803
TECHNICAL NOTES
Vol. 133
The radioisotope in the mold was distributed according to the Manchester System (1). The diameter d of the radioactive ring was 2.54 cm, and the treatment distance h was 1 cm, giving a dl h ratio of 2.54, close to the dl h ratio of 2.83 which gives an ideal distribution (1). Computer dosimetry showed no variations in dose distribution greater than 10% in the plane midway between the two rings over an area 2.54 cm in diameter. The patient received 4,200 rad (42 Gy) from the mold plus an additional 2,000 rad (20 Gy) by two laterally opposed 7 X 9-cm 2 ports using 25 MV x rays. Follow-up of this patient one month after treatment showed complete regression of the tumor which has not regrown over the ensuing six months. The patient has
Technical Notes
normal amounts of saliva and none of the sequelae seen with external irradiation. REFERENCE 1. Meredith WJ (ed): Radium Dosage, the Manchester System. Edinburgh, Livingston, 1967, pp 6-22 1 From the Division of Radiation Oncology, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St. Louis, MO (D.J.K., J.E.M.), and the Department of Therapeutic Radiology,University of Minnesota Hospital, Minneapolis, MN (S.C.S.). Received Jan. 16, 1979 and accepted May 8. (Reprint request to D. J. K., Division of Radiation Oncology, Mallinckrodt Institute of Radiology, St. Louis, MO 63110.) jr
Positioning Device for Cardiac Series 1 Manuel Viamonte, Jr., M.D. The author describes a new positioning device for use during radiography of the chest. This device is particularly helpful when doing a cardiac series. INDEX TERMS:
Radiography, instrumentation. Thorax, radiography
Radiology 133:803, December 1979
I wish to describe a new device for use in radiography of the chest, particularly cardiac series. While a variety of devices are available for support of the arms during chest radiography, this one has the advantage of being readily adjustable both for height and for the angle controlling the obliquity of the patient. The device is slowly moved upward until the arms are fully extended and vertical, at which point the vertical rod is locked into position with four wing nuts. The patient grasps the free end of the Lshaped rod which is supported by the vertical arm (Fig. 1). I take a left anterior oblique view at 45 0 without barium and a right anterior oblique view at 60 0 with barium.
1 From the Department of Radiology, Mount Sinai Medical Center, Miami Beach, Fla. 33140. Received Feb. 6,1979; accepted and revision requested June 20; revision received July 2. sjh
Nonoperative Retrieval of Impacted Intrahepatic Biliary Stones Using the Fogarty Balloon Catheter 1 Stephen L. Kaufman, M.D., Donald P. Harrington, M.D., Klemens H. Barth, M.D., Robert I. White, Jr., M.D., and John L. Cameron, M.D. Nonoperative removal of impacted intrahepatic stones was achieved in 2 patients using a Fogarty balloon catheter. The stones could not be dislodged with a basket. Fluoroscopic monitoring during the procedure reduces the risk of injury to the liver. INDEX TERMS: Bile ducts, calculi (Liver, biliary system, stone extraction, 7 [6] .1228) • Catheters and catheterization Radiology 133:803-805. December 1979
Fig. 1.
Position of the patient for a 45 0 left anterior oblique view of the chest.
Burhenne's technique for nonoperative extraction of stones from the bile ducts using a steerable catheter and basket has greatly reduced the need for reoperation for stone removal following cholecystectomy and resulted in a success rate of 95 % (1-3). We recently encountered 2 patients with stones impacted within the intrahepatic bile ducts which could not be dislodged or snared with the basket. Removal was possible with a Fogarty arterial balloon catheter- preceding use of the stone basket.
CASE REPORTS CASE I: A 51-year-old man underwent a cholecystectomy and common bile duct exploration at another institution. Multiple stones had been removed during the procedure; however, a follow-up T-tube cholangiogram revealed two stones within the left hepatic duct (Fig. 1). Six weeks after surgery the patient was referred for nonoperative
804
TECHNICAL NOTES
December 1979
distal to the stone. Under fluoroscopic monitoring, the balloon was inflated with contrast material to a diameter equal to that of the duct. The balloon catheter was then withdrawn, dislodging the calculus into the common hepatic duct, from which it was extracted using the basket catheter. Follow-up cholangiography demonstrated that the biliary system was free of stones.
Fig. I.
CASE I. Postoperative T-tube cholangiogram shows two stones (arrows) within the left hepatic duct.
extraction of the residual stones. The T-tube was removed and a steerable catheterSinserted through the T-tube tract into the left hepatic duct. The larger, more proximal stone was retrieved with a basket. 3 Numerous attempts to snare the distal stone with the basket were unsuccessful, nor could it be dislodged. A straight drainage tube was placed within the biliary system, and a repeat cholangiogram the next day revealed that the position of the stone was unchanged. Two days later, removal was again attempted. At this time a 4 French Fogarty catheter was inserted through the steerable catheter and positioned
CASE II: A 36-year-old woman underwent a cholecystectomy at another hospital in 1972. A choledochojejunostomy was performed because of a "common bile duct malformation." Due to recurrent episodes of cholangitis and obstructive jaundice, the patient was admitted to this institution in 1977. Many stones were removed from the biliary tree surgically and a Silastic transhepatic stent was placed through the choledochojejunostomy into the right hepatic duct and brought out through the anterior liver capsule and abdominal wall (4). Follow-up cholangiography through the stent revealed multiple stones impacted within several branches of the right hepatic duct (Fig. 2, a). Following an unsuccessful attempt to remove the stones through the stent tube tract, the stent was converted into a transhepatic U-tube for easier accessibility into the intrahepatic ducts (5). A subsequent attempt at percutaneous retrieval of the stones through the new lower end of the U-tube tract using a basket catheter was only partially successful due to apparent impaction of multiple stones within the largest of the obstructed branches (Fig. 2, b). The U-tube was replaced, and two days later removal was again tried. Following introduction of the steerable catheter into the obstructed branch, a 4 French Fogarty catheter was placed within the branch distal to the stones. Under fluoroscopic monitoring, the balloon was inflated with contrast material to approximately the diameter of the duct. The balloon catheter was withdrawn from the duct, dislodging most of the stones into the right hepatic duct and subsequently through the choledochojejunostomy into the bowel. Several passes were required to extract all of the stones. A stone which had become lodged within the left hepatic duct during the initial procedure was also removed in this manner. Follow-up cholangiography revealed no residual stones.
DISCUSSION
Nonoperative removal of retained biliary stones can be achieved in approximately 95 % of cases with low morbidity
2a,b
Fig. 2. CASE II. a. Cholangiogram through the stent tube shows stones within several branches of the right hepatic duct (arrows). b. Following stone retrieval with the basket, multiple stones remain impacted within the largest right hepatic duct (large arrow). A stone has been dislodged into the left hepatic duct (small arrow).
805
TECHNICAL NOTES
Vol. 133
using the Burhenne technique with a stone basket (2, 3). This is the procedure of choice for removal of most biliary calculi. The lack of success with this technique in our 2 patients can probably be attributed to the firm attachment of the calculus to the bile duct wall in CASE I and to partial impaction of many calculi within the biliary duct in CASE II, to the extent that although some contrast material was able to pass distally, the stones could not be dislodged with the basket. The stones were successfully dislodged in both patients using a Fogarty balloon catheter. An adaptation of the Fogarty embolectomy catheter has been used for many years to extract calculi from the biliary ducts during exploration of the common bile duct (6). This technique has not been without hazard, as reports have shown disruption of the bile ducts on follow-up cholangiography (7, 8). This complication has been attributed to overdistension of the balloon within the ducts (7), which can be avoided when this procedure is performed under fluoroscopic guidance (as opposed to during surgery, when placement of the balloon catheter and inflation are performed without fluoroscopy). Contrast material should be used to inflate the balloon during percutaneous stone retrieval. Under fluoroscopic monitoring the uninflated catheter is placed beyond the calculus. The balloon is then inflated with contrast material to the diameter of the duct. As the catheter is withdrawn into larger ducts, more contrast material is slowly added, so that the diameter of the balloon continually equals that of the surrounding duct. In this manner the calculus will always remain proximal to the balloon. Depending upon the situation, the calculus may be removed using only the balloon catheter, or it may be withdrawn to a position more accessible to the stone basket. This technique appears to be especially useful for retrieval of intrahepatic calculi, which we have found to be more difficult to remove than common duct calculi. It has not been
Technical Notes
necessary to employ the balloon catheter for removal of stones within the common hepatic or common bile ducts. The transhepatic U-tube was advantageous in our second patient, as it made all of the intrahepatic bile ducts accessible to the steerable catheter (5).
REFERENCES 1. Burhenne HJ: Nonoperative retained biliary stone extraction. A new roentgenologic technique. Am J Roentgenol 117:388-399, Feb 1973 2. Burhenne HJ, Richards V, Mathewson C Jr, et al: Nonoperative extraction of retained biliary tract stones requiring multiple sessions. Am J Surg 128:288-292, Aug 1974 3. Burhenne HJ: Nonoperative extraction of stones from the bile ducts. Semin Roentgenol 11:213-217, Jul 1976 4. Cameron JL, Skinner DB, Zuidema GO: Long term transhepatic intubation for hilar hepatic duct strictures. Ann Surg 183:488-494, May 1976 5. Burhenne HJ, Peters HE: Retained intrahepatic stones. Use of the U tube during repeated nonoperative stone extractions. Arch Surg 113:837-841, Jul1978 6. Fogarty TJ, Krippaehne WM, Dennis DL, et al: Evaluation of an improved operative technic in common duct surgery. Am J Surg 116:177-183, Aug 1968 7. Henzel JH, Blessing WD, Deweese MS: Intrahepatic biliary disruption. Report of two cases occurring during use of balloon-tipped biliary catheters. Arch Surg 102:218-220, Mar 1971 8. Eaton SB Jr, Wirtz RD, Ten Eyck JR, et al: Iatrogenic liver injury resulting from ductal instrumentation with the Fogarty biliary balloon catheter. Radiology 100:581-584, Sep 1971 1 From the Russell H. Morgan Department of Radiology and Radiologic Science (S.L.K., D.P.H., K.H.B., R.I.W.) and the Department of Surgery (J.L.C.), Johns Hopkins Medical Institutions, Baltimore, Md. 21205. Received Feb. 9, 1979; accepted and revision requested June 5; revision received June 21. 2 Edwards Laboratories, Santa Ana, Calif. 3 Medi-Tech Division, Cooper Scientific Corp., Watertown, Mass. sjh
An Improved Technique of Loading Contrast Material for Angiograph y 1 Eddy C. K. Tong, M.D. The author describes a new technique which facilitates loading of contrast material into the injector syringe without interrupting the angiographic procedure. INDEX TERMS:
Angiography, instrumentation. Angiography, technique
Radiology 133:805-806, December 1979
The following technique was devised to facilitate loading contrast material into a power injector without interrupting the angiographic procedure. A three-way stopcock (two female, one male) is placed between the power injector and the high-pressure injecting tube. A disposable connecting tube is attached to the other opening of the stopcock and connected to a disposable 60-ml syringe. After removal of the plug, the syringe is clamped to the front of the power injector by a spring holder or taped in place. The container of the syringe is attached next to it to hold the injecting tube when it is not attached to the catheter (Fig. 1). During the initial loading, the stopcock is switched to the position con-
Fig. 1. 60-ml disposable syringe and its container attached to the front of the injector by spring holders. The syringe is linked to the power injector by a connecting tube attached to a three-way stopcock which is placed between the injector syringe and the injecting tube. During loading, contrast material is put into the disposable syrinqe and passes through the stopcock into the injector. There is no need to tilt the injector after the initial loading. The appropriate amount of contrast material can be drawn into the injector at any time during the angiographic procedure by simply switching the position of the stopcock.
TECHNICAL NOTES
Vol. 133
The radioisotope in the mold was distributed according to the Manchester System (1). The diameter d of the radioactive ring was 2.54 cm, and the treatment distance h was 1 cm, giving a dl h ratio of 2.54, close to the dl h ratio of 2.83 which gives an ideal distribution (1). Computer dosimetry showed no variations in dose distribution greater than 10% in the plane midway between the two rings over an area 2.54 cm in diameter. The patient received 4,200 rad (42 Gy) from the mold plus an additional 2,000 rad (20 Gy) by two laterally opposed 7 X 9-cm 2 ports using 25 MV x rays. Follow-up of this patient one month after treatment showed complete regression of the tumor which has not regrown over the ensuing six months. The patient has
Technical Notes
normal amounts of saliva and none of the sequelae seen with external irradiation. REFERENCE 1. Meredith WJ (ed): Radium Dosage, the Manchester System. Edinburgh, Livingston, 1967, pp 6-22 1 From the Division of Radiation Oncology, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St. Louis, MO (D.J.K., J.E.M.), and the Department of Therapeutic Radiology,University of Minnesota Hospital, Minneapolis, MN (S.C.S.). Received Jan. 16, 1979 and accepted May 8. (Reprint request to D. J. K., Division of Radiation Oncology, Mallinckrodt Institute of Radiology, St. Louis, MO 63110.) jr
Positioning Device for Cardiac Series 1 Manuel Viamonte, Jr., M.D. The author describes a new positioning device for use during radiography of the chest. This device is particularly helpful when doing a cardiac series. INDEX TERMS:
Radiography, instrumentation. Thorax, radiography
Radiology 133:803, December 1979
I wish to describe a new device for use in radiography of the chest, particularly cardiac series. While a variety of devices are available for support of the arms during chest radiography, this one has the advantage of being readily adjustable both for height and for the angle controlling the obliquity of the patient. The device is slowly moved upward until the arms are fully extended and vertical, at which point the vertical rod is locked into position with four wing nuts. The patient grasps the free end of the Lshaped rod which is supported by the vertical arm (Fig. 1). I take a left anterior oblique view at 45 0 without barium and a right anterior oblique view at 60 0 with barium.
1 From the Department of Radiology, Mount Sinai Medical Center, Miami Beach, Fla. 33140. Received Feb. 6,1979; accepted and revision requested June 20; revision received July 2. sjh
Nonoperative Retrieval of Impacted Intrahepatic Biliary Stones Using the Fogarty Balloon Catheter 1 Stephen L. Kaufman, M.D., Donald P. Harrington, M.D., Klemens H. Barth, M.D., Robert I. White, Jr., M.D., and John L. Cameron, M.D. Nonoperative removal of impacted intrahepatic stones was achieved in 2 patients using a Fogarty balloon catheter. The stones could not be dislodged with a basket. Fluoroscopic monitoring during the procedure reduces the risk of injury to the liver. INDEX TERMS: Bile ducts, calculi (Liver, biliary system, stone extraction, 7 [6] .1228) • Catheters and catheterization Radiology 133:803-805. December 1979
Fig. 1.
Position of the patient for a 45 0 left anterior oblique view of the chest.
Burhenne's technique for nonoperative extraction of stones from the bile ducts using a steerable catheter and basket has greatly reduced the need for reoperation for stone removal following cholecystectomy and resulted in a success rate of 95 % (1-3). We recently encountered 2 patients with stones impacted within the intrahepatic bile ducts which could not be dislodged or snared with the basket. Removal was possible with a Fogarty arterial balloon catheter- preceding use of the stone basket.
CASE REPORTS CASE I: A 51-year-old man underwent a cholecystectomy and common bile duct exploration at another institution. Multiple stones had been removed during the procedure; however, a follow-up T-tube cholangiogram revealed two stones within the left hepatic duct (Fig. 1). Six weeks after surgery the patient was referred for nonoperative
804
TECHNICAL NOTES
December 1979
distal to the stone. Under fluoroscopic monitoring, the balloon was inflated with contrast material to a diameter equal to that of the duct. The balloon catheter was then withdrawn, dislodging the calculus into the common hepatic duct, from which it was extracted using the basket catheter. Follow-up cholangiography demonstrated that the biliary system was free of stones.
Fig. I.
CASE I. Postoperative T-tube cholangiogram shows two stones (arrows) within the left hepatic duct.
extraction of the residual stones. The T-tube was removed and a steerable catheterSinserted through the T-tube tract into the left hepatic duct. The larger, more proximal stone was retrieved with a basket. 3 Numerous attempts to snare the distal stone with the basket were unsuccessful, nor could it be dislodged. A straight drainage tube was placed within the biliary system, and a repeat cholangiogram the next day revealed that the position of the stone was unchanged. Two days later, removal was again attempted. At this time a 4 French Fogarty catheter was inserted through the steerable catheter and positioned
CASE II: A 36-year-old woman underwent a cholecystectomy at another hospital in 1972. A choledochojejunostomy was performed because of a "common bile duct malformation." Due to recurrent episodes of cholangitis and obstructive jaundice, the patient was admitted to this institution in 1977. Many stones were removed from the biliary tree surgically and a Silastic transhepatic stent was placed through the choledochojejunostomy into the right hepatic duct and brought out through the anterior liver capsule and abdominal wall (4). Follow-up cholangiography through the stent revealed multiple stones impacted within several branches of the right hepatic duct (Fig. 2, a). Following an unsuccessful attempt to remove the stones through the stent tube tract, the stent was converted into a transhepatic U-tube for easier accessibility into the intrahepatic ducts (5). A subsequent attempt at percutaneous retrieval of the stones through the new lower end of the U-tube tract using a basket catheter was only partially successful due to apparent impaction of multiple stones within the largest of the obstructed branches (Fig. 2, b). The U-tube was replaced, and two days later removal was again tried. Following introduction of the steerable catheter into the obstructed branch, a 4 French Fogarty catheter was placed within the branch distal to the stones. Under fluoroscopic monitoring, the balloon was inflated with contrast material to approximately the diameter of the duct. The balloon catheter was withdrawn from the duct, dislodging most of the stones into the right hepatic duct and subsequently through the choledochojejunostomy into the bowel. Several passes were required to extract all of the stones. A stone which had become lodged within the left hepatic duct during the initial procedure was also removed in this manner. Follow-up cholangiography revealed no residual stones.
DISCUSSION
Nonoperative removal of retained biliary stones can be achieved in approximately 95 % of cases with low morbidity
2a,b
Fig. 2. CASE II. a. Cholangiogram through the stent tube shows stones within several branches of the right hepatic duct (arrows). b. Following stone retrieval with the basket, multiple stones remain impacted within the largest right hepatic duct (large arrow). A stone has been dislodged into the left hepatic duct (small arrow).
805
TECHNICAL NOTES
Vol. 133
using the Burhenne technique with a stone basket (2, 3). This is the procedure of choice for removal of most biliary calculi. The lack of success with this technique in our 2 patients can probably be attributed to the firm attachment of the calculus to the bile duct wall in CASE I and to partial impaction of many calculi within the biliary duct in CASE II, to the extent that although some contrast material was able to pass distally, the stones could not be dislodged with the basket. The stones were successfully dislodged in both patients using a Fogarty balloon catheter. An adaptation of the Fogarty embolectomy catheter has been used for many years to extract calculi from the biliary ducts during exploration of the common bile duct (6). This technique has not been without hazard, as reports have shown disruption of the bile ducts on follow-up cholangiography (7, 8). This complication has been attributed to overdistension of the balloon within the ducts (7), which can be avoided when this procedure is performed under fluoroscopic guidance (as opposed to during surgery, when placement of the balloon catheter and inflation are performed without fluoroscopy). Contrast material should be used to inflate the balloon during percutaneous stone retrieval. Under fluoroscopic monitoring the uninflated catheter is placed beyond the calculus. The balloon is then inflated with contrast material to the diameter of the duct. As the catheter is withdrawn into larger ducts, more contrast material is slowly added, so that the diameter of the balloon continually equals that of the surrounding duct. In this manner the calculus will always remain proximal to the balloon. Depending upon the situation, the calculus may be removed using only the balloon catheter, or it may be withdrawn to a position more accessible to the stone basket. This technique appears to be especially useful for retrieval of intrahepatic calculi, which we have found to be more difficult to remove than common duct calculi. It has not been
Technical Notes
necessary to employ the balloon catheter for removal of stones within the common hepatic or common bile ducts. The transhepatic U-tube was advantageous in our second patient, as it made all of the intrahepatic bile ducts accessible to the steerable catheter (5).
REFERENCES 1. Burhenne HJ: Nonoperative retained biliary stone extraction. A new roentgenologic technique. Am J Roentgenol 117:388-399, Feb 1973 2. Burhenne HJ, Richards V, Mathewson C Jr, et al: Nonoperative extraction of retained biliary tract stones requiring multiple sessions. Am J Surg 128:288-292, Aug 1974 3. Burhenne HJ: Nonoperative extraction of stones from the bile ducts. Semin Roentgenol 11:213-217, Jul 1976 4. Cameron JL, Skinner DB, Zuidema GO: Long term transhepatic intubation for hilar hepatic duct strictures. Ann Surg 183:488-494, May 1976 5. Burhenne HJ, Peters HE: Retained intrahepatic stones. Use of the U tube during repeated nonoperative stone extractions. Arch Surg 113:837-841, Jul1978 6. Fogarty TJ, Krippaehne WM, Dennis DL, et al: Evaluation of an improved operative technic in common duct surgery. Am J Surg 116:177-183, Aug 1968 7. Henzel JH, Blessing WD, Deweese MS: Intrahepatic biliary disruption. Report of two cases occurring during use of balloon-tipped biliary catheters. Arch Surg 102:218-220, Mar 1971 8. Eaton SB Jr, Wirtz RD, Ten Eyck JR, et al: Iatrogenic liver injury resulting from ductal instrumentation with the Fogarty biliary balloon catheter. Radiology 100:581-584, Sep 1971 1 From the Russell H. Morgan Department of Radiology and Radiologic Science (S.L.K., D.P.H., K.H.B., R.I.W.) and the Department of Surgery (J.L.C.), Johns Hopkins Medical Institutions, Baltimore, Md. 21205. Received Feb. 9, 1979; accepted and revision requested June 5; revision received June 21. 2 Edwards Laboratories, Santa Ana, Calif. 3 Medi-Tech Division, Cooper Scientific Corp., Watertown, Mass. sjh
An Improved Technique of Loading Contrast Material for Angiograph y 1 Eddy C. K. Tong, M.D. The author describes a new technique which facilitates loading of contrast material into the injector syringe without interrupting the angiographic procedure. INDEX TERMS:
Angiography, instrumentation. Angiography, technique
Radiology 133:805-806, December 1979
The following technique was devised to facilitate loading contrast material into a power injector without interrupting the angiographic procedure. A three-way stopcock (two female, one male) is placed between the power injector and the high-pressure injecting tube. A disposable connecting tube is attached to the other opening of the stopcock and connected to a disposable 60-ml syringe. After removal of the plug, the syringe is clamped to the front of the power injector by a spring holder or taped in place. The container of the syringe is attached next to it to hold the injecting tube when it is not attached to the catheter (Fig. 1). During the initial loading, the stopcock is switched to the position con-
Fig. 1. 60-ml disposable syringe and its container attached to the front of the injector by spring holders. The syringe is linked to the power injector by a connecting tube attached to a three-way stopcock which is placed between the injector syringe and the injecting tube. During loading, contrast material is put into the disposable syrinqe and passes through the stopcock into the injector. There is no need to tilt the injector after the initial loading. The appropriate amount of contrast material can be drawn into the injector at any time during the angiographic procedure by simply switching the position of the stopcock.
