242
October 1979
TECHNICAL NOTES
1,2
Fig. 1. Fig. 2.
The device for barium-enema examination following colostomy. A direct barium-air double-contrast radiograph of the colon with the new device.
short that no petechiae or complications were seen, except a slight reddening around the opening. There are several advantages to using this inexpensive appliance. The examination is quick and simple, with no leakage of barium from the stoma, while allowing good visualization for the double-contrast study. There is also no danger of perforating
the stoma or bowel, and the procedure is without pain or complication for the patient.
Percutaneous Transbopatlc Gallstone Removal by Needle Tract 1
utilize a needle tract through the skin, hepatic parenchyma, and into the biliary tree for stone removal.
Charles T. Dotter, M.D., Marcia K. Bilbao, M.D., and Ronald M. Katon, M.D.
CASE REPORT
A percutaneous transhepatic cholangiogram tract was used to visualize a large stone in the common duct; following the tract's dilation, the stone was crushed and partially removed. Fragments were flushed and also passed spontaneously into the duode -um, The approach described offers a feasible alternative to surgery: I
INDEX TERMS: Bile ducts. calculi. Bile ducts, stone extraction. Cholangiography, indications. (Liver, biliary system, percutaneous cholangiography, 7161.1226) • (Liver, biliary system, stone extraction, duct dilation, 716 J. 1228) • (Liver, biliary system, abnormal biliary tract, 7 [61·280)
Radiology 133:242-243, October 1979
Gallstones can be nonsurgically removed from the biliary system by various methods. Use of the t-tube tract for the removal of retained stones following biliary surgery is commonplace (1), as is the use of a needle/catheter tract to establish biliary drainage in jaundiced patients (2). It is also possible to
1 From the Institute of Clinical Medicine, University of Tsukuba, Niihari-gun. Ibaraki-ken, 300-31, Japan. Received Jan. 11, 1979, and jr accepted March 30.
One year following cholecystectomy done for repeated episodes of biliary colic. a 62-year-old rancher was admitted because of eight months of similar recurrent colic." Direct (percutaneous transhepatic) cholangiography disclosed a large (l-cm diameter) biliary calculus (Fig. 1a) lodged in the distal common bile duct (maximum diameter about 3.5 mm). A 5.6-French biliary drainage catheter was put in place and prophylactic antibiotics started. The next day, the tract was dilated with a tapered-tip 8-French Teflon catheter and the drainage catheter replaced by a larger (8.3-Fr) catheter. Lidocaine was injected in an attempt to relax the sphincter and flush the stone into the duodenum.This having failed, on the next day a #8 Burhenne catheter and stone basket were used to entrap the stone. When it proved too large to remove. it was forcibly crushed into multiple fragments by pulling the stone basket into the Burhenne catheter. A small fragment came out with the basket. Forced injections of saline were used to flush the fragments into the duodenum,and the drainage tube was replaced. A week later. follow-up cholangiography showed a single, freely mobile, nonobstructing 4 X 5-mm fragment remaining (Fig. 1b). Efforts to remove this failed. On the assumption that it would pass spontaneously, the drainage catheter was removed and the patient discharged. A single transient episode of biliary colic occurred several weeks following discharge, and since then the patient has been free of symptoms for a year, the fragment apparently having passed spontaneously.
243
TECHNICAL NOTES
Vol 133
Technical Notes
Fig. 1. a. Initial percutaneous transhepatic cholangiogram shows a large gallstone (arrow) 8 X 12 mm in size in the distal common bile duct. b. Repeat cholangiogram one week after nonoperative gallstone crushing shows a remaining fragment (arrow) which subsequently passed.
1a,b
DISCUSSION
In retrospect, dilation of the transhepatic tract to a caliber sufficient to allow transhepatic extraction of the intact stone would have been a feasible, preferable course of action. After two or three days, a biliary catheter of given size can readily be substituted for a larger equivalent. In our patient, this would have avoided the episode of biliary colic attendant upon passage of the remnant fragment and hypothetically would obviate problems associated with noncrushable stones. Transhepatic stone removal offers an alternative to biliary surgery. In patients with demonstrably normal or previously removed gallbladders, the approach shows promise of greater speed, safety, and convenience. REFERENCES 1. Burhenne HJ: Nonoperative roentgenologic instrumentation technics of the postoperative biliary tract. Treatment of biliary stricture and retained stones. Am J Surg 128:111-117. Jul 1974 2. Nakayama T. Ikeda A. Okuda K: Percutaneous transhepatic drainage of the biliary tract: technique and results in 104 cases. Gastroenterology 74:554-559. Mar 1978
'From the Department of Diagnostic Radiology (C.TD.. M.K.B.),and the Department of Internal Medicine, Division of Gastroenterology (R.M.K.), School of Medicine, University of Oregon Health Sciences Center, Portland, OR 97201. Received Dec. 12, 1978; accepted and revision requested March 30, 1979; received April 13. 2Referred by Dr. Robert Morrison, Burns, OR. jr
Bacteriologic Flora on Diagnostic Ultrasonic Transducers 1 Gretchen A. W. Gooding, M.D., and W. James DeMartini, M.D. In a study to determine the presence of bacteria on ultrasonic transducers, the authors found micro-organisms in 82% of cultures. The results show that 70 % isopropyl alcohol Is not a consistently effective germicide for the sterilization of transducers. The presence of bacteria, however, appears to be of little clinical consequence. INDf:X TERMS:
Staphylococci. Ultrasound, instrumentation
Radiology 133:243-244. October 1979
Stethoscopes and sphygmomanometers have been reported to serve as reservoirs for potential pathogens (1. 2). As ultrasonic transducers are also in direct contact with the skin of numerous patients, we studied the possibility that they too might be a potential source of contagious infection. MATERIALS AND METHODS
All ultrasonic examinations were performed with a gray-scale unit (Picker EDC)using 2.25- and 3.5-MHz transducers with direct skin contact. Mineral oil was the coupling agent. The majority of the studies were abdominal, extending from the xiphoid to the umbilicus. None of the patients had open wounds or known skin infections. One day each week, consecutive cultures of the transducer face were taken both before and after scanning. In 39 instances the transducer was cleaned with 70 % isopropyl
October 1979
TECHNICAL NOTES
1,2
Fig. 1. Fig. 2.
The device for barium-enema examination following colostomy. A direct barium-air double-contrast radiograph of the colon with the new device.
short that no petechiae or complications were seen, except a slight reddening around the opening. There are several advantages to using this inexpensive appliance. The examination is quick and simple, with no leakage of barium from the stoma, while allowing good visualization for the double-contrast study. There is also no danger of perforating
the stoma or bowel, and the procedure is without pain or complication for the patient.
Percutaneous Transbopatlc Gallstone Removal by Needle Tract 1
utilize a needle tract through the skin, hepatic parenchyma, and into the biliary tree for stone removal.
Charles T. Dotter, M.D., Marcia K. Bilbao, M.D., and Ronald M. Katon, M.D.
CASE REPORT
A percutaneous transhepatic cholangiogram tract was used to visualize a large stone in the common duct; following the tract's dilation, the stone was crushed and partially removed. Fragments were flushed and also passed spontaneously into the duode -um, The approach described offers a feasible alternative to surgery: I
INDEX TERMS: Bile ducts. calculi. Bile ducts, stone extraction. Cholangiography, indications. (Liver, biliary system, percutaneous cholangiography, 7161.1226) • (Liver, biliary system, stone extraction, duct dilation, 716 J. 1228) • (Liver, biliary system, abnormal biliary tract, 7 [61·280)
Radiology 133:242-243, October 1979
Gallstones can be nonsurgically removed from the biliary system by various methods. Use of the t-tube tract for the removal of retained stones following biliary surgery is commonplace (1), as is the use of a needle/catheter tract to establish biliary drainage in jaundiced patients (2). It is also possible to
1 From the Institute of Clinical Medicine, University of Tsukuba, Niihari-gun. Ibaraki-ken, 300-31, Japan. Received Jan. 11, 1979, and jr accepted March 30.
One year following cholecystectomy done for repeated episodes of biliary colic. a 62-year-old rancher was admitted because of eight months of similar recurrent colic." Direct (percutaneous transhepatic) cholangiography disclosed a large (l-cm diameter) biliary calculus (Fig. 1a) lodged in the distal common bile duct (maximum diameter about 3.5 mm). A 5.6-French biliary drainage catheter was put in place and prophylactic antibiotics started. The next day, the tract was dilated with a tapered-tip 8-French Teflon catheter and the drainage catheter replaced by a larger (8.3-Fr) catheter. Lidocaine was injected in an attempt to relax the sphincter and flush the stone into the duodenum.This having failed, on the next day a #8 Burhenne catheter and stone basket were used to entrap the stone. When it proved too large to remove. it was forcibly crushed into multiple fragments by pulling the stone basket into the Burhenne catheter. A small fragment came out with the basket. Forced injections of saline were used to flush the fragments into the duodenum,and the drainage tube was replaced. A week later. follow-up cholangiography showed a single, freely mobile, nonobstructing 4 X 5-mm fragment remaining (Fig. 1b). Efforts to remove this failed. On the assumption that it would pass spontaneously, the drainage catheter was removed and the patient discharged. A single transient episode of biliary colic occurred several weeks following discharge, and since then the patient has been free of symptoms for a year, the fragment apparently having passed spontaneously.
243
TECHNICAL NOTES
Vol 133
Technical Notes
Fig. 1. a. Initial percutaneous transhepatic cholangiogram shows a large gallstone (arrow) 8 X 12 mm in size in the distal common bile duct. b. Repeat cholangiogram one week after nonoperative gallstone crushing shows a remaining fragment (arrow) which subsequently passed.
1a,b
DISCUSSION
In retrospect, dilation of the transhepatic tract to a caliber sufficient to allow transhepatic extraction of the intact stone would have been a feasible, preferable course of action. After two or three days, a biliary catheter of given size can readily be substituted for a larger equivalent. In our patient, this would have avoided the episode of biliary colic attendant upon passage of the remnant fragment and hypothetically would obviate problems associated with noncrushable stones. Transhepatic stone removal offers an alternative to biliary surgery. In patients with demonstrably normal or previously removed gallbladders, the approach shows promise of greater speed, safety, and convenience. REFERENCES 1. Burhenne HJ: Nonoperative roentgenologic instrumentation technics of the postoperative biliary tract. Treatment of biliary stricture and retained stones. Am J Surg 128:111-117. Jul 1974 2. Nakayama T. Ikeda A. Okuda K: Percutaneous transhepatic drainage of the biliary tract: technique and results in 104 cases. Gastroenterology 74:554-559. Mar 1978
'From the Department of Diagnostic Radiology (C.TD.. M.K.B.),and the Department of Internal Medicine, Division of Gastroenterology (R.M.K.), School of Medicine, University of Oregon Health Sciences Center, Portland, OR 97201. Received Dec. 12, 1978; accepted and revision requested March 30, 1979; received April 13. 2Referred by Dr. Robert Morrison, Burns, OR. jr
Bacteriologic Flora on Diagnostic Ultrasonic Transducers 1 Gretchen A. W. Gooding, M.D., and W. James DeMartini, M.D. In a study to determine the presence of bacteria on ultrasonic transducers, the authors found micro-organisms in 82% of cultures. The results show that 70 % isopropyl alcohol Is not a consistently effective germicide for the sterilization of transducers. The presence of bacteria, however, appears to be of little clinical consequence. INDf:X TERMS:
Staphylococci. Ultrasound, instrumentation
Radiology 133:243-244. October 1979
Stethoscopes and sphygmomanometers have been reported to serve as reservoirs for potential pathogens (1. 2). As ultrasonic transducers are also in direct contact with the skin of numerous patients, we studied the possibility that they too might be a potential source of contagious infection. MATERIALS AND METHODS
All ultrasonic examinations were performed with a gray-scale unit (Picker EDC)using 2.25- and 3.5-MHz transducers with direct skin contact. Mineral oil was the coupling agent. The majority of the studies were abdominal, extending from the xiphoid to the umbilicus. None of the patients had open wounds or known skin infections. One day each week, consecutive cultures of the transducer face were taken both before and after scanning. In 39 instances the transducer was cleaned with 70 % isopropyl
