Extracorporeal shock-wave lithotripsy (ESWL). II. In vivo canine results of blast path treatment of human gallstones

To evaluate the role of ESWL in vivo for the treatment of human gallstones positioned on the blast path, a canine model was developed to determine the efficacy of stone fragmentation and the subsequent histopathological injury that occurs as a result of this therapeutic technique. Twenty-four 16- to 20-kg mongrel dogs were divided into five groups: I: ESWL without stone, autopsy at 48 hr (N = 6); II: ESWL with stone (mean diameter 16.8 mm, range = 14-19 mm), autopsy at 48 hr (N = 10); III: ESWL without stone, autopsy at 41-46 days (N = 6); IV: ESWL without stone, autopsy immediately after ESWL (N = 1); V: No ESWL or stone, autopsy 2 hr after anesthesia induction (N = 1). A human gallstone (96% cholesterol) was inserted by cholecystotomy (N = 10) in Group II only. All groups (N = 24) had operative placement of a 6.5 Fr accordion catheter into the gallbladder for radiographic visualization. For each blast path treatment, 2000 discharges were delivered at 18-24 kV. Histopathologically, the Group V gallbladder served as a control. Groups I, II, and IV revealed mild subacute injury; dog gallbladders in Group III showed regression of these changes. Total surface area (TSA) of Group II stones increased from a pre-ESWL mean of 6.60 +/- 0.0.84 cm2 to 53.84 +/- 26.8 cm2 post-ESWL (P less than 0.001). Cumulative post-ESWL fragment sizes for particles in less than or equal to 2-, less than or equal to 3-, less than or equal to 5-, less than 10- and greater than or equal to 10-mm categories represented 32.9, 41.6, 49.4, 74.3, and 100% of pretreatment stone weight, respectively. These data indicate that human gallstones can be fractured to a variable degree when treated on the ESWL blast path and that TSA increased significantly. Gallbladder histopathologic changes appear to be reversible by 41-46 days post-ESWL.

Splenic arteriovenous fistula with portal hypertension, ascites, and diarrhea

A 66-year-old woman had sudden onset of portal hypertension manifested by diarrhea, ascites, and varices. When a splenic arteriovenous fistula was found to be the cause, the fistula was resected. Her signs and symptoms did not recur.

Localization and resection of gastrinomas in Zollinger-Ellison syndrome

From 1971-1986, 24 patients were diagnosed as having Zollinger-Ellison syndrome (ZES) and 22 patients had laparotomy. Of this group, gross tumor was identified in 15 of 22 patients. Ten of 15 patients had resection of their gastrinomas with the specific aim of curing the disease. This group had responded favorably to either cimetidine or ranitidine before operation. Preoperative transhepatic portal venous sampling (PVS) with gastrin determinations was performed in six patients; three patients had this procedure twice. The tumor was correctly localized by PVS in five of six patients. In four of six patients, the tumor was easily found at surgery. In two of six patients (33%) PVS was vital to intraoperative decisions. Criteria for biochemical cure are normal periodic fasting gastrin and secretin infusion tests. Of the 10 patients who had resection for potential cure, two patients failed within 48 hours of surgery on the basis of an elevated fasting serum gastrin level in one patient and a positive secretin infusion test in the other patient. Eight patients were considered cured with follow-up from 6 months through 15 years. Of the eight cured patients, the tumors were located as follows: four were extraintestinal and extrapancreatic, four were in the duodenal wall, one patient had a tumor located in the uncinate process of the pancreas, and one tumor was located in a lymph node along the lesser curve of the stomach. Two patients had mobilization of the pancreas and duodenum for a "blind" pancreatoduodenectomy based on preoperative PVS (2 procedures each patient). In one patient a 3-mm gastrinoma was enucleated from the posterior uncinate process. The second patient had pancreatoduodenectomy with findings of two duodenal wall gastrinomas. Both patients remained cured of ZES beyond 2 years. It is concluded that PVS does indeed locate some tumors before operation, even those not easily found at surgery. ZES can be cured by an aggressive approach combining preoperative tumor localization and tumor resection. Of the eight patients biochemically and perhaps biologically cured, follow-up was greater than four years in five patients, greater than two years in two patients, and beyond six months in one patient.

The treatment of acute cholangitis. Percutaneous transhepatic biliary drainage before definitive therapy

Forty-two patients with acute cholangitis, as evidenced by fever (95%), jaundice (86%), and right upper quadrant pain (67%), were treated with fluid and electrolyte resuscitation, broad spectrum antibiotic coverage, and initial percutaneous transhepatic biliary drainage (PTD). Despite a 17% incidence of nondilated ductal systems, drainage was established in all patients using a 22-gauge "skinny" needle and "accordion" catheter. No attempt was made at definitive cholangiogram; only 1-2 mL of contrast were injected to confirm placement of the catheter. Sepsis began to resolve in all patients within 24 hours of PTD, after which definitive cholangiogram was performed. PTD was accompanied by a 7% (3/42) complication rate, none of which contributed to subsequent morbidity and mortality. Two patients in severe septic shock had PTD but died within 8 hours of admission, constituting a 5% mortality rate. Definitive therapy after resolution of sepsis included: surgical (16 patients), internal/external drainage (14 patients), balloon dilatation (10 patients), mono-octanoin infusion (1 patient), and ampullary dilatation (1 patient). The surgical morbidity rate was 18%. There was no mortality. PTD is effective in providing decompression as initial therapy for acute cholangitis with minimal morbidity. Accurate diagnosis provided by the definitive cholangiogram obviates the need for multiple surgical procedures. PTD provides a portal to the biliary tract for alternative procedures (i.e., internal/external drainage, balloon dilatation), especially in patients with medical contraindications to surgery.

The ureteral access system: a review of the immediate results in 43 cases

The ureteral access set was used 43 times during an 18-month period between 1984 and 1985. Stones lodged throughout the ureter and in the renal pelvis were extracted with a success rate of 51 per cent. Of the upper tract strictures 92 per cent were dilated successfully. Filling defects were diagnosed in 88 per cent of the cases. Foreign bodies were retrieved, Double-J stents were placed and biopsies were successful in each case. Ureteral perforation in 28 per cent of the cases was caused by the dilator in 8 of 12 (19 per cent over-all). The technique and short-term results are discussed. Long-term followup data are not yet available.

Percutaneous transhepatic choledochoenterostomy in a patient with a biliary obstruction

A needle guide was used to create a fistula from an obstructed common bile duct to the duodenum in a patient with a large tumor of the head of the pancreas. The tortuosity and severity of the stricture prevented the use of routine guide wire passage. A 5-F hyperalimentation catheter was also placed, in addition to the biliary drainage stent.

Retrievable Gianturco-coil introducer

A new delivery system for placement of Gianturco coils has been devised that permits retrieval of the coil if malposition occurs. The delivery system itself consists of a very fine coaxial cannula that will cut the monofilament once the coil is properly placed. It has been successfully used on three patients in whom a total of 48 coils were employed to occlude great vein of Galen aneurysms. The system is applicable for routine coil embolization but has particular application in treating high-flow vascular lesions (arteriovenous fistulas or malformations).

Spiral exchange cannula for the occluded drainage catheter

A technique for exchange of occluded drainage catheters or placement of two guide wires into a target using a spiral exchange cannula is described. A spiral exchange cannula with a preloaded sheath and threads at the distal end is "screwed" into the drainage catheter, and the sheath is advanced over the catheter. This method prevents dislodgment of the drainage catheter and also permits easy catheter exchange when the lumen of the drainage catheter is occluded.

Translumbar catheter redirection using a tip-deflector technique

A new technique is described for reversing the direction of the catheter tip during translumbar aortography, without the need for partial withdrawal of the catheter from the aortic lumen. The method ensures optimal delivery of contrast medium at the desired level, while avoiding the risk of retroperitoneal bleeding or dislodgement during catheter manipulation.

Retrograde nephrostomy and percutaneous calculus removal in 30 patients

We used a new technique, retrograde nephrostomy, to provide intrarenal access for percutaneous calculus removal in 30 consecutive patients. Under fluoroscopic control, we maneuvered cystoscopically a 5F and 9F coaxial catheter pair over a guide wire into the calix selected for nephrostomy. Then, a sheathed 20 to 21 gauge needle was passed through the 9F catheter into the flank to create the nephrostomy. Eight patients were given general and 22 intravenous sedation and local anesthesia for nephrostomy placement and calculus removal. Retrograde nephrostomy and subsequent calculus removal were completed successfully in 90 and 83 per cent of the 30 patients, respectively. There were 6 complications and 3 failures among the first few patients due to inferior equipment and inexperience with the technique. Over-all, we found that retrograde nephrostomy provided reliable, precise intrarenal access and we believe that it could become an alternative technique to aid in percutaneous calculus removal procedures.

Evaluation of percutaneous transhepatic balloon dilatation of benign biliary strictures in high-risk patients

During the period from 1979 through 1984, 17 patients with benign biliary strictures underwent percutaneous transhepatic balloon dilatation. All patients presented with either hyperbilirubinemia and acute cholangitis, a history of intermittent chills and fever, or both. Balloon dilatation was most successful in those patients with intrahepatic strictures, sclerosing cholangitis, strictured biliary enteric anastomoses, and distal common bile duct strictures with retained calculi. Two patients with postsurgical common bile duct injury had treatment failure 3 and 18 months after dilatation and subsequently underwent elective hepaticojejunostomy. Although our longest treatment success is now more than 4 1/2 years in an 83 year old woman who is 15 years posthepaticojejunostomy, the mean follow-up of the entire group has only been 2 years. On the basis of our early experience and that of others, we now recommend an initial attempt at balloon dilatation in most patients with postsurgical benign biliary strictures. Further technical advances and longer follow-up in present and future series may certainly broaden the appeal of this nonoperative procedure.

Preoperative angioinfarction of localized renal cell carcinoma using absolute ethanol

A total of 25 patients with renal cell carcinoma underwent angioinfarction of the tumor using absolute ethanol. An average of 15 ml. absolute ethanol was injected into the main renal artery through a balloon occlusion catheter. Complete cessation of renal arterial flow could be demonstrated in all cases. The post-embolization syndrome of pain, nausea, vomiting, hypertension and fever was minimal compared to other methods of renal artery occlusion. Of the patients 21 underwent post-infarction transabdominal radical nephrectomy without intraoperative or postoperative complications attributable to the injection of absolute ethanol. No damage to extrarenal tissue was noted at operation. Subsequent surgical dissection was facilitated, particularly in cases of large tumors when control of the renal pedicle often is difficult. Median blood loss was 725 ml. In light of recent reports concerning the benefit of angioinfarction and nephrectomy in metastatic disease a similar approach may be applicable to localized disease. This pilot study shows the safety of preoperative angioinfarction with absolute ethanol and may be used as a reference for future randomized prospective studies comparing angioinfarction and nephrectomy to nephrectomy alone for localized renal cell carcinoma.

Single-step placement of a self-retaining "accordion" catheter

The "accordion" catheter was developed as an adjunct to the Hawkins needle guide to provide safe single-step percutaneous drainage. The Hawkins needle guide is a long, 22-gauge "skinny" needle-cannula system that can be used like any other skinny needle. It can also be used for drainage catheter placement. The accordion catheter is a 6.5 French Teflon catheter with a sigmoid tip. With the use of monofilament, the sigmoid tip can be retracted into a "T" configuration to prevent dislodgment. The 22-gauge needle guide, preloaded with an accordion catheter, can be manipulated safely while the drainage target is located. Then the accordion catheter can be advanced into the target over the needle guide. The "accordion" is easily formed, even in small targets. Successful drainage was achieved in 127 of 131 drainage procedures in which this technique was used. Sepsis did not occur as a complication in any of these procedures.

Retrograde nephrostomy for stone removal: combined cystoscopic/percutaneous technique

The retrograde percutaneous nephrostomy, a new technique for access to the urinary tract for stone removal, involves cystoscopic placement of a 9 French catheter into a selected minor calix, through which a sheathed 20- or 21-gauge needle is then advanced to exit at the skin. The tract is then dilated over this needle. This technique has been used successfully in 38 patients with only three complications. The technique is more reliable and less time-consuming than the standard antegrade percutaneous approach, particularly in the nondilated pelvicaliceal system. However, to avoid damage to the liver, spleen, or pleural cavity, care must be taken to ensure that the needle does not exit in a cranial direction.

Percutaneous cholecystostomy in acute cholecystitis and common duct obstruction

Percutaneous cholecystostomy was performed in 36 patients, of whom 22 patients with acute cholecystitis had decompression of the gallbladder and 14 patients with common duct obstruction had biliary decompression through the gallbladder. In almost all cases of acute cholecystitis, percutaneous cholecystostomy quickly confirmed the diagnosis and brought relief. Bile leakage occurred in one patient when catheter placement was performed under ultrasonic guidance alone; subsequent procedures were performed in a single step using an "accordion" catheter under fluoroscopic control following ultrasound localization. This technique has proved to be useful as both a diagnostic and therapeutic procedure.

New monofilament and soft-wire baskets for stone removal

A new-design basket for stone removal uses a standard Teflon catheter with radially positioned holes at its tip to hold either monofilament or soft wire. The strands are positioned to form a basket that will change in both size and shape simply by advancing or retracting these strands. This basket is much safer, can be changed in size during maneuvering , will transmit instruments for stone fragmentation, and can be advanced over a guide wire. It has been effective both in vitro and in the retrieval of biliary and urinary tract stones in 20 patients, several of which could not be retrieved by standard methods.

A new deflector handle for catheter exchange

The standard deflecting handle and deflecting wire have been modified to permit deflectors to be used as exchange wires. The spherical knobs are removed from the proximal end of the deflecting wire, and simple inserts are attached to the deflector handle. The handle can be used with deflector wires that have various length extensions (J or straight floppy tips) and with guidewires of variable stiffness.

The Hawkins needle-guide system for percutaneous catheterization: 1. Instrumentation and procedure

In 1979, a new 22 gauge "skinny"-needle cannula system was introduced for combined percutaneous transhepatic cholangiography and drainage procedures. This small-bore system safely permits multiple passes when searching for small targets. Once the area of interest is entered, drainage can be accomplished with the same needle insertion by advancing either a 5 French straight Teflon or 6.5 French Teflon retention catheter over the stiff 22 gauge cannula. The distal tip of a catheter is looped using a continuous strand of monofilament, which helps to prevent catheter dislodgment. For 103 cholangiograms attempted, the overall success rate was 97%, including 95% in nondilated intrahepatic biliary tracts, with no major complications.

The Hawkins needle-guide system for percutaneous catheterization: 2. Clinical experience in biliary tract and abscess drainage

In 1979, a new, 22 gauge needle guide was introduced for combined percutaneous transhepatic cholangiography and biliary drainage procedures. In 103 biliary procedures and 29 abscess drainages using this needle guide, there were no major complications. The use of a small-volume (1-2 ml), low-pressure contrast injection followed by 24 hr of external decompression using self-retaining catheters (Cope loop, accordion) has reduced sepsis as a problem in biliary procedures. Small targets (1-2 cm abscess cavities) can be safely searched for with this 22 gauge needle guide. Two multiloculated abscesses were successfully drained by applying the surgical principle of ingress-egress irrigation catheters for infected cavities.

Curved stylus for redirection of the fine-needle guide

A new curved stylus, fabricated from a new alloy (rocket wire), can be used in fine-needle biopsy and drainage procedures after a near miss of the target. This permits reorientation of the tip of the needle into the target and obviates the need for additional passes.

Removal of an entangled monofilament with a Chiba needle

A monofilament which has become entangled during an interventional procedure may be cut free by advancing a catheter over the free ends and sliding a 22 gauge Chiba needle over the monofilament. When the knot is encountered, the sharp tip of the Chiba needle cuts and releases the monofilament.

The cerebrovascular effects of intraarterial CO2 in quantities required for diagnostic imaging

The recent development of digital subtraction angiography (DSA) has renewed interest in the use of gases, especially carbon dioxide, as contrast agents. Both early physiologic studies and recent clinical reports suggest that arterial CO2-DSA is a safe and useful diagnostic tool in the examination of extremity circulation. The present study examined the neurologic sequelae, pathologic changes, and effects on the blood-brain barrier to intravenous Evans-Blue and horseradish peroxidase of intracarotid CO2, in albino rats. As with other forms of cerebral gas embolization, CO2 produced multifocal ischemic infarctions and disrupted the blood-brain barrier to macromolecular tracers. The site of the barrier lesion is the endothelial cell membrane, although the precise mechanisms of damage remain unknown. Caution must be urged in the use of CO2-DSA to avoid embolization of the central nervous system.

Aggressive fibromatosis: evaluation by computed tomography and angiography

Fifteen CT scans of 13 patients who had aggressive fibromatosis were generally accurate in showing the extent of disease, although the CT definition of half or more of the margins of nine lesions was poor. Fibromatosis tumors were typically isodense or slightly hypodense with muscle when no contrast medium was used, and they enhanced to hyperdense with better delineation during infusion of contrast medium. Obliterated intermuscular planes did not always signify disease extension; the relationship to bone was often obscured by beam-hardening artifact; and small blood vessels were often invisible. Arteriograms of seven of eight patients showed some hypervascularity and helped to delineate lesions and vessels that were poorly seen on CT scans. In four instances CT findings were clearer, in two instances arteriographic findings were clearer, and twice the findings were equally clear. Three of six bone scintigrams added accurate information about involvement of adjacent bones. Since fibromatosis can microscopically infiltrate beyond the margins indicated by radiographic studies and even by direct palpation at operation, the surgeon should obtain a wide margin beyond the defined tumor limits.

Radiology of giant cell tumors of bone: computed tomography, arthro-tomography, and scintigraphy

Radiologic studies of 50 giant cell tumors of bone in 48 patients were useful in assessing the anatomic extent for planning surgical treatment. Contrast-enhanced computed tomography (CT) provided the most useful and complete evaluation, including soft tissue extent and relationship to major vessels. Angiography was useful when the extraosseous extent and vascular relationships were not entirely clear on CT. Arthro-tomography was the best way to evaluate tumor invasion through subchondral cortex and articular cartilage. Reactive soft tissues, with edema and hyperemia, were difficult to distinguish from tumor tissue on CT and angiograms. Bone scintigrams often showed intense uptake beyond the true tumor limits.

Hawkins-Hunter retrograde transcutaneous nephrostomy: a new technique

Retrograde nephrostomy, a new technique to aid in stone management, has been performed successfully in dogs. It has also been used without complication in a human patient to help remove a renal stone percutaneously under local anesthesia. The technique consists of placing a coaxial catheter over a guidewire under fluoroscopy into the exact calyx desired and advancing a long needle out to the skin to establish a transcutaneous tract. The advantages of the technique include increased control and precision of tract placement, efficient working angles for percutaneous stone removal, and the ability to perform the procedure under local anesthesia.

Radiologic imaging of osteosarcoma: role in planning surgical treatment

We reviewed radiographic studies of 50 central osteosarcomas to assess their accuracy and contributions to surgical treatment planning. Accurate anatomic delineation was especially important when limb-sparing tumor resection was considered. The plain roentgenograms yielded most of the diagnostic information, and often showed large masses located so that major neurovascular involvement was inevitable. Conventional tomography added little. Computed tomography (CT) usually was accurate in showing tumor extent and relationships to major nerves and vessels. However, CT was less useful when vessels were not seen, when edema and hemorrhage (especially after biopsy) blurred tumor margins, or when tumor margin and soft tissue planes blended together without clear definition. Angiography was essential when vascular relationships were unclear on CT. Scintigraphy occasionally revealed subtle intra-marrow tumor extension, but nonspecific increased uptake beyond the true tumor limits was more common than occult tumor spread.

Radiology of medullary chondrosarcoma: preoperative treatment planning

We evaluated the radiologic studies of 30 medullary chondrosarcomas with respect to their accuracy in diagnosis and surgical staging. There were 30 sets of plain radiographs, 14 conventional tomograms, 26 radionuclide bone scans, 19 arteriograms, and 15 computed tomograms (CT). Plain radiographs provided most of the diagnostic information although many tumours looked benign. CT provided the most complete anatomic staging, including intra- and extraosseous tumor, and neurovascular involvement. However, it was difficult to be sure about subtle soft tissue invasion. Arteriography remained useful for evaluating major vessel involvement or cortical penetration when CT and conventional tomography were equivocal. Scintigrams disclosed increased uptake, usually corresponding to the true tumor extent; "extended uptake" beyond the tumor was uncommon. Conventional tomography has been largely replaced by CT, but was occasionally useful when the tumor was near the end of a bone.

Control of hypertension by ethanol renal ablation

Five patients underwent therapeutic renal ablation with intraarterial injection of ethanol as treatment for uncontrollable systemic hypertension. All patients either showed complete resolution of the hypertension or improved medical manageability of the hypertension became possible. Ethanol appears to cause permanent renal ablation by cell death while decreasing the risks associated with other embolization techniques.

New coaxial exchange guide wire with a variable-length tip

A new coaxial exchange guide wire, which has a variable-length, flexible "J"-shaped tip for exchanging drainage catheters in both large and small structures, is described. The design provides a gradual transition from the softness of the tip to the stiffness of the cannula. The system is presently available in two sizes (0.89 mm [0.035 in.] and 0.64 mm [0.025 in.]) and can also be used as a catheter end-hole dilator.

New monofilament basket for bladder calculi

Successful stone manipulation was facilitated with the new monofilament basket in experimental situations and in patients. Advantages over other baskets include: in vivo adjustability, reduced mucosal trauma, ability to irrigate and aspirate through the basket, and ability to pass lithotriptor electrodes within the basket. Basket modifications under study might prove useful within the ureter, renal pelvis, and biliary tree.

Carbon dioxide digital subtraction arteriography

Arterially injected carbon dioxide coupled with digital subtraction fluoroscopy consistently produced clinically useful images of arteries in 17 patients. Occasionally good parenchymal images and venograms were also obtained. The buoyancy of the gas requires that the area of interest be in a nondependent position to insure good arterial perfusion. The exceedingly low viscosity of gas should permit delivery of the CO2 via microcatheters which would lessen the risk of arterial injury. CO2 does not produce hypersensitivity reactions and, even in large volumes, should not produce the discomfort associated with iodinated contrast material.

Percutaneous cholecystostomy

Percutaneous cholecystostomy was performed in 13 patients; five patients had suspected acute cholecystitis and eight patients had suspected obstruction of the common bile duct. An anterior abdominal wall approach was used in nine patients, right anterior axillary line puncture in four. One patient developed peritonitis and fatal septic shock after inadvertent cholecystostomy catheter removal. None of the other patients became septic, developed peritonitis, or had any other complication related to cholecystostomy. Two of the patients had external drainage as outpatients for more than 6 months without complication. Technical and clinical points are reviewed.

Radiological evaluation of chondroblastoma

Eleven new and six recurrent chondroblastomas were studied with multiple radiological imaging methods (plain radiography, conventional tomography, computed tomography, radionuclide bone scanning, and angiography). When the plain radiographic appearance was typical, conventional tomography or computed tomography (CT) was helpful, but other studies were not. Periosteal reaction and angiographic hypervascularity were common and did not indicate cortical breakthrough. For large, aggressive, or atypical lesions, conventional tomography and CT were helpful in delineating anatomic extent, and angiography was of value in demonstrating major vessel displacement. Radionuclide bone scanning was not useful.

The value of angiography in planning surgical treatment of bone tumors

Evaluation of 314 angiograms revealed that they were often very useful in planning nonablative resection of bone tumors because they demonstrated the relationships of the tumors to major vessels. Increasing experience indicates that computed tomography can accurately define intraosseuous and soft-tissue extent of bone tumors. If vascular relationships are not precisely shown by computed tomography, angiography may still be required. The angiograms occasionally also helped in anticipating operative blood loss, demonstrating variants of vascular anatomy, or planning biopsy. Meticulous angiographic technique and close communication between surgeon and angiographer are essential.

Radiology of infiltrating angiolipoma

Infiltrating angiolipomas are rare benign soft-tissue neoplasms that are locally aggressive and require wide surgical excision. Of 10 patients studied, five showed serpiginous densities intermixed with fat on plain films. Six radionuclide bone scans showed uptake by the soft-tissue lesion. Eight angiograms demonstrated poorly marginated, very hypervascular lesions. Computed tomography (CT) in five patients yielded excellent visualization of predominantly low density lesions that invaded and replaced skeletal muscle. The combination of angiography and CT indicated the specific diagnosis and demonstrated the size, extent, and vascularity of the tumors.