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HYPOTHESIS: Portoenterostomy may be an effective treatment for patients sustaining a thermal injury to the hepatic duct confluence during laparoscopic cholecystectomy. DESIGN: Case series. SETTING: A tertiary care referral hospital. PATIENTS: A consecutive series of 5 female patients referred and treated between November 13, 1991, and December 17, 1998. Ages ranged from 29 to 65 years. In addition to the ductal injuries at or above the hepatic duct confluence, 3 patients also had a major hepatic vascular injury. The patients were available for follow-up for 7 to 91 months postoperatively. INTERVENTIONS: All patients underwent a portoenterostomy (Kasai procedure) with suturing of a Roux limb to the hepatic tissue surrounding the transected hepatic ducts. Transhepatic stents were inserted either preoperatively or postoperatively for rising liver enzyme levels in 4 patients. MAIN OUTCOME MEASURES: Symptoms and results of liver function tests. RESULTS: Stents remained in place for 9 to 25 months in 4 patients. All 5 patients were symptom free and functioning normally; 3 had normal liver functions; 2 had mildly elevated alkaline phosphatase levels only. CONCLUSION: Portoenterostomy, usually in combination with postoperative stenting, may be an option to consider in life-threatening injuries involving the hepatic duct bifurcation in which standard biliary reconstruction techniques are not feasible.

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An aorto-right ventricular fistula secondary to nonpenetrating trauma is described. Review of the literature is reported. Ascending aortic injuries present as either traumatic pseudoaneurysms or, less commonly, as aortocardiac fistulas. Blunt cardiac injury is a frequent concomitant injury and contributes to the high mortality of this lesion. Prompt surgical intervention is required for survival.

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Renal computed tomography (CT), 3-dimensional CT angiography (3D-CTA), and simultaneous measurement of glomerular filtration rate (GFR) by x-ray fluorescence determination of plasma contrast clearance (PCC) are alternatives to intravenous urography (IVU), renal arteriography (RA), and 24-hr urine creatinine clearance (CrCl) for evaluation of renal structure and function in living renal donor (LRD) candidates. To determine if CT, 3D-CTA, and PCC provide data comparable to IVU, RA, and CrCl, both methods were used to evaluate 23 LRD candidates. Costs were also compared. Conventional RA identified 19 accessory arteries and one case of medial fibroplasia. Each of these anomalous vessels was recognized on 3D-CTA. Venous anatomy was more clearly delineated on 3D-CTA than the venous phase of conventional RA. CT demonstrated 3 benign cysts and a single, small intraparenchymal calcification in 3 renal units. GFRs measured by PCC and CrCl were 91 +/- 4 and 132 +/- 7 ml/min/1.73m2, respectively (r = 0.64, P < 0.05). Total cost for CT/3D-CTA/PCC was 46% less than that of IVU/RA/CrCl and 40% less than RA/CrCl. CT/3D-CTA/PCC provided reliable structural and functional data at substantially less cost, discomfort, and inconvenience to the living renal donor candidate. As such, CT/3D-CTA/PCC is superior to conventional methods for evaluation of the living renal donor candidate.

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Klatskin tumors often pose a challenge for diagnosis and treatment. Most of these neoplasms are diagnosed clinically because of the difficulty in obtaining tissue that will provide histologic proof of the disease. When a non-operative course is sought, exhaustive attempts should be made to obtain a tissue diagnosis because of the potential for a false-positive clinical diagnosis. We describe a new way to obtain tissue for diagnosis by placing a laparoscopic choledochoscope through a percutaneous transhepatic cholangiogram track, thus allowing the tumor to be directly visualized and biopsied.

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UNLABELLED: Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion [1] and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. CONCLUSION: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.

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A case of a large, lytic, tophaceous defect in the upper end of the tibia has been reported in a 44-year-old man as a solitary lesion. The term "gouty tophus" should not be confused with the geode or subchondral bone cyst.

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Twelve iatrogenic femoral arteriovenous fistulas are reported, 11 of which arose from the superficial or deep femoral arteries. All but two occurred in association with cardiac angiographic procedures. It appears that the femoral crease was used as a landmark to establish the cutaneous entry point for vascular puncture and resulted in an excessively distal puncture site. The femoral crease is an unreliable landmark in many patients. This complication may be minimized by using physical examination to identify the level of the inguinal ligament or fluoroscopy to localize the distal half of the femoral head.

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Aneurysms of the thoracic aorta are most often the result of arteriosclerotic disease. Other causes include degeneration of the medial layer of the aortic wall, either idiopathically or due to genetic disorders such as Marfan syndrome; aortic dissection; trauma; syphilis and other bacterial infection; noninfective aortitis; and congenital anomaly. We review normal anatomy of the aorta and discuss our technique and interpretation of computed tomography (CT) in the evaluation of the thoracic aorta. We illustrate the CT appearance of different types of aortic aneurysms as well as discuss the use of CT for assessing complications of aneurysms, for postoperative follow-up, and in the differentiation of aortic aneurysm from a paraaortic mass.

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Since systemic reactions to contrast media (CM) in patients often resemble pathophysiologic conditions associated with prostaglandin metabolites prostacyclin (PGI2), and thromboxane B2 (TXB2), plasma levels of these mediators are likely to provide an index of CM pathogenesis. In this study, patients undergoing peripheral arteriography were injected either with a hyperosmolal CM sodium diatrizoate or with a newer low osmolal CM, iohexol. Arterial blood samples were collected before and after the procedure. Prostacyclin and thromboxane were quantified as 6 ketoprostaglandin F1a (PGF1a) and TXB2 by using radioimmunoassay kits. Diatrizoate caused prostaglandin I2 (PGI2) release in 60% of patients, whereas 66% receiving iohexol also exhibited increased levels of PGI2 in their plasma. TXB2 concentration remained unchanged. No clinically adverse reactions were seen following the procedure. These results indicate that both high and low osmolality CM are capable of stimulating vascular endothelium, thereby causing prostacyclin release. Molecular mechanisms, however, remain to be determined.

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Three patients with idiopathic aneurysms of the superior vena cava, left innominate vein, and inferior vena cava are presented. The advantages of CT over other diagnostic modalities are discussed.

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A case of anomalous inferior vena cava with azygos continuation first diagnosed by computed tomography (CT) and later confirmed by venography is presented. In addition to identifying the dilated azygos vein in the chest, CT can determine the direction of flow in the vein by means of a bolus contrast medium injection. Once this is established, a search for the etiology of the dilated vein can be directed to the appropriate anatomic area.

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A patient with esophageal carcinoma presenting with hematuria is described. Initial studies confirmed the presence of a renal mass that was thought to be a primary renal neoplasm. Further studies to evaluate anemia before a renal operation led to the discovery of an unsuspected esophageal carcinoma. Although metastases to the kidneys are relatively common it is uncommon for these lesions to be clinically apparent or responsible for producing initial symptomatology. Only after discovery of the esophageal lesion was the possibility of a secondary renal neoplasm considered. Intractable hematuria was treated successfully by embolizing the renal artery of the bleeding kidney with gelatin sponge fragments.

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