Use of the computerized tomographic scan in the diagnosis and treatment of abscesses

Over a 5 year period, 89 patients underwent one or more computerized tomographic scans to locate an abscess during 92 hospitalizations. The scans were a most sensitive (93 percent), specific (98 percent), and accurate (96 percent) means of abscess detection. Thirty-nine patients had positive scans. Sixteen patients were treated directly by open surgical methods, 1 of whom required percutaneous drainage in the postoperative period for incomplete drainage. An additional 23 patients underwent attempted percutaneous abscess drainage. In 17 patients, drainage was successful. Five patients underwent percutaneous drainage and later required laparotomy, two of whom underwent unavoidable surgical procedures and three surgery for incomplete drainage. Overall, percutaneous abscess drainage was successful in 83 percent. Of 11 deaths, 8 occurred in the group with computerized tomographic scans negative for abscess. Three of these were false-negative scans. Three deaths occurred in the group with scans positive for abscess. All were of patients with hepatic abscesses treated by open surgical drainage, one after failed percutaneous drainage. Twelve patients had multiple organ failure, and 8 of these patients died, for a mortality of 67 percent. The computerized tomographic scan is the diagnostic procedure of choice in the diagnosis of abscesses. In selected patients, percutaneous abscess drainage is also a successful means of abscess treatment and avoids the complications of a laparotomy. The onset of multiple organ failure in the surgical patient should alert the diagnostician to the possibility of a septic focus. The role of early laparotomy in these patients is uncertain. We recommend early use of the computerized tomographic scan in the septic surgical patient. Prompt diagnosis and treatment of abscesses, whether by open or percutaneous routes, may avert the development of multiple organ failure and reduce morbidity and mortality.     

Treatment of pyogenic hepatic abscesses. Surgical vs percutaneous drainage

A retrospective review of 39 patients with pyogenic hepatic abscess treated from 1977 through 1984 included 23 patients who were surgically treated and 16 who underwent percutaneous drainage. The average age in each group was similar (about 55 years). The most common cause of abscesses in each group was biliary tract disease. Abscesses caused by portal seeding and local extension were more common in the surgical group, 14 of whom required additional surgical procedures at the time of surgical drainage. Of the 16 patients in the percutaneously drained group, seven were seen during the immediate postoperative period. Most of the abscesses occurred in the right lobe of the liver, but single abscesses in the left lobe (30%) and multiple abscesses (57%) were more common in the surgical group. Klebsiella enterobacter and group D streptococcus were most common in the surgically and percutaneously drained groups, respectively. All patients received antibiotics, with a mean length of treatment of 14 days. Mean time to defervescence was about four days in both groups, with a longer hospital stay for the percutaneously drained group (26 vs 46 days). Morbidity was high in both groups (surgical, 48%; percutaneous, 69%). Three of the percutaneously treated patients required surgical drainage because of highly viscous abscess contents. Mortality was 17% in the surgical group and 13% in the percutaneously drained group. Percutaneous drainage with computed tomography probably should be the initial drainage procedure in patients with pyogenic hepatic abscesses in whom no concomitant surgical procedure is planned. Regardless of treatment, the morbidity and mortality remain high.     

Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan

BACKGROUND: Percutaneous abscess drainage guided by computed tomography scan is considered the initial step in the management of patients presenting with Hinchey II diverticulitis. The rationale behind this approach is to manage the septic complication conservatively and to follow this later using elective sigmoidectomy with primary anastomosis. METHODS: The clinical outcomes for Hinchey II patients who underwent percutaneous abscess drainage in our institution were reviewed. Drainage was considered a failure when signs of continuing sepsis developed, abscess or fistula recurred within 4 weeks of drainage, and emergency surgical resection with or without a colostomy had to be performed. RESULTS: A total of 34 patients (17 men and 17 women; median age, 71 years; range, 34-90 years) were considered for analysis. The median abscess size was 6 cm (range, 3-18 cm), and the median duration of drainage was 8 days (range, 1-18 days). Drainage was considered successful for 23 patients (67%). The causes of failure for the remaining 11 patients included continuing sepsis (n = 5), abscess recurrence (n = 5), and fistula formation (n = 1). Ten patients who failed percutaneous abscess drainage underwent an emergency Hartmann procedure, with a median delay of 14 days (range, 1-65 days) between drainage and surgery. Three patients in this group (33%) died in the immediate postoperative period. Among the 23 patients successfully drained, 12 underwent elective sigmoid resection with a primary anastomosis. The median delay between drainage and surgery was 101 days (range, 40-420 days). In this group, there were no anastomotic leaks and no mortality. CONCLUSION: Drainage of Hinchey II diverticulitis guided by computed scan was successful in two-thirds of the cases, and 35% of the patients eventually underwent a safe elective sigmoid resection with primary anastomosis. By contrast, failure of percutaneous abscess drainage to control sepsis is associated with a high mortality rate when an emergency resection is performed. The current results demonstrate that percutaneous abscess drainage is an effective initial therapeutic approach for patients with Hinchey II diverticulitis, and that emergency surgery should be avoided whenever possible.     

Treatment of Acute Pancreatic Pseudocysts After Severe Acute Pancreatitis

Treatment of acute pancreatic pseudocysts (APP) after an episode of severe acute pancreatitis (SAP) remains controversial. Both population heterogeneity and limited numbers of patients in most series prevent a proper analysis of therapeutic results. The study design is a case series of a large, tertiary referral hospital in the surgical treatment of patients with APP after SAP. An institutional treatment algorithm was used to triage patients with complicated APP and organ failure based on Sequential Organ Failure Assessment scores to temporizing percutaneous or endoscopic drainage to control sepsis and improve their clinical condition before definitive surgical management. Over a 10-year period of study (December 1995 to 2005), 73 patients with APP after an episode of SAP were treated, 43 patients (59%) developed complications (infection 74.4%, perforation 21%, and bleeding 4.6%) and qualified for our treatment algorithm. Percutaneous/endoscopic drainage was successful in controlling sepsis in 11 of 13 patients (85%) with severe organ failure and allowed all patients to undergo definitive surgical management. The morbidity (7 vs 44.1%, P = 0.005) and mortality rates (0 vs 19%, P = 0.04) were significantly higher in complicated vs uncomplicated APP. Acute pancreatic pseudocysts after SAP are unpredictable and have a high incidence of complications. Once complications develop, there is a significantly higher morbidity and mortality rate. In complicated APP with severe organ failure, percutaneous/endoscopic drainage is useful in controlling sepsis and allowing definitive surgical management.     

Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients

OBJECTIVE: To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis. SUMMARY BACKGROUND DATA: Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15-year period is described. METHODS: Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality. RESULTS: The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure > or =3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay > or =6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02). CONCLUSIONS: Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement.     

Pancreatic Pseudocysts: Is Delayed Surgical Intervention Associated with Adverse Outcomes?

Background Nonsurgical interventions are increasingly applied for pancreatic pseudocysts. We hypothesized that surgical therapy applied after failure of percutaneous or endoscopic therapies for pseudocysts is associated with poorer outcomes than cases in which surgery is the initial intervention. Materials and methods Medical records of all 284 patients admitted with pancreatic pseudocysts at our institution (1/1990–9/2005) were analyzed. Forty-six patients underwent surgery as the initial intervention (group A). Among 162 patients who underwent percutaneous or endoscopic drainage as the initial intervention, 75 patients required subsequent surgery after failure of nonsurgical intervention (group B). Results Groups were comparable in demographic variables and in location, number, and size of pseudocysts. Forty-two percent of group B patients developed infection within their pseudocysts after their nonsurgical interventions. Compared to group A patients, group B patients had higher rates of overall perioperative morbidity (47.8% vs 73.3%, p = 0.01) and postoperative readmission (24.0% vs 44.7%, p = 0.04). Five (6.7%) group B patients died in the perioperative period; there were no perioperative deaths among group A patients. Conclusion Delayed surgical intervention for pancreatic pseudocysts is associated with higher incidences of postoperative complications, readmission, morbidity, and mortality. The increasing application of nonsurgical interventions needs to be reevaluated. This study was presented at the American Hepato-Pancreato-Biliary Association 2007 Annual Meeting on April 21, 2007 at Las Vegas, Nevada.     

多房性细菌性肝脓肿手术和经皮穿刺引流的评价

目的 探讨治疗多房性细菌性肝脓肿的两种首选方案,比较手术和经皮穿刺引流的临床结果.方法 回顾性分析华西医院2003年6月至2008年6月收治的45例患者多房性细菌性肝脓肿的临床资料.根据手术方式分为2组,其中穿刺引流组21例,行B超或CT引导下经皮穿刺置管引流(pereutaneous drainage PD),开腹引流组24例,行经腹切开引流(surgical drainage SD).比较2组患者的退热时间、治疗失败、再次手术、住院天数及死亡率.结果 2组患者退热时间比较差异无统计学意义(4.85 d vs.4.38 d,P＞0.05),但是开腹引流组治疗失败率低(2例vs.9例,P＜0.05);再次手术机会小(1例vs.11例,P＜0.01);而且住院天数更短(8 d vs.11 d,P＜0.05).两组患者均无死亡.结论 根据结果显示,开腹引流在多房性细菌性肝脓肿治疗中能达到比经皮穿刺引流更好的临床结果.可提高成功率、减少再次手术机会和缩短住院天数,应作为首选治疗方案.     

Repeated laparotomy for postoperative intra-abdominal sepsis. An analysis of outcome predictors

To identify factors modifying the outcome of reoperation for intra-abdominal infection, we analyzed the management of 47 patients who underwent repeated laparotomy from July 1980 through July 1985. Overall mortality was 30% (14/47). Factors predictive of death were as follows: age greater than 60 years (86% mortality vs 21% mortality), preoperative vs no organ failure (57% vs 6%), multiple vs single abscess (53% vs 16%), and exploratory vs directed operative approach (39% vs 17%). Although the interval between the primary surgery and reoperation was similar between survivors (13 days) and nonsurvivors (14 days), five (36%) of 14 nonsurvivors were in septic shock and eight (57%) of 15 survivors showed evidence of organ failure prior to reoperation. The median survival period following reoperation in this group was only four days. Computed tomography (CT) and/or ultrasonography were performed to localize a source of infection in 24 patients. In nine (82%) of 11 patients, CT identified the abscess, while ultrasonography was positive in 15 (72%) of 21 patients. Neither the interval to operation nor the mortality was significantly different in patients diagnosed with CT and ultrasonography when compared with those who underwent exploration on the basis of clinical findings. To lower the mortality and to shorten the interval to reoperation in these high-risk patients, noninvasive diagnostic testing and confirmation by percutaneous sampling must be sought before the onset of clinical sepsis and organ failure.     

Surgical Versus Nonsurgical Treatment of Infected Pancreatic Necrosis: More Arguments to Change the Paradigm

Objectives

This study aimed to compare primary surgical versus nonsurgical treatment in a series of patients with infected pancreatic necrosis (IPN) and to investigate whether the success of nonsurgical approach is related to a less severe disease.

Methods

Thirty-nine consecutive patients with IPN have been included and further subdivided into two groups: primary surgical (n?=?21) versus nonsurgical (n?=?18). Outcome measures were the differences in mortality, morbidity, and pancreatic function. Comorbidity, organ failure, and other severity indexes were compared between the two groups.

Results

Mortality occurred in 16.7 % of cases in the nonsurgical group versus 42.9 % in the surgical group. In the primary nonsurgical group, seven were operated on due to failure of initial conservative treatment. In this latter group, mortality was 28.6 % and was performed significantly later than in the primary surgical group. The group of primary surgical treatment was associated with a significant higher rate of multiple organ failure (MOF) at IPN diagnosis, new onset or worsening of organ failure, and MOF and nosocomial infection after surgery.

Conclusions

Initial nonsurgical approach in IPN is associated with better results both in cases which respond to this treatment as well as in those who, failing this conservative approach, have to be operated on after a delayed period. Primary surgically treated patients had a more severe disease at the time of IPN.     

Unexpected, late cardiovascular effects of surgery for peripheral artery disease. Veterans Affairs Cooperative Study 199.

In reviewing late morbidity of a multicenter clinical trial comparing balloon angioplasty (percutaneous transluminal angioplasty) with bypass surgery for lower-extremity ischemia, an unexpectedly high incidence of adverse systemic events in surgical patients was uncovered. The study was prospective and randomized, and included a total of 263 patients, with follow-up from 2 to 6 years. When end points of related deaths, amputations, and intervention failures were summed, surgery was favored over percutaneous transluminal angioplasty at 4 years. Progression of cardiac and renal dysfunction and mortality differed between groups. A total of 42 deaths were in the group who underwent surgery and 27 in those who underwent percutaneous transluminal angioplasty. The percentage difference in death rate between the two groups increased each year to reach 10% at 5 years. A significant difference in renal function was noted in nine patients who underwent surgery and zero who underwent percutaneous transluminal angioplasty. Myocardial infarctions were greater on follow-up of surgical patients. After 6 years, congestive heart failure had occurred in 19 patients who underwent surgery and eight who underwent percutaneous transluminal angioplasty. The trends in this study of patients with only moderately severe peripheral arterial disease suggest an increased rate of deterioration of cardiac and renal function in patients who have arterial operations. In surgical patients, mortality was 13.1% per year, whereas it was 8.4% for patients treated with percutaneous transluminal angioplasty. Future intervention studies should include long-term follow-up of such cardiovascular events.     

经皮穿刺置管引流与直接开腹手术引流治疗胰腺坏死组织感染的疗效比较

目的 比较经皮穿刺置管引流和直接开腹手术引流治疗重症急性胰腺炎(SAP)合并胰腺坏死组织感染的临床效果.方法 回顾性分析2008年1月至2009年12月治疗的90例合并胰腺坏死组织感染的SAP患者的临床资料,根据针对感染的胰腺坏死组织首先采取的治疗方法的不同将患者分为经皮穿刺置管引流组和直接开腹手术引流组,其中经皮穿刺置管引流组27例,直接开腹手术引流组63例.经皮穿刺置管引流组首先在彩色超声或CT引导下穿刺置管引流,冲洗3 d后评价引流效果,无明显改善则中转开腹手术引流.直接开腹手术引流组在确诊胰腺坏死组织感染后直接开腹手术引流.结果 经皮穿刺置管引流组的避免开腹手术引流率(48.1%比0,P＜0.05)和一次开腹手术引流成功率(92.9%比85.7%,P＜0.05)均明显高于直接开腹手术引流组,而术后残余脓肿(7.1%比28.6%,P＜0.05)、术后新发单脏器功能障碍(7.4%比28.6%,P＜0.05)、新发消化道瘘(7.4%比27.0%,P＜0.05)、远期并发症(3.7%比22.2%,P＜0.05)的发生率均低于直接开腹手术引流组.此外,经皮穿刺置管引流组的平均ICU治疗时间[(21.2±9.7)d比(28.7±12.1)d,P＜0.01],平均住院时间[(48.2±12.5)d比(59.6±17.5)d,P＜0.05]和住院费用[(191 762±5892)元比(341 689±10 854)元,P＜0.05]均低于直接开腹手术引流组.结论 经皮穿刺置管引流能有效降低多次开腹手术引流率和术后残余脓肿发生率,治疗后近期和远期并发症的发生率均明显下降,并且平均ICU治疗时间、平均住院时间、平均住院费用明显下降.     

超声引导经皮肾穿刺置管引流治疗急性梗阻性肾衰

目的探讨超声引导经皮肾穿刺置管引流在治疗急性梗阻性肾功能衰竭的应用价值。方法回顾性分析2005年6月至2010年6月52例行超声引导经皮肾穿刺置管引流的急性梗阻性肾功能衰竭患者的临床资料。结果52例患者行72例次经皮肾穿刺置管,成功71次,成功率98．6％。术后102周49例患者肾功能恢复正常,3例肾功能明显好转;未出现大出血、败血症、邻近脏器损伤并发症。结论超声引导经皮肾穿刺置管引流治疗急性梗阻性肾功能衰竭具有创伤小、疗效快等优势,为进一步的治疗赢得时间。     

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

Background

The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.

Methods

The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.

Results

Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.

Conclusions

Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.     

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目的探讨经皮穿刺置管引流治疗重症急性胰腺炎的价值和时机。方法回顾性分析北京协和医院2007年1月至2012年3月收治的29例重症急性胰腺炎病人(男性18例,女性11例;年龄23~79岁,平均38岁)的临床资料。所有病人接受了CT引导下经皮穿刺置管(管径大小10~18F)引流治疗。结果 29例病人中,25例(86.2%)穿刺引流治疗有效,其中有19例免于外科手术,有6例于穿刺引流后14~49d(中位时间23d)接受了外科手术治疗;4例(13.8%)引流治疗无效的病人,均死于感染和器官功能衰竭。有1例发生穿刺引流后出血。结论当保守治疗重症急性胰腺炎无效时,经皮穿刺治疗引流可以有效地控制胰腺坏死、感染引起的全身脓毒症状,为择期外科手术治疗创造条件,甚至可以免于外科手术治疗。     

The late results of antero-lateral cordotomy for pain relief

Summary The operation of antero-lateral cordotomy was carried out on 56 patients with intractable pain between 1968 and 1978. The follow-up of these patients was continued for at least three years or until death to determine the late success of this procedure. Of the 33 patients who underwent surgery for malignant pain 95% of survivors had effective relief on discharge from hospital, the success rate falling to 73% at six months, and 55% at one year of follow-up. The operation was judged successful for patients with malignant disease because of short life expectancy.Thirteen patients had chronic pain from non-malignant conditions, and 85% obtained initial relief, the success rate falling to 35% at one year, and 20% at three years of follow-up.Two patients died from respiratory failure, giving an operative mortality of 3.5%. The results and complications of open cordotomy are compared with those of the percutaneous method, and the role of this procedure discussed in relation to alternative stimulatory analgesic procedures.     

Endoscopic versus percutaneous drainage of symptomatic pancreatic fluid collections: a 14-year experience from a tertiary hepatobiliary centre

Introduction

Endoscopic transmural drainage (ED) or percutaneous drainage (PD) has mostly replaced surgery for the initial management of patients with symptomatic pancreatic fluid collections (PFCs). This study aimed to compare outcomes for patients undergoing ED or PD of symptomatic PFCs.

Methods

Between January 2000 and December 2013, all patients who required PD or ED of a PFC were included. Rates of treatment success, length of hospital stay, adverse events, re-interventions and length of follow-up were recorded retrospectively in all cases.

Results

In total, 164 patients were included in the study; 109 patients underwent ED; and 55 had PD alone. During the 14-year study period, the incidence of ED increased and PD fell. In the 109 patients who were managed by ED, treatment success was considerably higher than in those managed by PD (70 vs. 31 %). Rates of procedural adverse events were higher in the ED cohort compared to the PD group (10 vs. 1 %), but patients managed by ED required fewer interventions (median of 1.8 vs. 3.3) had lower rates of residual collections (21 vs. 67 %) and need for surgical intervention (4 vs. 11 %). In the ED group, treatment success was similar for walled-off pancreatic necrosis (WOPN) and pseudocysts (67 vs. 72 %, P = 0.77). There were no procedure-related deaths.

Conclusion

Compared with PD, ED of symptomatic PFCs was associated with higher rates of treatment success, lower rates of re-intervention, including surgery and shorter lengths of hospital stay. Outcomes in WOPN were comparable to those in patients with pseudocysts.

     

细菌性肝脓肿的放射介入和双介入治疗

目的: 探讨放射介入和双介入治疗细菌性肝脓肿的临床疗效. 方法: 回顾分析51例细菌性肝脓肿病人(其中12例行放射介入或双介入治疗)的临床资料. 结果: 介入组12例病人无1例需中转手术引流,均痊愈出院;对照组39例中,有2例因脓肿导管引流不畅需行手术引流,39例中死亡3例,均死于多脏器功能衰竭,病死率为7.7%(3/39),两组差异无显著性(P>0.05);两组病人的退热时间差异无显著性(P>0.05),但介入组脓肿消退时间显著短于对照组(P<0.01). 结论: 放射介入治疗联合经皮肝脓肿穿刺引流,即双介入治疗细菌性肝脓肿具有良好的疗效.     

不同胆囊穿刺方式在急性胆囊炎治疗中的应用

目的 分析不同经皮胆囊穿刺方式在急性胆囊炎治疗中的应用.方法 对2019年1月至2019年11月在宁德市医院行经皮胆囊穿刺引流术的94例急性胆囊炎患者进行回顾性分析,按照穿刺方式分为A组(置换穿刺法,39例)和B组(一步穿刺法,55例),比较两组炎症因子如白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、应激...     

Percutaneous transhepatic cholangiography, drainage, and biopsy in patients with malignant biliary obstruction. An alternative to surgery

We retrospectively reviewed our experience with 100 patients with malignant biliary obstruction who underwent percutaneous transhepatic cholangiography alone or in combination with percutaneous drainage. On the basis of this study, we found percutaneous transhepatic cholangiography to be a safe and effective procedure for demonstrating the site, nature, and extent of obstructive lesions. Percutaneous cholangiography was successful in 98 percent of patients, and only one patient (4.1 percent) had a significant complication. Likewise, percutaneous drainage has been highly successful in providing palliative biliary drainage in patients with unresectable malignancies. Percutaneous drainage was successful in 74 of 76 patients (97.4 percent). Five of these patients (6.6 percent) had significant complications, including one death (1.3 percent). The mean survival period of patients with carcinoma of the bile ducts was 29 months, whereas for those with carcinoma of the pancreas it was 3.4 months. Thus, mortality and complication rates were lower, and patient survival rates were similar or improved when compared with those of patients palliated by surgical bypass. Percutaneous drainage thus provides a satisfactory alternative to surgery. Biopsy performed in conjunction with these procedures can often provide a definitive diagnosis. Final tissue diagnoses were made in 20 of 23 patients (87 percent) by transcatheter or percutaneous biopsy.