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Biomedical subjects

Y Atomi

Publications and source records attributed to Y Atomi.

At least 55 records · Page 3Linked to original sources
PubMed1999

Differential diagnosis of small polypoid lesions of the gallbladder: the value of endoscopic ultrasonography.

OBJECTIVE: To evaluate the accuracy of endoscopic ultrasonography (EUS) in making a differential diagnosis of small (< or =20 mm) polypoid lesions of the gallbladder. SUMMARY BACKGROUND DATA: Differential diagnosis of these lesions is often difficult using conventional imaging modalities. METHODS: The findings of EUS and transabdominal ultrasonography were retrospectively analyzed in 65 surgical cases of small polypoid lesions (cholesterol polyp in 40, adenomyomatosis in 9, adenoma in 4, and adenocarcinoma in 12). RESULTS: Polypoid lesions exceeding 10 mm suggested malignancy. EUS showed a tiny echogenic spot or an aggregation of echogenic spots with or without echopenic areas in 95% of patients with cholesterol polyps. EUS showed multiple microcysts or comet tail artifact in all adenomyomatosis cases. Adenomas and adenocarcinomas were not associated with the echogenic spots, microcysts, or artifacts. Among adenomas and adenocarcinomas, all sessile lesions were adenocarcinomas. EUS differentiated among polypoid lesions more precisely than ultrasonography (97% vs. 71%). CONCLUSIONS: A tiny echogenic spot or an aggregation of echogenic spots and multiple microcysts or comet tail artifact is pathognomonic for cholesterol polyp and adenomyomatosis, respectively. Polypoid lesions without these findings indicate adenoma or adenocarcinoma on EUS. Routine use of EUS is recommended for differential diagnosis of polypoid gallbladder lesions when ultrasonography shows no signs indicative of either cholesterol polyp or adenomyomatosis.

Adult↗
PubMed1999

Immunohistochemical localization of beta-1,4-galactosyltransferase in human pancreatic tissues.

beta-1,4-Galactosyltransferase (GalTase) is the glycosyltransferase in the Golgi apparatus that transfers galactose from UDP-galactose to terminal N-acetylglucosamine residues in glycoconjugates with formation of a beta-1,4 linkage. Neoplasms undergo various changes in the carbohydrate moieties of their glycoconjugates. This process also indicates the possibility of changes in glycosyltransferases themselves. Therefore, we compared the binding pattern of a monoclonal antibody (MAb8628) against GalTase in both normal and neoplastic exocrine pancreatic tissues. Ten normal and 11 neoplastic human exocrine pancreatic tissues obtained from surgery were used. Frozen sections were incubated with this antibody. Supranuclear regions and terminal bars of normal duct cells and acinar cells revealed positive staining for GalTase at the light microscopic level. Centroacinar cells revealed positive staining in their perinuclear region. Neoplastic cells were also stained in their supranuclear regions and terminal bars. Supranuclear regions were well developed in neoplastic cells and intensely stained compared with those in normal cells. The supranuclear regions and the terminal bars corresponded to the trans cisternae of the Golgi apparatus and the junctional complex (i.e., tight junction and adherens junction), respectively, seen at the electron microscopic level. Pancreatic neoplastic changes thus led to an increase in the expression of GalTase in the Golgi apparatus, the increase of which may have an important effect on the intercellular adhesion and communication among pancreatic epithelial cells. Measurement of this enzyme is useful for diagnosis of exocrine pancreatic neoplastic changes from normal tissues.

Adenocarcinoma↗
PubMed1999

Does endoscopic sphincterotomy cause prolonged pancreatobiliary reflux?

OBJECTIVE: Endoscopic sphincterotomy (ES) reduces sphincter function, which may allow reflux of pancreatic juice and intestinal contents into the common bile duct. The reflux, if present, may cause development of biliary tract carcinomas, as may anomalous pancreaticobiliary junction. We prospectively investigated pancreatobiliary and duodenobiliary reflux after ES. METHODS: In 15 patients with choledocholithiasis, ductal bile was sampled for amylase concentration and bacterial culture during endoscopic retrograde cholangiopancreatography, before and at 7 days to 5 yr after ES. To provide comparative data, ductal bile was sampled in 11 patients with gallbladder cholesterol polyps or anomalous pancreaticobiliary junction who did not undergo ES. RESULTS: Amylase concentration of ductal bile in patients with choledocholithiasis before ES was not different from that in patients with gallbladder polyps. Its concentration was increased 7 days after ES compared with that before ES, reaching the level of that in patients with anomalous pancreaticobiliary junction. Thereafter, amylase concentration gradually decreased, returning to that before ES by 1 yr. After ES, bactobilia occurred in 60-80% of patients, although none developed acute cholangitis. CONCLUSIONS: Although ES causes transient pancreatobiliary reflux, the reflux is abolished by 1 yr after ES. ES is unlikely to increase the risk for development of biliary tract carcinoma as long as cholangitis or bile duct stones do not recur.

Adult↗
PubMed1999

Extrapancreatic neoplasms occur with unusual frequency in patients with intraductal papillary mucinous tumors of the pancreas.

OBJECTIVE: Intraductal papillary mucinous tumor (IPMT) of the pancreas has a favorable prognosis. Non-pancreatic primary neoplasms have potential prognostic significance in patients with IPMT. This study focused on the incidence and characteristics of nonpancreatic neoplasms in IPMT patients. METHODS: Forty-two patients (mean age, 64 yr) with IPMT underwent surgery; 16 had adenoma and 26 adenocarcinoma. Preoperative and postoperative, nonpancreatic neoplasms were investigated. The mean postoperative follow-up period was 4.2 yr (range, 0.2-13 yr). Furthermore, 46 patients with pancreatic ductal adenocarcinoma were analyzed for nonpancreatic neoplasms. RESULTS: Five-year survival rates were 100% for benign and 82% for malignant IPMT. Twenty patients (48%) had nonpancreatic neoplasms, before (n = 11), at (n = 4), and after (n = 10) surgery for IPMT. Fifteen patients (32%) had nonpancreatic malignancies. Nonpancreatic neoplasms included colorectal adenomas (21%) and adenocarcinomas (12%), and gastric carcinomas (10%). One patient died of subsequent bile duct carcinoma. Development of nonpancreatic neoplasms was related to age but not to gender, family history, adjuvant chemotherapy, or IPMT pathology. The incidences of nonpancreatic neoplasms and malignancies were significantly higher in patients with IPMT than in those with pancreatic ductal adenocarcinoma (11% and 7%, respectively). CONCLUSIONS: IPMT is associated with a high incidence of nonpancreatic neoplasms, particularly colorectal neoplasms. In IPMT patients, systemic surveillance may allow early detection of second tumors. In preoperative screening and postoperative follow-up of patients with nonpancreatic neoplasms, the possibility of IPMT should be considered.

Adenocarcinoma, Mucinous↗
PubMed1999

Reappraisal of intraoperative ultrasonography for pancreatobiliary carcinomas: assessment of malignant portal venous invasion.

BACKGROUND: Conventional preoperative imaging modalities are unreliable for assessing portal venous invasion by pancreatobiliary carcinoma. We evaluated the usefulness of intraoperative ultrasonography for detecting pancreatobiliary carcinoma and assessing portal venous invasion, compared with other imaging modalities. METHODS: Ninety-one patients with pancreatic carcinoma (n = 66) or bile duct carcinoma (n = 25) underwent ultrasonography, computed tomography, angiography, and endoscopic ultrasonography preoperatively. All these patients underwent tumor resection, with (n = 23) or without (n = 68) portal vein resection, after intraoperative ultrasonography. Portal venous invasion was histologically examined in all patients. RESULTS: Intraoperative ultrasonography was significantly more sensitive (100%) than ultrasonography (79%), computed tomography (81%), and angiography (54%) for detecting carcinomas, especially bile duct carcinomas and small (< or = 2.0 cm) tumors. Portal venous invasion was confirmed histopathologically in 25 patients. For diagnosing portal venous invasion, intraoperative ultrasonography was more sensitive (92%) and specific (92%) than ultrasonography (56% and 73%), computed tomography (64% and 79%), and angiography (76% and 83%), respectively. Endoscopic ultrasonography showed a 95% detectability for carcinomas and a 92% accuracy for assessing portal venous invasion. CONCLUSIONS: Intraoperative ultrasonography is a simple and accurate procedure for detection of pancreatobiliary carcinomas and assessment of portal venous invasion.

Adult↗
PubMed1999

Pancreatic disorders associated with anomalous pancreaticobiliary junction.

BACKGROUND: The aim of this study was to establish an optimal management strategy for pancreatic disorders associated with anomalous pancreaticobiliary junction (APBJ). METHODS: In 64 adult surgical cases of APBJ (common channel 15 mm or longer) (43 with and 21 without choledochal cyst), associated pancreatic disorders, pancreatographic results, and treatment outcomes were analyzed. RESULTS: Of 64 patients, 56 had pancreatobiliary symptoms. Twenty-four patients (38%) had pancreatic disorders: acute pancreatitis (n = 20), chronic calcifying pancreatitis (n = 2), and pancreatic carcinoma (n = 2). Twenty patients (31%) had abnormal pancreatograms. The incidence of acute pancreatitis was significantly higher in patients with an abnormal pancreatogram, particularly dilatation, protein plugs or stones of the common channel or main pancreatic duct, and coexisting pancreatic ductal anomaly. All patients with choledochal cyst underwent cyst excision and hepaticojejunostomy. Eleven patients without choledochal cyst or pancreatobiliary carcinoma underwent cholecystectomy alone. Protein plugs and pancreatic stones were extracted through the bile duct stump or by sphincterotomy. No patients experienced pancreatitis during a mean postoperative follow-up of 6.7 years. CONCLUSIONS: In managing APBJ, attention should be paid to the possibility of associated pancreatic disorders and an abnormal pancreatogram. APBJ with choledochal cyst requires cyst excision. Cholecystectomy alone may be adequate for APBJ without cyst.

Adolescent↗
PubMed1998

Molecular cloning of human Frizzled-6.

The Frizzled genes encode receptors for WNTs, secreted glycoproteins implicated in development as well as in carcinogenesis. In this paper, we report molecular cloning of Hfz6, the human homologue of Mfz6. Nucleotide sequence analysis showed that the Hfz6 gene encodes the 706 amino-acid protein with seven transmembrane domains, a cystein-rich domain in the N-terminal extracellular region, two N-linked glycosylation sites, and two cystein residues in the second and third extracellular loops. Hfz6 mRNA 4.4-kb in size was detected in various normal adult and fetal tissues, and a larger amount of Hfz6 mRNA was detected in both fetal lung and fetal kidney. The Hfz6 gene has been mapped to human chromosome 8q22.3-q23.1. In conclusion, we have cloned Hfz6, which encodes a seven-transmembrane receptor with the cystein-rich domain in the N-terminal extracellular region, but without the Ser/Thr-X-Val motif in the C-terminus.

Amino Acid Sequence↗
PubMed1998

Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly?

In elderly patients emergent cholecystectomy for acute cholecystitis is a high risk procedure. We prospectively assessed the value of percutaneous cholecystostomy for acute cholecystitis in 38 consecutive elderly (> or = 80 years) patients. All 38 underwent percutaneous transhepatic cholecystostomy under ultrasonographic and fluoroscopic guidance for acute cholecystitis (25 calculous, 13 acalculous). Eight (21%) patients had acute severe medical problems, such as shock and respiratory distress. Thirty-one (82%) patients had chronic severe underlying diseases, including cardiovascular and neurologic diseases. Cholecystostomy was successful in all 38 patients. Prompt clinical improvement was obtained in 36 (95%) patients. Morbidity and mortality rates were 3% and 3%, respectively. After cholecystostomy, 10 patients with cholelithiasis underwent elective cholecystectomy without serious complications. Two patients underwent percutaneous cholecystolithotomy, which produced complete resolution of symptoms. Four of 12 patients with and none of 12 without cholelithiasis had recurrent cholecystitis after catheter removal during a mean follow-up of 1.8 years. A second cholecystostomy was successful in these four patients. Elderly patients are often poor surgical candidates because of severe cholecystitis or concomitant medical problems. Percutaneous cholecystostomy is a safe, effective treatment for acute cholecystitis even in elderly patients. For calculous cholecystitis, cholecystostomy can be followed by elective surgery, if possible, or by nonsurgical treatment or expectant conservative management in high-risk patients. Cholecystostomy may be a definitive treatment for acalculous cholecystitis.

Acute Disease↗
PubMed1998

Significance of "hands-on training" in laparoscopic surgery.

BACKGROUND: The objective of this study is to investigate the role and significance of a hand-on program designed to teach laparoscopic skills. METHODS: The course consisted of 3 half days. In vitro training in suturing and knot tying was covered on the 1st half day, and live animal surgery on the 2nd and 3rd half days, respectively. In vitro suturing and knot tying of the 15 course participants were video-recorded and analyzed four times during the course, basing on the time required to mount a needle in the needle driver (M), driving the needle in a rubber glove (D), and knot tying (T). RESULTS: Laparoscopic skills which require two-hand coordination (M, T) were significantly improved by hands-on training. Needle driving skill appeared to be essentially the same as that needed for open surgery. CONCLUSION: Hands-on training is an effective format particularly for laparoscopic skills in which two-hand coordination is essential.

Adult↗
PubMed1998

Intraductal papillary tumors of the pancreas: evaluation with endoscopic ultrasonography.

BACKGROUND: We retrospectively analyzed the endoscopic ultrasonographic characteristics of intraductal papillary tumors of the pancreas and identified signs indicative of malignant tumors. METHODS: Twenty-eight patients with intraductal tumors and 38 with other pancreatic cystic lesions underwent endoscopic ultrasonography, conventional ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Intraductal tumors were classified into three subtypes, and endoscopic ultrasonographic characteristics were assessed. In main duct type tumors, the main pancreatic duct showed a segmental or diffuse moderate-to-marked dilatation, often associated with intraductal nodules. Pancreatic parenchymal atrophy was frequently recognized. Branch duct type tumors consisted of multiple 5 to 20 mm cysts with the appearance of a cluster of grapes. The main duct was mildly dilated or nondilated. Combined type tumors had features of both main duct and branch duct types. Endoscopic ultrasonography (92%) differentiated pancreatic cystic lesions more precisely than ultrasonography (82%) and ERCP (89%). Main duct or combined type tumors, large tumors (> or = 30 mm for branch duct type), marked dilatation of the main pancreatic duct (> or = 10 mm for other types), and mural nodules suggested malignancy. Endoscopic ultrasonography demonstrated these signs more accurately than ultrasonography or ERCP. CONCLUSION: Endoscopic ultrasonography is useful for diagnosing intraductal papillary tumors, particularly for predicting malignancy.

Aged↗
PubMed1998

Laparoscopic removal of a large gastric trichobezoar.

A large trichobezoar has been traditionally removed by open surgery, which has entailed an upper abdominal incision. With the advent of laparoscopic surgery, it became feasible to retrieve a foreign body from the stomach without the necessity of a large skin incision in the upper abdomen. A 7-year-old girl presenting with abdominal pain, nausea, and appetite loss was admitted and evaluated. Results of an upper gastrointestinal series showed a large mass in the stomach that extended into the duodenum. Endoscopical removal had been tried twice under general anesthesia and resulted only in the retrieval of the small portion of the trichobezoar in the duodenum; total removal seemed impossible with endoscopic techniques. Laparoscopic removal was then under-taken to avoid the surgical scar in the upper abdomen. The trichobezoar was successfully retrieved through a gastrotomy and removed via a small suprapubic incision. This approach may be the treatment of choice for future cases of trichobezoar when surgery is indicated.

Bezoars↗
PubMed1998

Anomalous pancreaticobiliary junction without congenital choledochal cyst.

BACKGROUND: Anomalous pancreaticobiliary junction (APBJ) without congenital choledochal cyst (CCC) carries a high risk of gallbladder carcinoma development. The aim of this study was to obtain information allowing early diagnosis and appropriate management. METHODS: The clinical features, imaging findings and surgical outcome of 18 patients with APBJ without CCC were analysed retrospectively. RESULTS: Fourteen patients had symptoms, including those of acute pancreatitis (five patients). In 16 patients the gallbladder showed abnormalities, including carcinoma (eight) and mucosal hyperplasia (11). Ultrasonography detected gallbladder carcinoma with 100 per cent sensitivity and mucosal hyperplasia with 91 per cent sensitivity. A long common channel was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) in all patients, endoscopic ultrasonography in nine of ten, and magnetic resonance cholangiopancreatography (MRCP) in five of five. Five of eight patients with gallbladder carcinoma underwent extended cholecystectomy with bile duct excision. Three patients with cancer and eight with no cancer had cholecystectomy alone. None developed bile duct carcinoma or acute pancreatitis after operation. All patients without malignancy remained asymptomatic for a mean follow-up period of 4.7 years. CONCLUSION: Prophylactic cholecystectomy is recommended for patients with APBJ without CCC. For early diagnosis of APBJ, gallbladder abnormalities on ultrasonography or acute pancreatitis of unknown aetiology should prompt further investigation with ERCP or less invasive imaging modalities such as endoscopic ultrasonography and MRCP.

Adult↗
PubMed1998

Follow-up of more than 10 years after endoscopic sphincterotomy for choledocholithiasis in young patients.

BACKGROUND: With the advent of laparoscopic cholecystectomy, the indications for endoscopic sphincterotomy (ES) have been extended to young patients with choledocholithiasis. However, the long-term results of ES are largely unknown. METHODS: Between 1977 and 1986, 115 patients aged 60 years or less underwent ES for choledocholithiasis. Stone classification, and early and long-term outcomes of ES were analysed retrospectively. RESULTS: Early complications occurred in nine patients (7.8 per cent), but there were no deaths. ES and stone clearance were successful in 110 patients. Long-term information was available in 103 of the 110 patients, with a mean overall follow-up duration of 14-2 (range 10.4-19.3) years. Ten patients (9.7 per cent) developed late complications, including stone recurrence and/or cholangitis (nine patients) and acute cholecystitis (one of 23 patients with the gallbladder in situ). The choledochal complication rate was somewhat higher in patients with calcium bilirubinate stones at ES (seven of 65 patients) than in those with cholesterol stones (two of 38 patients). Choledochal complications were manageable endoscopically. CONCLUSION: Approximately 10 per cent of patients develop late complications. However, endoscopic retreatment is safe and effective. ES is a reasonable method for treating choledocholithiasis, even in young patients.

Adult↗
PubMed1998

Intraductal papillary mucinous tumors of the pancreas: imaging studies and treatment strategies.

OBJECTIVE: We analyzed clinicopathologic and imaging features and the prognosis of intraductal papillary mucinous tumor (IPMT) of the pancreas to identify imaging findings indicative of malignancy and to establish the optimal treatment strategy. SUMMARY BACKGROUND DATA: In IPMT, preoperative differentiation between adenoma and adenocarcinoma is often difficult. Appropriate treatment based on pathologic study and surgical outcome has not been adequately documented. METHODS: Forty-one patients with IPMT underwent surgery; 15 with adenoma and 26 with adenocarcinoma; main duct type in 13, combined type in 12, and branch duct type in 16. RESULTS: In malignant IPMT, deep invasion was found in 62% and lymph node metastasis in 23% (peripancreatic nodes in 19% and distant nodes in 4%). Tumors with mural nodules (86%) had a significantly higher incidence of carcinoma than tumors without nodules (37%). IPMT with a main pancreatic duct > or =15 mm or tumor diameter > or =30 mm (branch duct type) showed a high prevalence of adenocarcinoma. Main duct (54%) and combined (58%) type tumor, and tumors with mural nodules (64%) often showed invasion. All five branch duct tumors less than 30 mm without nodules were adenomas. However, imaging studies could not definitely distinguish adenocarcinomas from adenomas. Complete resection was possible for all adenomas and 88% of adenocarcinomas. Five-year survival rates for patients with adenomas and adenocarcinomas were 100% and 82%, respectively. CONCLUSIONS: IPMT has a favorable prognosis, regardless of deep invasion or node metastasis. IPMT requires peripancreatic node dissection in addition to complete tumor excision. Node dissection may be omitted for branch duct tumors less than 30 mm without mural nodules.

Aged↗
PubMed1998

Intraductal papillary tumors of the pancreas: evaluation with magnetic resonance cholangiopancreatography.

OBJECTIVE: We analyzed the findings of intraductal papillary tumors of the pancreas by magnetic resonance cholangiopancreatography (MRCP). METHODS: Twelve patients with intraductal papillary tumors (main duct type, n = 3; branch duct type, n = 8; combined type, n = 1) underwent endoscopic retrograde cholangiopancreatography (ERCP) (n = 11) and MRCP, using half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequences (n = 12). Imaging findings were compared with operative and pathological findings in all the patients. RESULTS: Although ERCP failed to fully depict the main pancreatic duct and cystic tumors in six of 11 patients because of copious intraductal mucin, MRCP provided complete images of these structures in all 12 patients. In main duct type tumors, MRCP demonstrated moderate-marked, diffuse dilation of the main pancreatic duct. Branch duct type tumors showed "grape-like" clusters of cysts with no or only mild, diffuse dilation of the main duct. In combined type tumors, MRCP demonstrated a markedly dilated main duct with a large unilocular cyst of the collateral duct. MRCP detected more mural nodules (75%, three of four patients) than ERCP (25%, one of four). MRCP allowed more precise diagnosis of the type, size, and extent of tumors than ERCP, as confirmed by pathologic findings. CONCLUSION: MRCP demonstrates intraductal papillary tumors less invasively and more completely than ERCP.

Adenocarcinoma, Papillary↗
PubMed1998

Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis.

OBJECTIVE: Magnetic resonance cholangiography (MRC), using a half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence, noninvasively provides very rapid (1-2 s) and high-quality images of the biliary tract. We assessed the diagnostic usefulness of HASTE-MRC for choledocholithiasis. METHODS: A total of 101 patients with suspected choledocholithiasis underwent MRC, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 97 patients in whom ERCP fully depicted the common bile duct, we retrospectively analyzed the capability of MRC to image the common bile duct and to diagnose choledocholithiasis, in comparison with that of ultrasonography. RESULTS: In 34 patients, ERCP demonstrated bile duct stones, which were confirmed at endoscopic or surgical treatment. The common bile duct was fully delineated in 98% by MRC and in 70% by ultrasonography. MRC (91%) was more sensitive than ultrasonography (71%) for detecting choledocholithiasis (p < 0.05). MRC demonstrated bile duct stones in all patients with stones > or =11 mm but missed calculi in the 29% of patients with small (3-5 mm) stones. MRC was capable of detecting choledocholithiasis regardless of bile duct caliber. The specificity of MRC (100%) was higher than that of ultrasonography (95%). CONCLUSION: HASTE-MRC, a fast and noninvasive procedure, can accurately diagnose choledocholithiasis although the detectability for small stones is limited.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1998

The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis.

OBJECTIVE: Endoscopic nasobiliary drainage for acute cholangitis is performed with or without endoscopic sphincterotomy. However, sphincterotomy carries a small but important risk of complications. We evaluated the benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. METHODS: A total of 166 patients underwent endoscopic nasobiliary drainage with sphincterotomy (73 patients, sphincterotomy group) or without (93 patients, nonsphincterotomy group). The indications were acute cholangitis due to choledocholithiasis (120 patients) or benign (10 patients) or malignant (36 patients) biliary stricture. Patient backgrounds were similar in the two groups. The outcomes of nasobiliary drainage were compared between the groups. RESULTS: Nasobiliary drainage was successful in 69 patients (95%) in the sphincterotomy group and in 89 (96%) in the nonsphincterotomy group. Efficient drainage was achieved in 67 patients (92%) in the sphincterotomy group and in 87 (94%) in the nonsphincterotomy group. Procedure-related complications developed in eight sphincterotomy-group patients (hemorrhage in three, acute cholecystitis in three, acute pancreatitis in one, catheter withdrawal in one) and in two nonsphincterotomy patients (pancreatitis in one, catheter withdrawal in one) (11% vs 2%; p < 0.05). There were no deaths. CONCLUSIONS: Endoscopic nasobiliary drainage without endoscopic sphincterotomy is a simple, safe, and effective treatment for acute cholangitis. This procedure is especially useful for critically ill patients and those with coagulopathy.

Acute Disease↗