Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set.

BACKGROUND AND OBJECTIVES: Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse. METHODS: We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest. RESULTS: We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure. CONCLUSION: Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada.

BACKGROUND: Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context. METHODS: A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement. RESULTS & CONCLUSION: The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

Feasibility of intraoperative angioembolization for trauma patients using C-arm digital subtraction angiography.

PURPOSE: Hemodynamically unstable trauma patients who would benefit from angioembolization (AE) typically also require emergent surgery for their injuries. The critical decision of transferring a patient to the operating room versus the interventional radiology (IR) suite can be bypassed with the advent of intra-operative AE (IOAE). Previously limited by the availability of costly rooms termed RAPTOR (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using C-arm digital subtraction angiography (DSA) is a comparable alternative. This case series aims to establish the feasibility and safety of IOAE. METHODS: We conducted a retrospective analysis of all trauma patients at our level 1 trauma center who underwent IOAE with a concomitant surgical intervention from January 2011 to May 2019. Descriptive analyses were conducted. RESULTS: A total of 49 patients (80% male, 44 ± 17 years, 92% blunt) underwent IOAE using the C-arm DSA during the study period. All but one patient underwent exploratory laparotomy, 56% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopedic). Either Gelfoam® (Pfizer, New York, USA) (90%), coils (2.0%), or a combination (8.2%) were used for embolization. Internal iliac embolization was performed in 88% of cases (59% bilateral). IOAE was successful in all but four cases (8.2%) and thirty-day mortality was 31%. CONCLUSION: IOAE appears to be a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control.

Modified endoscopic ultrasound-guided double-balloon-occluded gastroenterostomy bypass (M-EPASS): a pilot study.

INTRODUCTION: We recently developed a double-balloon device, using widely available existing technology, to facilitate endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Our aim is to assess the feasibility of this modified approach to EUS-guided double-balloon-occluded gastroenterostomy bypass (M-EPASS). METHODS: This was a single-center retrospective study of consecutive patients undergoing M-EPASS from January 2019 to August 2020. The double-balloon device consists of two vascular balloons that optimize the distension of a targeted small-bowel segment for EUS-guided stent insertion. The primary end point was the rate of technical success. RESULTS: 11 patients (45 % women; mean [standard deviation (SD)] age 64.9 [8.6]) with malignant gastric outlet obstruction were included. Technical and clinical success (ability to tolerate an oral diet) were achieved in 91 % (10/11) and 80 % (8/10) of patients, respectively. There was one adverse event (9 %) due to stent migration. Two patients (18 %) required re-intervention for stent obstruction secondary to food impaction. The mean (SD) time to a low residue diet was 3.5 (2.4) days. CONCLUSION: M-EPASS appears to facilitate the technique of EUS-GE, potentially enhancing its safety and clinical adoption. Larger studies are needed to validate this innovative approach to gastric outlet obstruction.

Hepatic Hilar Nerve Block for Hepatic Interventions: Anatomy, Technique, and Initial Clinical Experience in Thermal Ablation of Liver Tumors.

Background Image-guided procedures for treatment of liver diseases can be painful and require heavy sedation of the patient. Local-regional nerve blocks improve pain control and reduce oversedation risks, but there are no documented liver-specific nerve blocks. Purpose To develop a safe and technically simple liver-specific nerve block. Materials and Methods Between March 2017 and October 2019, three cadavers were dissected to evaluate the hepatic hilar anatomy. The hepatic hilar nerves were targeted with transhepatic placement of a needle adjacent to the main portal vein, under US guidance, and evaluated with use of an injection of methylene blue. A hepatic nerve block, using similar technique and 0.25% bupivacaine, was offered to patients undergoing liver tumoral ablation. In a prospective pilot study, 12 patients who received the nerve block were compared with a control group regarding complications, safety, pain scores, and intraoperative opioid requirement. Student t tests were used to compare the groups' characteristics, and Mann-Whitney U tests were used for the measured outcomes. Results Cadaver results confirmed that the hepatic nerves coursing in the hepatic hilum can be targeted with US for injection of anesthetic agents, with adequate spread of injected methylene blue around the nerves in the hepatic hilar perivascular space. The 12 participants (mean age ± standard deviation, 66 years ± 13; eight men) who received a hepatic hilar block before liver thermal ablations demonstrated reduced pain compared with a control group of 12 participants (mean age, 63 years ± 15; eight men) who received only intravenous sedation. Participants who received the nerve block had a lower mean visual analog scale score for pain than the control group (3.9 ± 2.4 vs 7.0 ± 2.8, respectively; P = .01) and decreased need for intraprocedural fentanyl (mean dose, 152 µg ± 78.0 vs 235.4 µg ± 58.2, respectively; P = .01). No major complications occurred in the hepatic hilar nerve block group. Conclusion A dedicated hepatic hilar nerve block with 0.25% bupivacaine can be safely performed to provide anesthesia during liver tumoral ablation. © RSNA, 2021.

Transhepatic Approach for Retrograde D2 Duodenal Stent Placement: New Technique and Case Series.

Transhepatic duodenal stent placement may be a solution when endoscopy fails or when duodenal and biliary stents are needed simultaneously. This approach is usually not considered as an option when the duodenal stent must be deployed across the ampulla of Vater. The authors present a series of 10 patients who underwent a novel transhepatic technique to place a duodenal stent across the ampulla of Vater by establishing a wire scaffold from the liver toward the jejunum and then curving back on itself retrogradely through the duodenal tumor and out the mouth. Technical success was 90% with no associated mortality.

Overuse of small chest drains for pleural effusions: a retrospective practice review.

PURPOSE: Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place. DESIGN/METHODOLOGY/APPROACH: We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable. FINDINGS: A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03). ORIGINALITY/VALUE: Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

A Preclinical Trial and Molecularly Annotated Patient Cohort Identify Predictive Biomarkers in Homologous Recombination-deficient Pancreatic Cancer.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) arising in patients with a germline BRCA1 or BRCA2 (gBRCA) mutation may be sensitive to platinum and PARP inhibitors (PARPi). However, treatment stratification based on gBRCA mutational status alone is associated with heterogeneous responses. EXPERIMENTAL DESIGN: We performed a seven-arm preclinical trial consisting of 471 mice, representing 12 unique PDAC patient-derived xenografts, of which nine were gBRCA mutated. From 179 patients whose PDAC was whole-genome and transcriptome sequenced, we identified 21 cases with homologous recombination deficiency (HRD), and investigated prognostic biomarkers. RESULTS: We found that biallelic inactivation of BRCA1/BRCA2 is associated with genomic hallmarks of HRD and required for cisplatin and talazoparib (PARPi) sensitivity. However, HRD genomic hallmarks persisted in xenografts despite the emergence of therapy resistance, indicating the presence of a genomic scar. We identified tumor polyploidy and a low Ki67 index as predictors of poor cisplatin and talazoparib response. In patients with HRD PDAC, tumor polyploidy and a basal-like transcriptomic subtype were independent predictors of shorter survival. To facilitate clinical assignment of transcriptomic subtype, we developed a novel pragmatic two-marker assay (GATA6:KRT17). CONCLUSIONS: In summary, we propose a predictive and prognostic model of gBRCA-mutated PDAC on the basis of HRD genomic hallmarks, Ki67 index, tumor ploidy, and transcriptomic subtype.

Predictors of Mortality from Spontaneous Soft-Tissue Hematomas in a Large Multicenter Cohort Who Underwent Percutaneous Transarterial Embolization.

Purpose To evaluate the safety and efficacy of percutaneous transarterial embolization (PTAE) for the treatment of spontaneous soft-tissue hematomas (SSTHs) and identify variables predictive of short-term outcome. Materials and Methods Between 2011 and 2017, the outcome was retrospectively analyzed for 112 patients (mean age ± standard deviation, 72 years ± 14; range, 28-92 years), including 65 women (mean age, 73 years ± 12.7; range, 39-92 years) and 47 men (mean age, 70 years ± 14.9; range, 28-91 years), with SSTH treated with PTAE. Thirty-day mortality, technical and clinical success, simplified acute physiology score (SAPS) II, anticoagulation, embolic agent, hematoma volume and location, serum hemoglobin level, hemodynamic instability, and presence of active bleeding at CT and/or angiography were recorded. Clinical success was defined as cessation of bleeding as determined by hemodynamic stability and/or serum hemoglobin level stabilization after PTAE. Univariable and multivariable analyses were performed by using a Cox model to identify variables associated with time to death. Results Mortality rate was 26.8% (30 of 112 patients), angiographic success rate was 95.5% (107 of 112 patients), and clinical success rate was 83% (93 of 112 patients). For surviving patients, mean SAPS II was 19.6 ± 7.1 (range, 13-31) and mean hematoma volume was 862 cm3 ± 618 (range, 238-1887 cm3). For deceased patients, mean SAPS II was 42 ± 13.2 (range, 18-63) and mean hematoma volume was 1419 cm3 ± 788 (range, 251-3492 cm3). SAPS II (P < .001), hematoma volume (P = .01), and retroperitoneal location (P = .01) were independently associated with fatal outcome. Conclusion Percutaneous transarterial embolization is effective for the emergency treatment of spontaneous soft-tissue hematomas. Simplified acute physiology score II, hematoma volume, and retroperitoneal location are predictors of short-term outcome. © RSNA, 2019 Online supplemental material is available for this article.

Transcatheter Arterial Embolization of Spontaneous Soft Tissue Hematomas: A Systematic Review.

BACKGROUND: Severe spontaneous soft tissue hematomas (SSTH) are usually treated with transcatheter arterial embolization (TAE) although only limited retrospective studies exist evaluating this treatment option. The aim of this study was to systematically assess the efficacy and safety of TAE for the management of SSTH. METHODS: Medline, EMBASE, PubMed and Cochrane Library were searched from inception to July 2017 using MeSH headings and a combination of keywords. Eligibility was restricted to original studies with patients suffering from SSTH treated with TAE. Patients with traumatic hematomas or who were treated with solely conservative or surgical management were excluded. For each publication, clinical success based on the control of the bleed, rebleeding rates and complications (including mortality) was collected, as well as technical details. RESULTS: Sixty-three studies met the inclusion criteria, with an aggregate total of 267 patients. Follow-up extended from 1 day to 10 years. Bleeding was mainly localized to the iliopsoas (n = 113/267, 42.3%) and anterior abdominal wall (n = 145/266, 54.7%). When information was available, 81.0% (n = 158/195) of patients were on anticoagulant therapy prior to the bleeding episode. Initial stabilization with control of the bleed was obtained in 93.1% (n = 242 patients, n = 60 studies). The most common embolic materials were coils (n = 129, 54.4%). Rebleeding was reported in 25 patients (9.4%). Only two embolization complications were reported (0.7%). The 30-day mortality was 22.7% (n = 42/1857). CONCLUSION: TAE represents a safe and effective procedure in the management of SSTH. We present a management algorithm based on these data, but further studies are needed to address the knowledge gap.

Interventional Radiology in Canada: Current Challenges and Future Directions.

OBJECTIVE: We aim to define the practice of interventional radiology (IR) in Canada, barriers that have been faced by interventional radiologists, and ways in which the Canadian Interventional Radiology Association (CIRA) have attempted to address these issues. CONCLUSION: IR has faced significant challenges in the Canadian setting. Recognizing the need to address these challenges, leaders in the field of IR in Canada founded the CIRA to serve as our national voice and lobby group.

Superior Hypogastric Nerve Block as Post-Uterine Artery Embolization Analgesia: A Randomized and Double-Blind Clinical Trial.

Purpose To evaluate the effectiveness of superior hypogastric nerve block (SHNB) in reducing narcotic use after uterine artery embolization (UAE). Materials and Methods This study was a prospective, randomized, double-blind, parallel clinical trial in patients referred to a tertiary care university teaching hospital for UAE. Forty-four participants were enrolled (mean age, 46 years; range, 32-56 years). No consenting patient was excluded. All participants were randomized 1:1 to undergo either a sham procedure or SHNB. There were 22 participants in each group. One participant was lost to follow-up regarding home survey results. Use of narcotics and antiemetics was recorded in-hospital. Pain scores were recorded at home for 10 days with use of a visual analog scale (range, 1-10). Statistical analysis was performed by using the t test and χ2 test, with P < .05 considered indicative of a statistically significant difference. The full study protocol can be found at www.clinicaltrials.gov (NCT02270255). Results Participant demographic characteristics, fibroid volume, symptoms, and perceived sensitivity to pain were similar in both groups. Immediately after embolization, the pain score was lower in the SHNB group than in the sham group (mean, 1.0 ± 2.1 vs 2.6 ± 2.0, respectively; P = .01). The total need for fentanyl in the postanesthesia care unit was lower in the SHNB group than in the sham group (mean, 56 µg ± 67 vs 124 µg ± 91, respectively; P = .009). The morphine-equivalent dose needed was lower in the SHNB group than in the sham group (mean, 5.1 mg ± 5.8 vs 11.0 mg ± 9.0, respectively; P = .014). Of the 22 participants in the SHNB group, five (23%) needed antiemetics versus 12 of 22 participants (55%) in the sham group (P = .03). No difference in hospital admissions was observed between the two groups, and no major complications occurred from the SHNB. Conclusion Use of superior hypogastric nerve block reduces the amount of pain-related narcotics and antiemetics after uterine artery embolization. © RSNA, 2018.

Percutaneous cholecystostomy: A simple bridge to surgery or an alternative option for the management of acute cholecystitis?

BACKGROUND: Percutaneous cholecystostomy (PC) is an alternative among high-risk surgical patients or those with multiple comorbidities, but its indications have not been clearly established in the literature. The aim of this paper is to provide the reader with an updated review of the literature summarizing what is known on this topic. DATA SOURCES: We reviewed articles from 1979 to 2016 using the PubMed/Medline Database on PC and especially those evaluating this option as a bridge to surgery. CONCLUSIONS: There remains a paucity of randomized control trials to ascertain the use of PC as a definitive treatment for acute cholecystitis. In most studies, more than 50% of patients underwent PC as a definite treatment without subsequent cholecystectomy. A newer avenue of endoscopic ultrasound is also discussed, which requires rigorous trials to determine its appropriate applications.