Pragmatic staging of oesophageal cancer using decision theory involving selective endoscopic ultrasonography, PET and laparoscopy.

BACKGROUND: Following CT, guidelines for staging oesophageal and gastro-oesophageal junction (GOJ) cancer recommend endoscopic ultrasonography (EUS), PET-CT and laparoscopy for T3-T4 GOJ tumours. These recommendations are based on generic utilities, but it is unclear whether the test risk outweighs the potential benefit for some patients. This study sought to quantify investigation risks, benefits and utilities, in order to develop pragmatic, personalized staging recommendations. METHODS: All patients with a histological diagnosis of oesophageal or GOJ cancer staged between May 2006 and July 2013 comprised a development set; those staged from July 2013 to July 2014 formed the prospective validation set. Probability thresholds of altering management were calculated and predictive factors identified. Algorithms and models (decision tree analysis, logistic regression, artificial neural networks) were validated internally and independently. RESULTS: Some 953 patients were staged following CT, by [(18) F]fluorodeoxyglucose PET-CT (918), EUS (798) and laparoscopy (458). Of these patients, 829 comprised the development set (800 PET-CT, 698 EUS, 397 laparoscopy) and 124 the validation set (118 PET-CT, 100 EUS, 61 laparoscopy). EUS utility in the 71.8 per cent of patients with T2-T4a disease on CT was minimal (0.4 per cent), its risk exceeding benefit. EUS was moderately accurate for pT1 N0 disease. A number of factors predicted metastases on PET-CT and laparoscopy, although none could inform an algorithm. PET-CT altered management in 23.0 per cent, and laparoscopy in 7.1 per cent, including those with T2 and distal oesophageal tumours. CONCLUSION: Although EUS provided additional information on T and N category, its risk outweighed potential benefit in patients with T2-T4a disease on CT. Laparoscopy seemed justified for distal oesophageal tumours of T2 or greater.

Antibiotics in interventional radiology.

The range and number of interventional procedures is rapidly increasing each year. A major complication associated with many procedures is infection, which can result in serious adverse outcomes for the patient. Consequently, antibiotics are amongst the most common pharmaceuticals used by the interventionist, particularly for non-vascular procedures, yet almost no randomized controlled trial data exist to inform our decision when formulating appropriate antibiotic prophylaxis regimens. The purpose of this review is to provide an update on the utilization of antibiotics for common interventional radiology procedures, focusing on timing and duration of antibiotic prophylaxis.

Percutaneous cholecystostomy: the radiologist's role in treating acute cholecystitis.

Acute cholecystitis is a common condition, with laparoscopic cholecystectomy considered the gold-standard for surgical management. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant. Percutaneous cholecystostomy (PC) is an image-guided intervention, used to decompress the gallbladder, reducing patient's symptoms and the systemic inflammatory response. PC has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery. This review aims to develop a broader understanding of PC, discussing its specific indications, patient management, technical factors, imaging guidance, and outcomes following the procedure.

The role of interventional radiology and imaging in pancreatic islet cell transplantation.

Pancreatic islet cell transplantation (PICT) is a novel treatment for patients with insulin-dependent diabetes who have inadequate glycaemic control or hypoglycaemic unawareness, and who suffer from the microvascular/macrovascular complications of diabetes despite aggressive medical management. Islet transplantation primarily aims to improve the quality of life for type 1 diabetic patients by achieving insulin independence, preventing hypoglycaemic episodes, and reversing hypoglycaemic unawareness. The islet cells for transplantation are extracted and purified from the pancreas of brain-stem dead, heart-beating donors. They are infused into the recipient's portal vein, where they engraft into the liver to release insulin in order to restore euglycaemia. Initial strategies using surgical access to the portal vein have been superseded by percutaneous access using interventional radiology techniques, which are relatively straightforward to perform. It is important to be vigilant during the procedure in order to prevent major complications, such as haemorrhage, which can be potentially life-threatening. In this article we review the history of islet cell transplantation, present an illustrated review of our experience with islet cell transplantation by describing the role of imaging and interventional radiology, and discuss current research into imaging techniques for monitoring graft function.

Angioseal versus manual compression for haemostasis following peripheral vascular diagnostic and interventional procedures--a randomized controlled trial.

The aim of this study was to compare the angioseal device to manual compression for femoral artery puncture following peripheral vascular procedures, in the context of day case vascular procedures. One hundred patients were prospectively randomised to haemostasis using the angioseal device or manual compression following arterial puncture for peripheral vascular diagnostic or intervention procedures. Data were collected regarding time to haemostasis and complications immediately post-procedure, at 1h, 2h and at 1 week. There were 50 patients in each group. There were no significant differences in demographic variables, or in complication rates immediately, at 1h, 2h and at 1 week (Chi-squared). The only significant difference between the two groups was time to haemostasis. The mean time to haemostasis in the compression group was 10.6 min and 2.0 min in the angioseal group (t-test p<0.0001). In conclusion, no significant differences in complications were found between manual compression and angioseal. However, there was a significant difference in time to haemostasis.

Technical and Clinical Outcomes Following Colonic Stenting: A Seven-Year Analysis of 268 Procedures.

AIMS: To assess the factors contributing to the technical and clinical success of colorectal stenting for large bowel obstruction. METHODOLOGY: 268 cases of colonic stenting for large bowel obstruction were performed in 249 patients of mean age of 72 years (28-98) between 2006 and 2013. The majority of strictures were due to malignant disease, 244/268 (91 %). Diverticular strictures accounted for 24/268 (9 %). RESULTS: Overall technical success rate was 81 % (217/268), with a clinical success rate of 65 % (174/268). Duration of symptoms ranged from 0 to 180 days (mean 8 days). Technical success rate was seen to decrease with increasing symptom duration. For symptom duration of less than 1 week, technical success was 85.4 % (181/212) versus 69.6 % (39/56) for those with symptoms of greater than a week (p < 0.05). Clinical success rates fell from 71.3 % (107/150) to 59.3 % (70/118) (p < 0.05) when attempting to stent lesions of greater than 5 cm. There was also a significant reduction in clinical success when stenting lesions on a bend rather than a straight segment of colon 75.7 % (109/144) versus 59.7 % (74/124) (p < 0.05). A total of 20 (7.46 %) perforations were identified during the study. Stent migration occurred in 6.6 % of cases. In-stent stenosis occurred in 3.3 %. The overall 30-day all cause mortality rate was 9 %. CONCLUSION: Lesion size, location and duration of obstructive symptoms are statistically significant determinants of patient outcome. These factors could be used to advise patient selection for colonic stenting or direct progression to surgical intervention.

Acute upper limb ischemia: a complication of coronary artery bypass grafting.

We present the case of a patient with acute upper limb ischemia after radial artery harvest for coronary artery bypass grafting. This occurred despite adequate preoperative and intraoperative assessment with the Allen test, hand-held Doppler and radial artery backbleeding. A successful outcome was achieved by performing brachioradial bypass grafting using reversed cephalic vein.

Thrombin injection for acute hemorrhage following angiography.

Femoral arterial puncture is the main access for diagnostic and therapeutic intervention in vascular disease. Significant complications are unusual and include uncontrolled bleeding which usually requires surgery. We report the use of ultrasound-guided thrombin injection that prevented any immediate need for surgery in 2 cases of uncontrolled bleeding following femoral arteriography. Clinical presentations and treatment are reported, together with a review of the literature.

An evidence-based review for the management of cystic pancreatic lesions.

The incidental finding of pancreatic cysts is becoming more common because of the increased use of cross-sectional imaging. As a result, the perspective from historical series of symptomatic patients is not always applicable to the current cohort of patients with cystic lesions in their pancreas. In this review, the characteristic radiological features that aid diagnosis are highlighted, and the complementary role of different imaging methods and the appropriate use of tissue sampling are identified. Based on the literature regarding the diagnostic role of imaging in characterizing cystic pancreatic lesions, it is possible to recommend a practical imaging algorithm for the diagnosis of cystic pancreatic lesions.

The frequency and significance of silent myocardial ischemia due to hyoscine butylbromide use in peripheral angiography.

PURPOSE: Hyoscine-N-butylbromide (HB) is an anticholinergic drug used in digital subtraction angiography of the aortoiliac region because it decreases bowel gas movement artifact. HB also causes an increase in heart rate. We investigated whether this could cause silent myocardial ischemia (SMI) in susceptible patients during peripheral angiography. METHODS: Thirty-six patients undergoing peripheral angiography were randomized into two groups, with 17 patients receiving 20 mg HB intraarterially during the angiogram and 19 patients receiving no drug. All patients were fitted with a Holter monitor that recorded the electrocardiogram before, during, and after the angiogram. Heart rate trends and ST segments were then analyzed. RESULTS: Patients given HB had a statistically significant rise in heart rate compared with the control group. Although the difference was not statistically significant, two (12%) patients receiving HB had procedural ST depression compared with none in the control group. Pre- and postprocedural episodes of ST depression were common, occurring in 41% of patients receiving HB and 37% of patients receiving no drug, and were associated with an increase in heart rate. CONCLUSION: The infrequent episodes of procedural SMI, potentially caused by the positive chronotropic effects of HB, are probably insignificant when compared with the high frequency of SMI episodes occurring outside the procedure.

The timing and frequency of complications after peripheral percutaneous transluminal angioplasty and iliac stenting: is a change from inpatient to outpatient therapy feasible?

PURPOSE: A prospective study was performed to assess the frequency and timing of complications after transluminal angioplasty and stent placement with a view to changing our practice and performing these procedures on an outpatient basis. METHOD: A total of 266 angioplasties and 51 stent deployments were attempted on 240 consecutive patients. Immediate complications were documented by the radiologists. The timing and nature of any complications during and beyond the first 24 hr were reported by the vascular surgeons. RESULTS: There were 14 complications in 240 patients, giving a complication rate of 4.8% per vessel segment dilated. There were five major and nine minor complications. Eighty-six percent of complications were evident before the patient had left the angiography suite. All complications were evident within 4.5 hr of the procedure. CONCLUSION: The timing of complications suggests it would be reasonable to perform percutaneous transluminal angioplasties and iliac stenting on an outpatient basis in suitable patients.