Part 2: Current Concepts in Radiologic Imaging & Intervention in Acute Biliary Tract Diseases.

Acute cholangitis is encountered commonly in critically ill, often elderly, patients. The most common causes of cholangitis include choledocholithiasis, biliary strictures, and infection from previous endoscopic, percutaneous, or surgical intervention of the biliary tract. Rare causes of acute cholangitis in the United States include sclerosing cholangitis and recurrent pyogenic cholangitis, the latter predominantly occurring in immigrants of Asian descent. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, gastroenterologists, endoscopists, and infectious disease physicians typically involved in the care of these patients. In this paper intended for intensivists predominantly, we will review the imaging findings and radiologic interventional management of critically ill patients with acute cholangitis, primary and secondary sclerosing cholangitis, and recurrent pyogenic cholangitis.

Part 1: Current Concepts in Radiologic Imaging and Intervention in Acute Cholecystitis.

Acute calculous cholecystitis and acute acalculous cholecystitis are encountered commonly among critically ill, often elderly, patients. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, infectious disease physicians, gastroenterologists, and endoscopists able to contribute to patient care. In this article intended predominantly for intensivists, we will review the imaging findings and radiologic treatment of critically ill patients with acute calculous cholecystitis and acute acalculous cholecystitis.

Transitioning from interventional radiology: ideas for the inevitable.

BACKGROUND: Interventional Radiology (IR) is a highly rewarding specialty, both for its salutary effects for patients, as will as the satisfaction it provides for the operating radiologists. Nonetheless, arduous work and long hours have led to numerous reports of burnout amongst interventional radiologists (IRs). MATERIALS AND METHODS: Six long-term academic radiologists in leadership positions briefly chronicle their becoming IRs, their type of transitioning from IR, and the pros and cons of those respective transitions. RESULTS: The specific transitions include reduced time in IR, switching to diagnostic radiology, becoming involved in medical school education, ceasing IR leadership, and retirement. Pros and cons of the various transition strategies are highlighted. CONCLUSION: As the taxing work and long hours are so ubiquitous for IRs, and as burnout is so common, transitioning from IR is highly likely eventually for IRs. The varied transition experiences highlighted in this report hopefully will be helpful for current and aspiring IRs.

Percutaneous treatment of renal tumours.

Image-guided ablation is an accepted treatment option in the management of renal cell carcinoma. Percutaneous renal ablation offers the possibility of minimally invasive treatment while attempting to preserve renal function. Over the past several years there have been advances in tools and techniques that have improved procedure safety and patient outcomes. This article provides an updated comprehensive review of percutaneous ablation in the management of renal cell carcinoma.

Image-Guided Percutaneous Omental and Mesenteric Biopsy: Assessment of Technical Success Rate and Diagnostic Yield.

PURPOSE: To assess biopsy technique, technical success rate, and diagnostic yield of image-guided percutaneous biopsy of omental and mesenteric lesions. MATERIALS AND METHODS: This retrospective study included 186 patients (89 men, 97 women; mean [SD] age, 63 [13.8] y) who underwent percutaneous image-guided biopsy of omentum and mesentery between March 2007 and August 2015. Biopsies were performed with computed tomography (CT) (n = 172) or ultrasound (US) (n = 14) guidance using coaxial technique yielding core and fine-needle aspiration (FNA) specimens. Biopsy results were classified as diagnostic (neoplastic or nonneoplastic) or nondiagnostic based on histopathology and cytology. Technical success rate and diagnostic yield of omental and mesenteric lesions were calculated. RESULTS: There were 186 image-guided percutaneous biopsies of omental (n = 95) and mesenteric (n = 91) lesions performed. Technical success rate was 99.5% for all biopsies, 100% for omental biopsies, and 98.9% for mesenteric biopsies. Overall sensitivity was 95.5%, specificity was 100%, negative predictive value was 78.3%, and positive predictive value was 100%, which was comparable for omental and mesenteric biopsies. Core biopsies had higher diagnostic yields compared with FNA: 98.4% versus 84% overall, 99% versus 88% for omental biopsies, and 97.7% versus 80% for mesenteric biopsies. Spearman rank correlation showed no correlation between lesion size and diagnostic yield (P = .14) and lesion depth and diagnostic yield (P = .29) for both groups. There were 5 complications. CONCLUSIONS: Image-guided percutaneous omental and mesenteric biopsies have high technical success rates and diagnostic yield regardless of lesion size or depth from the skin for both omental and mesenteric specimens.

Long-Term Outcomes Following Percutaneous Cholecystostomy Tube Placement for Treatment of Acute Calculous Cholecystitis.

INTRODUCTION: Percutaneous cholecystostomy tube (PCT) placement is considered a safe alternative to cholecystectomy for the treatment of acute calculous cholecystitis (ACC), but data regarding long-term outcomes following PCT are limited. METHODS: We retrospectively reviewed our institutional experience of patients undergoing PCT for ACC between 1997 and 2015. Recurrent biliary events were defined as cholecystitis, cholangitis, or gallstone pancreatitis. RESULTS: PCT was placed for 288 patients with ACC. Mean age and age-adjusted Charlson comorbidity index were 72 ± 15 years and 5.3 ± 2.4, respectively. Following PCT placement, 91% of patients successfully resolved their episode of ACC. PCT dysfunction occurred in 132 patients (46%), with 80 patients (28%) requiring re-intervention, while 7% developed procedure-related complications. Interval cholecystectomy reduced the risk of recurrent biliary events to 7% from 21% (p = 0.002). Cholecystectomy was completed laparoscopically in 45% of patients receiving an interval operation vs. 22% of those undergoing urgent surgery for PCT failure or recurrent biliary event (p = 0.03). CONCLUSIONS: PCT placement is a highly successful treatment for acute calculous cholecystitis and is associated with low complication rate, but high rate of tube dysfunction requiring frequent re-intervention. Interval cholecystectomy is associated with a decreased likelihood of recurrent biliary events and increased likelihood of successful laparoscopic completion.

High-Content Biopsies Facilitate Molecular Analyses and Do Not Increase Complication Rates in Patients With Advanced Solid Tumors.

PURPOSE: Precision oncology relies on frequent pathologic, molecular, and genomic assessments of tumor tissue to guide treatment selection, evaluate pharmacodynamic effects of novel agents, and determine drug resistance mechanisms. Newer forms of analyses such as drug screens in cell lines and patient-derived xenografts demand increasing amounts of tissue material. It remains unknown how the need for serial biopsies with large numbers of tumor cores relates to tissue yields and biopsy complication rates. MATERIALS AND METHODS: In this study, we performed a retrospective analysis of 199 focal liver biopsies performed in 143 patients in the setting of oncologic research protocols (research biopsy group) over a 4-year period at a single-intervention oncology service. Practice patterns and complication rates were compared with those related to 1,522 consecutive biopsies performed in 1,154 patients in whom two cores were obtained for standard clinical management of patients (standard biopsy). RESULTS: In the research biopsy group, 1,100 tissue cores (average, 5.5 cores per procedure) were harvested and distributed to trial sponsors, internal research laboratories, and pathology services. The complication rate in this cohort was 0.5% for major complications (one of 199) and 1.0% for minor complications managed conservatively (two of 199). In the standard biopsy control group, major complications were observed in 1.4% of procedures (22 of 1,522) and minor complications in 0.2% (three of 1,522). These complication rates were not statistically different. CONCLUSION: Harvesting extra tissue cores through coaxial needles during focal liver biopsies does not increase complication rates and yields valuable tissue for additional experimental testing.

Combined endoscopic trangastric drainage and video assisted retroperitoneal pancreatic debridement - The best of both worlds for extensive pancreatic necrosis with enteric fistulae.

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas.

Revenue Potential for Inpatient IR Consultation Services: A Financial Model.

PURPOSE: Interventional radiology (IR) has historically failed to fully capture the value of evaluation and management services in the inpatient setting. Understanding financial benefits of a formally incorporated billing discipline may yield meaningful insights for interventional practices. MATERIALS AND METHODS: A revenue modeling tool was created deploying standard financial modeling techniques, including sensitivity and scenario analyses. Sensitivity analysis calculates revenue fluctuation related to dynamic adjustment of discrete variables. In scenario analysis, possible future scenarios as well as revenue potential of different-size clinical practices are modeled. RESULTS: Assuming a hypothetical inpatient IR consultation service with a daily patient census of 35 patients and two new consults per day, the model estimates annual charges of $2.3 million and collected revenue of $390,000. Revenues are most sensitive to provider billing documentation rates and patient volume. A range of realistic scenarios-from cautious to optimistic-results in a range of annual charges of $1.8 million to $2.7 million and a collected revenue range of $241,000 to $601,000. Even a small practice with a daily patient census of 5 and 0.20 new consults per day may expect annual charges of $320,000 and collected revenue of $55,000. CONCLUSIONS: A financial revenue modeling tool is a powerful adjunct in understanding economics of an inpatient IR consultation service. Sensitivity and scenario analyses demonstrate a wide range of revenue potential and uncover levers for financial optimization.

Catecholamine Surge during Image-Guided Ablation of Adrenal Gland Metastases: Predictors, Consequences, and Recommendations for Management.

PURPOSE: To identify retrospectively predictors of catecholamine surge during image-guided ablation of metastases to the adrenal gland. MATERIALS AND METHODS: Between 2001 and 2014, 57 patients (39 men, 18 women; mean age, 65 y ± 10; age range, 41-81 y) at two academic medical centers underwent ablation of 64 metastatic adrenal tumors from renal cell carcinoma (n = 27), lung cancer (n = 23), melanoma (n = 4), colorectal cancer (n = 3), and other tumors (n = 7). Tumors measured 0.7-11.3 cm (mean, 4 cm ± 2.5). Modalities included cryoablation (n = 38), radiofrequency (RF) ablation (n = 20), RF ablation with injection of dehydrated ethanol (n = 10), and microwave ablation (n = 4). Fisher exact test, univariate, and multivariate logistical regression analysis was used to evaluate factors predicting hypertensive crisis (HC). RESULTS: HC occurred in 31 sessions (43%). Ventricular tachycardia (n = 1), atrial fibrillation (n = 2), and troponin leak (n = 4) developed during HC episodes. HC was significantly associated with maximum tumor diameter ≤ 4.5 cm (odds ratio [OR], 26.36; 95% confidence interval [CI], 5.26-131.99; P < .0001) and visualization of normal adrenal tissue on CT or MR imaging before the procedure (OR, 8.38; 95% CI, 2.67-25.33; P < .0001). No HC occurred during ablation of metastases in previously irradiated or ablated adrenal glands. CONCLUSIONS: Patients at high risk of catecholamine surge during ablation of non-hormonally active adrenal metastases can be identified by the presence of normal adrenal tissue and tumor diameter ≤ 4.5 cm on pre-procedure CT or MR imaging.

A Quality Improvement Initiative to Reduce Catheter Exchange Rates for Fluoroscopically Guided Gastrostomy Tubes.

PURPOSE: To evaluate the effectiveness of a data-driven quality improvement initiative to reduce catheter exchange rates. MATERIALS AND METHODS: A single-institution retrospective analysis of all percutaneous radiologic gastrostomy (PRG) placement and replacement procedures between January 2010 and July 2015 was conducted. A statistical model predicting the risk for catheter exchange for any reason and exchanges specifically for tube malfunction was created; a quality improvement plan to reduce catheter exchanges was designed and implemented in June 2014. The outcomes for subsequent PRG procedures from July 2014 through March 2015 were followed until July 2015. RESULTS: Between 2010 and June 2014, 1,144 primary PRG procedures and 442 replacement procedures were performed in 1,112 patients. Of the 442 exchange procedures, 289 were "rescue" procedures secondary to catheter malfunction. A quality improvement plan was implemented in June 2014 that encouraged primary gastrojejunostomy catheter and balloon-retained PRG catheter placement and placement of skin sutures in patients considered high risk for catheter dislodgment. From July 2014 through March 2015, 229 PRG catheters were placed, and 71 exchange procedures were performed through July 2015. There was a statistically significant decrease in the number of rescue exchanges performed secondary to catheter malfunction (P = .036). CONCLUSIONS: Procedural and patient-specific risk factors for PRG complications were identified, and a statistical model to predict rates of minor complications was created. These findings were used to implement a quality improvement program that resulted in a decrease in PRG exchanges secondary to catheter malfunction.

Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage.

BACKGROUND: Percutaneous drainage is the standard treatment for perforated appendicitis with abscess. We studied factors associated with complete resolution (CR) with percutaneous drainage alone. METHODS: Ninety-eight patients underwent percutaneous drainage for acute appendicitis complicated by abscess (October 1990 to September 2010). CR was defined as clinical recovery, resolution of the abscess on imaging, and drain removal without recurrence. Patients achieving CR were compared with patients not achieving CR. RESULTS: The rate of CR was 78.6% (n = 77). Abscess grade was the only radiological factor associated with CR (P = .007). The CR rate was higher with transgluteal drainage (90.9% vs 79.2%) than with other anatomic approaches (P = .018) and higher with computed tomography-guided drainage than with ultrasound-guided drainage (82.7% vs 64.3%, P = .046). CONCLUSION: CR was more likely to be achieved in patients with lower abscess grade, computed tomography-guided drainage, and a transgluteal approach.

Nonvascular Interventional Procedures in an Urban General Hospital: Analysis of 2001-2010 with Comparison to the Previous Decade.

RATIONALE AND OBJECTIVES: To determine trends in nonvascular image-guided procedures at an urban general hospital over a 10-year period and to compare utilization of nonvascular interventional radiology (IR) over the decade 2001-2010 to a previously reported analysis for 1991-2000. METHODS: With institutional review board approval, a 20-year quality assurance database verified against the radiology information system was queried for procedure location (eg, pleura, liver, bowel, and abdomen) and type (eg, biopsy, catheter insertion, and transient drainage), demographics, and change over time. Yearly admissions and new hospital numbers assigned each year served to normalize for overall hospital activity. RESULTS: A total of 50,195 IR procedures were performed in 24,309 distinct patients (male:female, 12,625:11,684; average age, 60 years), 940 procedures performed in age <20 years, and 571 procedures performed in patients aged ≥90 years. A total of 15345, 4377, and 1754 patients had one, two, or three procedures, respectively; 470 had ≥10 procedures. Twenty-seven supervising radiologists and 277 individuals participated as operators, double the previous decade. Biopsy (4.8% average yearly increase), abdominal drainage (7.3%), paracentesis (12.9%), tube manipulation (13.0%), suprapubic bladder tube insertion (21.0%), and gastrostomy (44.6%) all increased strongly (P < .001) over 120 months but not biliary drainage, nephrostomy, or chest tubes. Procedures increased faster than either admissions or new hospital numbers (P < .001). For each 1000 new hospital numbers, IR service performed 48 procedures versus 31 the previous decade (P < .0005). CONCLUSIONS: Referrals for nonvascular IR procedures have doubled over 2 decades, outpacing growth in new hospital patients and requiring increased resource allocation.

Palliative gastrostomy in the setting of voluminous ascites.

OBJECTIVE: We report the indications, methods, and complications of percutaneous gastrostomy/gastrojejunostomy (G/GJ) in patients with voluminous ascites. METHODS: Following institutional review board approval, 69 patients (14 male, 55 female, mean age 58±12 years, range 32-89 years) who underwent percutaneous G/GJ with paracentesis were identified from a prospectively acquired database. Electronic medical record data extracted included diagnosis, method of G/GJ insertion, clinical course, and complications, which were graded by The Society of Interventional Radiology (SIR) criteria. Statistics were performed using Graphpad Instat. RESULTS: Sixty-six G and three GJ catheters were placed in 62 patients with malignant and 7 patients with benign disease; 47 procedures were conducted using fluoroscopy and 22 using computed tomography (CT; 10 patients had failed fluoroscopy). Sixty-six patients had 1980±1371 mL (range, 20-5000 mL) ascites drained (more in males, p=0.01) 0.8±1.6 days (range, 0-5 days) prior to placement. Forty-one patients had significantly less ascites (1895±1426 mL; range, 100-5400 mL) drained after G/GJ (p>0.0.5). Mean survival after insertion was 43±57 days (range, 1-252 days) among 38 patients for whom data were available. Fifty-six patients had a mean postprocedure hospital stay of 8.6±8.4 days (range, 0-45 days); 3 were outpatients and 10 patients died in the hospital. Successful gastropexy was confirmed on subsequent cross-sectional imaging in 22 of 25 patients. There were 25 tube maintenance issues that included catheter displacement and leakage, one patient experienced hemorrhage, and there were two deaths. All except one patient had satisfactory gastrostomy function. CONCLUSION: Effective G/GJ placement is possible in most patients with voluminous ascites provided ascites is drained and gastrocutaneous fistula formation occurs. Caution is advised; placement is generally for fragile terminal patients, and fluoroscopy or CT guidance is required.