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Three surface methods for measuring lumbar sagittal motion (LSM) were tested for validity using radiographs as the "gold standard" reference. The three methods used were the Pleurimeter V double inclinometer, the carpenter double inclinometer, and the computerized sensor single inclinometer. In this study, 30 volunteers were examined independently by three occupational health professionals. Each volunteer rotated twice through three stations at which LSM was measured by each of the three methods. Radiographs were made during the first rotation. Predictability of the skin marks of T12 and S1 for the corresponding bone measures was acceptable for one examiner, mixed for another, and unacceptable for a third. The intraclass correlation coefficients (ICCs) ranged from 0.81 to 0.99, with half above the acceptable level of 0.90. However, the skin marks and the bone measures showed a linear relationship for all examiners (r > or = 0.89). For flexion and extension, all ICCs between the radiograph and each surface method were far below 0.90, indicating poor validity for each surface method. We concluded that skin placement of T12 and S1 has a linear relationship to bony landmarks, and that each of the tested surface methods does not validly measure LSM.

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Three surface methods for measuring lumbar sagittal motion (LSM) were tested for reliability. The three methods used were the Pleurimeter V double inclinometer, the carpenter double inclinometer, and the computerized single sensor inclinometer. In this study, 30 volunteers were examined independently by three occupational health professionals. Each volunteer rotated twice through three stations at which LSM was measured by each of the three methods. The intra- and interexaminer reliabilities in identifying the skin levels of T12 and S1 were acceptable, having intraclass correlation coefficients (ICC) greater than or equal to 0.75. With a single exception, all ICC values for the intraexaminer reliability of LSM measurements fell below 0.90 (a clinically desirable level). The interexaminer reliability was poor, with all ICC values below 0.75. The largest source of measurement error was attributable to the examiner and its associated factors. We concluded that the intra- and interexaminer reliabilities varied greatly, limiting the clinical usefulness of the three surface methods.

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Thirteen intrahepatic and 22 extrahepatic biliary tract complications were detected radiologically in 35 adult patients who had undergone cholecystectomy and bile duct exploration. Intraoperative usage of Fogarty balloon catheters to extract biliary calculi without fluoroscopic guidance resulted in focal ectasia or rupture of intrahepatic radicles in two and seven cases, respectively. Metallic surgical instruments such as Bakes dilators and biliary forceps or clamps accounted for most of the common duct injuries; these were manifested as submucosal dissection (two cases), transmural laceration (four cases), or localized trauma with subsequent stricture (three cases). Technical mishaps during T-tube placement led to common duct perforation (four cases) and extraluminal malposition of T tubes (three cases). The remaining complications included choledochoduodenal fistula (three cases), biliovenous fistula (two cases), biloma (three cases), and retained intraductal fragments of biliary drainage catheters (two cases). Knowledge about radiologic features and causal factors of such iatrogenic processes can play a crucial role in their prevention, correct diagnosis, and management.

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PURPOSE: The purpose of this investigation was to test the feasibility of using a recently developed technique of placing internalized biliary stents into patients who have had reobstruction after initial surgical bypass. PATIENTS AND METHODS: Seven men and three women, 46 to 85 years of age (eight with pancreatic carcinoma, one with metastatic colon, and one with metastatic ovarian carcinoma), all had reobstruction after initial surgical bypass palliation. Subsequent attempts to place stents via endoscope failed in five patients; a pair of 7-Fr stents placed in one patient failed to drain well. Endoscopic stenting in four patients was not even attempted because of severely distorted anatomy. Nine of the 10 patients then had successful internal stent placement by a combined percutaneous-transhepatic and peroral-endoscopically guided technique. RESULTS: One of these nine placeable stents failed to drain well and the patient died 8 days later with massive tumor. Seven showed a significant decrease in bilirubin levels and improved quality of life. Two of these had sepsis that responded to antibiotics. Life span ranged between 11 days and 10 months, with one patient still alive; no deaths were directly due to stents. CONCLUSION: A combined transhepatic-peroral technique of placing internalized biliary stents can be expected to result in repalliation in a majority of patients with reobstruction after earlier surgical bypass and in whom subsequent attempts at endoscopic placement of stents have failed or in whom tumor growth prevents undertaking the endoscopic approach.

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A new device and a geometric algorithm facilitate consistent insertion of a needle tip into nonpalpable breast lesions on a single attempt. With the breast compressed by dual grid plates, two oblique exposures are taken. Three intersecting planes through the lesion referenced to the grid markings permit easy determination of the lesion coordinates. In initial trials for preoperative breast lesion localization in 11 patients, the needle tip was within the lesion in nine patients and was within 0.5 cm of the lesion in two patients. The results indicate that this system is very useful for accurate localization and needle aspiration of breast lesions.

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The placement of large-bore endoprostheses for relief of biliary obstruction by the percutaneous-transhepatic route is painful, requires a large hepatic parenchymal tract, and has a fairly high complication rate. The alternative technique of endoscopically placing similar-sized stents requires special instruments and skills, and may fail in passing very tight stenoses. We report a simpler combined percutaneous-endoscopic biliary stent (PEBS) placement technique with a high placement rate used in 11 patients with advanced malignant obstruction. In all 11 patients, 10 and 11.5 French stents were easily placed. Three patients developed sepsis but responded to antibiotics. One clogged stent required replacement. Two stents needed later endoscopic adjustment. Results of liver function test improved in 10 patients, and 8 patients showed improved quality of life.

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A case of significant hemorrhage into an ileal wall periappendiceal abscess in a 62-year-old man is described. Pathologic correlation of an unusual collection of contrast seen at the distal end of a branch of the ileocolic artery during angiography is discussed and illustrated.

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Visceral arteriography was performed in 35 adult patients who had undergone various types of gastric surgery. Nineteen of these patients had presented with gastrointestinal hemorrhage at different postoperative intervals (4 days-23 years). Arteriography showed the bleeding site in 14 (74%) and permitted its nonoperative control in 8 cases. Diffuse hemorrhage from the gastric pouch as well as localized bleeding from suture line, marginal or stress ulcers, and other sources were recognized. Arteriography was also crucial in the diagnosis of iatrogenic arteriovenous fistulas, telangiectasia in the anastomotic regions, inadvertently ligated arteries, and postoperative changes in the vascular architecture. Value and limitations of arteriography of the postsurgical stomach are presented together with a review of the pertinent literature.

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The first CT description of accessory hemiazygos continuation of a left-sided inferior vena cava is presented. This venous anomaly appears as a mediastinal mass on plain chest films and may simulate an aortic dissection on CT or angiography. Careful attention to the various abnormal vascular pathways will obviate the need for further invasive testing.

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A case of cavernous hemangioma of the liver resembling a metastatic deposit is reported in a patient with renal cell carcinoma. The clinical and angiographic features that distinguish hepatic hemangiomas from metastatic renal cell carcinoma are discussed. The importance of this distinction in patient management is emphasized.

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This report summarizes the course of a patient with asymptomatic chronic pancreatitis associated with hemorrhage into the pancreatic duct and metastatic fat necrosis. Retrograde cannulation of the pancreatic duct and superior mesenteric arteriography established the presence of a pseudocyst with a pancreatic duct-arteriovenous (DAV) fistula as the cause of the syndrome. Ligation of feeder vessels with external drainage of the cyst as the initial surgical procedure stopped the bleeding but failed to prevent recurrence of the pancreatic duct-venous fistula. A pancreaticoduodenectomy with resection of the cyst and fistula was required to arrest destruction of distant tissues. Although serum and urine amylase concentrations were markedly elevated, serum lipase levels were normal throughout the patient's course. Elevation of serum lipase does not seem to be a necessary condition for the development of the metastatic fat necrosis syndrome.

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Nonoperative extraction of retained common duct stones was successful in 17 patients during the past two years. Eleven required only one manipulation; the largest number of manipulations required was five. The Burhenne catheter and Dormia basket were employed frequently, but were not always effective. When difficulties occurred with their use, Mazzariello biliary forceps resulted in successful stone extraction, particularly in the management of impacted stones. Extraction procedures were performed under fluoroscopic control, usually on an outpatient basis. Recently, we have employed a flexible fiberoptic endoscope that allows visual investigation of suspected defects and decreases fluoroscopic exposure. These results indicate that all patients with retained common duct stones are candidates for sinus tract manipulation six weeks after common duct exploration. It is recommended that secondary operations for retained common duct calculi not be performed until nonoperative extraction has been given an appropriate trial.

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