超声引导下胆囊置管术在急性胆囊炎治疗中的临床应用

目的 探讨超声引导下胆囊置管术在急性胆囊炎治疗中的临床应用.方法 选取2016年10月-2020年9月普外科急性胆囊炎就诊患者54例,分为两组,观察组为超声引导下胆囊置管引流+腹腔镜下胆囊切除病例22例,对照组为腹腔镜下胆囊切除病例32例.结果 随访两组患者腹腔镜手术术中及术后情况,对比术中出血量、术后白细胞计数、并发...     

Percutaneous Cholecystostomy as a First-Line Therapy in Chronic Hemodialysis Patients with Acute Cholecystitis with Midterm Follow-up

Purpose  

The purpose of this article was to share midterm results of percutaneous cholecystostomy (PC) as a first-line therapy in chronic hemodialysis patients with acute cholecystitis.     

Removal of a Trapped Endoscopic Catheter from the Gallbladder via Percutaneous Transhepatic Cholecystostomy: Technical Innovation

Background Percutaneous cholecystostomy is used for a variety of clinical problems. Methods Percutaneous cholecystostomy was utilized in a novel setting to resolve a problematic endoscopic situation. Observations Percutaneous cholecystostomy permitted successful removal of a broken and trapped endoscopic biliary catheter, in addition to helping treat cholecystitis. Conclusion Another valuable use of percutaneous cholecystostomy is demonstrated, as well as emphasizing the importance of the interplay between endoscopists and interventional radiologists.     

Gallbladder Cryoablation for Chronic Cholecystitis in High-Risk Surgical Patients: 1-Year Clinical Experience with Imaging Follow-up

PurposeTo assess the short-term safety and efficacy of gallbladder cryoablation in high-risk patients.Materials and MethodsA single-center, retrospective review of clinical and imaging follow-up from patients who were referred for gallbladder cryoablation between August 2018 and July 2019 was performed. All patients had serious pre-procedural comorbidities and were unacceptable surgical candidates (mean age, 52.5 years; mean American Society of Anesthesiologists score, 3.67). Primary efficacy measures included technical success, absence of symptoms after cholecystostomy tube removal, and imaging evidence of cystic duct obstruction and gallbladder involution. The primary safety measure was the absence of Society of Interventional Radiology moderate or greater adverse events.ResultsTechnical success was 86%, with 1 of 7 patients unable to undergo cryoablation because of adhesions preventing hydrodissection of the colon away from the gallbladder. Mean duration of clinical follow-up after discharge was 278 days (range, 59–498 days). Abdominal pain was absent in all patients after ablation. Cholecystostomy tubes were removed immediately after ablation (n = 5) or on post-procedure day 11 (n = 1). Computed tomography or magnetic resonance imaging was obtained at 1–3 months (n = 6), 4–6 months (n = 4), and 6–12 months (n = 5) after the procedure and demonstrated gallbladder involution in 5 of 6 patients. One patient had asymptomatic distention of the gallbladder on follow-up imaging. Hepatobiliary iminodiacetic acid scans were completed in 5 of 6 patients 1 month after ablation and demonstrated cystic duct occlusion in all 5 patients. One moderate adverse event (infection) and 1 life-threatening adverse event (hemorrhage) occurred.ConclusionsGallbladder cryoablation might be a viable treatment option for high-risk patients with gallbladder disease and warrants further investigation.     

双导丝技术在经皮胆囊穿刺引流术中的应用

目的 探讨双导丝技术在经皮胆囊穿刺引流术中的应用价值及临床疗效.方法 回顾性分析2012年2月至2014年4月采用双导丝技术进行经皮穿刺胆囊引流术的48例高危急性胆囊炎患者资料,其中36例为结石性胆囊炎,12例为非结石性胆囊炎;34例行经皮经肝穿刺引流,14例行经腹腔胆囊穿刺引流;4例在DSA引导下行经皮胆囊穿刺引流术,44例在CT引导下行经皮胆囊穿刺引流术.引流管直径为8F,引流管拔出前给予闭管1周.结果 48例患者均成功置入外引流管,操作成功率为100％.1例合并急性心功能衰竭患者死亡.1例术后第3天突发腹痛,CT显示小肠破裂,行小肠破裂修补术后治愈.1例术后第3天腹痛复发,行胆囊造影显示引流管破裂,更换引流管后好转,其余47例患者术后引流通畅,术后72 h腹痛等症状减轻或消失,体温及白细胞降至正常.19例结石性胆囊炎患者术后1～3个月行择期胆囊切除术,17例结石性胆囊炎患者选择带管生存,12例非结石性胆囊炎患者术后6～7周拔管.结论 双导丝技术在经皮胆囊穿刺引流术中具有操作简单、创伤小、安全性高、疗效确切的优点,具有重要临床应用价值.     

Percutaneous Radiologic Gastrostomy Using the One-Anchor Technique in Patients after Partial Gastrectomy

Objective

The purpose of our study was to assess the feasibility of performing percutaneous radiologic gastrostomy (PRG) in patients who had undergone partial gastrectomy and to evaluate factors associated with technical success.

Materials and Methods

Nineteen patients after partial gastrectomy, who were referred for PRG between April 2006 and April 2012, were retrospectively analyzed. The remnant stomach was punctured using a 21-gauge Chiba-needle. A single anchor was used for the gastropexy and a 12-Fr or 14-Fr gastrostomy tube was inserted. Data were collected regarding the technical success, procedure time, and presence of any complications. Univariable analyses were performed to determine the factors related to the technical success.

Results

Percutaneous radiologic gastrostomy was technically successful in 10 patients (53%), while a failed attempt and failure without an attempt were observed in 5 (26%) and 4 (21%) patients, respectively. Percutaneous radiologic jejunostomy was successfully performed in 9 patients who experienced technical failure. In the 10 successful PRG cases, the mean procedure time was 6.35 minutes. Major complications occurred in 2 patients, tube passage through the liver and pneumoperitonum in one and severe hemorrhage in the other. The technical success rate was higher in patients with Billroth I gastrectomy (100%, 6/6) than in patients with Billroth II gastrectomy (31%, 4/13) (p = 0.011).

Conclusion

Percutaneous radiologic gastrostomy can be successfully performed using the one-anchor technique in approximately half of the patients after partial gastrectomy.     

Successful Percutaneous Transluminal Angioplasty and Stenting in Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a life-threatening emergency. The complications are high by the time of diagnosis in most cases and therefore only few data on primary percutaneous intervention with percutaneous transluminal angioplasty (PTA) and stenting in AMI are available. We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea. She had previously undergone percutaneous transluminal embolectomy for an acute occlusion of the left common femoral artery. Due to suspicion of intestinal infarction, conventional angiography of the aorta and the superior mesenteric artery (SMA) was performed and confirmed a proximal occlusion of the SMA. Percutaneous SMA recanalization with balloon dilation and subsequent stent implantation was carried out successfully. The abdominal symptoms subsided after this procedure. In AMI that is diagnosed early, endovascular stenting should be considered as an alternative treatment to the surgical approach that avoids the need for surgical bowel resection.     

Percutaneous necrosectomy in patients with acute, necrotizing pancreatitis

The objective of this retrospective study was to evaluate the outcome of patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy. By searching the radiological, surgical and internal medicine databases, all patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy between 1992 and 2004 were identified. Demographic, laboratory, and clinical data, and details about invasive procedures were collected by reviewing patient charts, radiological and surgical reports. The computed tomography severity index (CTSI) scores were determined by reviewing CT images. Eighteen patients were identified. Median Ranson score on admission was 2. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was median 22. Median CTSI score was 7. Initially all patients were treated with CT-guided drainage placement. Because passive drainage proved not to be effective, subsequent minimally invasive, percutaneous necrosectomy was performed. Eight out of 18 patients recovered fully without the need for surgery. Ten of 18 patients required additional surgical necrosectomy. For one of ten patients, percutaneous necrosectomy allowed postponing surgery by 39 days. Four of ten surgically treated patients died: three from septic multiorgan failure, one from pulmonary embolism. Percutaneous minimally invasive necrosectomy can be regarded as a safe and effective complementary treatment modality in patients with necrotizing pancreatitis. It is suitable for a subset of patients to avoid or delay surgery.     

冠心病介入诊疗或搭桥术期间发生急性胆囊炎发作病人的超声引导下经皮胆囊穿刺引流及其临床意义

目的探讨超声引导下的胆囊穿刺引流对冠心病介入诊断治疗或搭桥术期间发生急性胆囊炎发作病人治疗价值。方法对7例冠状动脉支架术后病人,3例冠状动脉搭桥术后病人,1例拟行冠状动脉造影病人发生胆囊炎急性发作时实施超声引导下的胆囊穿刺引流,针具为8号PTCD套管针,采用经肝脏胆囊床进入胆囊途径。引流中以超声对胆囊情况进行监测。结果11例患者均一次穿刺成功抽出胆汁,引流出胆汁130~240ml,未发生胆漏和出血等并发症。术后2d病人体温全部恢复正常,复查白细胞总数和中性粒细胞均恢复正常。1周内均拔除了导管,心脏情况恢复顺利。结论超声引导下经皮胆囊穿刺创伤小,能有效缓解和控制胆系感染,对保证冠心病的有创诊断和治疗圆满成功有重要意义。     

Percutaneous Recanalization of Acute Internal Carotid Artery Occlusions in Patients with Severe Stroke

Background Sudden symptomatic occlusions of the proximal internal carotid artery (ICA) resulting in severe middle cerebral artery (MCA) ischemia and stroke are usually not accessible by rt-PA thrombolysis and the prognosis is usually very poor. Mechanical recanalization of the proximal ICA combined with intravenous and intra-arterial thrombolysis was therefore used as a rescue procedure. Methods Ten patients (9 men, 1 woman; mean age 56.1 years) were treated with emergency recanalization of the proximal carotid artery by using stents and/or balloon angioplasty as a rescue procedure. Three patients showed dissection, and 7 had atherothrombotic occlusions. Nine of 10 presented with an initial modified Rankin Scale (mRS) of 5, the remaining patient with mRS 4 (average NIHSS 21.4). After sonographic confirmation of ICA with associated MCA/distal ICA occlusion and bridging with rt-PA (without abciximab) an emergency angiography was performed with subsequent mechanical recanalization by percutaneous transluminal angioplasty (PTA) (n = 1) or primary stenting (n = 9) using self-expanding stents. Distal protection was used in 1 of 10 patients. Results Recanalization of the proximal ICA was achieved in all. At least partial recanalization of the intracerebral arteries was achieved in all, and complete recanalization in 5. In 4 of 10 patients limited hemorrhage was detected during CT controls. Major complications included 2 patients who had to undergo hemicraniectomy. One patient died from malignant infarction. At the time of discharge from the stroke unit 9 of 10 patients had improved markedly, 5 patients having an mRS of ≤2, and 3 patients a mRS of 3. At control after a mean of 20 weeks, 7 of 8 (88%) patients had a mRS ≤2, and 1 a mRS of 3. Conclusions Primary mechanical recanalization of ICA occlusions by stent and PTA combined with fibrinolysis and/or GPIIb/IIIa-receptor antagonists seems to be feasible to improve patient outcome significantly.     

Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study

PurposeTo demonstrate the feasibility of cystic duct embolization and chemical gallbladder ablation as an alternative to cholecystectomy in high-risk patients with calculous cholecystitis who were not candidates for surgery.Materials and MethodsThis prospective study included 10 patients with acute cholecystitis (7 males and 3 females) aged 70–91 years (average age, 81.6 years) between 2013 and 2019. A cholecystostomy catheter was inserted during the acute phase, followed by cystic duct coil embolization performed via the existing drainage tube tract. Once asymptomatic, 3% aethoxysklerol was injected into the gallbladder, and the drain was removed upon sonographic confirmation that the gallbladder remained contracted. Each phase of the procedure was performed with an interval of 2–3 weeks. Clinical, cholangiographic, and sonographic data were collected before and after drain removal at 1-month follow-up.ResultsCystic duct embolization was technically successful in all patients, with no immediate post-procedure complications. Gallbladder ablation performed in 10 patients was technically successful in all of them (median follow-up, 11 months). One patient required repeat ablation at 14 months, and the prolonged biliary excretions of 1 other patient ceased only at 8 months.ConclusionsCystic duct embolization with gallbladder ablation is a feasible procedure for patients in whom cholecystectomy is contraindicated.     

Asymptomatic gangrenous cholecystitis diagnosed using contrast-enhanced ultrasonography in a patient with pancreatic cancer

A 72-year-old female without abdominal symptoms visited our hospital for routine follow-up while undergoing pancreatic cancer treatment (using TS-1). Her vital signs were normal, and her abdomen was soft and non-tender. Blood test revealed elevated C-reactive protein levels with normal white blood cell count. Computed tomography was performed for follow-up of pancreatic cancer. Contrast-enhanced computed tomography showed partial discontinuity and irregular thickness of the gallbladder wall; however, a definitive diagnosis was not obtained due to unclear imaging. Contrast-enhanced transabdominal ultrasonography revealed intraluminal membranes in the gallbladder and a perfusion defect at the bottom, indicating gangrenous cholecystitis. Surgical resection was performed, and pathological examination showed severe necrosis of the gallbladder wall, consistent with the findings of contrast-enhanced transabdominal ultrasonography.     

The Efficacy of the Coaxial Technique Using a 6-Fr Introducer Sheath in Stent Placement for Treating the Obstructions Proximal to the Descending Colon

Objective

We wanted to evaluate the efficacy of stent placement using the coaxial technique with a stiff, long introducer sheath in patients with technical failure using an angiographic catheter for the obstructions proximal to the descending colon.

Materials and Methods

Self-expandable metallic stent placement was attempted under fluoroscopy-guidance in 77 consecutive patients who had malignant colorectal obstruction. Stent placement was performed using an angiographic catheter and a guide wire. If the angiographic catheter could not be advanced over the guide wire into the obstructive lesions proximal to the descending colon, then a 6-Fr introducer sheath was used. The technical success rate, the clinical success rate and the complications were analyzed.

Results

Successful stent placement was achieved in 75 of 77 patients (97%). The angiographic catheter failed to advance into the obstructive lesions of 11 patients (M:F = 7:4; mean age, 65.5 years) whose lesions were at the level of the splenic flexure or transverse colon. Therefore, the coaxial technique was implemented in all these 11 patients using a 6-Fr stiff introducer sheath and then the stent placement was successful. There were no complications related to the use of a stiff introducer sheath. Clinical success, which was defined as relief of clinical obstructive bowel symptoms, was obtained within 24 hours in all of patients.

Conclusion

The coaxial technique using a stiff introducer sheath can increase the technical success of fluoroscopy-guided, self-expandable metallic stent placement in patients with colonic obstruction proximal to the descending colon.     

Percutaneous Treatment of Pyocystis in Patients with Autosomal Dominant Polycystic Kidney Disease

The course of autosomal dominant polycystic kidney disease (ADPKD) is frequently complicated by infection of a cyst within a polycystic kidney, which is a diagnostic and therapeutic dilemma damaging the clinical course of patients. The aim of this study was to demonstrate the safety and efficacy of percutaneous drainage in management of infected cysts in ADPKD patients. Between May 2003 and December 2006, percutaneous drainage was performed in 16 infected renal cysts of four kidneys in three patients (two females, one male), with a mean age of 57.3 years. Cyst dimensions, total amount of drained cyst fluid, catheterization duration, isolated microorganisms, and follow-up duration were recorded. Technical, clinical success rates were 100%; the complication rate was 0%. Diameters of cysts ranged between 3 and 8 cm. Average volume of drained fluid and average duration of catheterization for one cyst were 226 ml and 9.8 days. No recurrence was encountered but one patient (no. 3), who had pyocystis in the right kidney and was treated with catheterization, referred with left flank pain due to pyocystis in her left kidney 3 months later. Follow-up durations were 35, 47, and 11 months for patients 1, 2, and 3, respectively. For patient 3, follow-up duration for the second procedure was 7 months. We conclude that percutaneous drainage with antibiotic therapy should be the initial method in management of infected cysts in ADPKD patients, with high success and low complication rates.     

Percutaneous Transhepatic Treatment of Benign Bile Duct Strictures Using Retrievable Covered Stents: Long-Term Outcomes in 148 Patients

ObjectiveTo investigate the long-term outcomes of percutaneous treatment of benign biliary strictures using temporary placement of a retrievable expanded polytetrafluoroethylene (PTFE) covered stent.Materials and MethodsWe retrospectively analyzed the outcomes of 148 patients (84 male and 64 female; age range, 11–92 years) who underwent percutaneous transhepatic placement and removal of a retrievable PTFE-covered stent for the treatment of benign biliary strictures between March 2007 and August 2019 through long-term follow-up. Ninety-two patients had treatment-naïve strictures and 56 had recurrent/refractory strictures.ResultsStent placement was technically successful in all 148 patients. The mean indwelling period of the stent was 2.4 months (median period, 2.3 months; range, 0.2–7.7 months). Stent migration, either early or late, occurred in 28 (18.9%) patients. Clinical success, defined as resolution of stricture after completing stent placement and removal, was achieved in 94.2% (131 of 139 patients). The overall complication rate was 15.5% (23 of 148 patients). During the mean follow-up of 60.2 months (median period, 52.7 months; range, 1.6–146.1 months), 37 patients had a recurrence of clinically significant strictures at 0.5–124.5 months after removal of biliary stent and catheter (median, 16.1 months). The primary patency rates at 1, 3, 5, 7, and 10 years after removal of biliary stent and catheter were 88.2%, 70.0%, 66.2%, 60.5%, and 54.5%, respectively. In the multivariable Cox proportional hazard regression analysis, sex, age, underlying disease, relation to surgery, stricture type, biliary stones, history of previous treatment, and stricture site were not significantly associated with the primary patency.ConclusionLong-term outcomes suggest that percutaneous treatment of benign biliary strictures using temporary placement of retrievable PTFE-covered stents may be a clinically effective method.     

Percutaneous Treatment of Hepatocellular Carcinoma in Patients with Transjugular Intrahepatic Portosystemic Shunts

Purpose To assess the role of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in patients with hepatocellular carcinoma (HCC) and transjugular intrahepatic portosystemic shunts (TIPS). Methods Between January 1999 and September 2004, 6 patients with HCC and TIPS were treated with either TACE (n = 3) or TACE in combination with PEI (n = 3). One patient had a known advanced, untreated HCC prior to TIPS. In the remaining 5 patients HCC was diagnosed 14, 17, 51, 69, and 76 months respectively after elective TIPS. TACE was performed using a mixture of 30–60 mg of epirubicin and 10 ml of lipiodol following superselective catheterization of tumor-feeding vessels. PEI was performed under CT guidance. Methods The mean follow-up time after treatment of HCC was 26.2 months (range 7–46 months). During follow-up, all patients were free of rebleeding. Two patients died 7 and 38 months after one session of TACE and PEI (77 months after TIPS) and three sessions of TACE (91 months after TIPS), respectively. The cause of death was liver failure (Child-Pugh class C) and peritonitis, respectively. A third patient underwent liver transplantation 24 months after TIPS and several sessions of TACE. In the remaining 3 patients, the HCC is well controlled 13, 30, and 46 months after repetitive percutaneous treatment without signs of hepatic deterioration or metastasis. Conclusion Transcatheter arterial superselective chemoembolization and percutaneous ethanol injection seems to be beneficial even in HCC patients treated with TIPS, provided that the liver function is adequate.     

Percutaneous Repair of Radial Artery Pseudoaneurysm in a Hemodialysis Patient Using Sonographically Guided Thrombin Injection

We report a case of a radial artery pseudoaneurysm complicating an incorrect puncture of a Brescia-Cimino hemodialysis fistula that was treated with percutaneous ultrasound-guided thrombin injection. The pseudoaneurysm recurred after the initial successful thrombin injection. With a second injection we obtained permanent pseudoaneurysm occlusion. Our case illustrates that this procedure is an effective treatment in this type of arteriovenous fistula complication. We compare this case with the only similar one we could find in the literature.