Steven K. Teplick

Use of Computed Tomography to Assess Mediastinal Complications after Median Sternotomy

Thirty computed tomographic (CT) scans from 27 patients who had undergone median sternotomy were reviewed. A control group of 15 asymptomatic patients was studied either early (within 21 days) or late (46 days to 22 years) after sternotomy. Twelve patients with symptoms ranging from sternal click to obvious mediastinitis also were studied within 30 days of sternotomy. The CT findings were correlated with the patients clinical course. Imperfect sternal closure (sternal step-offs and gaps) was found in 10 of the 15 asymptomatic patients. Focal retrosternal fluid collections, air, and hematomas were seen in more than 75% of the asymptomatic patients. Retrosternal abscess, presternal abscess, and sternal disruption were noted in 3 symptomatic patients. Computed tomography correctly diagnosed the extent of mediastinal abscess in all patients. In the 3 patients in whom there was a discrepancy between the CT scan and the clinical findings, the scan ultimately was shown to be correct. These results indicate that computed tomography is a valuable tool in diagnosing wound problems after sternotomy because it accurately depicts the extent and depth of the wound infection.

Pitfalls and unusual findings in computed tomography of the lumbar spine.

A number of interesting and often unusual computed tomographic (CT) abnormalities that were seen in the course of a large series of CT studies of the lumbar spine are presented. These include conjoined nerve roots, extremely gas in the canal, extremely lateralized disk herniations, “vacuum” disks, and Schmorl nodes. In the postoperative patient, extradural hematoma. iatrogenic vacuum disk, and iatrogenic pseudonieningocele can be encountered.

Percutaneos pancreaticobiliary biopsies in 173 patients using primarily ultrasound or fluoroscopic guidance

Two hundred and one biopsies of the pancreas and/or extrahepatic bile ducts were performed in 173 patients using primarily ultrasound (US) or fluoroscopic guidance. Computed tomographic (CT) guidance was used twice. The success rate for detecting malignancy was 82.4%. Patients with primary ductal carcinoma had the lowest success rate. Seven complications occurred: five vasovagal reactions, one fever, and one acute pancreatis in a patient with a normal variation, which resembled a mass. In this large series, aspiration biopsy of the pancreas and extrahepatic bile ducts proved to be a safe and reliable procedure that often can be performed on an outpatient basis. Fluoroscopic and US guidance are satisfactory for the majority of biopsies. CT guidance probably should be reserved for patients who undergo a repeat biopsy, or when US fails to adequately demonstrate the pancreas.

Appendiceal filling by double-contrast barium enema

The barium enema is a safe and useful diagnostic modality in the evaluation of patients with suspected acute appendicitis. Complete appendiceal filling with barium virtually excludes this diagnosis. Frequently positive diagnostic information is obtained. Only 1 study in the literature documents the frequency of normal appendiceal filling by barium enema. The authors utilized the singlecontrast technique. We recorded the frequency of normal appendiceal filling with the double-contrast technique and then compared our data with the previously published study to determine if there is a significant clinical disadvantage to the doublecontrast technique when acute appendicitis is a diagnostic consideration.

GALLBLADDER ABLATION WITH GALLSTONES IN SITU IN AN ANIMAL MODEL

RATIONALE AND OBJECTIVES.The authors evaluated a method of gallbladder sclerosis in the presence of cholelithiasis. METHODS.The study was performed in 20 pigs. The gallbladders of 16 pigs contained surgically placed human gallstones. Control groups included animals that had their gallbladders sclerosed in the absence of stones, as well as a surgical sham control. Sclerosis followed cystic duct ligation to prevent extravasation of the sclerosing agent (95% Ethanol with 2 mole% trifluoroacetic acid) into the biliary tree. After sclerosis, a pigtail catheter was placed in the gallbladder to drain any post-procedure fluid accumulations. Catheters were removed after all drainage had ceased. Animals were killed at either 8 weeks (n=6) or 6 months (n=14). RESULTS.Stones were enveloped within the sclerosed and fibrotic gallbladder remnant in 13 of 15 test animals (87%). CONCLUSIONS.Sclerosis of gallbladders with stones in situ was achievable. Total mucosal obliteration did not appear to be required to produce a dysfunctional gallbladder in the time frame of this study.

Squamous cell metastases to the gastric cardia

Three patients with squamous cell carcinoma metastasized to the gastric cardia (1 from the esophagus, 1 from the hypopharynx, and 1 of unknown origin) are described. Two patients presented after apparent successful treatment of the primary malignancy. In all 3 cases the lesion appeared as a large solitary submucosal mass in the region of the gastric cardia. Squamous metastases should be considered in the radiographic differential diagnosis of a large submucosal gastric mass. Metastasis to the proximal stomach from carcinoma of the esophagus may be more common than suspected. Contrast evaluation of this area may be indicated in both the initial evaluation and the routine follow-up in these patients.

Balloon dilatation of benign postsurgical biliary-enteric anastomotic strictures

Five benign postsurgical strictures in 3 patients were successfully dilated using the Grüntzig balloon catheter. Various aspects of the procedure as well as potential problems are discussed.We concluded that, although considerably more experience is needed, balloon dilatation potentially can reduce the need for surgical repair and provide a means to remove indwelling biliary drainage catheters.

Percutaneous Cholecystostomy in Obstructive Jaundice

Percutaneous insertion of a cholecystostomy tube is a potential alternative to percutaneous transhepatic biliary drainage. A case is presented in which percutaneous cholecystostomy was successfully performed without complications. The procedure and its possible usefulness are discussed.

Giant hyperplastic polyps of the gastric remnant simulating carcinoma

Large hyperplastic polyps of the gastric remnant were detected in 2 male patients who had undergone Billroth II gastrojejunostomy for peptic ulcer disease 13 and 18 years earlier. Both patients presented with iron deficiency anemia due to chronic occult gastrointestinal bleeding. The clinical and radiographic findings were initially suggestive of gastric stump malignancy, and one of the resected hyperplastic polyps contained foci of carcinoma in situ. We illustrate the radiographic and pathologic features of these lesions together with a review of the pertinent literature.

Interventional radiology of the biliary system and pancreas

In recent years, newer techniques have become available to the clinician for the diagnosis and treatment of biliary and pancreatic disease. This article emphasizes interventional procedures through the liver, such as percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, and ancillary techniques. Also discussed are the nonsurgical management of bile duct calculi and the diagnosis and treatment of pancreatic tumors, abscesses, and pseudocysts.