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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Case 50 Occluded Ureteral Stent
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Figure 50.4
Figure 50.5
Figure 50.6
Findings
▶ Antegrade nephrostogram (Fig. 50.4) demonstrates no contrast passing through the indwelling ureteral stent
(arrowheads), conrming it is occluded. e ureter is obstructed at the level of the pelvic brim (arrow).
▶ Asnare (Fig. 50.5, arrow) has been advanced through the nephrostomy tract and is being used to snare the
proximal pigtail of the ureteral stent. e stent was then removed through a sheath in the tract (not shown).
▶ e stent has been replaced with a nephroureterostomy catheter (Fig. 50.6) to drain the obstructed kidney.
is catheter allows both internal drainage into the bladder and external drainage into a nephrostomy bag.
Teaching Points
▶ In early failure of ureteral stent, an antegrade urinary drainage cathether may be required to provide urinary
drainage.
▶ In most cases, nephroureteral catheters are favorable to nephrostomy because they are more stable and allow
for internal as well as external drainage.
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▶ In certain situations, however, nephrostomy is favored over nephroureterostomy. ese include (1)urinary
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diversion to prevent urine from entering the bladder (e.g., in the presence of a vesicovaginal stula), (2)to
relieve debilitating bladder spasm associated with nephroureterostomy or stent, and (3)bladder hemorrhage
that is exacerbated by the presence of a catheter.
▶ Ureteral stents may be removed from the bladder by cystoscopy, or from the renal pelvis, as in this case. In
this case, the advantage to the latter is twofold:(1)access across the obstruction is maintained, facilitating
nephroureterostomy catheter placement; and (2)it is done by a single operator in a single procedure.
Management
▶ Routine exchange of urinary drainage catheters is required every 3–6months to prevent catheter
occlusion.
▶ Unlike most drainage catheters, in abscesses or the biliary tree for example, urinary drainage catheters do not
require routine forward ushes.
▶ Nephroureterostomy catheters may be capped, rendering their function that of a ureteral stent. If a patient
tolerates this without pain, fever, or pericatheter leakage, conversion to a ureteral stent may again be
considered.
▶ However, in patients with ileal conduits or neobladders, nephroureteral catheters should not be capped
because mucus produced by the bowel quickly occludes the distal sideholes, causing obstruction of a
colonized system that results in infection.
Further Reading
Stokes, LS, Meranze SG. Percutaneous nephrostomy, cystostomy and nephroureteral stenting. In:Mauro MA, Murphy
KPJ, omson KR, Venbrux AC, and Morgan RA, eds, Image-Guided Interventions. Philadelphia, PA:Elsevier Saunders,
2014:1076–1088.
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Case 51
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History
▶ A65-Year-Old Female with Cervical Cancer Status post Radiation erapy with Leakage of Urine from
Rectum
Figure 51.1
Figure 51.2
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Case 51 Uretero-colic Fistula Treated with Urinary Diversion
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and Ureteral Embolization
Figure 51.3
Figure 51.4
Figure 51.5
Findings
▶ Contrast injection through a right nephrostomy (Fig. 51.3) shows stula between the ureter into an ill-dened
structure at the level of the sacrum (arrow). is nding was also demonstrated by delayed imaging during a
preceding contrast-enhanced computed tomography (CT) (Fig. 51.2).
Figure 51.6
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▶ An Amplatzer vascular plug has been placed in the mid ureter above the leak (Fig.51.4, arrow). N-butyl
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cyanoacrylate (NBCA) was injected into the Amplatzer vascular plug, and the small lling defects (hollow
arrows) in the proximal ureter represent migrated NBCA fragments. Because the NBCA did not remain
in position, additional coils were placed immediately proximal to the Amplatzer vascular plug (Fig.51.5,
arrowhead).
▶ Aer injection of Gelfoam slurry into the ureter, a second Amplatzer vascular plug was placed in the proximal
ureter to complete the embolization using a “sandwich” technique (Fig.51.5). Note residual opacied NBCA
fragment in renal pelvis (hollow arrow).
▶ Final contrast injection into the nephrostomy demonstrates occlusion of the ureter with no evidence of
leakage into the bowel (contrast overlying the pelvic brim remains from an earlier injection [Fig.51.6, star]).
Teaching Points
▶ Percutaneous nephrostomy alone may be used to divert urine from ureteral or bladder stulae. In most
cases, this alone will resolve symptoms. In refractory cases, “permanent” irreversible occlusion by ureteral
embolization may be required.
▶ Because urine contains urokinase (an anticoagulant) and does not contain blood with its associated
coagulation factors, it does not clot and it can be dicult to achieve complete and durable occlusion.
▶ NBCA polymerizes when in contact with ionic solution. erefore, the catheter through which it is introduced
should be ushed with water (not saline) prior to injection to prevent it from solidifying within the catheter.
e volume to be injected is typically estimated by a contrast injection before administration. NBCA is
typically mixed with either lipiodol or tantalum powder to render it radio-opaque prior to administration.
Varying concentrations of lipiodol: NBCA may be used to change the rate of polymerization, depending on
the indication and location to be embolized.
Management
▶ ere are several techniques to perform ureteral embolization. Detachable silicone balloons (not currently
available in the United States) have historically provided the most durable results. Another common technique
is the use of either Amplatzer vascular plugs and/or coils in conjunction with gelfoam or NBCA in a sandwich
technique described in this case.
Further Reading
Schild, HH, Meyer C, Mohlenbroch M, etal. Transrenal ureter occlusion with an Amplatzer vascular plug. J Vasc Interv Radiol.
2009:1390–1392.
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Case 52
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History
▶ Recurrent Ascites aer Resection of Testicular Carcinoma. What Device has been Placed to Treat the Ascites?
Figure 52.1
Figure 52.3
Figure 52.2
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Case 52 Peritoneovenous Shunt Placement for Chylous Ascites
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Figure 52.4
Figure 52.5
Figure 52.6
Findings
▶ Coronol computed tomography (CT) reconstruction (Fig. 52.4) shows ascites and surgical clips in the
retroperitoneum suggesting previous lymph node dissection.
▶ Scout image from an abdominal CT (done for other reasons) aer peritoneovenous shunt placement (Fig.
52.5) shows a contiguous catheter extending from the pelvis (arrowhead) in a subcutaneous tunnel and
terminating at the high right atrium (star.) e valve (arrow) is positioned over the lower ribs.
▶ Asingle image from a CT 6months aer shunt placement (Fig. 52.6) shows resolution of ascites. e valve
(arrow) of the shunt is seen in cross section over the lower anterolateral rib cage.
Teaching Points
▶ For select patients with refractory malignant, hepatic or chylous ascites placement of a peritoneovenous
shunt can provide relief from asictes while preventing the loss of protein-rich ascites from repeated
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large-volume paracentesis. is procedure is most appropriate for patients with life expectancy greater
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than 3months.
▶ e Denver Shunt
11.5 F and 15.5 F, with either a double- or single-valve system. e valve prevents blood from the venous limb
from back-bleeding into the ascites. e single valve is preferred for viscous or very large-volume ascites.
(Carefusion, Waukegan, IL), currently available in the United States, comes in two sizes,
®
▶ Contraindications to shunt placement include peritonitis/sepsis, uncorrected coagulopathy, and loculated
ascites. Congestive heart failure and varices are relative contraindications, as they can be aggravated by the
resulting increase in intravascular volume.
Management
▶ Major complications of peritoneovenous shunt placement include disseminated intravascular coagulopathy
and bacterial peritonitis. Increase in intravascular volume may aggrevate congestive heart failure and increase
the risk of variceal bleeding in patients with portal hypertension.
▶ e valve chamber should be positioned over a lower chest wall for ease of access. e patient or care partner
needs to pump this chamber several times a day in the supine position to prevent occlusion of the valve with
protenacious or crystalloid debris.
▶ Shunts should be ligated or removed prior to abdominal surgery to prevent air in the abdomen from entering
the venous system and causing air embolism.
Further Reading
Martin LG. Percutaneous placement and management of peritoneovenous shunts. Semin Intervent Radiol. 2012;
29(2):129–134.
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Case 53
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History
▶ Esophageal Cancer Post Gastric Pull-up with Proximal Small-Bowel Obstruction Access for Enteral Feeding Is
Required
Figure 53.1
Figure 53.3
Figure 53.2
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Case 53 Percutaneous Jejunostomy Catheter Placement
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Figure 53.4
Figure 53.5
Figure 53.6
Findings
▶ Using computed tomography (CT) guidance, an 18-gauge needle has been advanced through the skin directed at
a loop of decompressed small bowel in the le upper quadrant (arrows, Fig. 53.4). Aer the needle was advanced
into the loop, contrast injection under uoroscopy conrms intraluminal position of the needle tip (Fig. 53.5).
▶ Aer placement of a single retention suture (arrows, Fig. 53.6) a 12 French catheter is seen positioned within
the lumen of the jejenum. Contrast injected into the catheter ows antegrade into the unobstructed more
distal small bowel.
Teaching Points
▶ Compared to parenteral nutrition, enteral feeding is associated with decreased morbidity, infection, and organ
failure.
▶ Percutaneous jejunostomy is indicated for enteral feeding in patients in whom the stomach is inaccessible,
who have altered gastric anatomy, and/or have malignant small-bowel obstruction requiring decompression.
Alternative options include endoscopic or surgical jejunostomy.
▶ CT or uoroscopy is most commonly used to access the small bowel. When uoroscopy is used, insuation of
the small bowel via a naso-jejunal catheter with air may be helpful to identify and distend an appropiate loop
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