primary biliary cirrhosis (stages I-Ill), five were found to have lymph nodes enlarged to over 1.0 cm in diameter. We speculate that the lower percentage of patients with lymph node enlargement in our study might reflect earlier stages of disease. Furthermore, none of the remaining 122 patients with metabolic or noninflammatory liver disease (eg, steatosis, hemochromatosis, and a-l-antitrypsin deficiency) had enlarged lymph nodes in the porta hepatis. Finally, in our experience, it has never been a problem to distinguish vascular structures from enlarged lymph nodes, particularly with the help of duplex sonography. We were glad to learn that the conclusion made in our study, namely, that enlargement of lymph nodes in the porta hepatis can be a sign of inflammatory liver disease after exclusion of malignant disease, was confirmed in a CT investigation.

neum

of the

fossa,

the

clips.

The

stone

vantage

that

in pri171:731-

1.

Martin

H,

lymph

Vogel

node

er disease.

W,

Dietze

B, Judmaier

enlargement

in

Ultraschall

1989;

the

G.

liver

hilum

The in

significance

2.

EC,

Percutaneous System

Transjejunal

RN,

Access

to the

3.

RN,

Adam

hilar

and

puncture

in

with

rates patients

recurrent

of Roux-en-Y

calculi

after

radiologic

with

primary

jejunal

AG,

tern

colonized

obstructed

mation. Our lems

by

segments,

or strictures.

dilation

are

sclerosing

own

approach

generally

tion

of the

286

#{149}

bacteria and

efferent

Radiology

(4), may

The

5.

Gibson

limb

R.

skin

the ad-

with

infection,

Percutaneous

system.

the

and

the

A,

transjejunal

Radiology

A, Czerniak

1989;

A, et al.

and

Yeung

Benign

biliary

strictures:

management.

Percutaneous

Aust

techniques

J Intervent

strictures.

ap-

172:1031-1034.

radiological

E, et a!.

intrahepatic

Cotton

PB,

1988;

108:546-553.

RN.

J, et a!.

Rode

a light

In:

Louis:

by

and

in

Radiol

ed.

1990;

stent

1988;

blockage

microscopy

radiology

JT,

Mosby,

Biliary

electron

Interventional

Ferrucci

for

Advances

in

benign

with

study.

Ann

biliary

stric-

hepatobiliary

In-

radiology.

St

395-412.

of Increased Lung Scans

Tank

and

complex access

Roux-en-Y

U

for stone biliary

by

superficial

loop

to the

Oxford,

the

OX3

interest

the

authors’

9DU,

England

by

perfusion

microaggregated size only. Thus,

of a pulmonary

segment

on

Hospital

Meignan

issue

et al (1), I was

of Radiology.

criterion (“hot

selection

of increased

tion of injected on is based on

Radcliffe

1989

for excluding spots”) caused

at least

two

views

which surprised

ap-

artifactual by aggrega-

human albumin. hot spots smaller

all

on

BAO

John

article

October

Spots)

This cnitenithan 25%

are

dismissed

as

artifactual and excluded from consideration. This, I believe, might be rather inaccurate. Work by Duffy et al (2) emphasizes that since aggregates of radiopharmaceutical vary in radioactivity and distance from the radiation detector, estimation of their size with lung scintigraphy is difficult. Indeed, many of the hot spots illustrated in that article are certainly larger than 25% of a pulmonary segment. These hot “clots” (3) might

be

more

peripheral

appropriately

location

suspected

(4)

and

focal

basis of their size. In fact, as circular areas of increased ure).

I believe

that

distribution these more

such

hot

the

basis

(2,4)

than

clots

of their on

the

are represented

radiopharmaceutical uptake investigation of radiopharmaceutical

any

on lung definite

most

on

character

perfusion characteristics

scans

should of artifactual

take

(Fig-

into account hot clots.

References 1.

Meignan

M,

creased

perfusion

with 2.

Palmer

pulmonary

Duffy

GJ,

EL,

(hot

AC,

GL,

pulmonary

Strauss

on perfusion

arteriograms.

DeNardo

dioactive

Waltman

spots)

Radiology Abington

emboli

in

Origin

Zones

scans:

1989;

RB. man.

HW.

lung

of in-

correlation

173:47-52. and

Radiology

evolution

1968;

of ra-

91:1175-

3.

Neumann

4.

tilation-perfusion Johnson PM. Semin

RD.

NucI

Sostman

HD,

Gottschalk

A.

imaging. Semin NucI role of lung scanning

The Med

1971;

Current

Med 1980; in pulmonary

status

of yen-

10:198-217. embolism.

1:161-184.

reg-

formasupare

of infection

a nidus

be

with

radiologic

of the

a source

MB, BCh,

of Radiology,

in the

(Hot

1180.

over

(3).

a

Perfusion

F. Massoud,

with

zones

reported

19%-34%

cholangitis

are

well

in patients

is to create

Bixon

biofilm: Med

peared

loops

Martin et al argue that long-term access by means of tube is preferable in at least some patients, since it allows ular flushing, which may help prevent recurrent stone tion. As they point out, there are as yet no good data to port this. Furthermore, tubes placed in the biliary tract rapidly

has

catheter

3:125-130. Speer

Editor: I read

when the loop has not been fixed surgically to the anterior abdominal wall. The second message, which is implicit, is that fixation of Roux-en-Y jejunal loops should be considered at the time of hepaticojejunostomy, especially when dealing with complex biliary problems. It is vital that interventional radiologists encourage our surgical colleagues to do so, in order that simple long-term percutaneous transjejunal biliary access is provided for subsequent stricture dilation or stone extraction, as required. As Martin et al emphasize, the use of both radiologic and surgical approaches to complex biliary strictures can be invaluable. The techniques can be combined in a number of ways (2), but one of the major requirements is the availability of safe and easy long-term radiologic access to the biliary tract. Repeated radiologic procedures are needed in many pa-

50%

Adam

benign

Department

The article by Martin et al (1), which appeared in the Septemben 1989 issue (RSNA-SCVIR special series) of Radiology, contains two important messages for biliary interventional radiologists. The first is the description of a number of innovative techniques for gaining access to the biliary system by means

to deal

KJ, biliary

Gibson

From:

Biliary

Editor:

restenosis

dilation

approach

liv-

Robert N. Gibson, MD,’ Neil A. Collier, MD,2 and Antony G. Speer, MD3 Departments of Radiology,’ Surgery,2 and Gastroenterology,3 Royal Melbourne Hospital Parkvillc, Victoria, Australia 3050

tients

percutaneously

This

leakage, (5).

iliac

of surgical

stricture

drainage

combined surgical 1987; 57:361-368.

Headington,

percutaneous

punctured and

external

right

ring

10:127-131.

From:

of direct

Laffey

a proposed NZ J Surg

U Zones Perfusion

U

be

as necessary. is no

to the

Gibson

of

non-malignant

removal

proaches

tures.

Kathrein

then

the

a

by

References

733. 2.

can

toward

cholangiography

there

bacterial

Lymphadenopathy Radiology 1989;

marked

inherent problems of bile need for regular replacement

References Outwater E, Kaplan MM, Bankoff MS. mary biliary cirrhosis: CT observations.

wall

being

loop

follow-up

and/or

abdominal

of fixation

jejunal

to allow

4.

1.

anterior

site

in

forprobfixa-

penito-

Dr Strauss We

read

difference

responds: with in

interest the

the patients in our al, the artifacts due shown while of the

the

hot

spots

letter

from

Dr

identified

article is the to microsphere

in the figure accompanying those seen in our patients borders of bronchopulmonary

in

shape

Massoud. his

of the clumping

Dr usually

letter

A major and

those

lesions. In are round

Massoud’s followed segments.

in

gener(as

letter), at least part Clearly, when

April

1990