Faculty Bibliography

In patients with suspected severe acute pancreatitis and known or suspected cholelithiasis, it may be extremely difficult to exclude the diagnosis of gangrenous cholecystitis or obstructive cholangitis by nonoperative means. Since early intra-abdominal surgery has, in our experience, led to markedly increased morbidity in patients with gallstone pancreatitis, non-operative visualization of the biliary tree by percutaneous transhepatic Chiba-needle cholangiography (PTCNC) has been evaluated in 14 patients with suspected acute pancreatitis in whom life-threatening acute biliary disease could not be excluded by other nonoperative means. The final diagnosis was acute pancreatitis in nine patients (Group A) (mean serum amylase 3242 SU%) and acute biliary disease with hyperamylasemia in five patients (Group B) (mean serum amylase 2084 SU%). PTCNC made visualization of the biliary system possible in all patients and excluded the diagnosis of cystic duct or common duct obstruction in each case. Following PTCNC, potentially hazardous early laparotomy was avoided in eight of nine Group A patients. Biliary surgery was undertaken on day 3 to 13 in four Group B patients. When early laparotomy may be needed to evaluate or treat possible life-threatening acute biliary disease but is considered undesirable because of possible acute pancreatitis. PTCNC appears to be a safe and effective nonoperative method of obtaining precise anatomical delineation of the biliary tree

Four cases of nonfunctioning adrenal adenomas associated with renal cell carcinoma are reported. The adenomas were found incidentally during angiographic examination of the renal carcinoma, and originally were thought to be metastases to the adrenal gland. Reports in the pathologic literature indicate an increased incidence of adrenal adenomas in patients with renal cell carcinoma. Adrenal adenomas occur in 12%-15% of patients with renal cell carcinoma as compared to 2%-3% of the general population. Since a vascular metastasis to the adrenal gland and an adrenal adenoma may appear identical angiographically, awareness of this association is important to avoid overdiagnosis of metastatic disease

Renal emphysema is most often due to emphysematous pyelonephritis in diabetics. The emphysema is the result of infection by gas-forming organisms. Intrarenal gas can also be seen under noninfective conditions. The report is a case of renal emphysema following traumatic renal infarction

Inferior vena cavography plays an important role in the staging of renal cell carcinoma. The renal angiograms and inferior vena cavograms in a series of patients with renal cell carcinoma were reviewed to determine which patients require cavography. Our findings show that renal angiography is of great value in suggesting tumor involvement of the renal vein or vena cava, and that the decision to do cavography can be made from the angiographic findings. In the series of 172 patients with renal carcinoma, 15 or 9% had inferior vena cava involvement

Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a 'second look' operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel

Of all aortic dissections, 10% are chronic. Typically they arise distal to the left subclavian artery and have reentry points into the true lumen. Pain may be minimal or absent and patients often present with cardiac failure. Chronic dissections are more likely to appear radiographically as atherosclerotic aneurysms on a chest film than are acute dissections. Four cases of chronic dissections found incidentally during angiography are presented