Percutaneous gastrostomy in patients with extensive ascites

ABSTRACTS The aim of this study was to develop a scoring system applicable to the 28 day chest radiograph in low birth weight infants. Thus it should have good inter-observer agreement and be able to identify infants with chronic lung disease. A pilot study involving three Radiologists independently reviewing and scoring 50 films on a single blind basis demonstrated very good inter-observer agreement (no significant difference on paired test). All films were from infants treated in the Neonatal Intensive Care Unit at King's College Hospital in 1987 who had a chest film taken at 28-34 days of age. The scoring system has been applied to a series of 50 chest radiographs on infants treated at King's College Hospital in 1988. There was a significant difference in the scores obtained from those infants with chronic lung disease and those without. The results will be discussed with reference to the potential of the scoring system to identify chronic lung disease and predict oxygen dependency.

THE SOCIAL AND CLINICAL DILEMMA OF PELVIABDOMINAL MASSES IN UNMARRIED SUDANESE FEMALES M. E. ABDEL BAGI

King Fahd Military Medical Complex, Dhahran, Saudi Arabia The Sudan is a male dominated multiracial multicultural society. The majority are Moslems and there are large numbers of practising Christians. Sudanese pagans have strict noble beliefs and behavioural disciplines. Chastity of the unmarried female is much valued by all factions. There is, however, a recent impact of civil war, famine and modernization waves on morality. Twenty-eight unmarried females aged between 11 and 37 years were found to have pelvi-abdominal masses by ultrasound examination in Khartoum between January 1984 and December 1986. Twenty of those had palpable pelvi-abdominal masses while eight were normal illegitimate pregnancies discovered during the ultrasound examination. All cases were accompanied by worried guardians who insisted on knowing the ultrasound result. The objectives of this study is to present and discuss the social and clinical dilemma when pelvi-abdominal masses develop in single Sudanese females and the stress on the medical team handling these cases.

ASSESSMENT OF CARCINOMA OF THE CERVIX: COMPARISON BETWEEN EUA, TRU AND MRI J. M. H A W N A U R , R. J. JOHNSON, B. CARRINGTON, J. P. R. JENKINS, R. D. H U N T E R and I. ISHERWOOD

University of Manchester, Manchester Prognosis in carcinoma of the cervix is influenced mainly by stage and volume of turnout at presentation. The accuracy of MRI staging is wellestablished and recent reports have implied that transrcctal ultrasound (TRU) may be of similar value. The aim of this study was to correlate the results of tumour staging and volume assessment by examination under anaesthesia (EUA), T R U and magnetic resonance imaging (MRI) in patients with carcinoma of the cervix treated by radiotherapy. Thirty-nine women with primary squamous cell or adenocarcinoma of the cervix have been studied. MRI was performed on a 0.26T superconducting system using T 1- and T2-weighted spin echo sequences (TR 820-2000: TE 26-120) in various planes. EUA, and T R U with a 4 MHz probe, were performed independently by experienced personnel. The extent and size of cervical tumour was recorded prospectively for each modality on a computerized proforma. There was concordance between EUA, T R U and MRI tumour stage in fewer than one third of patients. T R U assessment was at variance with the other modalities more frequently than either MRI or EUA. .Turnour volume measurement by MRI and T R U agreed to within 10% In only eight patients and overall correlation for the two techniques was relatively poor (r=0.59). Problems encountered with T R U included difficulty determining craniocaudal extent and lateral extension to the pelvic sidewall. Enlarged pelvic or para-aortic lymph nodes reported by MRI were not demonstrated by either E U A or TRU. Overall T R U was found to be o f limited value in staging carcinoma of the cervix and in Providing a reliable estimation of tumour volume.

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UTERINE LEIOMYOMAS: THE ROLE OF MRI IN INFORMING MANAGEMENT DECISIONS R. W. K E R S L A K E and B. S. W O R T H I N G T O N

University Hospital, Nottingham Thirty-five women with pathologically proven single or multiple uterine leiomyomas, ranging in size from less than 1 cm up to a conglomerate mass of 23 cm, have been studied by M R I employing a variety o f pulse sequences. The clearly defined uterine zonal anatomy on T2 weighted sequences allows separation of extrinsic from intrinsic pathology and localization of leiomyomas to a submucosal, subserosal or most commonly, an intramural location where they appear as well defined rounded masses of low signal intensity. This is important for surgical planning when myomectomy is contemplated in treatment of secondary infertility or menorrhagia. Degeneration was only seen in leiomyomas greater than 2 cm and the predominant pattern seen in all types was irregular areas of high signal intensity within the mass on T2 weighted sequences. Clear depiction of incidental leiomyomas avoided incorrect assessment of the primary pathology in 11 patients. We conclude that there is a distinctive pattern of M R features which allows the diagnosis and precise localization of leiomyomas to be made as well as indicating the presence and extent o f degeneration.

DEFINING INDICATIONS F O R C O M P U T E D T O M O G R A P H Y IN CARCINOMA OF THE OVARY R. K. WINTER, J. P. G A R R E T T and S. J. G O L D I N G

Churchill Hospital, Oxford This study was carried out to determine the role of computed tomography (CT) in the management of carcinoma of the ovary in the setting of a general oncology service in which CT was carried out only when the clinician could demonstrate that it would be immediately relevant to management. In other circumstances requests were declined or diverted to other appropriate techniques. One-hundred and seventeen patients underwent 186 examinations between July 1982 and December 1987. In all cases the liver, abdomen and pelvis were examined. The clinical records were reviewed to determine the indications which had been accepted on these criteria, and the relationship to clinical management. The results showed a significantly different referral pattern from the conventional view of the use of CT in malignant disease. There were very few diagnostic or staging studies, usually because this information had been provided by ultrasound and laparotomy. Only 30% of the patients referred to this centre with this disease were examined. The most common uses were to provide baseline readings for treatment (27.5%), to monitor treatment (27%), prior to second-look laparotomy (21%), and to confirm a clinical suspicion of recurrent disease (18 %). The study confirms the view of others that CT cannot replace second-look laparotomy, although a significant number of patients may avoid surgery if CT is used first. These findings are relevant to the practice of CT in general hospitals where in the treatment of carcinoma o f the ovary it is desirable to limit investigations.

PERCUTANEOUS GASTROSTOMY IN PATIENTS WITH EXTENSIVE ASCITES M. J. LEE, S. SAINI, M. C. MORRISON, J. A. BRINK, P. F. H A H N and P. R. M U E L L E R

Massachusetts General Hospital Boston, USA Early reports considered ascites a contraindication to percutaneous gastrostomy (PG) because o f possible pericatheter leakage of ascites with the attendant risk of infection, and catheter dislodgement into the peritoneal cavity due to progressive ascites displacing the stomach away from the abdominal wall. In a retrospective review of 120 patients who had PG performed, we found 12 patients who had extensive ascites. PG with gastropexy (T-tack method) (Brown et al. 1986) was performed in these patients for relief of malignant small bowel obstruction. Abdominal paracentesis was performed prior to PG in nine patients and after PG in one patient. Amounts of fluid removed varied between 0.5 and 7 litres. Gastrostomy catheters were inserted without complication in all patients. Clinical follow up revealed that pericatheter leakage o f ascitic fluid and skin excoriation occurred only in the three patients who did not have paracentesis performed prior to PG. No dislodgement of gastrostomy catheters occurred but mild peritonitis was noted in one patient. Our experience suggests that PG with abdominal paracentesis and

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ABSTRACTS

gastropexy prevents pericatheter leaks of ascitic fluid and catheter dislodgement in patients with extensive ascites undergoing radiologic PG. Brown, AS, Mueller, P R & Ferrucci, JT (1986) Controlled percutaneous gastrostomy: Nylon T-fastener for fixation of the anterior gastric wall. Radiology, 158, 543 545 BILIARY E N D O P R O S T H E S I S OCCLUSION: PRESENTATION AND MANAGEMENT M. J. LEE, P. R. M U E L L E R , S. SAINI, M. C. MORRISON, J. A. B R I N K and P. F. H A H N

Massachusetts General Hospital, Boston, USA A retrospective review of 20 cases of endoprosthesis occlusion in 17 patients with malignant biliary strictures was performed, detailing the clinical presentation and radiological management of these stent occlusions. The average length of stent patency prior to occlusion was 3.7 months. Clinical manifestations included, 6ne or a combination of cholangitis (17 patients), jaundice (9) and leakage of bile or purulent material from the percutaneous insertion site (6). Ultrasound or CT of the liver demonstrated dilated biliary ducts in 6 of 10 episodes of occlusion. Eighteen of 20 episodes of endoprosthesis occlusion were successfully treated. No therapy was attempted in two episodes of stent occlusion due to widespread metastatic disease at the time of presentation. All 17 patients received intravenous fluid replacement therapy and intravenous broad spectrum antibiotics. This was sufficient therapy to relieve symptoms in two cases of occlusion. Occluded stents were removed in the remaining 16, by radiologic (10) or endoscopic (6) methods. New endoprostheses were inserted percutaneously in 10 cases of occlusion, long term internal-external catheters in five and a surgical bypass operation in one. We conclude that endoprosthesis occlusion should not be considered as a terminal event in patients with malignant biliary disease, as the occluded endoprosthesis can readily be removed and a fresh stent inserted. Techniques and methods of removal will be presented.

C O M P L I C A T I O N S ATTRIBUTABLE TO FORMATION OF THE TRACK IN PATIENTS UNDERGOING P E R C U T A N E O U S NEPHROLITHOTOMY J. E. PAGE and W. J. W A L K E R

• Royal Surrey County Hospital, Guildford Serious complications associated with percutaneous nephrolithotomy have been reported in as few as 3% of procedures in some specialist centres (track complications as low as 1%). In general, complication rates are much higher than these results suggest. A survey of 62 institutions (Lang, 1987) revealed a serious complication rate of 15 % in the learning period, falling to 1.5 % with increasing experience. Trauma during track dilatation was the commonest cause of complications and most were related to poor technique. In our series of 110 procedures performed by an experienced radiologist, major complications occurred in 3.6% with only one complication directly attributable to formation of the track (0.9%). The procedure was abandoned due to failure to gain access in two patients (1.8%). Radiation dose to the hands was monitored and results confirm that with meticulous attention to technique, dosages may be kept very low. We conclude that prior training in interventional techniques is a major factor in reducing both the morbidity associated with percutaneous nephrolithotomy and the radiation dose to the operator.

PERCUTANEOUS CYSTOGASTROSTOMY IN THE TREATMENT OF PANCREATIC PSEUDOCYSTS J. I. S. REES and D. LL. C O C H L I N

Cardiff Royal Infirmary, Cardiff Pancreatic pseudocysts are becoming increasingly common, and have been shown sonographically to domplicate up to 50% of cases of acute pancreatitis. Even though 15-40% of these are reported to resolve spontaneously (mainly those cysts measuring less than 4 cm in diameter), some form o f interventional treatment is required in the remainder, particularly if the cyst enlarges or the patient's condition deteriorates, and also to reduce the risk of complications such as secondary infection, severe haemorrhage or rupture. The optimal surgical methods of treatment involve either internal

drainage via the stomach, duodenum or jejunum, or less frequently external drainage. More recently percutaneous methods have been advocated as the initial treatment of choice, and although high recurrence rates of up to 78% have been reported after simple needle aspiration, prolonged external drainage via indwelling catheters have been more successful. The latest approach involves percutaneous cystogastrostomy, with the insertion of a double pigtail stent under combined endoscopic and ultrasound guidance. We have reviewed 11 patients where this method of percutaneous cystogastrostomy was performed. Initially all patients had repeated simple needle aspiration, but the cysts rapidly reaccumulated. In nine cases, the technique was successful, and with complete cyst drainage on follow-up sonography, although one required a second stent due to suspected occlusion of the initial stent. The technique failed in one patient due to the unfavourable anatomic situation of the cyst with respect to the stomach, and one patient with a satisfactory stent position had a persisting cyst, despite initial reduction, which required surgery. The stents were removed endoscopically, in most cases 6 weeks following insertion, but in one patient the stent has remained in situ for 2 years without complication. We conclude that if repeated, needle aspiration is unsuccessful, percutaneous cystogastrostomy is a safe and simple method of treatment of pancreatic pseudocyst, provided the anatomic situation is suitable.

ULTRASOUND FEATURES OF E X P E R I M E N T A L INTERSTITIAL LASER H Y P E R T H E R M I A A. C. STEGER, A. MASTERS, K. WALMSLEY, P. SHORVON, R. CHISHOLM, S. G. BOWN and W. R. LEES

University College and Middlesex Hospital, London Interstitial laser hyperthermia (ILH) is a precise method of producing thermal necrosis that may be of use in the treatment of liver tumours. Ultrasound has been used to study the changes in canine liver heated by ILH. The Nd-YAG laser delivered 1.5 W for 670 s. The laser fibre was inserted into liver at laparotomy. An intraoperative ultrasound probe was used. After 30 s a white hyperechoic star (5 6 mm diameter), appeared around the fibre tip, with a darker hypoechoic ring (3 mm diameter) outside this. The central star did not change but the outer hypoechoic ring reached 5 mm in diameter by 400 s (total diameter 13 15 mm). Echogenic foci suggestive of gas bubbles were seen. There was a clear transition between the hypoechoic region and normal liver. With four fibres the changes at each fibre tip were as above. Overlap of the four hypoechoic regions occurred by 670 s. The dimensions of thermal necrosis measured on sonography (3.3 x 2.5 cm) were close to the actual measurements (3.5 x 2.7 cm). Ultrasound appearances corresponded to pathological evidence of necrosis and temperature measurements (55-65°C). Follow up scans showed resolution and a return to normal echogenicity by 6-9 months. The creation of areas of thermal necrosis by ILH can be accurately monitored with ultrasound and then followed in healing. This combination of techniques may be of use in the treatment of hepatic turnouts.

RADIOLOGICAL CHANGES FOLLOWING INTERSTITIAL LASER H Y P E R T H E R M I A F O R SOLID ORGAN CANCERS K. WALMSLEY, A. MASTERS, A. C. STEGER, S. G. BOWN and W. R. LEES

University College and Middlesex Hospital, London Interstitial laser hyperthermia (ILH) is a precise and safe technique of inducing tissue necrosis in experimental models that can be monitored with ultrasound. Nine patients, with four or less hepatic metastases (25 treatments in total) and three patients with inoperable pancreatic cancers (five treatments in all) were treated by ILH. N o tumour exceeded a diameter of 7.0 cm. After sedation and intravenous antibiotics, one to four 0.8 mm hollow needles each bearing a thifl (0.2 ram) laser fibre were inserted into the tumour under ultrasound control. Each fibre emitted a power of 1.5-2.0 W from a Nd: YAG laser for 500 s or until an homogeneous hyperechoic appearance between fibre tips was seen. 1.5 cm separation was maintained between the fibre tips during treatment. Ultrasound monitoring showed that the treated lesion which was initially of mixed echogenicity was converted to one of hyperechogenicity. There were no procedure related complications. All patients left hospital within 48 h of admission. In the liver contrast CT studies 2 months after treatment showed areas