Perihepatic Fluid Collections Research Articles

Functional hepatobiliary MR imaging in children

Clinical application efforts for the hepatocyte-specific MRI contrast agent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) have mainly been directed toward detection and characterization of various hepatic masses in the adult population. Here we report our initial experience with Gd-EOB-DTPA for evaluating congenital and acquired hepatobiliary pathologies in the pediatric population. Twenty-one consecutive children receiving Gd-EOB-DTPA for functional hepatobiliary evaluation at our institution were retrospectively identified with IRB approval. The use of Gd-EOB-DTPA was classified in each case as definite, potential, or no clinical utility, focusing on the clinical value gained beyond traditional noncontrast fluid-sensitive MR cholangiopancreatography (FS-MRCP) and other imaging modalities. Definite added value of Gd-EOB-DTPA was found in 12 patients, with potential value in 4 patients, and no value in 5 patients. Benefit was seen in cases of iatrogenic and non-iatrogenic biliary strictures, perihepatic fluid collections for biliary leak, hepatobiliary dysfunction in the absence of hyperbilirubinemia, and in the functional exclusion of cystic duct occlusion that can be seen in acute cholecystitis. This is the first reported series of children with Gd-EOB-DTPA and this early work suggests potential pediatric applications.

Outcomes of Laparoscopic Liver Resection for Lesions Located in the Right Side of the Liver

Laparoscopic right-sided liver resection may be feasible and safe. Retrospective analysis. Department of surgery at a university hospital. Of 103 consecutive laparoscopic liver resections performed from May 1, 2003, to April 30, 2007, 46 patients underwent a right-sided laparoscopic liver resection. Six operations required conversion (13%) to open surgery. Overall, data from 40 patients with benign liver tumors (n = 2), intrahepatic duct stones (n = 3), liver metastasis from colorectal cancer (n = 8), and hepatocellular carcinomas (n = 27) were analyzed. Feasibility and operative outcome. The operations included 12 major resections (5 right hemihepatectomy and 7 right posterior sectionectomy) and 28 minor resections (14 segmentectomy and 14 tumorectomy). No operative mortality, subsequent operation, or life-threatening complications occurred. Overall, 11 patients (28%) experienced complications; 2 had bile leakage, 6 had perihepatic fluid collection, 2 had prolonged ascites, and 1 had pleural effusion. All recovered after conservative management. The mean operation time was 300 minutes, the mean blood loss was 620 mL, and the mean hospital stay was 11 days. For lesions located at segment VII or VIII (n = 15), the mean operation time and amount of blood loss in those receiving a minor liver resection were similar to those who received a major resection (P = .21 and .88, respectively). Although greater technical refinement is required for a minor resection in the superior part of the right side of the liver, laparoscopic right-sided liver resection is feasible and safe.

Spontaneous intraperitoneal rupture of hepatic hydatid cyst with biliary peritonitis: a case report

IntroductionSpontaneous intraperitoneal rupture with biliary peritonitis in a case of hepatic hydatid cyst is extremely rare but serious complication. It is a surgical emergency with high morbidity and mortality rates. Very few cases have been reported in the literature.Case presentationWe report an unusual case of a biliary peritonitis due to spontaneous rupture of hepatic hydatid cyst in a male patient of 34 years of age. He presented with acute peritonitis. Contrast enhanced computed tomography 2 days prior to laparotomy showed a dumbbell shaped hydatid cyst of right lobe of the liver with perihepatic fluid collection. At operation 1.5 L bile was found in the peritoneal cavity with rupture of the anterior wall of the cyst and large cystobiliary communication. He was managed with deroofing of the cyst, cholecystectomy, and placement of T tube in the cystobiliary communication and in the extrahepatic bile duct. He developed biliary fistula which was closed over a period of 34 days with conservative therapy. At 6 months follow up patient is well and free of recurrence.ConclusionThough rare, ruptured hydatid cyst should be considered in the differential diagnosis of acute abdomen in a patient residing in the endemic zone.

Percutaneous Therapy for Anastomotic Bile Leak in Liver-Transplant Patients with Nondilated Bile Ducts

Bile leaks remain a significant cause of postoperativemorbidity in 4.9% to 26.6% of liver transplant recipients[1–4] and can be managed surgically or nonsurgically.Most leaks can be treated with interventional radiologictechniques. However, in cases with bile ducts that aredecompressed because of massive leakage (mostly anas-tomotic), percutaneous access into a peripheral bile duct isusually difficult. In the cases presented here, we performedretrograde catheterization of a peripheral bile duct to makethe percutaneous procedure easier to perform and lesstraumatic for the patient.Case ReportsCase 1Forty-nine days after orthotopic liver transplantation, a 59-year-oldman presented withabdominalpainandtenderness.A large perihepatic fluid collection, or biloma, was found onultrasound examination. After bile-stained fluid aspiration,percutaneous drainage of the perihepatic biloma was per-formed under ultrasonographic guidance. Following thisprocedure, output through the drainage catheter was high(>200 ml per 24 h). Two weeks later, drip-infusion pouch-ography obtained via the drainage catheter showed a com-munication between the biloma and the biliary system at thesite of the surgical anastomosis. Endoscopic managementwas our first treatment option, but it failed in crossing theanastomosis. We decided to perform percutaneous transhe-patic biliary drainage. Because the leak had caused decom-pressionofbileducts,wedecidedtouseourbilomaaccesstomake the percutaneous bile duct puncture easier.The procedure was performed after antibiotic prophy-laxis. After initiation of intravenous (IV) sedation and localanesthesia, the drainage catheter was exchanged for a 6-Fintroducer sheath (Arrow International, Inc., Reading, PA,USA) positioned over a guide wire. A 5-F catheter (SOSOMNI; AngioDynamics, Queensbury, NY, USA) was in-serted from the biloma pouch and passed through the dis-rupted anastomosis. Then a microcatheter (fast tracker;Boston Scientific, Natick, MA, USA) was coaxially in-serted into a peripheral bile duct available for percutaneousaccess (Fig. 1), and contrast material was injected throughthe microcatheter to opacify and distend this duct. Underfluoroscopy and using a 21-gauge needle (AccuStickIntroducer System; Boston Scientific), a percutaneouspuncture was made in the same duct.After the percutaneous needle puncture was made in theduct, a coaxial dilator (AccuStick Introducer System;Boston Scientific) was placed over an 0.018-in. Nitinolguide wire, then a 0.035-in. glide wire (Terumo, Tokyo)was advanced through the dilator, and a 6-F introducer(Terumo) was inserted into the duct over the wire. A 5-Fcatheter (Terumo) with a guide wire was used to cross theleak site. Then, over a stiff guide wire (Amplatz Super StiffGuide Wire; Boston Scientific), a 10-F biliary drainagecatheter (Flexima; Boston Scientific) with multiple sideholes positioned on both sides of the anastomosis wasplaced to divert bile away from the defect. The leak haddisappeared after 57 days of percutaneous biliary drainage.

Radiofrequency Ablation of Liver Metastases from Breast Cancer: Results in 14 Patients

To evaluate the results of radiofrequency ablation in treating hepatic metastases from breast cancer. Fourteen breast cancer patients with 16 hepatic metastases measuring 1.1 to 4.0 cm in the longest axis (mean, 1.9 cm) were prospectively studied. All patients had previously received chemotherapy. Radiofrequency ablation was done using 17-G, internally cooled electrodes under ultrasound guidance. A single index tumor was treated in 12 patients, and two tumors each were treated in two patients. Follow-up was done using serial computed tomography for a duration ranging from 6 to 45 months (mean, 18 months; median, 16 months). All patients were treated in a single session. No major complications occurred. Minor complications or side effects (asymptomatic pleural effusion, perihepatic fluid collection) were observed in three patients. Complete necrosis, defined as an absence of detectable disease on computed tomography at 6 months follow-up was achieved in 14 (88%) of 16 index tumors. Treatment failure due to the development of new metastases was observed in seven (50%) of 14 patients. Five (36%) patients died in the first 12 months after radiofrequency ablation due to the development of new hepatic and extrahepatic metastases. At the time of writing, nine (64%) of 14 patients are alive, of whom four patients (29%) are disease-free and three patients (21%) are progression-free. A high overall treatment failure rate (50%) was observed due to the development of new metastases on follow-up. Despite this, radiofrequency ablation appears to be a safe and effective adjunct to systemic chemotherapy for the loco-regional treatment of liver metastases from breast cancer.

Successful Endoscopic Treatment of Bouveretʼs Syndrome with Intracorporeal Electrohydraulic Lithotripsy

We describe two cases of duodenal obstruction caused by an impacted gallstone (Bouveret's syndrome) successfully treated with endoscopic therapy using electrohydraulic lithotripsy. Case 1: An 84-year-old man presented with two days of nausea and recurrent coffee-ground emesis. His medical history included a shallow duodenal bulb ulcer on endoscopy one month earlier, and a large (3 cm) solitary gallstone in the gallbladder on abdominal imaging six months previously. On admission, plain abdominal radiographs revealed a markedly distended stomach. Endoscopy revealed a large gallstone impacted in the duodenal bulb, prohibiting passage of the endoscope. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a cholecystoduodenal fistula. Due to the size of the impacted stone, fragmentation using mechanical lithotripsy was not feasible. Therefore, intracorporeal endoscopic electrohydraulic lithotripsy (Northgate Technologies, Inc., Arlington Heights, IL.) using the Micro II 1.9 French lithotripsy probe at a setting of 70–100 watts was used to successfully fracture the stone into small fragments. Clinically, the patient's gastric outlet obstruction resolved. Follow-up endoscopy three days later revealed no remaining stone fragments in the duodenum. Case 2: A 69 year-old man presented with four days of right upper quadrant pain, nausea and vomiting in the setting of known cholelithiasis. After treatment for presumed cholecystitis, he was taken to the operating room for laparoscopic cholecystectomy. Significant inflammation was encountered in the perihepatic region; thus cholecystectomy was deferred and a percutaneous drain was placed. A post-operative CT scan suggested extravasation of oral contrast from the duodenum toward a perihepatic fluid collection, and a round filling defect was demonstrated in the proximal duodenum on upper GI. Subsequent endoscopy revealed a large obstructing gallstone in the duodenal bulb. Intracorporeal endoscopic electrohydraulic lithotripsy was performed at 70–90 watts with successful fragmentation of the stone. An opening to a fistulous tract was then identified in the duodenal bulb. The patient improved clinically and was discharged 15 days after endoscopy, with plans to pursue cholecystectomy in the outpatient setting. These cases illustrate the potential for effective endoscopic therapy for this historically surgical condition, which is particularly desirable in elderly patients with significant medical comorbidities.

3470: The role of Doppler US in segmental liver transplantation in children

Doppler US plays an important role in postoperative evaluation for children with segmental liver transplantation. Problems following transplantation include acute rejection, perihepatic fluid collections, and vascular and biliary complications. Focal fluid collections were most often seen immediately after surgery along the cut surface of the graft. Vascular complications included stenoses of the hepatic arteries, hepatic veins and portal veins. Radiologic interventions involved drainage of fluid collections under US guidance, percutaneous cholangiography and angioplasty of vascular anastomoses.

Ultrasound of living donor liver transplantation

Liver transplantation is the most effective treatment for various end-stage liver diseases. Living donor liver transplantation (LDLT) was first developed in Asia due to the severe lack of cadaveric graft in this region. The Liver Transplant Service at Queen Mary Hospital (QMH), Hong Kong, has pioneered the application of LDLT to patients using both left lobe and right lobe grafts. The QMH liver transplant programme is the largest of its kind in China and Southeast Asia.Ultrasound (US) is often employed in the initial work-up of potential donor and recipient of LDLT. It is the imaging technique of choice to assess the early and late complications of LDLT, with colour Doppler ultrasound being the most useful in the evaluation of post-LDLT vascular complications. The use of ultrasound contrast agents improves the visualisation of the hepatic vasculature, possibly delaying or removing the need for more invasive investigations. Intra-operative ultrasound facilitates the determination of the resection plane during donor hepactectomy.Computed tomography (CT) or magnetic resonance imaging (MRI) can be used as the single imaging modality in the evaluation of LDLT candidates.Ultrasound is most useful as the initial screening test in detecting hepatic parenchymal abnormalities, while CT or MRI is the modality of choice in the demonstration of vascular and biliary anatomy of the potential liver donor.Biliary complications are more common in LDLT than in cadaveric liver transplantation. The ductal dilatation, resulting from biliary stricture, is clearly demonstrated by ultrasound. Bilomas can be aspirated under ultrasound guidance to confirm the diagnosis and to promote healing. Perihepatic fluid collections and abscesses are also common after LDLT. Intra-hepatic collections may represent seromas, haematomas or infarction. Ultrasound is a sensitive means of detecting these collections and can be employed to guide drainage in suitable patients.Transplant-related malignancies include recurrent neoplasia and post-transplant lymphoproliferative disease (PTLD). Ultrasound can be used to screen for recurrent disease and to detect PTLD in the transplanted liver.

Nonvascular Complications in Pediatric Liver Recipients: Multidetector Computed Tomography Evaluation

In pediatric liver transplantation postoperative diagnosis of complications is crucial for graft salvage. Multidetector computed tomography (MDCT) is a technique to evaluate complications. In this study we present nonvascular abdominal complications encountered in pediatric recipients after liver transplantation. We retrospectively examined 113 MDCT examinations in 43 pediatric patients who underwent liver transplantation between 1997 and 2005. Computed tomography (CT) examinations were made by a 16-detector multislice CT scanner. The pathological findings on CT images were: intraperitoneal free fluid, intrahepatic bile duct dilatation, graft liver infarction, perihepatic and intraperitoneal fluid collections (six biloma), colonic and/or intestinal dilatation, splenic infarction, perihepatic hematoma, right adrenal hemorrhage, perihepatic abscess, incisional hernia, intrahepatic biloma and periportal collar. In one patient intestinal hemorrhage was suspected. Intestinal perforation was suspected in three patients. Among these three patients, one patient died before any surgical intervention. In two patients the diagnosis was confirmed at surgery. In pediatric patients, the short examination time, brief sedation duration, and high-resolution images make MDCT an effective radiological method to evaluate nonvascular transplant complications.

Feasibility, Safety, and Efficacy of Percutaneous Transhepatic Injection of β-Cell Grafts

To evaluate the safety, feasibility, and clinical efficacy of percutaneous transhepatic injection of beta-cell grafts in patients with type 1 diabetes mellitus. Between December 2001 and November 2003, 15 patients with C-peptide-negative type 1 diabetes underwent 31 percutaneous injections for intraportal implantation of beta-cell grafts. Grafts consisted of cultured beta-cell preparations as previously described. In 13 cases, the transplant procedure was done under sedation, whereas in 18 cases, general anesthesia was given. In all procedures, percutaneous access to the right portal vein occurred under ultrasound (US) guidance with use of a microbore puncture needle. The subsequent catheterization of the main portal vein was performed under fluoroscopic and angiographic control with use of a microbore delivery catheter and guide wire. Clinical, biochemical, and radiologic evaluation was performed before and after the procedure. In all cases, it was possible to access the portal vein (median number of needle passes, 1; range, 1-6). The volume of cultured beta-cell grafts injected for each transplantation averaged 0.58 mL (range, 0.26-1.60 mL) and the mean recorded procedure time (from puncture to catheter withdrawal) was 19 minutes (range, 10-80 min). Three patients presented with transient abdominal pain immediately after the procedure; postprocedural duplex US of the liver revealed a patent portal vein and end branches in all cases and a minor perihepatic fluid collection in another three patients. From the end of week 1 to week 3, a mean 3.8-fold increase in liver aminotransferase levels was measured in all recipients after the first implantation session. A similar increase was seen in only one patient after a second transplantation session. At 6 months after transplantation, 13 of 15 patients (86%) had a functioning graft with plasma C-peptide levels greater than 0.5 ng/mL. The combined US, fluoroscopic, and angiographic monitoring of percutaneous transhepatic injection with use of a microbore delivery catheter is a safe and reproducible radiologic procedure for transplantation of beta-cell grafts in diabetic patients. Increased posttransplantation C-peptide levels, which demonstrate acceptable graft function, can be obtained.

PERCUTANEOUS TRANSHEPATIC BETA CELL TRANSPLANTATION IN TYPE 1 DIABETIC PATIENTS USING A COMBINED ULTRASOUND- AND FLUOROSCOPY-GUIDED TECHNIQUE.

P447 Aims: To evaluate the safety and feasibility of percutaneous transhepatic beta cell transplantation in patients with type 1 diabetes mellitus using a combined ultrasound- and fluoroscopy-guided puncture technique. Methods: Between December 2001 and November 2003, 15 C-peptide negative type 1 diabetic patients underwent 31 percutaneous beta cell transplantation procedures in our JDRF center. In 13 cases the transplant procedure was done under sedation, while in 18 cases general anesthesia was given, in 12 cases using a laryngeal mask and in 6 an endotracheal tube. In all procedures percutaneous access to the right portal vein was made under ultrasound guidance and subsequent catherisation of the main portal vein was performed under fluoroscopic control. The volume of beta cell grafts injected for each procedure was recorded as well as the total procedure time. Clinical, biochemical and radiological evaluation was performed before and after the procedure. Results: In all cases it was possible to achieve access to the portal vein (median number of seeker needle passes = 1, range 1 – 6). The volume of cultured beta cell grafts injected for each transplantation was 0.58 ml (range 0.26 – 1.60 ml) and the recorded procedure time (from puncture to catheter withdrawal) was 19 min (range 10 – 80 min). Three patients presented with transient abdominal pain immediately after the procedure; postprocedural duplex ultrasound of the liver revealed a patent portal vein and endbranches in all cases and a minor perihepatic fluid collection in 3 patients. From the end of week 1 up to week 3, an increase in liver transaminases was measured in all recipients (3.0 fold, range 1.8 – 11.3 fold). Conclusions: The combined ultrasound and fluoroscopic monitoring of percutaneous transhepatic injection is a new, safe and reproducible radiological procedure for transplantation of beta cell grafts in type 1 diabetic patients.

US of liver transplants: normal and abnormal.

Whole-liver transplantation is an accepted and successful method of treating end-stage liver disease. As a result of the shortage of cadaveric livers, split-liver transplantation and living donor liver transplantation are becoming more commonplace. Ultrasonography (US) is the initial imaging modality of choice for detection and follow-up of early and delayed complications from all types of liver transplantation. Vascular complications include thrombosis and stenosis of the hepatic artery, portal vein, or inferior vena cava, as well as hepatic artery pseudoaneurysms and celiac artery stenosis. Biliary complications include leaks, strictures, stones or sludge, dysfunction of the sphincter of Oddi, and recurrent disease. Neoplastic disease in the transplanted liver may represent recurrent neoplasia or posttransplantation lymphoproliferative disorder. Parenchymal disease may take the form of a focal mass or a diffuse parenchymal abnormality. Perihepatic fluid collections and ascites are common after liver transplantation. Knowledge of the surgical technique of liver transplantation and awareness of the normal US appearance of the transplanted liver permit early detection of complications and prevent misdiagnosis.

CHEST WALL PAIN - FOOTBALL

HISTORY A 16-year-old varsity high school football player was struck by an opponent in the right anterior chest wall while running down field to make a block on punt return. The hit lifted him up off his feet, he landed flat on his back and he had immediate pain in the right anterior chest wall. He required assistance to get off the field and did not play again in that game. Three days later player presented to the Sports Medicine office. Player complained of right anterior chest wall and right upper quadrant pain with deep inspiration since hit. PHYSICAL EXAMINATION Examination in the office revealed a well-developed male in no apparent distress and within normal vital signs. He had no chest or abdominal wall deformity or ecchymosis. He was tender to palpation on the right anterior chest wall over fourth through sixth ribs in the midclavicular line, right anterior costochondral junction T7-T8, and in the right upper quadrant of abdomen. Bowel sounds were present, abdomen was soft and flat, without rigidity or guarding. Liver and spleen were non-palpable. There was negative Cullen Sign and negative Gray Turner Sign. Heart was regular rate and rhythm and lungs were clear to auscultation and percussion. DIFFERENTIAL DIAGNOSIS Chest wall contusion Occult rib fracture Liver contusion Liver hematoma TESTS AND RESULTS Chest and rib detail radiographs were unremarkable. Labs revealed: WBC 10.8, Lymphocytes 15.5, Hemoglobin 14.5, Hematocrit 43.6, AST 95, ALT 237. Repeat blood tests one week later revealed normal CBC and liver function tests. INTERIM EVENTS: Player was restricted from contact/collision and strenuous non-contact activities. Three weeks into treatment he attempted to run a timed mile. He developed nausea and increased right upper quadrant abdominal pain. Additional tests were immediately performed. Abdominal ultrasound: parenchymal hematoma in the anterior segment of right lobe of liver, possible underlying liver laceration. Abdominal CT: 7.0 × 2.3 cm liver laceration at the junction between medial segment left hepatic lobe and anterior segment right hepatic lobe, with 1 cm parenchyma more superficial to the laceration. No perihepatic fluid collection. FINAL/WORKING DIAGNOSIS Liver laceration and hematoma TREATMENT AND OUTCOMES Disqualification from football for remainder of season No vigorous activities for at least 8 weeks Observation and education of player and family of warning signs that would require immediate evaluation Repeat liver CT in 2 months

Living-related liver transplantation in children: The ‘Parisian’ strategy to safely increase organ availability

Purpose: The aim of the authors was to report their experience with living related liver transplantation (LRLT) in children, particularly focusing on the safety of the two-center “Parisian’ strategy.Methods: The records of donors and recipients of 26 pediatric living-related donor liver transplantations performed between November 1994 and March 1998 were reviewed retrospectively. Donors were assessed 1 year after transplantation for medical and overall status.Results: Indications for LRLT included biliary atresia (n = 18), Byler's disease (n = 5), alpha-1-antitrypsin deficiency (n = 1), Alagille syndrome (n = 1), and undefined cirrhosis (n = 1). Liver harvesting consisted of either a complete left hepatectomy (n = 14) or left lateral hepatectomy (n = 12) without vascular clamping. The recipient procedure essentially was the same as in split liver transplantation. Mean overall cold ischemia time averaged 140 minutes (range, 90 to 230 minutes). Twenty-four of 26 patients had end-to-end vascular anastomoses without interposition. Biliary reconstruction consisted of a Roux-en-Y choledochojejunostomy in all patients. All recipients except one received cyclosporine A (CSA). Mean donor hospitalization was 8 days (range, 6 to 13) with normalization of all liver function assays by the time of discharge. There were no donor deaths and two postoperative complications (perihepatic fluid collection and bleeding from the wound). One year after donation, the initial 19 donors had resumed their pretransplant status. Two of the children who underwent transplant died. Thirteen of the recipients required reoperation for hepatic artery thrombosis (n = 2), portal vein thrombosis (n = 2), biliary complications (n = 6), fluid collection (n = 3), small bowel perforation (n = 1), and plication for diaphragmatic eventration (n = 1). With mean follow-up of 2 years, 24 of 26 patients are alive and well (patients and graft survival rate, 92%).Conclusions: LRLY is still controversial, even with minimal and decreasing donor risk. The “Parisian” strategy consists of harvesting the liver in an adult unit by an adult hepatic surgery team. The transplantation is then performed in a pediatric hospital by the pediatric liver transplantation team. The two steps of the procedure allow units specialized in adult surgery, on one hand, and pediatric liver transplantation, on the other hand, to dedicate themselves completely to their respective procedures, improving the safety of the harvest, and alleviating stress for both the medical staff and the families.

Post-operative Imaging of Living Related Liver Transplantation in Pediatric Patients

Purpose: The purpose of this study was to evaluate the findings and significance of postoperative imaging after living related liver transplantation (LRLT) in pediatric patients. Materials and Methods : We retrospectively reviewed all imaging findings, including those of post-LRLT ultra-sonography (US) and computed tomography (CT), in 20 children who had undergone LRLT at our institute. Results : Postoperative findings on US and CT were perihepatic or subcapsular fluid collection (60%), periportal edema (35%), anastomotic narrowing of the IVC (10%), biliary stricture (5%), and focal hepatic infarction (5%). Liver biopsy was performed in nine patients in whom rejection was clinically suspected, and pathologic examination revealed acute rejection in five. US and CT revealed perihepatic fluid collection in one of these, periportal edema and fluid collection in two, and normal findings in two. Conclusion : An understanding of the various postoperative findings after LRLT is helpful for accurate diagnosis and appropriate decisions regarding the preservation of normal graft function.

Bile duct disruption after laparoscopic cholecystectomy

The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. We have reviewed the first 823 laparoscopic cholecystectomies performed at our institution and found 13 symptomatic biliary complications necessitating further therapy (prevalence 1.6%). This finding represents a decrease from the 2.7% prevalence found in our earlier series. The incidence of biliary complications will likely continue to vary depending on patient selection, operator experience, and new developments in laparoscopic technique. Bile duct injury and bile leaks are often difficult to diagnose but must be strongly considered in postoperative patients with abdominal pain, fever, jaundice, or continued bilious drainage from a surgical drain. Whereas computed tomography (CT) and sonography are sensitive in detecting perihepatic or free peritoneal fluid collections, they are nonspecific and definitive diagnosis of biliary tract injury requires hepatobiliary scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), or percutaneous aspiration. Disruption of the biliary tree has commonly been treated with reoperation or percutaneous drainage. More recently, endoscopic management has shown encouraging results for bile leaks and strictures in small series.

Early sonographic evaluation of the transjugular intrahepatic portosystemic shunt (TIPS).

The purpose of this study was to evaluate duplex and color Doppler findings in patients before and within 24 h after transjugular intrahepatic portosystemic shunts (TIPS). Conventional duplex and color Doppler were used in the assessment of 19 patients who underwent TIPS as part of a prospective protocol. Patients were examined within 24 h before and after the procedure. Before TIPS, patency, flow direction, and peak flow velocity in the main portal vein and hepatic artery were studied, as well as patency and flow direction in hepatic veins, splenic vein, and inferior vena cava (IVC). Immediately after the procedure, sonographic identification of stent position, shunt patency, and flow dynamics were evaluated and patency and flow direction of hepatic veins, splenic vein, and IVC were determined. The portogram performed at the end of the procedure was compared with the 24-h sonographic studies after TIPS to determine sonographic/angiographic correlation. No intraparenchymal abnormalities or perihepatic fluid collections were detected after the procedure. The metallic stent was clearly seen in all patients. Mean peak shunt flow velocities were 139 +/- 50 cm/sec within 24 h after TIPS. Absence of flow through the shunt was correctly identified in one case and confirmed angiographically. Mean peak flow velocity in the portal vein before TIPS was 22 +/- 13.6 cm/sec and increased to 43.6 +/- 9.1 cm/sec after TIPS (p < 0.05). The hepatic artery peak systolic velocity increased from 77 +/- 51 cm/sec before TIPS to 119 +/- 53 cm/sec after the procedure (p = 0.029).(ABSTRACT TRUNCATED AT 250 WORDS)

CT findings after percutaneous biliary procedures.

A prospective study was performed to determine the frequency, type, and extent of abnormalities depicted with computed tomography (CT) after percutaneous biliary procedures (PBPs). Abdominal CT scans were obtained 24-72 hours after the PBP in 31 consecutive cases in 29 patients. Fifteen abnormalities were proved with CT in 14 patients (45%), as follows: subcapsular hematoma (two patients), subcapsular or perihepatic fluid collection (three patients), intrahepatic hematoma (three patients), nonspecific intrahepatic fluid collection (three patients), subcutaneous hematoma at the puncture site (one patient), free intraperitoneal air (one patient), intraperitoneal collection of contrast material (one patient), and inadvertent transxiphoid catheter tract (one patient). Only five of these patients had clinically apparent post-PBP complications that could be explained with CT findings. The 14 patients with positive CT findings required more needle passes (mean, 8.3 vs 4.6) during the PBP, had a difficult PBP more often (five patients [36%] vs four patients [27%]), and had more frequent placement of an internal-external drain (nine patients [64%]) than those with negative findings (eight patients [53%]). Positive findings on CT scans are common after a PBP and often are not associated with clinical symptoms.

CT of amebic liver abscess.

CT findings in 23 patients with amebic liver abscess were analyzed retrospectively. A solitary abscess was present in 17 patients. Five patients had two to five lesions. One patient, a male homosexual, had 15 abscesses. Of the 46 abscesses, 74% occurred in the right lobe. The lesions were generally round or oval. One-half of the abscesses were 2-6 cm in diameter; 11% measured 13-16 cm. An enhancing wall was present in most cases. An incomplete rim of edema was seen in eight abscesses. The margin of the abscess was smooth in 63% and nodular in 37%. Internal septations were noted in 30%. Four patients had focal intrahepatic biliary dilatation peripheral to an abscess. One patient had intraabscess hemorrhage. Extrahepatic abnormalities were present in 18 patients; right pleural effusion (nine), perihepatic fluid collection (five), gastric or colonic involvement (eight), and retroperitoneal extension (one). Gas within an abscess was due to hepatobronchial fistula in one patient and hepatocolic fistula in another. Amebic abscess should be included in the differential diagnosis when CT shows one or more cystic or complex masses in the liver, especially when there is evidence of extrahepatic extension.

Upper abdomen: CT findings following partial hepatectomy.

The appearance on computed tomographic (CT) scans of the upper abdomen after partial hepatectomy is complex. The findings expected at CT should not be confused with those of surgical complications, such as abscess, biloma, or hematoma. The findings on CT scans and the records of 17 patients who had undergone partial hepatectomy for malignancy were reviewed. Operations included wedge resection, left medial and lateral segmentectomies, left lobectomy, right subsegmentectomy, right lobectomy, and extended right lobectomy (trisegmentectomy). When partial hepatectomy had been performed with no complications, findings at CT included a small region of low attenuation at the surgical margin, probably due to transient accumulation of blood and bile; a right pleural effusion; extraluminal gas; shift of abdominal organs; hepatic regeneration; and fat attenuation at the resection margin representing the omental patch placed at surgery. Findings associated with surgical complications--such as abscess, biloma, and hematoma--included large or high-attenuation perihepatic and subphrenic fluid collections that did not conform to the resection margin.