Search

We found the paper entitled TIPS for refractory ascites: a single center experience by Thalheimer et al. [1] to be of great interest, since it reports the retrospective analysis of their results obtained in patients with refractory ascites submitted to transjugular intrahepatic portosystemic shunt (TIPS) according to a protocol in which the stent used to construct the shunt was not completely expanded. The authors suggest that an incomplete stent expansion may reduce the occurrence of hepatic encephalopathy by also maintaining the efficacy of the shunt in terms of resolution of ascites. However, to test such a hypothesis, a randomized controlled trial comparing a limited versus a complete stent expansion should have been carried out. This was not the case, and, considering that the paper is a pilot study, we have some doubts regarding the methodology used and the possibility that a limited stent expansion can be useful in patients who need a TIPS. The portal pressure gradient (PPG) value that should be achieved after the stent expansion to solve the ascites and the PPG value that can avoid the occurrence of encephalopathy are in fact both unknown. It is therefore difficult to understand why the authors decided to stop the stent dilatation when the PPG reduction was more than 25%. Furthermore, we do not believe that the PPG value measured immediately after TIPS opening remains stable over time. Immediately after the procedure, in fact, the amount of blood reaching the heart increases rapidly, and a rise in the right atrium and the central venous pressure has already been described [2]. This value does not remain stable over time [3, 4]; it is therefore possible that a reduction of 25% in the PPG value measured immediately after TIPS may not be the same a few days or weeks later. We therefore wonder whether the authors have some evidence that the PPG value reached immediately after TIPS opening had remained stable over time. In addition, the authors used a self-expandable stent (Memotherm) to construct the shunt. This is an uncovered, nitinol, laser-cut stent that is no longer available in the market. It has thermal memory, which means that the nominal stent diameter expands fully when immersed in warm water. When this stent is released into a narrower liver tract, as is described by the authors in their paper, the radial force will continue to push against the surrounding liver parenchyma until the nominal size is reached. Unless the surrounding tissues are very fibrotic, this will occur in a few days. Most probably, then, although this is not specified in the paper, this type of stent continued to dilate after its initial expansion to finally reach its nominal diameter. Another issue, therefore, is whether the authors have some evidence that a partially dilated self-expandable stent is able to maintain the diameter initially reached after balloon dilatation. As a final consideration, we would like to underline that uncovered stents are presently less frequently used for TIPS creation, since the new PTFE-covered stents offer a higher patency rate and a better clinical efficacy [5, 6]. For all of these reasons, we think that the idea of modulating both the stent diameter and the PPG in TIPS construction is a good one, but randomized controlled trials comparing stents of different diameters are needed to An answer to this letter to the editor is available at doi:10.1007/s00535-009-0177-9.

Background: Malignant peripheral neuroectodermal tumors (MPNETs) are primitive neuroblastic tumors that arise, unlike neuroblastomas, outside the autonomic nervous system. A renal origin has been described in very few cases. Case report: We report the case of a young male patient with a large MPNET of the right kidney, studied with ultrasound and computed tomography before surgical resection. The main radiologic features, the microscopic appearance and the typical immunohistochemical findings, are described and discussed.

In the year 2000, portal vein anatomy and pathology are no longer being studied by invasive proeedures, but rather with imaging techniques such as ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT), which provide all the necessary information for correct evaluation of patency, flow direction anomalies and eollateral circulation.

Transjugular intrahepatic portosystemic shunt (TIPS) has become a widely accepted treatment for complications of portal hypertension. Shunt or hepatic vein stenoses or occlusions are common shortand mid-term complications of the procedure, with a I-year primary patency ranging from 25% to 66%. When promptly identified, shunt stenosis or occlusion may be treated before the recurrence of gastrointestinal bleeding or ascites. The revision is usually successful and the primary-assisted patency of TIPS is approximately 85% at 1 year (Haskal et al. 1994; LaBerge et al. 1993; Lind et al. 1994).

Our purpose was to assess the accuracy of CT with drug-induced hypotonia and water filling in revealing the depth of tumor invasion of the gastric wall, according to the T factor of TNM classification, and to verify the capability of this technique in differentiating diffuse from intestinal gastric cancer.Forty patients (age range, 35-78 years) with histologically proven gastric tumors underwent CT, in the prone position, with drug-induced hypotonia and water filling. The images were prospectively reviewed by two radiologists who were asked to assess the depth of tumor invasion in the gastric wall. The thickening of the hypodense layer and the contrast enhancement of lesion were measured.CT correctly assessed gastric wall invasion in 77% and 82% of cases for observers A and B, respectively; overstaging was 20% and 15%, respectively; and understaging occurred in 3% of cases for both observers. Diagnostic sensitivity for serosal invasion was 100% for both observers; specificity was 80% and 87%, respectively. Substantial agreement between the observers was obtained (kappa = .6). Diffuse and intestinal cancers could be differentiated by CT in 92% of cases, considering the thickening of the hypoattenuating layer of the gastric wall (diffuse cancer: 7 +/- 1.2 mm; intestinal cancer: 1.4 +/- 0.4 mm) and contrast enhancement (diffuse cancer: 85 +/- 8.2 H; intestinal cancer: 51 +/- 3 H).CT with patients in a drug-induced hypotonia and in a prone position, and using water filling, is a promising technique for evaluating the depth of tumor invasion and for differentiating intestinal from diffuse gastric cancer.

In the definition of non-vascular abdominal interventions many procedures are considered, including: 1. Percutaneous biliary endoscopy for lithotripsy of hepatic lithiasis 2. Drainage a. Biliary (malignant and benign) b. Abscesses c. Lymphoceles d. Percutaneous nephrostomy e. Hematomas 3. Tumor ablation a. Embolization or chemoembolization b. Alcohol injection c. Laser or thermoablation 4. TIPS for portal hypertension 5. Foreign body retrieval

To investigate the ability of contrast agent-enhanced color Doppler ultrasonography (US) in evaluating the response of hepatocellular carcinoma (HCC) to percutaneous ethanol injection (PEI).Forty-two patients (36 men, six women; age range, 51-79 years) with 54 1.3-7.0-cm-diameter (mean +/- SD, 2.8 cm +/- 1.1) HCC lesions were examined with contrast-enhanced color Doppler US before and after PEI. Spiral computed tomography (CT) and percutaneous biopsy also were performed to establish the outcome of therapy.Before PEI, intratumoral color signals were demonstrated at contrast-enhanced color Doppler US in 47 (87%) lesions (in 40 patients). After PEI, blood flow signals were no longer detected in all 34 of the lesions that were found to be necrotic at spiral CT and biopsy. In 12 (92%) of 13 lesions containing residual viable tumor, intratumoral color signals corresponding to the enhancing areas at spiral CT were still identified at contrast-enhanced color Doppler US. These 12 lesions were retreated with PEI by targeting the areas of residual tumor with contrast-enhanced color Doppler US guidance. Complete necrosis was seen after the second PEI cycle in nine of 12 lesions.Contrast-enhanced color Doppler US shows promise in assessing the therapeutic effect of PEI on HCC and in guiding additional treatment in cases of incomplete response.

Objective. Intraoperative ultrasound has gradually expanded in the last two decades to a variety of surgical specialties and has gained an established role in many surgical procedures. Laparoscopic and thoracoscopic ultrasound are the latest modes of intraoperative sonography. They have been introduced mainly to overcome the two major drawbacks of laparoscopy, i.e. the capability of showing only the surface of the organs and the lack of manual palpation of the anatomical structures. We review and discuss the established and the most recent applications of intraoperative and laparoscopic ultrasound. Material and methods. The technology, new indications and results of intraoperative and laparoscopic ultrasound are reviewed. This review is based on the experience gained in our Institution during more than 500 surgical procedures and the analysis of the literature on the subject. Results. The yield of intraoperative and laparoscopic ultrasound consists in confirming preoperative studies and acquiring new data which would not be available otherwise. An important role of these techniques is determining the anatomy of the involved organs, thus providing a guidance for surgery. Both techniques have an important role in surgical decision-making, particularly with respect to hepatic, biliary and pancreatic malignancies. In some series the rate of major changes in the surgical strategy can be as high as 38%. A relatively new application of intraoperative ultrasound is the possibility to perform interstitial therapy of tumors at the time of the initial surgery. This can be useful, for example, in patients undergoing liver resection, when other unresectable lesions are found in a different segment or in the contralateral lobe. Finally, laparoscopic sonography has an important role in staging abdominal neoplasm, providing more information than preoperative imaging and laparoscopic exploration. This feature can be used to effectively stage gastrointestinal malignancies, pancreatic carcinoma, and abdominal lymphomas. Conclusion. The application of intraoperative ultrasound will increase in the era of minimally access surgery and this will be dependent not only on technical improvements in ultrasound technology. Indeed, it may be expected that a variety of open procedures will be performed with videolaparoscopic monitoring and will need the guidance of laparoscopic sonography. In the future, the staging of abdominal neoplasm may be markedly improved by laparoscopy combined with laparoscopic ultrasound; however a cost-benefit analysis of these techniques and a comparison with preoperative tests should be carried out.

To evaluate the effectiveness of partially covered metallic Wallstents to prevent tumoral ingrowth in patients with neoplastic obstruction of the biliary tract.Twenty-one patients with malignant obstructive jaundice have been treated with Wallstents partially covered with a polyurethane polymer. In total, 36 covered stents (8 and 10 mm in diameter, 70 and 90 mm long) were deployed. All the stents were free from covering at both ends.Jaundice was successfully treated in 100% of cases. There were no problems related to the releasing system during stent positioning, no major complications, and no incompatibility reactions to the materials composing the endoprostheses. At 23-month follow-up, 6 patients are still alive and 15 are dead; of these 15 patients, 11 died in the first 6 months and the last 4 died between 6 and 23 months. Seven patients had an obstructed stent; in four of these, cholangioscopy showed the presence of tumoral ingrowth and in one it showed necrotic tissue with biliary pigments and inflammatory cells. No biopsy specimen was obtained in the remaining two patients with stent obstruction. The follow-up, ranging from 7 to 23 months, showed a primary patency of 46.8% and 24.6% and an assisted patency of 66.3% and 59% at 6 months and 23 months, respectively.Covered metallic stents are effective and may produce improved survival in patients with malignant biliary obstruction (27. 8% at 23 months). Stent patency, however, is similar to that of uncovered stents. Modifications in the design of the covering membrane may reduce stent obstruction resulting from disruption of the plastic covering.

Purpose Aortic graft infection is a rare complication of aortic surgery associated with high mortality and morbidity rates. The aim of the study was to evaluate the authors’ experience with diagnostic and interventional procedures in the management of aortic graft infection. Methods Six patients with clinical signs suggestive of graft infection were studied. Abdominal computed tomography (CT) was performed in all patients. Diagnostic work-up was performed with perigraft puncture for fluid aspiration and contrast medium injection to confirm clinical signs or CT findings of graft infection, and to detect graft-enteric fistulas. Percutaneous drainage of the periprosthetic abscess was performed as attempted therapy in four patients. Results In four patients, CT examination findings were considered positive for graft infection. Culture and cytologic examination of aspirates revealed numerous white blood cells but did not show any growth. In three patients, direct contrast medium injection into the perigraft space allowed the detection of a graft-enteric fistula. In three patients, percutaneous drainage was performed as preoperative therapy, allowing improvement of the surgical outcome; in one patient the catheter was left in place as an attempt at definitive therapy, allowing a complete recovery. Conclusions The percutaneous approach to prosthetic graft infection permits both the drainage and aspiration of the fluid in the perigraft area for laboratory studies. Percutaneous drainage can offer the possibility of definitive cure in patients for whom surgical management is considered too risky or, at least, represents a temporizing maneuver to improve the patient's general condition before surgery.

Percutaneous cholangioscopy consists in the direct visualization of the biliary tree — for both diagnostic and therapeutic purposes — using a flexible endoscope that can be introduced percutaneously, either through a transhepatic tract created during biliary drainage or through a surgical T-tube tract. The technique was initially used in the early 1970s by some Japanese surgeons (Takada et al. 1974; Yamakawa et al. 1976) and then taken up around the world in the late 1980s and early 1990s by radiologists and surgeons (Picus et al. 1989; Nimura et al. 1989; Bonnel et al. 1991; Picus 1995; Rossi et al. 1996). More recently, many surgeons have begun to use a fine-caliber endoscope during laparascopic operations, to visualize the intrahepatic ducts or for therapeutic maneuvers (Lezoche and Paganini 1995).

This book, edited by Prof. PLINIO ROSSI, an internationally well-known expert in biliary tract radiology, provides in 31 chapters a very comprehensive update on both diagnostic and therapeutic radiology of the biliary tract. First, a very complete and interesting overview of the normal morphology of the ana tomical area is presented by an anatomist, a radiologist, and a surgeon. This is followed by a discussion not only of the well-known and accepted imaging modalities, but also of the newer ones such as, magnetic resonance imaging and endoluminal and laparoscopic ultra sound. The book thus illustrates very nicely the diversity of diagnostic radiological tech niques that are currently available. Considerable technical progress and remarkable new insights in biliary tract radiology have been achieved in the field of the radiological interventional approach during recent years. Therefore, much emphasis has been placed in this book on the therapeutic possibili ties of the radiologist using the percutaneous minimally invasive approach for the treat ment of the various pathological conditions of the biliary tract. It is most impressive to note the substantial progress in terms of patient comfort achieved by using the percutaneous as compared to the surgical methods. These new methods also result in shorter hospitalization times and thereby help to reduce health care costs. This book provides the interested reader with a fascinating and very complete over view of these new procedures."

In the last 7 years biliary metallic stents of various shapes and materials have been widely and successfully used to relieve malignant biliary strictures. They seem to present several advantages over conventional plastic stents and will probably come to replace them in the future, especially in the form of the covered metallic stent (Mueller et al. 1985; Yoshioka et al. 1990; Lammer 1990; Lee et al. 1991; Adam et al. 1991; Nicholson and Royston 1993; Roeren et al. 1990; Rossi 1996).

Benign biliary strictures present different clinical problems to malignant biliary strictures, because the life expectancy of the patients is much longer and is not tumor-related. Benign biliary strictures are less common than malignant biliary strictures, so the number of cases in reported series is always rather limited (Pellegrini et al. 1984; Davids et al. 1993; Lillemoe et al. 1992). In the majority of cases benign biliary stenosis follows surgical complications and affects people of working age. Patient numbers and the duration of invalidity are therefore very important.

Small bowel (SB) neoplasms are very rare tumours, but are still associated with high mortality rates, since the tumour-related symptoms occur late and are non-specific. In addition, endoscopy is not feasible in most cases, and radiological contrast studies do not reach the high accuracy obtained in the evaluation of upper and lower gastrointestinal tract. Cross-sectional imaging, and particularly CT, is becoming increasingly relevant in the diagnosis of these tumours. Both US and CT allow tumour detection, even when performed on an emergency basis, and are capable of showing the lesion as well as possible complications. Moreover, CT offers the possibility of a preoperative staging by evaluating tumour extension through the bowel wall, lymph node involvement and possible metastases. Finally, in most cases a direct correlation between cross-sectional findings and histology can be found, thus permitting tumour characterisation.

The aim of our study was to evaluate the performance and efficacy of a new self-expanding stent (nitinol Strecker stent) in the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We have successfully placed 64 nitinol Strecker stents in 48 patients. The average portosystemic gradient decreased from 22 to 11 mm Hg. Balloon dilatation was necessary in 12 of 35 angiographically controlled cases at 5 days (34%), because of incomplete stent expansion, small thrombi within the stent or obstruction. At 1–6 months stent malfunctions occurred in 8 of 23 patients who underwent control angiography (34%) and at 6–24 months in 6 of 7 patients (85%). Rebleeding occurred in 2 of 39 patients (follow-up > 1 month) (5%) and temporary crises of de novo encephalopathy were observed in 11 of 48 patients (23%). Refractory ascites completely resolved in 4 of 6 patients (66%) and improved in the remaining 2 cases. Compared with other self-expanding stents, nitinol Strecker stents seem to be equally effective in TIPS; no increase in complication rate was observed, either clinical or stent-related.

Despite the availability and wide use of modern imaging techniques, the diagnosis of Meckel's diverticulum is difficult. The signs and symptoms vary from none to those of an acute abdomen or gastrointestinal bleeding. Findings on physical examination may be inconsistent because of the variable location of the diverticulum, and bleeding may occur with no appreciable physical findings. Finally, small diverticula are often concealed by overlying small-bowel loops on routine small-bowel barium studies. The purposes of this article are to review the use of available techniques for the imaging diagnosis of Meckel's diverticulum, to discuss the relative advantages and indications for the various procedures, and to emphasize the role each plays in specific clinical circumstances. The embryology, anatomy, and clinical presentation of Meckel's diverticulum are also briefly discussed.

Forty-seven consecutive patients were prospectively evaluated to study the incidence of hepatic encephalopathy as well as modifications in the PSE index after TIPS. Various clinical, laboratory, and angiographic parameters were also recorded to identify risk factors for the development of post-TIPS hepatic encephalopathy (HE). Mean follow-up was 17 +/- 7 months. During follow-up, six patients died and one underwent transplantation. All other patients were followed for at least a year. Fifteen patients (32%) experienced 20 acute episodes of precipitated HE (hospitalization was necessary in 10 instances), and five patients (11%) presented a continuous alteration in mental status with frequent spontaneous exacerbation during follow-up. Both precipitated and spontaneous HE occurred more frequently during the first three months of follow-up. Moreover the PSE index was significantly worse than basal values one month after TIPS, thereafter returning to near basal values. HE was successfully treated in all patients but one who required a reduction in the stent/shunt diameter. Increasing age (65 years) and low portacaval gradient (10 mm Hg) were predictors of HE after TIPS. A gradual dilation of the stent/shunt should be performed to obtain a portacaval gradient10 mm Hg to avoid an unacceptable rate of HE after TIPS.

Laparoscopy is becoming the preferred approach for managing several abdominal disorders. The main limitations of laparoscopic surgery and diagnostic laparoscopy are the loss of the surgeon's tactile feedback and the inability to undertake a complete internal evaluation of solid parenchyma. Probes for laparoscopic sonography have been introduced to compensate for the limitations of laparoscopic surgery and to increase the diagnostic efficacy of laparoscopy [1]. In this article we describe our experience with laparoscopic sonography and illustrate the normal anatomic findings and some applications in biliary surgery and other abdominal laparoscopic procedures.

Transjugular intrahepatic portosystemic shunt (TIPS) was performed in two patients with portal vein thrombosis. In both patients, hepatopetal flow had been maintained by an anomalous insertion of the right gastric vein (RGV) into the portal vein bifurcation and into the left portal branch respectively. In one patient, the main portal trunk could not be recanalized and the RGV was used as an accessory portal vein to place one stent for TIPS. In the other case, access through the partial portal-vein occlusion was gained and three stents were placed from the hepatic vein to the main portal vein distal to the thrombus. In portal vein thrombosis, the aberrant insertion of the RGV into the left or right portal branches may maintain patency of the intrahepatic portal system and, in case of unsuccessful recanalization of the porta, may represent the sole pathway for placing a TIPS.

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed. From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n=15), associated in six cases also with percutaneous cholangiography (PTC). “Minimally invasive” treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by “minimally invasive” techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n=4), ductal stricture by endoloop (n=1), iliac artery injury (n=1), and phlegmon of gallbladder bed (n=1). It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging. After a first diagnostic phase, complications should be managed by a multidisciplinary approach wherein the radiologist and the endoscopist strictly cooperate with the surgeon in order to obtain an immediate relief of the initial clinical problem, such as jaundice, bile leak, or infection, and then plan a definitive treatment which is tailored to each patient's problem. Using this approach the whole event of LC and its complications can be managed within the field of minimally invasive therapy in most cases.

Interventional radiology plays a significant role in different fields of gastrointestinal oncology. Percutaneous techniques can be used to diagnose and stage bile duct and pancreatic cancer. Palliation of esophageal tumors and malignant biliary obstruction may be achieved with interventional techniques, whereas curative attempts are directed mainly towards primary and secondary liver tumors. The therapeutic potential of interventional radiology is still expanding, as are all other forms of minimally invasive therapy. This article reviews the relevant contributions on this subject that have appeared in the past year. The introduction of new techniques is described, and the results of clinical studies are discussed.

Objective: Menetrier’s disease, also called hypoproteinemic hypertrophic gastropathy, is a rare, acquired, premalignant disorder of the stomach. It is generally characterized by giant hypertrophic folds that most often involve the fundus, excessive mucus secretion, decreased acid secretion (hypochlorhydria), and hypoproteinemia due to selective loss of serum proteins across the gastric mucosa. Aims and methods: A four year old boy was referred to our Pediatric Gastroenterology and Liver Unit because of iron deficiency anemia. The child had been healthy since his birth; no illness during the delivery or the neonatal period were accounted. He had been breastfed till 12 months of age, his physical and psychological development was unremarkable and his growth curves were within the normal ranges. At medical history, it was reported that his grandfather suffered from Menetrier’s disease. Therefore, on suspicion of chronic obscure gastrointestinal bleeding, we performed upper gastrointestinal tract (GI) endoscopy which disclosed markedly thickened gastric folds with nodularity, erythema, and exudate involving the proximal stomach (corpus and fundus); the antrum and pylorus did not show pathological features. Histological specimens of the stomach obtained by multiple superficial cold forceps biopsies showed only foveolar hyperplasia and dilatation of some glands. Helicobacter pylori was not found. Cytomegalovirus (CMV) PCR on gastric aspiration, serum and urine did not show the presence of viral load. Results: After one month, we re-performed upper GI endoscopy in order to obtain a wider sample for histological examination by jumbo forceps. At this time, the pathologist identified marked foveolar hyperplasia and elongation of gastric pits, cystic dilatation of gastric gland in the deeper part of the mucosa, moderate atrophy of fundic glands; in the lamina propria there was no inflammation, but marked dilatation and congestion of small vessels, and diffuse edema has been observed. These findings suggested the diagnosis of Menetrier’s disease, and the child was thus treated with Octreotide longacting release (LAR) which brought to clinical amelioration of the anemia. Conclusion: The cause of Menetrier’s disease is unknown, although in children infection by CMV and by Helicobacter Pylori have been implicated. Classical symptoms include epigastric pain, vomiting, edema, anorexia, and weight loss. In this case of pediatric Menetrier’s disease, the only clinical feature was iron deficiency anemia, probably due to congested small vessel leakage. We might speculate that this child had not expressed yet all the other features of the disease, such as the protein-loss syndrome, because of his early diagnosis. The medical treatment of Menetrier’s disease consists of Octreotide administration, which is a somatostatin analogue, and in our case successfully controlled hemorrhage from gastric lesions.

Eighteen patients with recurrent benign biliary strictures (BBS) were selected for metallic stents placement because they failed to respond to percutaneous balloon dilatation. None were candidates for surgical corrections. We used “Z” single or double stents in 17 cases and a Wallstent in 1 case. After more than 3 years of follow-up (average period 37 months, range 30–41 months), 10 patients (55.5%) were asymptomatic without signs of bile statis; 5 patients (27.7%) had recurrence of symptoms and were eventually retreated; and 3 patients (16.6%) died, 2 of obstructive jaundice and liver failure and 1 of metastatic gastric cancer. Recurrence was due to stent occlusion by tissue ingrowth in 3 cases, stent migration in 1 case, and an inflammatory lesion of the papilla of Vater in another case, with patency of the metallic stent. The overall patency rate, at 3-year follow-up was 68.7%. In our series, the main factor determining long-term patency of metallic stents has been reactive tissue ingrowth. Nevertheless, long-term results obtained with metallic stents in recurrent benign biliary strictures should be considered satisfactory. In selected patients, metallic stents may represent the only long-term treatment available for maintaining bile flow.

Seventy patients with benign biliary strictures were treated by means of percutaneous balloon dilation and stenting. Patients with stenoses relapsing during catheter stenting (18/70) were treated with self-expanding metallic stents. Results were evaluated in 56 patients; in patients without sclerosing cholangitis (n = 47) the patency rate with both modalities of treatment was 96%, while in the patients with secondary sclerosing cholangitis (n = 9), it was 33%, for a total success rate of 86%. The average follow-up was 23 months (range 3-72 months). Major complications included one death for septic shock (1%), three severe hemorrhages (4%), two of which required arterial embolization, two pleural effusions (3%), and one liver abscess following arterial embolization. Moderate fever for 1-2 days was a common finding after percutaneous puncture and balloon dilation. Percutaneous management of benign biliary strictures so far has been attempted only in surgical failures or in complicated cases. In view of our midterm results it may well become the initial treatment in many patients.

Editor: The choice of sedation or anesthesia in interventional radiology is frequently a compromise between the needs of the interventional radiologist and the general conditions of the patient. In particular, the transjugular intrahepatic portosystemic shunt (TIPS) procedure is often performed in severely ill cirrhotic patients. In such patients, the anesthesiologist should provide the interventional radiologist with optimal and safe working conditions for the period of time required for the procedure. Initially, our choice was oriented toward deep sedation obtained through intravenous medication. However, because we have had some limitations in reaching and maintaining an acceptable level of sedation, we have changed our technique by employing a laryngeal mask, therefore avoiding intubation and the use of paralytic agents. The laryngeal mask is made of a tube linked at one end to anesthesia equipment; the other end is connected to a pear-shaped device surrounded by a silicone inflatable balloon positioned at the glottic orifice. The silicone balloon, when inflated, creates a good seal to gases and liquids (1-3). We have treated 68 patients undergoing TIPS procedure with the use of the laryngeal mask according to the following protocol: No preanesthetic medication; use of propofol as an inducing agent at a dosage of 2 mgkg, followed by a deepening with a mixture of O,, N,O, and isoflurane (1%-2%) obtained with face mask spontaneous breathing for 2-3 minutes; positioning of the laryngeal mask according to the standard method, and protracted administration of the same gas mixture in a semiclosed circuit, leaving the patient spontaneously breathing; monitoring the EtCO, (end tidal CO,) and the PsO, (partial saturation 0,). The EtCO, measures the CO, concentration in the expirated volume of the patient and allows us to follow the effectiveness of ventilation. The PsO, monitors the blood 0, saturation; 0, is administered at the end of the procedure until protective reflexes reappear and then the laryngeal mask is removed. In our experience, the laryngeal mask has proven easy to use, with successful results at the first attempt at insertion in 81% of cases. In the remaining 19% of cases, a second attempt was required after face mask ventilation. Oxygen arterial saturation never decreased below 97% and the blood pressure ranged within 15% ? of the initial value. The EtCO, never exceeded 45 mm Hg. There were no episodes of aspiration during the 68 procedures. The postoperative vomiting incidence was 4% (two patients). TIPS offers an ideal application for the laryngeal mask because the required degree of sedation is not very deep, whereas the patient's motionlessness for a protracted period is essential. Our experience, as also reflected by Ivens et al (4), confirms the better quality of gas exchange as compared with face mask spontaneous breathing or with intravenous sedation without controlling the airways. In addition, the laryngeal mask avoids the use of traditional general anesthesia, reaching deep sedation without the need of intubation and paralyzation in patients with advanced hepatic insufficiency who may present an unpredictable pharmacologic response to the administration of anesthetics and curare.

Technical and clinical data concerning 731 controlled patients submitted to nonsurgical percutaneous biliary drainage (PBD) for preoperative or palliative purposes were collected from eight institutions. Using a computerized analysis program, general and special statistics were obtained, with special attention given to 536 neoplastic cases. Technical success, type, level and nature of the lesions, purpose of drainage, surgery performed, complications, and other clinical and technical information were considered and compared with the clinical results. Statistically significant data were obtained comparing, respectively, bilirubin levels with duration of drainage, survival with type of treatment (PBD alone or followed by radical or palliative surgery), operative with post PBD mortality, survival with type of PBD (external catheter, internal catheter, and endoprosthesis), and complications with type of PBD used.

A new technique of transcatheter wiring of unresectable aortic aneurysm is described that provides simultaneous transcatheter occlusion of both common iliac arteries followed by axillofemoral bypass. The spring coil used for aortic aneurysm wiring was of our own making. The outer portion of a movable core stainless steel guidewire was bent in a coil shape and introduced into the aneurysm through a 7 French Teflon catheter via the right femoral artery. The same catheter was also used for coil embolus occlusion of both iliac arteries.

We report five children with a soft mass in the neck due to congenital jugular venous ectasia. Three had fusiform dilatation of the internal jugular vein, which in one case was associated with dilatation of the ipselateral external jugular vein. Two children had aneurysmal dilatation of the superficial cervical communicating vein. The first four cases required angiographic studies for final diagnosis. Venography via the femoral vein was most valuable for visualization of the dilated segments of internal jugular veins but failed to show the vascular mass communicating with the superficial vein of the neck. These were best visualized by direct injection of the contrast medium into the vessel. In the fifth case a correct diagnosis was obtained with xeroradiography alone.

Regional enteritis may be a protean disease, easily diagnosed when the common clinical presentation is noted. Occasionally, however, "atypical" features lead to the clinical suspicion of neoplastic disease. Four patients underwent angiographic evaluation in this clinical setting, all demonstrating similar changes in the mesenteric arteries. A serrated, "corkscrew" pattern was present and corresponded well to the perivascular fibrosis noted histologically. Recognition of this angiographic pattern may be important in differentiating neoplastic from inflammatory disease processes.

Thirty-three patients suspected of having a functioning tumor of the pancreas were studied with computed tomography (CT); 25 had angiographic studies also. Thirty-one cases were confirmed surgically; the other two were lost at follow-up and were excluded from the series. Of the 31 patients, 21 had insulinomas, five had Zollinger-Ellison syndrome, and five had assorted apudomas. CT was positive in 71% of the cases and negative in 29%; 22.6% of the studies were false negative and 6.4% were true negative. There were no false positives. Of the 21 patients with insulinomas, only one had false-negative CT and angiographic studies, caused by diffuse microadenomatosis. In one patient, two separate lesions of the pancreas were seen and identified correctly on both CT and angiography. All identified lesions smaller than 2 cm were seen only because of a hyperdensity on the enhanced CT scan. Lesions larger than 2 cm were identified either because their size distorted the pancreatic contour or because of their vascularity. The importance of proper CT technique using fast scanners and repeated bolus injections of contrast medium is stressed.

In the atypical case presented, a calcified myxoma of the left atrium simulated isolated mitral insufficiency. Unique hemodynamic and phonocardiographic events were recorded. A notch in the upstroke of the left ventricular pressure tracing during isometric contraction occurred simultaneously with an ejection sound, which fused with the first heart sound, and with an abrupt decrease in ventricular volume as the tumor was ejected from the ventricle. A similar notch in the downstroke of the ventricular pressure tracing was most likely due to the abrupt increase in ventricular volume as the tumor descended into the left ventricle. A third heart sound was present which was identified as a ventricular diastolic gallop and was differentiated from a mitral opening snap by simultaneous pressure tracings.