube (41), and a cracked tube or ruptured balloon (35). In 52 cases, the cause for G-J tube replacement was undetermined.CONCLUSIONS:G-J feeding tubes are associated with the frequent need for tube maintenance and replacement and may not be the most feasible clinical option in providing long-term (>1 month) enteral access in children intolerant to gastrostomy tube feeds. Future studies are needed to develop innovative percutaneous jejunostomy tube placement techniques that facilitate long-term enteral access.