Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology.

For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.

Management of single double-J stent failure in malignant ureteral obstruction: tandem ureteral stenting with less frequent stent exchange

PURPOSE: To evaluate the safety and efficacy of the placement and exchange of tandem ureteral stents (TUS) under fluoroscopic guidance in the management of indwelling single double-J stent (DJS) failure in patients with malignant ureteral obstruction. We also aimed to investigate whether the generally accepted exchange period of DJSs could be extended using TUS. METHODS: This retrospective study involved 11 patients (10 female) with an age range of 27-64 years, median of 49 years, who underwent TUS (ipsilateral two 8F DJSs) placement due to indwelling single DJS failure occurring in less than 3 months. TUS exchanges were performed initially at 6-month intervals, and subsequent exchange intervals were extended to 9 and 12 months for seven patients. The interval from initial TUS placement to percutaneous nephrostomy, repeat exchange, or death was defined as the duration of stent patency. RESULTS: Indwelling single DJS failure occurred during a median follow-up of 45 days (range, 35-60 days) in 14 ureters of 11 patients. TUS were successfully placed and exchanged with a technical success rate of 100% without any early major complications. Thirty-nine procedures (11 placement and 28 exchange procedures) in 55 ureters were performed. The median duration of urinary patency was significantly higher with TUS [300 days (range, 60-440 days)] compared with single DJSs [45 days (range, 35-60 days)] (P < 0.001). CONCLUSION: The placement and exchange of TUS can be safely and effectively performed under fluoroscopic guidance. The need for frequent DJS exchange could be reduced with increased duration of stent patency using TUS.

A Review on the Concepts for Initially Unresectable Liver Tumors - Bridge to Surgery.

Surgical treatments of advanced tumors have expanded in the last two decades as a result of ad-vances in surgical techniques, advanced interventional radiology methods, improved intensive care unit settings and increased overall life expectancy. Advanced liver tumors represent a broad category from various malignancies such as liver metastasis or native liver tumors. Not uncom-monly these tumors are not amenable to curative treatment and require down-staging, or local control at the initial diagnosis. Herein we discuss the portal vein embolization (PVE), transarterial radioembolization (TARE) with Yttrium-90 (Y-90), and surgical options namely, two-staged hepatectomy (TSH), and associating liver partition and portal vein ligation for staged hepatecto-my (ALPPS) as bridging strategies for definitive surgical treatment.

Radioembolization Followed by Transarterial Chemoembolization in Hepatocellular Carcinoma.

BACKGROUND AND OBJECTIVE: In recent years, combination therapies for hepatocellular carcinoma (HCC) have been increasingly used with superior treatment responses compared to monotherapies. However, the safety and efficacy of the transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) combinations for HCC patients have not been investigated in the literature. In this study, our aim was to evaluate the safety and outcomes of TACE after TARE in HCC patients. MATERIALS AND METHODS: All TARE procedures performed on HCC patients at a single institution between January 2008 and November 2016 were retrospectively reviewed. Seventy-three patients who did not receive any additional transarterial therapy in the areas targeted by TARE were assigned to the "TARE group," while 27 patients who received TACE after TARE to the same target area were assigned to the "Combo group." Post-procedural liver toxicity, tumor response, overall survival (OS), and time to progression (TTP) were evaluated. RESULTS: Fewer patients in the Combo group had worsening liver function than the TARE group based on the change in bilirubin levels (19% vs. 40%; p=0.029) and Child-Pugh score increase (28% vs. 51%; p=0.056). The median OS time of all patients was 11.04 months. The Combo group had a significantly longer median OS of 36.8 months (vs. 10.6, p=0.003) and median TTP of 14.4 months (vs. 5.5, p=0.018). After accounting for selection bias, OS and TTP were still in favor of the Combo group, with hazard ratios of 0.651 (p<0.05) and 0.63 (p<0.05), respectively. CONCLUSION: The addition of TACE to TARE is a safe and effective treatment in unresectable HCC patients and can be considered in select patients with a lack of complete response or disease progression.

Evaluation of staging systems to predict prognosis in hepatocellular carcinoma patients treated with radioembolization.

PURPOSE: To compare the prognostic accuracy of nine staging systems, some of which are well-known and some of which have only been more recently described, for patients with unresectable HCC treated with radioembolization (RE). MATERIALS AND METHODS: Individual scores or classes for the following staging systems were recorded or calculated for patients (n = 89) with unresectable HCC who underwent RE at a single tertiary care center from January 2008 to October 2016: Eastern Cooperative Oncology Group, Barcelona Clinic Liver Cancer, Hong Kong Liver Cancer, Okuda, Cancer of the Liver Italian Program (CLIP), Model for End Stage Liver Disease, Child-Pugh (CP) Categorical and Numeric, and Albumin-Bilirubin. For each staging system, a cox proportional hazards regression model was fit to the data and log-rank test statistics, concordance indices, Akaike Information Criteria (AIC) and other diagnostic statistics were calculated. RESULTS: Of the nine staging systems analyzed, the basic discriminatory ability assessed with the log-rank test (rejected at the α = .05-level) was significant for two of the systems: CP Numeric (p < .001) and CLIP (p < .05). Out of these two systems, CP Numeric system had a higher prognostic accuracy than CLIP with the lowest AIC (464.90), the highest optimism-corrected pseudo R2 (0.16), and the highest estimated concordance index (0.64). CONCLUSION: As applied to our patient population, the CP Numeric system contained the most predictive prognostic information for patients with HCC undergoing radioembolization. However, all evaluated staging systems performed suboptimally, and the relative superiority of any of the systems remains unclear when ranking them according to common practice. Further evaluation of current ranking methodologies is recommended.

Superselective embolization in posttraumatic high-flow priapism.

We present a case of a 24 year old man who presented with high flow priapism. Priapism is defined as an erection lasting four or more hours, either after or unrelated to sexual stimulation. Priapism can be categorized into low-flow, stuttering, and high-flow types, each with unique mechanisms and treatments. High-flow priapism is caused by an abnormal communication between the artery and sinusoids of the penis, often in the form of an arteriovenous fistula. Super-selective embolization is the treatment of choice for high-flow priapism if conservative measures fail. Super-selective embolization is associated with an 80% success rate and a low chance of post-procedure erectile dysfunction.

Peripancreatic Fluid Collections After Pancreas Transplant: Safety and Efficacy of Percutaneous Drainage.

OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of percutaneous drainage of peripancreatic fluid collections after pancreas transplant and to determine factors predicting a successful clinical outcome. MATERIALS AND METHODS. This single-center retrospective study included 28 patients who underwent percutaneous drainage for peripancreatic collections after transplant between January 2008 and December 2018. Clinical success was defined as drainage resulting in resolution of symptoms. Primary clinical success was defined as symptom resolution after the initial drainage procedure, and secondary success was defined as symptom resolution after additional drainage procedures. Operative intervention or death was considered clinical failure. Patient, collection, and procedural factors were assessed for their potential impact on the clinical outcome. RESULTS. Clinical success was achieved in 23 of 28 drainage procedures (82.1%), with primary success in 15 procedures. Of the five patients with failed drainage procedures, three required pancreatectomies, one required surgical washout, and one died from a disseminated infection. The median duration of drainage in the clinical success group was 25 days (range, 3-136 days), and patients with longer drainage periods had more successful outcomes (p = .04). Graft pancreatitis was diagnosed in five patients (17.9%) and was not associated with drainage outcome (p = .21). Collections were positive for bacterial growth in 13 patients (46.4%) and were high in amylase in 12 (42.9%). We observed drainage failure in collections with polymicrobial growth and in the presence of fistulas (p = .05 and p = .07, respectively). Patients with successful outcomes had smaller collection volumes (p = .045). No complications attributed to drainage were encountered. CONCLUSION. Percutaneous drainage is safe and effective for management of peripancreatic fluid collections after pancreas transplant.

A Quantitative Digital Subtraction Angiography Technique for Characterizing Reduction in Hepatic Arterial Blood Flow During Transarterial Embolization.

OBJECTIVE: There is no standardized and objective method for determining the optimal treatment endpoint (sub-stasis) during transarterial embolization. The objective of this study was to demonstrate the feasibility of using a quantitative digital subtraction angiography (qDSA) technique to characterize intra-procedural changes in hepatic arterial blood flow velocity in response to transarterial embolization in an in vivo porcine model. MATERIALS AND METHODS: Eight domestic swine underwent bland transarterial embolizations to partial- and sub-stasis angiographic endpoints with intraprocedural DSA acquisitions. Embolized lobes were assessed on histopathology for ischemic damage and tissue embolic particle density. Analysis of target vessels used qDSA and a commercially available color-coded DSA (ccDSA) tool to calculate blood flow velocities and time-to-peak, respectively. RESULTS: Blood flow velocities calculated using qDSA showed a statistically significant difference (p < 0.01) between partial- and sub-stasis endpoints, whereas time-to-peak calculated using ccDSA did not show a significant difference. During the course of embolizations, the average correlation with volume of particles delivered was larger for qDSA (- 0.86) than ccDSA (0.36). There was a statistically smaller mean squared error (p < 0.01) and larger coefficient of determination (p < 0.01) for qDSA compared to ccDSA. On pathology, the degree of embolization as calculated by qDSA had a moderate, positive correlation (p < 0.01) with the tissue embolic particle density of ischemic regions within the embolized lobe. CONCLUSIONS: qDSA was able to quantitatively discriminate angiographic embolization endpoints and, compared to a commercially available ccDSA method, improve intra-procedural characterization of blood flow changes. Additionally, the qDSA endpoints correlated with tissue-level changes.

Combination transarterial chemoembolization and microwave ablation improves local tumor control for 3- to 5-cm hepatocellular carcinoma when compared with transarterial chemoembolization alone.

PURPOSE: To compare transarterial chemoembolization (TACE) monotherapy to combination TACE and microwave ablation (MWA) for local control of 3- to 5-cm hepatocellular carcinoma (HCC). METHODS: Patients with HCC between 3 and 5 cm treated with TACE monotherapy or combination TACE + MWA at a single institution between 2007 and 2016 were retrospectively reviewed. Twenty-four HCCs (median diameter 3.8 cm) in 16 patients (13 males; median age 64 years) were treated using TACE monotherapy. Combination TACE + MWA was used to treat 23 HCCs (median diameter 4.2 cm) in 22 patients (18 males; median age 61 years). Microwave ablation was performed at a target time of two weeks following TACE. Individual tumors were followed by serial contrast-enhanced CT or MR. Response to treatment was evaluated on a tumor-by-tumor basis using mRECIST criteria with the primary outcome being local tumor progression (LTP). Data were analyzed using Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Time to LTP was estimated with the Kaplan-Meier method. RESULTS: Relative to TACE monotherapy, TACE + MWA provided a trend toward both a lower rate of LTP (34.8% vs. 62.5%, p = 0.11) and a higher complete response rate (65.2% vs. 37.5%; p = 0.12). Time to LTP (22.3 months vs. 4.2 months; p = 0.001) was significantly longer in the TACE + MWA group compared to TACE monotherapy. CONCLUSIONS: Combination therapy with TACE and microwave ablation improves local control and increases time to LTP for 3-5 cm HCC.

Complex Inferior Vena Cava Filter Retrieval Complicated by Migration of Filter Fragment into the Aorta and Subsequent Distal Embolization.

In 2005, a 48-year-old man with a spinal cord injury had an inferior vena cava filter placed for recurrent deep vein thrombosis and pulmonary embolism. He was referred for filter retrieval after a computed tomography scan demonstrated caval stenosis and 2 fractured filter arms, 1 in a pulmonary artery and 1 penetrating into the retroperitoneum and impinging on the aorta. During retrieval, 1 arm was inadvertently advanced into the aorta, and embolization of the arm occurred to the left profunda femoris artery. It was subsequently retrieved. This is the first reported case to the authors' knowledge of migration and embolization of a filter fragment into the systemic arterial system.

Safe and easy access technique for the first trocar in laparoscopic surgery.

BACKGROUND: Access-related injuries are still an important consideration and may increase morbidity and mortality. This study aimed to present in detail a safe and easy technique for open insertion of the first trocar. PATIENTS AND METHODS: This technique has been used routinely in the vast majority of laparoscopic procedures at first author's department since 1998. The data were collected prospectively and analyzed retrospectively for the 11-year period of January 2005 through December 2015. The primary site of access is the umbilicus, but this technique can be used for all insertion points. RESULTS: A total of 2579 laparoscopic surgical interventions were performed. The abdominal access was established in 2252 patients in open and in 321 cases with blind puncture using a Veress needle. There were three cases (0.9 %) of accidental injuries with blind puncture and two cases (0.09 %) with open technique. Injuries sustained with open technique injuries were less severe and immediately discernable. None of the patients were converted to open technique. CONCLUSION: The method can be used easily and rapidly, even in obese patients. It is safer than blind puncture and reduces costs.

Longitudinal Monitoring of Hepatic Blood Flow before and after TIPS by Using 4D-Flow MR Imaging.

Purpose To demonstrate the feasibility of four-dimensional (4D)-flow magnetic resonance (MR) imaging for noninvasive longitudinal hemodynamic monitoring of hepatic blood flow before and after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods The institutional review board approved this prospective Health Insurance Portability and Accountability Act compliant study with written informed consent. Four-dimensional-flow MR imaging was performed in seven patients with portal hypertension and refractory ascites before and 2 and 12 weeks after TIPS placement by using a time-resolved three-dimensional radial phase-contrast acquisition. Flow and peak velocity measurements were obtained in the superior mesenteric vein (SMV), splenic vein (SV), portal vein (PV), and the TIPS. Flow volumes and peak velocities in each vessel, as well as the ratio of in-stent to PV flow, were compared before and after TIPS placement by using analysis of variance. Results Flow volumes significantly increased in the SMV (0.24 L/min; 95% confidence interval [CI]: 0.07, 0.41), SV (0.31 L/min; 95% CI: 0.07, 0.54), and PV (0.88 L/min; 95% CI: 0.06, 1.70) after TIPS placement (all P < .05), with no significant difference between the first and second post-TIPS placement acquisitions (all P > .11). Ascites resolved in six of seven patients. In those with resolved ascites, the TIPS-to-PV flow ratio was 0.8 ± 0.2 and 0.9 ± 0.2 at the two post-TIPS time points, respectively, while the observed ratios were 4.6 and 4.3 in the patient with refractory ascites at the two post-TIPS time points, respectively. In this patient, 4D-flow MR imaging demonstrated arterio-portal-venous shunting, with draining into the TIPS. Conclusion Four-dimensional-flow MR imaging is feasible for noninvasive longitudinal hemodynamic monitoring of hepatic blood flow before and after TIPS placement. © RSNA, 2016 Online supplemental material is available for this article.

Intestinal obstruction due to phytobezoars: An update.

The term bezoar refers to an intraluminal mass in the gastrointestinal system caused by the accumulation of indigestible ingested materials, such as vegetables, fruits, and hair. Bezoars are responsible for 0.4%-4% of cases of mechanical intestinal obstruction. The clinical findings of bezoar-induced ileus do not differ from those of mechanical intestinal obstruction due to other causes. The appearance and localization of bezoars can be established with various imaging methods. Treatment of choice depends on the localization of the bezoar which makes the clinical findings.

The role of n-butyl-2-cyanoacrylate in the repair of traumatic diaphragmatic injuries.

Diaphragmatic injuries either by blunt or penetrating trauma require prompt surgical intervention and are often exigent to repair. N-butyl-2-cyanoacrylate (n-butyl-2-CA) is a tissue adhesive which has gained wide application in many areas of surgery including emergency. To repair the extensive injuries of the diaphragm it may be necessary the use of synthetic mesh by fixing it with sutures or staples. The use of tissue adhesives may circumvent the potential problems associated with mesh fixation. This study aimed to evaluate the efficacy and safety of tissue adhesives usage for mesh fixation in diaphragmatic injury repair. Twenty-four rats were divided into 3 groups each of them containing 8 rats. A 1- cm diaphragmatic defect was created in all rats. The defect was repaired by polypropylene suture in Group I, by mesh fixed with sutures in group II and by mesh fixed with n-butyl-2-CA in group III. The rats were sacrificed after 1 month. The episode of hernia and the adhesions were assessed by adhesion density score. Also, the abscess and inflammation in the repaired tissue were evaluated microscopically. The Kruskal-Wallis test was performed for the histopathological analysis. No diaphragmatic hernia was detected in any group. While Group III had higher adhesion density scores than group I (P: 0.027), there were no differences between group III and II (P: 0.317) and group II and I (P = 0.095) regarding adhesion density scores. The inflammation grade was higher in group III than group I and II (P < 0.001) and was higher in group II than group I (P < 0.05). There was no differences between each groups, concerning microabcsess formation (P > 0.05). Repair of traumatic diaphragmatic injury in penetrating wound, with polypropylene mesh fixed by n-butyl-2-CA in rats appears to be as efficacious and safe as conventional methods in early period. However, further experimental and clinical study are needed to compare the long-term results of adhesive mesh repair with those of the traditional sutured techniques.

Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy.

Intrahepatic cholestasis of pregnancy (ICP) is a reversible pregnancy-specific cholestatic condition characterized by pruritus, elevated liver enzymes, and increased serum bile acids. It commences usually in the late second or third trimester, and quickly resolves after delivery. The incidence is higher in South American and Scandinavian countries (9.2%-15.6% and 1.5%, respectively) than in Europe (0.1%-0.2%). The etiology is multifactorial where genetic, endocrine, and environmental factors interact. Maternal outcome is usually benign, whereas fetal complications such as preterm labor, meconium staining, fetal distress, and sudden intrauterine fetal demise not infrequently lead to considerable perinatal morbidity and mortality. Ursodeoxycholic acid is shown to be the most efficient therapeutic agent with proven safety and efficacy. Management of ICP consists of careful monitoring of maternal hepatic function tests and serum bile acid levels in addition to the assessment of fetal well-being and timely delivery after completion of fetal pulmonary maturity. This review focuses on the current concepts about ICP based on recent literature data and presents an update regarding the diagnosis and management of this challenging issue.

An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis.

Most ingested foreign bodies usually pass out in the feces uneventfully. Complications such as intestinal perforation and bleeding usually occur with sharp, thin, stiff, long, and pointed objects. This case describes the management of three lead pellets within the appendix vermiformis. A 45-year-old male visited our clinic complaining of a 4-month history of abdominal pain. The patient inquiry revealed that he had eaten hunted rabbit meat on numerous occasions and had unintentionally ingested three lead pellets. Plain abdominal films and a barium enema showed foreign bodies in the right lower abdominal quadrant. Since the lead pellets were thought to have migrated extraluminally, they were removed through laparotomy under fluoroscopic guidance. An appendectomy was performed. Pathologically, three lead pellets were embedded in the appendix, which showed signs of intramucosal inflammation. Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects enter the appendicular lumen, there is a high risk of appendicitis, perforation, or abdominal pain. An appendectomy was required to remove the ingested lead pellets in the appendix.

Visualizing biliary tracts with isosulphan blue to prevent injury during laparoscopic cholecystectomy: a preliminary cadaveric study.

BACKGROUND: Bile duct injury (BDI) as a complication of laparoscopic cholecystectomy may result in biliary cirrhosis with a high morbidity-mortality rate. Recurrent invasive procedures may be required for the optimum management. The most frequent causative factor in BDI is anatomical misidentification, particularly by inexperienced surgeons. Direct coloration of the cystic duct, bile duct, and gallbladder may decrease biliary tract injury. METHODS: This study was conducted during 10 standard, fresh cadaver autopsies at the Council of Forensic Medicine, Istanbul. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract. RESULTS: Of the ten fresh cadavers, three were males and seven were females; the mean age at death was 43 years (range 22-76 years). Successful visualization of the colored biliary tract, encompassing the gallbladder, cystic duct, and bile duct, was achieved in all of the cadavers. CONCLUSIONS: Visualization of the biliary tract may reduce the risk associated with dissection of Calot's triangle. Surgical BDI risk following anatomical misidentification could be reduced by intraoperative injection of isosulphan blue; further studies are required to validate the clinical utility of this technique.

Investigation of the protective effect of erdosteine against cyclosporine-induced injury in rat liver with histological and biochemical methods.

BACKGROUND/AIM: In the present study, the protective effect of erdosteine against cyclosporine-induced injury in rat liver was investigated with histological and biochemical methods. MATERIALS AND METHODS: Thirty-two Wistar albino male rats were randomly divided into 4 groups: control (n = 8), cyclosporine (n = 8, 20 mg kg(-1) day(-1) i.p.), cyclosporine + erdosteine (n = 8, erdosteine 12 mg kg(-1) day(-1) orally), and erdosteine (n = 8). At the end of day 12, liver tissues were removed for histological and biochemical analysis. After liver tissues were fixed in 10% buffered neutral formalin, routine histological processes were applied and tissue sections were stained with hematoxylin and eosin, periodic acid-Schiff, and elastic fiber stain methods. One hundred lobules of liver were examined for each group and evaluated statistically. The levels of malondialdehyde and glutathione peroxidase, as well as the activities of superoxide dismutase, were determined. RESULTS: The cyclosporine group showed significant histopathological changes compared to the control. In the cyclosporine + erdosteine group, histopathological changes of hepatic damage were markedly reduced. Histological findings were supported by biochemical results. CONCLUSION: Erdosteine could attenuate cyclosporine-induced liver injury.

The Analysis of Mean Platelet Volume and Platelet Distribution Width Levels in Appendicitis.

We aimed to analyze the diagnostic value of mean platelet volume and platelet distribution width, which are also known as the markers of platelet count, in acute and perforated appendicitis. The data of 202 patients who applied to general surgery clinic in Mustafa Kemal University Hospital from 2007 to 2012 with acute appendicitis were analyzed retrospectively. The findings were separated to two groups due to the perforation status (perforated vs. non-perforated). Age, sex, leukocyte, hemoglobin, hematocrit, mean platelet volume, and platelet distribution width were examined. The mean age of the patients was 35.8. Twenty-one of all cases were perforated appendicitis (10.4 %), and the rest was acute appendicitis (non-perforated) (n = 181, 89.6 %). The mean platelet volume value was 9.8 ± 2.1 fL; mean thrombocyte count, 340.9 × 10(9)/L; and mean platelet distribution width value, 18.3 %. There were statistically significant differences between sex and age, hemoglobin, hematocrit, leukocyte, mean platelet volume, and platelet distribution width. There was a positive correlation between mean platelet volume, platelet distribution width, and platelet. Age, leukocyte, platelet, mean platelet volume, and platelet distribution width were higher in cases with perforation as a comparison with non-perforated cases. We think that mean platelet volume and platelet distribution width may be valuable markers to detect the risk of perforation in early periods of acute appendicitis.