Biodegradable biliary stents placement using a "kissing-stent" technique for management of a recalcitrant stricture post-live donor liver transplant.

BACKGROUND: Biliary complications are common in pediatric liver transplant. Strictures resistant to interventional radiology procedures can be extremely challenging to manage and may result in the need of surgery or retransplantation. METHODS: This case report illustrates the use of biodegradable stents post left lateral segment live donor liver transplant in a pediatric patient with a recalcitrant chronic stricture of the biliary-enteric anastomosis. The patient developed a high stricture requiring multiple interventions and eventual access of both the segment II and segment III ducts of the graft. RESULTS: To ensure adequate biliary drainage, two biodegradable stents were deployed using a "kissing-stent" technique. The stents were successfully deployed and allowed the patient to remain free from an internal-external biliary drain for 11 months, with eventual redeployment of an additional biodegradable stent. CONCLUSION: In patients with recalcitrant stenosis of the biliary anastomosis, biodegradable stents may provide durable drainage, optimizing graft function and delaying retransplantation in addition to keeping patients without external devices, thus improving quality of life.

Fever at Time of Leukemia Diagnosis in Children: Predictor of Bloodstream Infection or Catheter Removal?

PURPOSE: To assess the incidence of fever at diagnosis in children with leukemia and determine if fever at diagnosis is a predictor of bloodstream infection (BSI) or central venous access device (CVAD) removal for infection either within the first 30 days or between 30 and 90 days after CVAD insertion. MATERIALS AND METHODS: One hundred fifty-one patients with acute leukemia (July 1, 2018, to December 31, 2020) who underwent a CVAD insertion within 2 weeks of diagnosis were included. Patient data included demographic characteristics, fever at diagnosis, CVAD type, antibiotics before and/or on the day of CVAD insertion, BSI incidence, BSI rates per 1,000 catheter days, and need for catheter removal after CVAD insertion within 30 days and between 30 and 90 days. RESULTS: Patients with fever at diagnosis had a significantly higher incidence of BSI within the first 30 days after CVAD insertion (17/23) than that among patients without fever (6/23) (P = .046) at diagnosis. No statistically significant difference was observed in the incidence of BSI between 30 and 90 days after CVAD insertion between patients with fever (5/11) and those without fever at diagnosis (6/11) (P = .519). Fever at diagnosis was not a predictor of CVAD removal within 30 days (9 patients required CVAD removal; 7/9 had fever and 2/9 had no fever) (P = .181) or between 30 and 90 days (4 patients required CVAD removal; 1/4 had fever and 3/4 had no fever at diagnosis) (P = .343) after insertion. CONCLUSIONS: Fever at diagnosis in patients with leukemia is not a predictor of CVAD removal for infection.

Safety and Effectiveness of Sclerotherapy for Nonparasitic Splenic Cysts: A Systematic Review and Meta-Analysis.

PURPOSE: To assess the reported safety and effectiveness of sclerotherapy for the treatment of nonparasitic splenic cysts through a systematic review and meta-analysis. MATERIALS AND METHODS: A systematic search of PubMed MEDLINE, Embase, Web of Science, and the Cochrane Library through July 2023 was performed. Studies including at least 5 patients reporting percutaneous sclerotherapy of nonparasitic splenic cysts, initial and posttreatment cyst size, clinical symptoms as well as adverse events (AEs), and recurrence rates were included. A 0-8-point scale for case reports and case series was used to assess bias. Data were analyzed using random-effects meta-analysis. RESULTS: Twenty-three of 833 citations were selected for full-text assessment, and 7 studies were included for a total of 99 patients. The methodological quality of the studies included scored 3-7. Composite analysis demonstrated 38% (95% CI, 23%-55%) rate of recurrence after treatment with significant heterogeneity; however, when assessed for a cyst size of <8 cm, recurrence dropped to 7% (95% CI, 2%-20%). Residual symptoms after treatment completion were present in 17% (95% CI, 7%-33%). Intraprocedural and postprocedural AE rates were 6% (95% CI, 3%-13%) and 6% (95% CI, 3%-12%) respectively. CONCLUSIONS: Sclerotherapy of splenic cysts seemed to be safe, with a high rate of recurrence for cysts ≥8 cm.

Findings in percutaneous trans-hepatic cholecysto-cholangiography in neonates and infants presenting with conjugated hyperbilirubinemia: emphasis on differential diagnosis and cholangiographic patterns.

BACKGROUND: Biliary atresia (BA) is one of the causes of conjugated hyperbilirubinemia in infants which if untreated leads to end-stage liver disease and death. Percutaneous Trans-hepatic Cholecysto-Cholangiography (PTCC) is a minimally invasive study which can be utilized in the diagnostic work-up of these patients. This study's purpose is to describe the experience with PTCC in neonates, the imaging findings encountered, and the abnormal patterns which warrant further investigation. METHODS: A 16-year single-center retrospective study of patients with persistent neonatal cholestasis (suspected BA) undergoing PTCC. Patient demographics, laboratory values, PTCC images, pathology and surgical reports were reviewed. RESULTS: 73 patients underwent PTCC (68% male, mean age 8.7 weeks, mean weight 4.0 Kg). The majority of studies were normal (55%). Abnormal patterns were identified in 33 cases, 79% were diagnosed with BA and 12% with Alagille syndrome. Non-opacification of the common hepatic duct with a narrowed common bile duct (42%) and isolated small gallbladder (38%) were the most common patterns in BA. CONCLUSION: PTCC is a minimally invasive study in the diagnostic work-up of infants presenting with conjugated hyperbilirubinemia (suspected BA). Further invasive investigations or surgery can be avoided when results are normal.

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

BACKGROUND: In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality. OBJECTIVE: To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children. MATERIALS AND METHODS: We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg. RESULTS: Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease. CONCLUSION: Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.

Findings encountered in percutaneous cholangiography in a case of post-transplant recurrence of hepatic Langerhans cell histiocytosis with biliary involvement.

This case report describes a four-year-old boy who presented with the diagnosis of LCH with liver involvement. This required a living-related liver transplant one year later. The primary disease recurred in the transplanted liver 6 months post-transplant and led to progressive biliary dilatation. A percutaneous trans-hepatic cholangiogram was performed five years after transplant, showing a pattern of multifocal biliary duct strictures mimicking the pattern of primary sclerosing cholangitis and a stenosis of the biliary-enteric anastomosis. Despite management with an internal-external biliary drain, the stenosis of the biliary-enteric anastomosis evolved to an occlusion one year after drain removal. This was associated with progression of the changes in the biliary tree, this time associated with significant saccular dilatations secondary to the multiple areas of stenosis. Due to these findings and progressive deterioration of the function of the graft, the patient required re-transplantation. This report illustrates the findings in imaging of the biliary tree secondary to the recurrence of LCH after liver transplantation, which may help to recognize this complication to physicians facing a similar clinical scenario.

Acute Budd-Chiari syndrome during hepatic vein catheterization.

This case report describes a 4-year-old male with a history of hepatoblastoma, treated with chemotherapy followed by a right extended hepatectomy. Secondary to this, the patient experienced recurrent hepatic vein stenosis. He was treated initially with conventional angioplasty, followed by paclitaxel-coated balloon dilatations in an attempt to prevent episodes of re-stenosis. During the catheterization of the hepatic vein in one of the treatments, hemodynamic instability due to an acute Budd-Chiari syndrome occurred. The hemodynamic compromise became unresponsive to intravascular resuscitation and inotropic support. The patient was then treated with an emergency conventional angioplasty of the hepatic vein, which resulted in a rapid response and eventually in a full recovery. The etiology of this complication remains unclear; however, it may have been secondary to endothelial damage leading to acute thrombosis and/or venous spasm. Conventional angioplasty was successful in managing this complication. Awareness of iatrogenic acute Budd-Chiari syndrome as a potentially fatal complication during hepatic catheterization/dilatation, especially in the posthepatectomy setting, successful management of this complication, and the importance of a multidisciplinary and rapid response, is emphasized.

Use of drug-coated balloons in the management of a recalcitrant postsurgical hepatic vein stenosis in a pediatric patient.

Drug-coated balloons (DCB) are a treatment alternative to conventional angioplasty in arterial, hemodialysis fistulas, and venous stenoses. This case report describes a child with the diagnosis of hepatoblastoma treated with chemotherapy and a right extended hepatectomy with venous reconstruction. The patient presented with signs and symptoms of portal hypertension due to a hepatic venous outflow obstruction secondary to stenosis of the surgical anastomosis. The response to conventional angioplasty was limited with frequent recurrence of symptoms. DCBs were used as an alternative prior to stent consideration aiming to assess if these devices could provide improvement of the symptoms and as a long-term therapy. The use of DCBs increased the time interval of reinterventions in comparison with conventional angioplasty. The patient eventually required stents due to recurrence of the primary disease. While this report does not provide an in-depth evaluation in terms of the efficacy and safety of DCB, this case illustrates a potential novel treatment modality to be considered for children, when stenotic venous lesions not amenable for stenting are present.

The utility of post-biopsy ultrasonography in detecting complications after percutaneous liver biopsy in children.

BACKGROUND: Surveillance post image-guided percutaneous liver biopsy in children is variable. OBJECTIVE: The aim of this study was to assess the value of 4-6-h post-procedure ultrasonography (US) in detecting post-liver-biopsy hemorrhage. MATERIALS AND METHODS: This prospective study included pediatric patients who underwent US-guided percutaneous liver biopsies. All children had a US study obtained pre-procedure and one obtained 4-6 h post-procedure; US examinations were deemed positive if abnormalities were present. We also reviewed any subsequent imaging that was performed within 7 days (late imaging) at the discretion of the referring team. Changes in US findings (ΔUS) were graded by two radiologists using a descriptive non-validated scale (none, minimal, marked). Hemoglobin (Hb) levels were assessed pre-procedure and 4 h post-procedure. The diagnostic accuracy of US changes for detecting post-procedural hemorrhage was calculated based on a drop in Hb >1.5 g/dL or Hb >15% from baseline (ΔHb). We used a Kruskal-Wallis test to correlate the ΔHb with ΔUS. Association between late-imaging and post-procedure US findings was tested using a chi-square test. We included 224 biopsies. RESULTS: The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of post-procedure US in detecting post-procedure hemorrhage ranged 26.3-42.1%, 72.4-93.3%, 0.22-0.42, and 0.87-0.88, respectively. No significant association was seen between the ΔHb and sonographic findings (P=0.068). No significant difference was seen in the need for late imaging between children who did and those who did not have positive US findings (P=0.814). CONCLUSION: The sensitivity and PPV of post-procedure US in detecting post-procedural hemorrhage are low. Our findings do not support routine post-procedure surveillance US.

Percutaneous removal of biliary stones post-liver transplant in a pediatric patient: Case report and review of the literature.

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

BACKGROUND: Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication. OBJECTIVE: To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access. MATERIALS AND METHODS: We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath. RESULTS: Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0). CONCLUSION: Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.

Experience with Compressed Gelfoam Plugs in Children during Liver Biopsies and Other IR Procedures: A Retrospective Single-Center Case Series.

PURPOSE: To analyze the experience using compressed gelfoam plugs (CGPs) in children during liver biopsies and other interventional procedures. MATERIALS AND METHODS: This was a single-center, retrospective, consecutive case series of 477 various pediatric interventional radiology procedures using CGPs (January 2012 to December 2016) performed on 397 children (209 males, 188 females; median age, 7 years [range, 9 days-17.8 years]; median weight, 18 kg [range, 2.7-141 kg]). Of 477 procedures, most (n = 371) were liver biopsies, 98 were biopsies of other organs, and 8 were non-biopsy procedures. Analysis focused on liver biopsies. RESULTS: Of liver biopsies, a median of 2 CGPs were used per procedure, and the mean drop in hemoglobin was -0.36 g/dl (-3.0% change). Thirty-seven mild, 8 moderate, 2 severe, and 1 life-threatening (an anaphylaxis to CGP) adverse events (AEs) occurred. Analysis of liver biopsies with AEs showed significant association between number of passes, cores, and focal-type lesions (unadjusted logistic regression: P = .007, P = .022, P = .028, respectively) and age, weight, and number of passes (adjusted multiple logistic regression: P = .006, P = .032, P = .046, respectively). Technical problems relating to CGP deployment were noted in 5 (1%), without any AEs. CONCLUSIONS: CGPs were used in a wide variety of procedures and organs in children. There was 1 life-threatening AE resulting from the rare risk of anaphylaxis caused by the gelfoam-containing plug. After liver biopsies, transfusion was required in 2/371 (0.5%) procedures, 1 related to pre-biopsy anemia (0.25%).

Technique, Safety, and Yield of Bone Biopsies for Histomorphometry in Children.

PURPOSE: To evaluate image-guided bone biopsy for bone histomorphometry to assess osteoporosis in children with respect to safety and yield. MATERIALS AND METHODS: A single-center retrospective review was performed of 79 bone biopsies in 73 patients performed between 2007 and 2015. Biopsies of the iliac bone were performed under general anesthesia, after tetracycline labeling, using a Rochester needle (Medical Innovations International, Inc, Rochester, Minnesota). Ultrasound and fluoroscopic guidance were used in all procedures. Biopsy technique, technical success, safety, and histomorphometry results (complete, incomplete, none) were analyzed. RESULTS: There were 41 male patients (51.8%). Technical success was achieved in 76/79 (96%) procedures. Of 79 biopsies, 75 (95%) were uneventful. Unplanned overnight observation was required in 3 (minor SIR grade B), and prolonged hospital stay owing to hematoma causing nerve compression pain was required in 1 (major SIR grade D). Complete histomorphometric reports were obtained in 69 (87%) procedures, incomplete reports were obtained in 7 (9%), and no reports were obtained in 3(4%). Incomplete reports were insufficient to provide a definitive diagnosis or guide treatment. Histomorphometry impacted subsequent therapy in 69 (87%) biopsies. CONCLUSIONS: Image-guided bone biopsy for osteoporosis using the Rochester needle is a valuable and safe technique for establishing the diagnosis of osteoporosis and directing treatment based on histomorphometry results.

Measuring hemoglobin prior to early discharge without routine surveillance ultrasound after percutaneous native renal biopsy in children.

BACKGROUND: We aimed to evaluate the role of post-procedural hemoglobin (hb), without pre-discharge ultrasound (US), after US-guided renal biopsy in children. METHODS: A retrospective review was conducted of consecutive outpatient native kidney biopsies over an 8-year period. Procedures were performed under real-time US guidance. Data collected included number of passes, presence and size of perinephric hematoma, age, body mass index (BMI), blood pressure (BP), fasting status, hb and platelets. Continuous variables were expressed as mean ± standard deviation, group differences were tested with Student's unpaired t test and analysis of variance and correlations were assessed using Pearson's r. Significance was defined as p < 0.05. Hb changes (g/L), percentage hb (%hb) change, hematoma size and positive and negative predictive values (PPV, NPV, respectively) were analyzed. RESULTS: A total of 330 procedures in 300 children (141 females, mean age 11.2 ± 4.30 years) were analyzed. Post-procedural hematoma occurred in 63%. There was a significant (p = 0.0001) post-procedural hb decrease of 6.3 ± 5.5 g/L and %hb decrease of 4.56 ± 4.01%. Fasting during pre-procedural hb estimation and procedural hematoma was associated with a greater hb drop. A ≥10% hb drop had 73% PPV for repeat blood work and US and a 17% PPV for admission, whereas a <10% hb drop had a NPV of 84% and 98%, respectively. Hb change showed a weak correlation with age, and hematoma size showed a weak inverse correlation with platelet count, but no correlation with BMI, number of passes or BP. CONCLUSIONS: Bleeding complications from US-guided native kidney biopsies in pediatric outpatients can be safely followed by a complete blood count at 6 h post procedure. A 10% hb decrease is strongly associated with requirement for further testing and/or admission.

Correlation of PET/CT and Image-Guided Biopsies of Pediatric Malignancies.

OBJECTIVE: The purpose of this study was to evaluate an early experience with correlation of PET/CT findings and image-guided biopsy results in pediatric patients. MATERIALS AND METHODS: In a single-center retrospective case series, the inclusion criterion was performance of image-guided biopsy within 6 weeks of PET/CT, either before or after the biopsy. RESULTS: Forty-five patients (23 boys, 22 girls; age range, 4-17 years; median, 10.5 years; weight range, 14.6-86.2 kg; median, 48 kg) underwent 47 PET/CT examinations and biopsies. Nineteen patients (20 biopsies) had known malignancy, and 26 patients had suspected malignancy. The results were malignant in 24 cases, benign in 16, and inadequate or normal in 7 cases. Thirty-nine of 47 PET/CT examinations had positive results, and eight had negative results. Final analysis of 37 of the 47 cases (confounders excluded) showed concordant results between biopsy and PET in 36 cases and discordant results in one case. CONCLUSION: PET/CT can be used for disease staging and follow-up. In the future PET/CT can play a valuable role in directing image-guided biopsies of children.

Pediatric thyroid FNA biopsy: Outcomes and impact on management over 24 years at a tertiary care center.

BACKGROUND: Thyroid malignancy is rare in young children, although the incidence increases sharply during adolescence. Nodular thyroid disease and thyroid cancer in children differ substantially from those in adults, because the rates of malignancy among children are roughly 5-fold higher, and local and distant metastases as well as recurrences are more common. Even with the recent introduction of pediatric guidelines, there remains a paucity of pediatric data on which to base clinical decision making. The objectives of this study were to characterize the outcomes of fine-needle aspiration biopsy (FNAB) of nodular thyroid disease at a pediatric tertiary-care institution over a 24-year period and to relate cytopathology to histopathology and management decisions in this population. METHODS: A retrospective review of patients who underwent preoperative FNAB and thyroid surgery between 1992 and 2015 was conducted. In total, 207 nodules were biopsied among 178 patients. RESULTS: Adequate FNAB samples were obtained in 74% of biopsies. Sixty-five patients underwent thyroidectomy after FNAB. In this group, the malignancy rates for lesions deemed benign, atypical, suspicious, and malignant on FNAB cytology were 16%, 67%, 71%, and 100%, respectively. Twenty-seven individuals underwent >1 biopsy; however, no malignancies were identified in these patients. Surprisingly, the rate of malignancy in patients who underwent preoperative FNAB was not significantly different from the rate in those who proceeded directly to surgery (n = 146). CONCLUSIONS: FNAB remains a valuable tool for preoperative assessment of pediatric thyroid nodules. When samples are adequate for assessment, cytology other than clearly "benign" merits referral for diagnostic or therapeutic thyroidectomy. In this series, FNAB did not reduce rates of surgery for benign disease. Cancer Cytopathol 2016;124:801-10. © 2016 American Cancer Society.

IR Approaches to Difficult Removals of Totally Implanted Venous Access Port Catheters in Children: A Single-Center Experience.

PURPOSE: To identify factors associated with adherence of implanted venous access port catheters in children and describe technical strategies for removing "stuck" ports. MATERIALS AND METHODS: A retrospective single-center review of port removals was conducted between 2003 and 2012. Cases were identified through radiology reports. Clinical details (eg, demographics, disease, port dwell time, interventional techniques) were obtained through patient charts. Cases were classified as difficult removals if there was documented adherence to soft tissues or vein, or simple removals if no difficulty was recorded. Difficult removals were categorized and graded on increasing invasiveness of techniques required. Successful removal was defined as complete removal of the port catheter. Difficult removals were compared with simple removals for factors associated with difficult removal. Of all removals (N = 1,306), 58 were classified as difficult removals (4%). RESULTS: Using various techniques, 57 of 58 (98%) adherent port catheters were successfully removed. Factors identified with difficult removals included primary diagnosis of acute lymphoblastic leukemia (ALL) (78% vs 37%, P < .0001), age at insertion (3.7 y vs 5.4 y, P = .0019), and port dwell time (median 1,087 d vs 616 d, P < .0001). CONCLUSIONS: Difficulty removing port catheters in children is uncommon. Port catheters can usually be removed successfully using various IR techniques ranging in invasiveness. There is an association of difficult removal with early age at insertion, ALL diagnosis, and long port dwell time. Awareness of these factors may help physicians inform parents of potential difficulties and plan the removal procedure.

Findings in percutaneous cholangiography in two cases of Type III cystic biliary atresia (with ultrasound correlation).

Cystic biliary atresia (Type III) is uncommon and it may be difficult to differentiate this from a choledochal cyst, an entity that has a very different management and prognosis. This report shows the percutaneous cholangiographic findings in two cases of Type III biliary atresia with a non-communicating cyst, with ultrasound and clinical correlation. These findings are helpful in the diagnosis and management of patients with this condition.

Successful use of indwelling tunneled catheters for the management of effusions in children with advanced cancer.

BACKGROUND: Malignant pleural effusion (MPE) and ascites (MA) negatively impact quality of life of palliative patients. Treatment options are limited. This study's purpose is to examine the experience with indwelling tunneled catheters (ITCs) for management of MPE/MA in children with advanced cancer. METHODS: Children with MPE/MA who underwent ITC insertion (2007-2012) were retrospectively reviewed. Clinical, procedural, complication and outcome details were analyzed. RESULTS: PleurX® ITCs (n = 12) were inserted in eight patients (5-18 years) with sarcoma (11 MPE, 1 MA), achieving symptom relief and facilitating discharge home post ITC (median 2 days). Median survival following ITC was 51 days. There were two major complications: pain (n = 1), late site infection (n = 1), and five minor complications. Drainage ceased in four patients (pleurodesis/tumor progression). At time of death, six ITCs (five patients) were still in situ. CONCLUSIONS: ITC appears to be a safe, effective treatment for MPE/MA in advanced pediatric cancer, achieving symptomatic relief and discharge home.

Lung tattooing combined with immediate video-assisted thoracoscopic resection (IVATR) as a single procedure in a hybrid room: our institutional experience in a pediatric population.

BACKGROUND: Analysis of small pulmonary nodules in children poses an important diagnostic and therapeutic challenge for clinicians. OBJECTIVE: To review our experience of lung tattooing with immediate video-assisted thoracoscopic resection (IVATR) performed as a single procedure in a hybrid room for technical difficulties, complications and diagnostic yield of the procedure. MATERIAL AND METHODS: Retrospective analysis of 31 children (16 boys, 15 girls) who underwent lung tattooing of various lesions from January 2001 to July 2011. Data were collected from the Interventional Radiology database, Electronic Patient Chart (EPC) and PACS. RESULTS: A total of 34 lesions were treated in 31 children. Tattooing was performed on lung lesions with median size 3 mm and median depth 2 mm from pleura. Technical success was 91.1% and diagnostic yield was 100%. In seven children, it was combined with other interventional radiologic procedures. The median procedure time for lung tattooing and IVATR was 197 min. CONCLUSION: Lung tattooing with IVATR as a single procedure in a hybrid room is safe and effective in children with several inherent advantages, including avoiding the need to move the child from the interventional radiology suite to the operating room.