Grey-scale ultrasonography and percutaneous transhepatic cholangiography in biliary tract disease.

Fifty-one patients with suspected obstructive jaundice and 14 without jaundice in whom disease of the biliary tract was suspected but infusion cholangiography had been unhelpful were examined by grey-scale ultrasonography and percutaneous transhepatic cholangiography and the findings analysed retrospectively. Grey-scale ultrasonography distinguished between obstructive and hepatocellular jaundice in 35 out of 46 patients (76%) and indicated the site of the obstruction in 27 (58%) and the cause of the obstruction in 13 (28%). Percutaneous transhepatic cholangiography distinguished between obstructive and hepatocellular jaundice in 42 of the patients (91%) and indicated the site of the obstruction in 42 (91%) and the cause in 29 (63%). In the 14 patients without jaundice percutaneous transhepatic cholangiography showed bile-duct stones in one an ampullary stenosis in three. It is concluded that grey-scale ultrasonography and percutaneous transhepatic cholangiography are complementary examinations and that ultrasonography should always be undertaken first as it is a non-invasive procedure that may provide the surgeon with all the diagnostic information he requires. Percutaneous transhepatic cholangiography should be performed when grey-scale ultrasonography has shown dilated bile ducts but failed to provide adequate diagnostic information. Cholangiography is also required when preoperative percutaneous drainage of the bile duct is contemplated. In those patients in whom grey-scale ultrasonography shows non-dilated ducts endoscopic retrograde cholangiopancreatography is probably the contract examination of choice.     

X-ray diagnosis of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) should be regarded as a disease of the bile tracts which is difficult to diagnose rather than a rare disease. Combined radiodiagnostic investigation in the preoperative period is of great importance. Direct methods of an induced contrast study of the biliferous system (transcutaneous transhepatic cholangiography, endoscopic retrograde pancreatocholangiography) play a major role in the diagnosis of PSC. The authors present 11 cases, describing in detail x-ray semiotics of various sites of PSC and its differential diagnosis with similar diseases.     

Transhepatic Cholangiography

Percutaneous transhepatic cholangiography is a method of visualizing the biliary tree by the injection of radio-opaque medium through the abdominal wall and liver into an intrahepatic bile duct. The procedure is indicated in the immediate preoperative evaluation of patients with obstructive jaundice of unknown etiology and is usually diagnostic in these cases. It may also be of value in avoiding operation in poor-risk patients with obstructive jaundice. Biliary leak resulting in chemical peritonitis is a complication in about 5% of these procedures. Intraperitoneal hemorrhage is a complication in less than 1%. Death results from the procedure in less than 0.5% of cases. Transhepatic cholangiography during surgical operation is of value in demonstrating obstructive lesions of the bile ducts. However, preoperative percutaneous transhepatic cholangiography is preferred, since it makes possible adequate preparation for technically difficult repairs and resections.     

Value of injection hepato-lymphography during percutaneous transhepatic cholangiography in patients with cholestasis

Injection hepatography (IH) was made in 278 patients with cholestasis to study the drainage function of the liver. In 208 cases. IH was performed as a test during percutaneous transhepatic cholangiography (PTHC). The hepatic lymph pathways were imaged in 167 (60%) patients. Images of the biliary tract were obtained in 245 (88.1%) patients with cholestasis, it being not dilated in 34 (12.2%) patients. The fact that hepatolymphography may be performed during PTHC as an independent test permits verification of hepatic lymph circulatory disorders that are an index of the rate of inflammation in the organ.     

Radiodiagnosis of patients with primary sclerosing cholangitis

Among diseases of the hepatobiliary system, primary sclerosing cholangitis is an undetectable disorder of the biliary tract rather than a rare nosological entity, complex radiation study is of great importance in its preoperative diagnosis. Among direct methods for contrasting the biliary tract, the authors gave preference to percutaneous transhepatic cholangiography that allows the dilated biliary tract to be contrasted virtually in 100% of cases. The specific features of X-ray semiotics of primary sclerosing cholangitis were identified in 17 patients.     

SPECIALTY CONFERENCE: The Treatment of Retained Gallstones

Various techniques are available to evaluate patients suspected of having common duct stones before an operation on the biliary tract. In patients without jaundice, intravenous cholangiography with tomography may provide satisfactory visualization of the biliary system and its contents. Sonography and computerized axial tomography are useful noninvasive methods. Endoscopic retrograde and transhepatic cholangiography are invasive techniques; but, when successful, they provide the most precise preoperative information obtainable about the presence or absence of stones in the biliary system. The most appropriate diagnostic procedures must be carefully selected for each patient. Each year in 3,000 to 4,000 cases, stones are found remaining in the bile ducts after common duct exploration for the removal of stones. Retained stones can be treated by nonoperative extraction, by irrigation techniques and by surgical removal. Extraction methods probably deserve first consideration, if experienced personnel are available. The technique of irrigation of the common bile duct with cholic acid or other solutions, although limited in success, may also be tried; if these procedures fail, then reoperation is indicated.     

Percutaneous Transhepatic Cholangiography—Report of a Technique

Percutaneous transhepatic cholangiography was carried out in 30 patients with jaundice of unknown cause. The examination was successful in 24, and the correct diagnosis was established before operation in 23.Among the specialized radiographic procedures useful in the differential diagnosis of jaundice, the percutaneous transhepatic cholangiogram is simple and reliable. It will distinguish intrahepatic from extrahepatic biliary obstruction. In benign structures, it can give a good anatomical and pathological definition of the problem which faces the surgeon. Occasionally, it may make operation unnecessary.Serious complications are hemorrhage and bile peritonitis. The incidence is low and by careful management they can be avoided.     

La cholangiographie percutanée transhépatique avec aiguille "fine" de Chiba.

In 40 patients percutaneous transhepatic cholangiography was performed by means of the "skinny" Chiba needle. The intrahepatic bile ducts were visualized in 100% of the patients with dilated ducts and in 67% of those with ducts of normal calibre. The results compare to those in the literature and demonstrate the usefulness as well as the reduced morbidity of this new procedure. Therefore nonvisualization of the intrahepatic bile ducts by this method signifies that the ducts are not dilated.     

Radiologic investigation of suspected extrahepatic biliary obstruction.

Data for 94 patients clinically suspected of having extrahepatic biliary obstruction who were referred for radiologic investigations were studied to compare the value of various imaging modalities used to detect this condition. Computed tomography emerged as the best indirect, noninvasive technique and percutaneous transhepatic cholangiography as the best direct technique. A standard approach to investigating suspected extrahepatic biliary obstruction is suggested that takes into consideration the interventional radiologic techniques currently used to treat this condition.     

New Diagnosis and Therapy Model for Ischemic-Type Biliary Lesions following Liver Transplantation—A Retrospective Cohort Study

Ischemic-type biliary lesions (ITBLs) are a major cause of graft loss and mortality after orthotopic liver transplantation (OLT). Impaired blood supply to the bile ducts may cause focal or extensive damage, resulting in intra- or extrahepatic bile duct strictures or dilatations that can be detected by ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and cholangiography. However, the radiographic changes occur at an advanced stage, after the optimal period for therapeutic intervention. Endoscopic retrograde cholangio-pancreatography (ERCP) and percutaneous transhepatic cholangiodrainage (PTCD) are the gold standard methods of detecting ITBLs, but these procedures cannot be used for continuous monitoring. Traditional methods of follow-up and diagnosis result in delayed diagnosis and treatment of ITBLs. Our center has used the early diagnosis and intervention model (EDIM) for the diagnosis and treatment of ITBLs since February 2008. This model mainly involves preventive medication to protect the epithelial cellular membrane of the bile ducts, regular testing of liver function, and weekly monitor of contrast-enhanced ultrasonography (CEUS) to detect ischemic changes to the bile ducts. If the liver enzyme levels become abnormal or CEUS shows low or no enhancement of the wall of the hilar bile duct during the arterial phase, early ERCP and PTCD are performed to confirm the diagnosis and to maintain biliary drainage. Compared with patients treated by the traditional model used prior to February 2008, patients in the EDIM group had a lower incidence of biliary tract infection (28.6% vs. 48.6%, P = 0.04), longer survival time of liver grafts (24±9.6 months vs. 17±12.3 months, P = 0.02), and better outcomes after treatment of ITBLs.     

Fine needle aspiration of the liver

A total of 81 transhepatic fine needle aspiration (FNA) biopsies were performed on 78 patients to rule out focal or diffuse neoplastic disease; 87.6% were performed with ultrasound guidance, 6.1% with CT guidance, 3.7% intraoperatively and 1 using fluoroscopy during percutaneous transhepatic cholangiography. Smears of the aspirated samples were cytologically evaluated with clinical and radiologic correlation; in addition, histologic examination of cell blocks was performed in 46% of the cases, ultrastructural examination in 34% of the cases and peroxidase-antiperoxidase staining in 3 cases. Ultrastructural definition of the type of malignancy was possible in 24 cases (29%). Minor complications in two patients were pain and tenderness at the puncture site. The sensitivity for malignancy was 91%, the specificity was 100%, the predictive value of positive results was 100%, and the predictive value of negative results was 73%. This series demonstrates that FNA biopsy with ultrasound guidance can provide an accurate diagnosis of malignancy and may preempt a lengthy workup in the search for a primary tumor.     

Ultrasonographic guidance in diagnostic and therapeutic interventions in diseases of the internal organs

A hundred fifty four invasive diagnostic and therapeutical interventions were made in patients with diseases of the abdomen and retroperitoneal space under ultrasonographic guidance. Various biopsies were performed in 139 patients; positive results were achieved in 120 (86.3%) cases. In 15 patients, diagnostic biopsies were combined with therapeutical interventions, such as aspiration of cysts in the liver (n = 3) and kidney (n = 2); drainage of abscesses in the abdomen (n = 5) and liver (n = 5). Fourteen patients with mechanical jaundice caused by extrahepatic bile duct tumors or pancreatic head cancer underwent percutaneous transhepatic cholecystocholangiography followed by external drainage. Percutaneous transhepatic drainage of the gallbladder was made in 1 patient with acute cholecystitis.     

Radiologic methods in the diagnosis of diseases of the spleen]

Ultrasonic and computer-aided tomographic examinations of 2457 patients with suspected diseases of the abdominal cavity organs have revealed splenic involvement in 48. The sensitivity of ultrasonic technique for the detection of splenic diseases has made up 70.8%, that of computer-aided tomography--95.8%. Invasive interventions monitored by these two methods were carried out in 26 patients; in 10 of these transcutaneous puncture drainage was carried out for cysts (2), hematoma (1), and abscesses of the spleen (7). In one patient with multiple abscesses of the spleen the drainage was found insufficient for complete cure and he had to be subjected to splenectomy, in the rest cases surgery did not have to be resorted to. Therefore, ultrasonic and computer-aided tomographic examinations of the spleen, used together with various invasive interventions, result not only in correct diagnosis and differential diagnosis of this organ's disease, but permit various therapeutic measures and help achieve cure without laparotomy.     

Brushing cytology in biliary tract obstruction

During a period of eight years (1980 to 1987), cytologic samples were obtained by brushing and reverse screw devices from 54 patients undergoing transhepatic cholangiography for evaluation of obstructive jaundice. Eight patients were excluded from this study, seven for inadequate follow-up and one because of unsatisfactory cytologic material. Of the remaining cases, 32 were cytologically diagnosed as adenocarcinomas; all but one patient proved to have malignant disease by histologic examination and/or through clinical follow-up. These included 21 pancreatic carcinomas, 6 bile duct carcinomas, 1 ampullary carcinoma, 1 gallbladder carcinoma and 2 metastatic carcinomas. In one case, the diagnosis of malignancy was found to be in error upon review of the cytologic smears. Of 14 patients with negative cytologic diagnoses, 7 were found to have malignant neoplasms and 7 had benign diseases. These findings indicate that, while a positive cytologic diagnosis is a reliable indicator of a malignant biliary obstruction, a negative result does not exclude malignancy.     

经皮肝穿刺胆道引流术与逆行胰腺胆管造影术对结石性梗阻性黄疸患者的疗效比较研究

目的:比较经皮肝穿刺胆道引流术(PTCD)与逆行胰腺胆管造影术(ERCP)对结石性梗阻性黄疸患者的治疗效果。方法:选取海军军医大学第三附属医院东方肝胆外科医院于2016年3月～2018年4月间收治的结石性梗阻性黄疸患者80例。按照介入治疗术式的异同将患者分为ERCP组(n=40,给予ERCP治疗)和PTCD组(n=40,给予PTCD治疗),记录两组手术时间、术中出血量、住院费用、住院时间、治疗成功率、黄疸缓解率、并发症发生情况,比较两组术前、术后1 d、术后7 d肝功能指标情况。结果:两组患者手术时间、术中出血量、治疗成功率、黄疸缓解率比较差异无统计学意义(P0.05),ERCP患者住院费用少于PTCD组患者,住院时间亦短于PTCD组患者(P0.05)。两组患者术后1 d、术后7 d丙氨酸转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)水平均较术前降低,且两组患者术后7 d上述指标水平低于术后1 d(P0.05),ERCP组术后1 d、术后7 d ALT、TBIL、DBIL水平与PTCD组比较差异无统计学意义(P0.05)。两组患者术后并发症总发生率比较差异无统计学意义(P0.05)。结论:PTCD、ERCP治疗结石性梗阻性黄疸,均能有效改善患者临床症状和肝功能,且手术安全性相当,但ERCP可明显减少住院时间和住院费用。     

Intravenous cholangiography; some observations on the use of cholografin

Intravenous cholangiography with cholografin is a safe procedure, most useful for the study of patients who have had cholecystectomy and later have symptoms related to the biliary ducts. When jaundice or liver impairment is present, the examination is usually unsuccessful. However, these conditions are not absolute contraindications to the procedure. There may be failure to visualize the biliary ducts even in the presence of a normal liver. Planigraphy is helpful in eliminating confusing superimposed structures and when there is only faint visualization of the common duct. Intravenous cholecystography is only of questionable value as a supplementary examination to oral cholecystography. It may prove useful in certain instances when patients are unable to retain or absorb the oral media or where emergency operation is contemplated.     

A Pilot Study to Assess the Feasibility of Transcutaneous Glomerular Filtration Rate Measurement Using Fluorescence-Labelled Sinistrin in Dogs and Cats

In dogs and cats an assessment of renal function is often needed, however, existing methods including urine and plasma clearances are invasive, cumbersome and time consuming. This pilot study evaluated the feasibility of a transcutaneous glomerular filtration rate (GFR) measurement in dogs and cats. Additionally the optimal dose and location for the transcutaneous measurement device were investigated. Renal elimination of fluorescein-isothiocyanate-labelled sinistrin (FITC-S) was measured transcutaneously for 4 hours. The procedures were performed in awake, freely moving animals using escalating doses of FITC-S (10 mg/kg, 30 mg/kg, 50 mg/kg) with a wash-out period of at least 24 h in between. Multiple devices were placed on each animal. The resulting FITC-S disappearance curves were visually assessed to determine the most suitable location and the appropriate dose to reach an adequate transcutaneous peak signal for kinetic analysis. In both species 30 mg/kg were adequate for kinetic calculation. The most suitable place for the device was the lateral thoracic wall in dogs and the ventral abdominal wall in cats, respectively. Transcutaneous FITC-S clearance was then repeated using the optimal dose and location and in parallel with an additional plasma sinistrin clearance. Plasma elimination half-lives [min] were 26, 31 and 35, and corresponding transcutaneous elimination half-lives [min] were 26, 34 and 55, respectively in the dogs. Plasma elimination half-lives [min] were 51, 60 and 61, and corresponding transcutaneous elimination half-lives [min] were 75, 96 and 83, respectively in the cats. In conclusion, transcutaneous FITC-S clearance is a feasible method for the assessment of GFR in awake dogs and cats. It is noninvasive, well tolerated and easy to perform even in a clinical setting with results being readily available. A dose of 30 mg/kg of FITC-S seems adequate for kinetic assessment. Further studies are now needed to establish reference values and evaluate transcutaneous renal clearance in various conditions.     

The application of intraoperative ultrasound during partial hepatectomy for the accurate detection and removal of intrahepatic bile duct stones

To evaluate the application of intraoperative ultrasound (IOUS) during partial hepatectomy to accurately detect and remove intrahepatic bile duct stones. Intrahepatic bile duct stones were precisely localized during surgery by using IOUS. Furthermore, guiding stone extraction, and determining the scope of liver resection and choice of surgical procedures were also evaluated using this technique. Of the 25 patients used in this study, 16 patients received a left lateral liver resection, 7 patients received a left liver resection, 1 patient had a liver resection of segments V and VI, 9 patients had common bile duct stones, and 6 patients had bile duct stones that underwent jejunal Roux-en-y anastomosis. In addition, IOUS exploration after liver resection and post-operative T-tube cholangiography showed one case with residual stones. The use of IOUS showed high diagnostic accuracy, while also rectifying the misdiagnosis and missed diagnosis of bile stones in preoperative imaging. IOUS also assisted with positioning accuracy, which is very important in determining the extent of surgical resection and choice of surgical procedure. Thus, IOUS can dynamically monitor the surgical procedure, guide the operation, and inspect the outcome of operations, therefore, effectively improving the quality of operation.     

Relation of transcutaneous to arterial pO2 in hypoxaemia, normoxaemia and hyperoxaemia. Investigations in adults with normal circulation and in patients with circulatory insufficiency

The transcutaneous oxygen tension was monitored continuously by a heated cutaneous polarographic electrode in 7 adult intensive care patients, 12 patients without circulatory insufficiency, and 5 healthy volunteers, Arterial pO2 values were varied from hypoxaemia to normoxaemia and hyperoxaemia by variations of the inspired oxygen concentration. In normal volunteers and in patients without circulatory failure, transcutaneous pO2 indicated on an average about 81-92% of the arterial pO2 in normoxaemia and hyperoxaemia with a correlation coefficient of 0.97. In hypoxaemia there was an over-proportional decrease of the transcutaneous pO2 to a mean value of 44% fo the arterial pO2. In one case the transcutaneous pO2 reproducibly dropped to zero at paO2 values of 41 respectively 38 mm Hg (5.5 respectively 5.1 kPa). In intensive care patients the transcutaneous pO2 values were considerably lower than the paO2 values. There was no constant transcutaneous to arterial pO2 ration in most of the intensive care patients at different pO2 levels. In adults without disturbance of peripheral perfusion paO2 can be predicted with satisfactory accuracy from transcutaneous pO2 values in normoxaemia and in hyperoxaemia. In hypoxaemia and in circulatory insufficiency, the transcutaneous pO2 is only an indicator of the trend of the arterial pO2. Under these conditions it does not allow a quantitative estimate of paO2 changes.     

INTRAVENOUS CHOLANGIOGRAPHY—Some Observations on the Use of Cholografin

Intravenous cholangiography with cholografin is a safe procedure, most useful for the study of patients who have had cholecystectomy and later have symptoms related to the biliary ducts.When jaundice or liver impairment is present, the examination is usually unsuccessful. However, these conditions are not absolute contraindications to the procedure. There may be failure to visualize the biliary ducts even in the presence of a normal liver.Planigraphy is helpful in eliminating confusing superimposed structures and when there is only faint visualization of the common duct.Intravenous cholecystography is only of questionable value as a supplementary examination to oral cholecystography. It may prove useful in certain instances when patients are unable to retain or absorb the oral media or where emergency operation is contemplated.