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Abstracts of oral presentations at the first RSSA/SGR Gastrointestinal Radiology Course: Stellenbosch, 7-9 August 2010.

(presenting author first)

Imaging the Rex recessus vein pre-operatively using wedged hepatic venous portography and the role of post-operative doppler ultrasound in Rex shunts

Andrew Lawson, Groote Schuur Hospital

Paul Rischbieter, Themba Hospital

Alp Numanoglu, Nicky Wieselthaler, Red Cross War Memorial Children's Hospital

Background. In children with extrahepatic portal vein obstruction (EHPVO), formation of a mesentericoportal bypass (Rex shunt) restores hepatopedal flow, relieves portal hypertension and reduces variceal bleeding. The Rex shunt is created by inserting a vein graft between the superior mesenteric vein and the umbilical segment of the left portal vein (Rex vein). We report our experience with wedged hepatic venous portography (WHVP) in the pre-operative evaluation of the Rex vein and the post-operative ultrasound findings.

Methodology. A retrospective chart review was done in patients with EHPVO who had been considered for a mesoportal bypass between January 2001 and January 2010 at Red Cross War Memorial Children's Hospital.

Results. Sixteen patients (13 boys, 3 girls, mean age 5, range 1-13 years) were considered for mesoportal bypass including 4 post reduced-size liver transplant patients. Ten patients (62%) underwent WHVP. The Rex vein was clearly identified in 8 (80%) patients. A poorly canalised Rex vein was reported in one of these cases yet found to be functionally viable at surgery. One Rex vein was seen at surgery despite not being demonstrated at WHVP. Six mesoportal bypasses were performed without WHVP of which 3 (50%) were successful. Two of the patients who underwent WHVP were post liver transplant patients; a patent Rex vein was demonstrated in both. The average shunt sizes on the first post-operative day as documented using Doppler ultrasonography was 7.8 mm with an average flow of 20.8 cm/s. The average flow rate increased to 27.1 cm/s after 1 month. All shunt occlusions (N=1) or partial thromboses (N=2) were detected by post-operative Doppler ultrasound.

Conclusion. Our series demonstrates the use of WHVP as an effective tool with a sensitivity of 80% and specificity of 100% in the preoperative patency assessment of the Rex vein. The sensitivity of WHVP in patients who had undergone liver transplantation remains above 90%. Doppler ultrasonography is useful for evaluating the size and flow rates in the post-operative shunt and is sensitive (100%) to the detection of early shunt thrombosis.

Abdominal lymphadenopathy in children with tuberculosis presenting with respiratory symptoms

Shaun Scheepers, Savvas Andronikou, Ayanda Mapukata, Peter Donald, Stellenbosch University and Tygerberg Hospital

Background. Tuberculosis (TB) remains one of the leading causes of childhood morbidity and mortality. Pulmonary TB (PTB) is the most common form; however, extrapulmonary TB is on the increase, with abdominal TB being most prevalent in the paediatric age group. The radiologic hallmark of primary TB in children is lymphadenopathy. Ultrasound is a sensitive tool for detecting abdominal lymphadenopathy and may have an important role in the primary investigation of suspected TB in children.

Objectives. To determine the prevalence of abdominal lymphadenopathy in children with culture-positive PTB, presenting with respiratory symptoms; to determine whether the presence of abdominal TB could predict the presence of thoracic (hilar and mediastinal) lymphadenopathy, given the predictable course of lymphatic spread; and to define the role of ultrasound in the primary investigation of suspected TB in children.

Materials and methods. Chest radiographs and abdominal ultrasound reports of 47 children, with culture-positive PTB and respiratory symptoms, were reviewed. The prevalence of abdominal lymphadenopathy and thoracic lymphadenopathy was determined. The relative effectiveness of ultrasound for predicting thoracic lymphadenopathy was determined using 2 x 2 tables.

Results. The prevalence of abdominal lymphadenopathy was 19% (N=9) as demonstrated on ultrasound. Thoracic lymphadenopathy was reported in 70% of our study participants. Abdominal ultrasonography had a sensitivity of 18% and a specificity of 79% for predicting thoracic lymphadenopathy when chest radiography was used as the radiological reference standard. Abdominal ultrasound did, however, identify one additional case of lymphadenopathy that was not detected on chest radiography.

Conclusion. Since patients were selected on the basis of having respiratory TB, the fact that 19% had abdominal lymphadenopathy is noteworthy. Owing to its poor sensitivity and overall accuracy, ultrasound cannot be used in isolation for the prediction of thoracic lymphadenopathy. It is therefore suggested that ultrasound remains a valuable supplementary tool for diagnosing TB in children, due to its safety, portability and affordability.

Effectiveness of percutaneously placed self-expanding metal stents for palliation of malignant biliary obstruction

Andrew Lawson (principle investigator), S Burmeister, J Krige, Groote Schuur Hospital

P Rischbieter, Themba Hospital

Background. Percutaneously placed self-expanding metal stents (SEMS) have been widely used for palliation of malignant biliary obstruction as an alternative to major bypass surgery or when endoscopic drainage is not technically feasible. We report our experience in the placement of SEMS at Groote Schuur Hospital.

Methods. A retrospective chart review was done of patients who had percutaneously placed SEMS for obstructing biliary malignancy between May 2008 and February 2010. Data included demographic information, level of biliary obstruction, efficacy and complications of SEMS insertion. Boston Scientific 6F, 69 mm*10 mm, Wallstent SEMS were used.

Results. Forty patients (23 men, 17 women, mean age 61, range 48-74 years) underwent percutaneous SEMS. Stent insertion was successful in all patients. Ten patients had obstruction at the level of the hilum, 5 in the mid common bile duct, and 25 in the low common bile duct. In 15 (37.5%) patients, SEMS were placed during the first attempt at biliary decompression. Five (12.5%) patients required bilateral SEMS insertion. The mean serum bilirubin decreased from 313 [micro]mol/l to 127 [micro]mol/l (60% decrease) 5 days post stent insertion. Mean hospital stay post stent insertion was 5.1 days. Nine patients (22.5%) developed complications unrelated to SEMS insertion that included gastric outlet obstruction requiring endoscopic stenting (N=6), myocardial ischaemic events (N=2) and pneumonia (N=1). Eight patients (20%) developed a procedure-related complication that included cholangitis after stent insertion (N=3), cholangitic liver abscess (N=1), subphrenic liver collection (N=1), bile leakage (N=1) and cholecystitis (N=2). Stent occlusion occurred in 4 patients (10%) within a week as a result of tumour ingrowth (N=3) or biliary sludge (N=1). Two (5%) stents occluded between 7 days and one month. Three (7.5%) patients died during hospital admission owing to pre-existing cholangitic sepsis (N=2) and pneumonia (N=1). Six patients (15%) survived less than one month, 10(25%) survived between 1 and 3 months, 8 (20%) survived between 3 and 6 months, and 9 (22.5%) survived beyond 6 months. Seven (17.5%) patients from distant referral institutes were not seen after discharge.

Conclusion. These data demonstrate that percutaneously placed SEMS achieve satisfactory palliation with a low complication rate in a highrisk patient group with advanced malignant biliary obstruction.
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Title Annotation:RADIOACTIVE NEWS; Radiological Society of South Africa
Publication:South African Journal of Radiology
Geographic Code:6SOUT
Date:Sep 1, 2010
Words:1124
Previous Article:The first RSSA/SGR Gastrointestinal Radiology Course: Stellenbosch, 7-9 August 2010.
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