American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: summary and recommendations.

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for the diagnosis of malignancy in patients with biliary strictures of undetermined etiology. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses the role of fluoroscopic-guided biopsy sampling, brush cytology, cholangioscopy, and EUS in the diagnosis of malignancy in patients with biliary strictures. In the endoscopic workup of these patients, we suggest the use of fluoroscopic-guided biopsy sampling in addition to brush cytology over brush cytology alone, especially for hilar strictures. We suggest the use of cholangioscopic and EUS-guided biopsy sampling especially for patients who undergo nondiagnostic sampling, cholangioscopic biopsy sampling for nondistal strictures and EUS-guided biopsy sampling distal strictures or those with suspected spread to surrounding lymph nodes and other structures.

American Society for Gastrointestinal Endoscopy guideline on role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: methodology and review of evidence.

Biliary strictures of undetermined etiology pose a diagnostic challenge for endoscopists. Despite advances in technology, diagnosing malignancy in biliary strictures often requires multiple procedures. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the available literature on strategies used to diagnose undetermined biliary strictures. Using a systematic review and meta-analysis of each diagnostic modality, including fluoroscopic-guided biopsy sampling, brush cytology, cholangioscopy, and EUS-guided FNA or fine-needle biopsy sampling, the American Society for Gastrointestinal Endoscopy Standards of Practice Committee provides this guideline on modalities used to diagnose biliary strictures of undetermined etiology. This document summarizes the methods used in the GRADE analysis to make recommendations, whereas the accompanying article subtitled "Summary and Recommendations" contains a concise summary of our findings and final recommendations.

Leaving the Placenta In Situ in Placenta Accreta Spectrum Disorders: A Single-Center Case Series.

OBJECTIVE: The most common treatment for placenta accreta spectrum (PAS) disorders is planned primary cesarean hysterectomy. However, other management strategies may improve outcomes and/or allow fertility preservation. The objective of this study was to describe the course and outcomes of patients with PAS managed by leaving the placenta in situ. STUDY DESIGN: This is a series of 11 patients with PAS managed by leaving the placenta in situ at a single academic center in the United States from 2015 to 2022. The approach described involves delivery of the fetus via cesarean, no attempt at placental removal, closure of the hysterotomy, prophylactic intravenous antibiotics for up to 1 week, and close outpatient follow-up until the uterus is empty. RESULTS: The uterus was successfully preserved in six (55%), minimally invasive hysterectomy was performed in four (36%), and abdominal hysterectomy was performed in 1 (9%). During cesarean delivery, the median estimated blood loss was 650mL (range: 200-1,000mL). The majority of patients had no vaginal discharge for several weeks after delivery, followed by brown or bloody discharge, and intermittent mild-to-moderate cramping. The median time to resolution of PAS was 18 weeks in patients with successful uterine preservation (range: 5-25 weeks). Indications for hysterectomy included hemorrhage (n=1), coagulopathy (n=1), endomyometritis (n=2), and pain (n=1), and these occurred at a median of 5 weeks postpartum (range: 1-25 weeks). Four patients had subsequent pregnancies of whom three were live births at or near term and one was a spontaneous abortion at 19 weeks. CONCLUSION: Leaving the placenta in situ may be an appropriate management strategy for some carefully selected and counseled patients with PAS. KEY POINTS: · Overall, 55% had uterine preservation (6/11).. · Minimally invasive approach in 80% of hysterectomies (4/5).. · Of patients, 67% with uterine preservation had subsequent pregnancies (4/6)..

JOURNAL CLUB: Standardizing CT-Guided Biopsy Procedures: Patient Dose and Image Noise.

OBJECTIVE: The objective of this study was to standardize our image acquisition protocol for CT-guided biopsy procedures. MATERIALS AND METHODS: The records of consecutive patients who underwent CT-guided biopsy 3 months before (n = 598 biopsies) and 3 months after (n = 540 biopsies) standardization of our image acquisition protocol were retrospectively reviewed. CT technical parameters were individualized on the basis of the sum of the anteroposterior and transverse dimensions of the patient. Information on patient demographic characteristics, biopsy site, complications associated with the procedure, and diagnostic yield was collected. The radiation dose metrics that were evaluated included the volume CT dose index, dose-length product, and size-specific dose estimate. Image noise was quantified using the SD of the CT number measured in subcutaneous fat. Fisher exact test and one-way ANOVA were used to evaluate statistical significance. RESULTS: The mean dose-length product decreased by 72.3% (from 699.7 to 193.9 mGy × cm; p < 0.0001), and statistically significant decreases in dose-length product were observed when data were stratified according to biopsy site (i.e., lung, solid organ, lymph node, or bone; for all sites, p < 0.0001). The mean size-specific dose estimate decreased by 58.9% (from 125 to 51.4 mGy), which was statistically significant (p < 0.001). Image noise increased during the study period, but this increase was not statistically significantly different among the four biopsy sites (p = 0.46). CONCLUSION: Standardization of the image acquisition protocol used in CT-guided biopsy procedures significantly reduced patient radiation dose and decreased variability in image noise.

Silent arterio-ureteral fistula: Diagnosis and endovascular management.

We report a patient with history of recurrent invasive rectal adenocarcinoma complicated by obstructive uropathy requiring nephro-ureteral catheter placement. Two years later during a regular catheter exchange, the patient developed unusually bloody urine raising suspicion for possible vascular injury. CT angiogram and conventional angiogram were negative. However, an antegrade nephrostogram revealed a fistulous communication between the right ureter and the right internal iliac artery. Subsequently, the artery was sacrificed using detachable coils. We discuss the rare encounter of a silent arterio-ureteral fistula, the value of antegrade nephrostogram as a diagnostic tool, and the management options in such scenario.

An Unusual Presentation of Extracavitary Primary Effusion Lymphoma: Internal Jugular Vein Occlusion, Intractable Symptoms of Intracranial Hypertension, and Prolonged Remission after Highly Active Antiretroviral Therapy.

Primary involvement of the skeletal muscle by extracavitary primary effusion lymphoma (PEL) is an extremely rare phenomenon. We report an unusual case of PEL involving the jugulodigastric skeletal muscle without serous cavity involvement which resulted in complete occlusion of the ipsilateral proximal internal jugular vein, causing the patient to present with clinical features of intractable throbbing headache, photophobia, acute confusion state, sporadic syncopal attacks, and dyspnea without obvious palpable neck swellings. This led to an initial clinical suspicion, dedicated diagnostic workup, and empiric therapy for acute meningoencephalitis, severe atypical pneumonia, and acute pulmonary embolism. Owing to his refractory symptoms, exploratory CT imaging eventually revealed a heterogenous jugulodigastric mass, and finally, a pathologic diagnosis of extracavitary PEL was identified as the cause of his intracranial hypertension. The patient remains in remission 22 months after commencing a dolutegravir-based HAART regimen without any chemotherapeutic intervention.

Multimodality lymphatic imaging of postoperative chylothorax in an infant with Noonan syndrome: a case report.

BACKGROUND: Chylothorax is a rare complication of pediatric cardiac operations that occurs more frequently in children with Noonan syndrome, a genetic disorder associated with cardiac defects and lymphatic anomalies. CASE PRESENTATION: We report a case of postoperative chylothorax in a 6-month-old infant with Noonan syndrome where multimodality lymphatic imaging guided management was followed. Drainage patterns of the lymphatic capillaries in the lower and upper extremities were visualized during near-infrared fluorescence lymphatic imaging (NIRFLI). Dynamic magnetic resonance lymphangiography (MRL) further identified the site of leakage in the thoracic duct and subsequently guided surgical intervention. CONCLUSIONS: Application of multimodality imaging allows for greater individualization of treatment and should be considered in patients with complex cases such as those with syndromes associated with a higher incidence of chylothorax. IRB Number: HSC-MS-13-0754, December 10, 2013.

Percutaneous transhepatic use of rigid bronchial forceps as bailout in difficult biliary stent retrieval.

Endoscopic retrieval of embedded, proximally migrated, or fractured plastic biliary stents may be technically challenging and sometimes unsuccessful. Percutaneous transhepatic techniques have previously been described to assist in such challenging cases. Here in, we describe a difficult case in which all commonly described endoscopic and percutaneous techniques failed to retrieve a proximally migrated, fractured, and looped plastic biliary stent. We finally successfully retrieved the plastic forceps after off-label utilization of rigid bronchial forceps via a percutaneous transhepatic approach. We describe the technique utilized in detail and this appears to be the first description of this off-label use in this challenging scenario.

Congenital aneurysm of the palmar digital artery: A case report and literature review.

Spontaneous arterial aneurysms of the hand are uncommon but are well-described in the adult population. In the pediatric population, however, congenital or true aneurysms of the hand are exceptionally rare. A case report and a literature review were performed for published cases of arterial aneurysms of the hand in the pediatric population. A 13-month-old child presented with an aneurysm of the common digital artery and underwent surgical excision without need for reconstruction. Literature review found 13 documented cases. Patient characteristics and management strategies were summarized. There are very few documented cases of hand arterial aneurysms in the pediatric population, with our patient being the third youngest ever reported. No cases were associated with hereditary disease, and aneurysm excision was performed in all cases. Our report highlights the need to include arterial aneurysm in a differential diagnosis when evaluating a pediatric patient with a palpable hand mass.

Page kidney secondary to subcapsular hematoma following percutaneous renal allograft biopsy.

Percutaneous renal biopsy with ultrasound guidance is a helpful procedure regularly performed to obtain renal tissue diagnosis for rejection in the postrenal transplant setting; however, it is not without risks. We report the case of a 42-year-old male with end stage renal disease who developed a subcapsular hematoma, with subsequent hypertension and renal failure, compatible with acute page kidney as a complication of the renal biopsy. The ultrasound images demonstrated classic imaging appearances which all diagnostic and interventional radiologists should be aware of. The patient was managed successfully with conventional open surgical evacuation of the hematoma with return to baseline laboratories and vital signs after the procedure.

Portal Venous Interventions: How to Recognize, Avoid, or Get Out of Trouble in Transjugular Intrahepatic Portosystemic Shunt (TIPS), Balloon Occlusion Sclerosis (ie, BRTO), and Portal Vein Embolization (PVE).

Portal venous interventions comprise a large portion of many Interventional Radiology practices today, and remain some of the more technically challenging cases in one's repertoire of procedures. The patients upon whom these procedures are performed are often critically ill, have decompensated disease, or are burdened with comorbid conditions such that they are poor surgical candidates. This leaves them with few options outside the care of Interventional Radiology. Some portal venous interventions, such as transjugular intrahepatic portosystemic shunt, have an established history of excellent clinical success with numerous technical advancements over the years helping to improve outcomes. Others, like balloon occlusion sclerotherapy or portal venous recanalization, are less well established but are nonetheless invaluable in the treatment of portal venous diseases. The goal of this article is to help dispel some of the anxiety experienced by individuals performing the three main procedures of the portal venous system, namely transjugular intrahepatic portosystemic shunt, balloon-occlusion retrograde transvenous obliteration, and portal vein embolization.

Effects of the Use of a Mallet during Bone Marrow Biopsy Collection on Specimen Quality: A Quality Improvement Project.

CONTEXT: Avoiding procedure-related morphologic distortion such as fragmentation and crush artifact is critical in bone marrow diagnosis. Use of a hammer or mallet, although infrequent, is a known technique of advancing the biopsy needle during specimen collection. OBJECTIVES: We performed a double-blinded, retrospective review of bone marrow biopsies collected by the Interventional Radiology department at our institution in order to assess specimen quality by using this technique. DESIGN: We reviewed 93 bone marrow biopsy specimens collected at our hospitals, between January 2015 and June 2015. Routine bone marrow core biopsy slides were reviewed. The presence of crush artifact, specimen fragmentation, and aspiration artifact, as well as the presence of osteopenia and an overall grade of specimen adequacy, was recorded for each specimen. RESULTS: A sterile mallet was used during the bone marrow biopsy procedure in 29 cases. Use of a mallet was significantly associated with the presence of suboptimal or inadequate specimen quality of bone marrow core biopsy (p<0.005) and was independently associated with severe specimen fragmentation (2+) (p<0.0001). There was no statistically significant association between length of the core and use of a mallet. CONCLUSIONS: Use of a mallet during bone marrow core biopsy collection is significantly associated with morphologic distortion in the form of severe specimen fragmentation and negatively affects specimen adequacy. There is no difference in length of core biopsy as previously thought by using a mallet to advance the needle during the procedure. We recommend that the use of this technique should be avoided during specimen collection.

Near-infrared fluorescence lymphatic imaging of Klippel-Trénaunay syndrome.

The relationship between lymphatic and venous malformations in Klippel-Trénaunay syndrome is difficult to assess. Herein the authors describe near-infrared fluorescence lymphatic imaging to assess the lymphatics of a subject with a large port-wine stain and right leg edema. Although lymphatic vessels in the medial, affected knee appeared dilated and perhaps tortuous, no definitive abnormal lymphatic pooling or propulsion was observed. The lymphatics in the affected limb were well defined but less numerous than in the contralateral limb, and active, contractile function was observed in all vessels. As demonstrated, near-infrared fluorescence lymphatic imaging enables the clinical assessment of lymphatics in lymphovenous malformations.