Computed tomography-guided percutaneous cholecystostomy: a single institution's 6-year experience.

Background: Acute cholecystitis (AC) is an emergency commonly managed by a surgical department. The interventional part of the standard treatment algorithm includes laparoscopic or open cholecystectomy. Percutaneous cholecystostomy (PC) under imaging guidance is recommended as the first-line approach in the subset of high-risk patients for perioperative complications, as a bridging therapy to elective surgery or as a definitive solution. The aim of the present study was to evaluate the mortality and morbidity of PC performed under computed tomographic (CT) guidance in patients at high surgical risk. Methods: Medical and imaging records from all consecutive patients who underwent a CTPC between 2015 and 2020 were reviewed. Adult patients with a definite indication for CTPC were recruited and mortality 7 and 30 days post-procedure was recorded. Variables potentially affecting those outcomes were retrieved and included in our analysis. Results: Eighty-six consecutive patients at high risk for surgical management were identified and included in the present study. Most patients (58.1%) were diagnosed with AC, while 14 (16.3%) had concurrent AC and cholangitis, 13 (15.2%) gallbladder empyema, and 9 (10.4%) hydrops. The 7- and 30-day mortality rates were 16.3% (14/86) and 22.1% (19/86), respectively, and were significantly associated with patients' hospitalization in the intensive care unit (P<0.05). Other parameters investigated, such as age, sex, diagnosis, catheter diameter, and duration of hospital stay were not significantly associated with our primary outcome. Conclusion: PC is a safe alternative to surgery in patients with high perioperative risk, thus providing acceptable mortality rates.

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience.

Introduction In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed. Material and methods Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted. Results A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection. Conclusion Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.

A meta-analysis evaluating the role of high-intensity focused ultrasound (HIFU) as a fourth treatment modality for patients with locally advanced pancreatic cancer.

BACKGROUND: This study aimed to evaluate the outcomes of high-intensity focused ultrasound (HIFU) on patients with advanced pancreatic cancer. METHODS: A literature search was performed in PubMed, Scopus and Cochrane databases, in accordance with the PRISMA guidelines. The Odds Ratio, Weighted Mean Difference, and 95% Confidence Interval were evaluated by means of the Random-Effects model. RESULTS: Nineteen articles met the inclusion criteria, incorporating 939 patients. This study reveals that patients in the HIFU group presented increased median overall survival (OS), along with higher OS at 6 and 12 months after treatment compared with the control group (p < 0.05). Furthermore, patients treated with HIFU in conjunction with chemotherapy presented reduced levels of pain (p < 0.05) compared to the traditional treatment group. In addition, HIFU contributed to significant tumor responsiveness, in terms of CA19-9 reduction (p < 0.05). Finally, HIFU was a considerably safe treatment modality with a low incidence of complications. CONCLUSION: These outcomes suggest that HIFU is a feasible and safe treatment modality for patients with advanced pancreatic cancer and provides enhanced outcomes regarding survival and quality of life. Given the lack of a significant number of randomized clinical trials, this meta-analysis represents the best currently available evidence. New randomized trials assessing HIFU are necessary to further evaluate their outcomes.

Metastatic rectal cancer in the ampulla of Vater: A unique case.

BACKGROUND: A metastatic lesion located in the ampulla of Vater is considered extremely rare, with only 32 cases reported globally. CASE: A 65-year-old patient was primarily diagnosed with a rectal adenocarcinoma. Twenty-four months later as part of the oncological follow-up, the patient was diagnosed with a single secondary tumor in the ampulla of Vater. After undergoing a pancreaticoduodenectomy (Whipple procedure), the patient experienced an uneventful recovery and received adjuvant chemotherapy. Sixteen months later the patient remained disease-free. CONCLUSION: To the best of our knowledge, the present case represents the first reported metastatic tumor in the ampulla of Vater, originating from a rectal adenocarcinoma. This case underlines the critical role of immunohistochemistry in arriving at a correct diagnosis in order to guide clinical decision-making.

A Kidney Transplant Recipient With a Perforated Cheek: Oral Epstein-Barr Virus-Positive Mucocutaneous Ulcer Complicated With an Opportunistic Bacterial Infection.

A 69-year-old female living donor kidney transplant recipient presented with right facial painful edema. The patient's body mass index was 14 (kilograms per meter squared), and her creatinine clearance was 15 mL/min. A computed tomography detected a subcutaneous mass under the nasolabial fold in contact with the maxillary bone. A biopsy from an ipsilateral oral mucosal ulcer returned the diagnosis of Epstein-Barr virus-positive mucocutaneous ulcer. Within 2 weeks, the lesion perforated the tissue. The mass and the affected bone were removed, and histopathology detected inflammation with many microorganisms. The opportunistic pathogen Streptococcus anginosus was isolated from wound cultures. Immunosuppressives were restricted, antibiotics were administered, and the patient started hemodialysis. Rituximab was applied for the lymphoproliferative disease. The lesion healed, allowing for surgical restoration. Two years later, the patient has remained free of local pathology and with improved nutritional and functional status. Epstein-Barr virus-positive muco cutaneous ulcers should be considered in the differential diagnosis of oral and facial lesions of immunocompromised patients and may be complicated with bacterial infections.

A meta-analysis evaluating contrast-enhanced intraoperative ultrasound (CE-IOUS) in the context of surgery for colorectal liver metastases.

BACKGROUND: This study aimed to assess the outcomes of contrast-enhanced intraoperative ultrasound (CE-IOUS) for patients with colorectal liver metastases (CRLMs) undergoing surgery. METHOD: A thorough literature search was performed in PubMed, Scopus, and Cochrane databases, in accordance with the PRISMA guidelines. The Odds Ratio, Weighted Mean Difference, and 95% Confidence Interval were evaluated, by means of Random-Effects model. RESULTS: Eleven articles met the inclusion criteria and incorporated 497 patients. The present study shows that CE-IOUS is associated with higher sensitivity and accuracy compared with multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), and intraoperative ultrasound (IOUS) in identifying CRLMs (p < 0.05). The positive predictive value was similar among the different modalities. Furthermore, new CRLMs were identified by CE-IOUS, thus affecting the surgical plan in 128 patients (51.8% of the patients with new CRLMs). Moreover, 91 patients (71%) underwent a more extensive hepatectomy and 15 patients (11.7%) were considered non-operable. Two alternative contrast agents, Sonazoid and Sonovue, were employed with similar sensitivity (p > 0.05). CONCLUSION: These outcomes suggest the superiority of the CE-IOUS over MDCT, MRI, and IOUS for the staging of patients with CRLMs undergoing surgery. However, they should be treated with caution given the small number of the included studies.

Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. METHODS: All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. RESULTS: Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). CONCLUSIONS: Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.

Facing a dilemma in the treatment of an internal mammary artery mycotic pseudoaneurysm: coil embolization or surgery? A case report and brief literature review.

While aneurysms of the internal mammary artery (IMA) complicate occasionally surgical procedures employing median sternotomy, or are associated with direct thoracic trauma, mycotic pseudoaneurysms of the vessel are rarely reported in the literature. We herein report a case of a 22-year-old man who developed a mycotic internal mammary artery pseudoaneurysm secondary to staphylococcal chest wall abscesses and was effectively treated by coil embolization. Additionally, the report provides a brief review focusing on the current state of treatment options for internal mammary artery aneurysms.

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature.

BACKGROUND: Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst. CASE DESCRIPTION: A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intractranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst's neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed. CONCLUSIONS: Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

PURPOSE: To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. MATERIALS AND METHODS: Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. RESULTS: In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. CONCLUSION: 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Soft tissue pseudotumours: a pictorial review with emphasis on MRI.

BACKGROUND: Several tumour-like conditions of the soft tissues may be encountered in clinical practice, or when patients undergo radiologic examinations. Al-though advances in cross sectional imaging (ultra-sound, MDCT and MRI) play a pivotal role in the correct evaluation of tumour-like lesions, a systematic approach is needed to achieve a definitive diagnosis or limit the differential diagnosis. Clinical history, physical examination and anatomic location are of paramount importance. METHODS: In this pictorial essay we review some of the most frequent benign soft tissue conditions which may be mistaken for malignancy and thus lead to need-less referrals, unnecessary biopsies and great anxiety to the patients and their carers. LEVEL OF EVIDENCE: IV.

The association of simple renal cysts with abdominal aortic aneurysms and their impact on renal function after endovascular aneurysm repair.

We validated the association of simple renal cysts with abdominal aortic aneurysm and other cardiovascular factors and assessed simple renal cysts' impact on renal function before and after endovascular abdominal aortic aneurysm repair. A retrospective analysis of prospectively collected data was conducted. Computed tomography angiograms of 100 consecutive male patients with abdominal aortic aneurysm who underwent endovascular abdominal aortic aneurysm repair (Group 1) were reviewed and compared with 100 computed tomography angiogram of aged-matched male patients without abdominal aortic aneurysm (Group 2). Patients' demographic data, risk factors, abdominal aortic aneurysm diameter, the presence of simple renal cyst and laboratory tests were recorded. No difference was observed between the two groups in respect to other cardiovascular risk factors except hyperlipidemia with higher prevalence in Group 1 (p < 0.05). Presence of simple renal cysts was independently associated with age (p < 0.05) and abdominal aortic aneurysm (p = 0.0157). There was no correlation between simple renal cysts and abdominal aortic aneurysm size or pre-operative creatinine and urea levels. No difference was observed in post-operative creatinine and urea levels either immediately after endovascular abdominal aortic aneurysm repair or in 12-month follow-up. In male patients, the presence of simple renal cysts is associated with abdominal aortic aneurysm and is increasing with age. However, their presence is neither associated with impaired renal function pre-endovascular abdominal aortic aneurysm repair and post-endovascular abdominal aortic aneurysm repair nor after 12-month follow-up.

Complexity of persistent type II endoleak associated with sac expansion after endovascular abdominal aortic aneurysm repair.

Type II endoleak after endovascular aortic aneurysm repair still remains the Achilles' heel of the treatment, the source of which regularly is difficult to identify and treat. We present a patient with a persistent type II endoleak associated with a continuous aneurysm sac expansion after endovascular aortic aneurysm repair for which many diagnostic modalities were used during his follow-up such as duplex scan, computed tomography angiography and magnetic resonance angiography. Attempts were undertaken to treat the source of endoleak including coil micro-embolisation of lumbar arteries and subsequent open ligation of the inferior mesenteric artery, but they failed to eliminate the endoleak. Finally, a middle sacral artery was identified as the source of the endoleak. At that time, the patient was subjected to surgery for sigmoid carcinoma, and simultaneously, a ligation of the sacral artery was undertaken which eventually eliminated the endoleak completely. This case highlights that type II endoleak may be evoked by various sources and there can be a great difficulty to identify these feeding vessels; thus, careful planning for its management is mandatory.

Safety and efficacy of transcatheter arterial chemoemboliazation in the real-life management of unresectable hepatocellular carcinoma.

BACKGROUND: Trans-arterial chemoembolization (TACE) is associated with better survival in BCLC-stage B patients with hepatocellular carcinoma (HCC) and Child-Pugh A whereas in Child-Pugh B there is no definite evidence of benefit. OBJECTIVES: To assess the safety and efficacy of TACE during routine clinical practice in a consecutive Greek cohort of patients with unrespectable HCC. PATIENTS AND METHODS: Seventy one patients enrolled for this study (mean follow-up:24.6 months). 100 mg cisplatin, 50 mg doxorubicin and 10 ml lipiodol as well as embolic materials were used. CT-scans and blood tests were obtained prior and post-TACE. Kaplan-Meier method and Cox proportional hazard model were used to evaluate survival and factors affecting survival. RESULTS: Survival at 1-year, 2-years, 3-years and 5-years was 73.2%, 45.4%, 33.2% and 14.9% respectively. Procedure-related mortality was 1.4%. Multivariate analysis showed lesion diameter, Child-Pugh classification, alcohol abuse, tumor response and AFP prior TACE as independent prognostic factors of survival. Patients diagnosed during surveillance had significantly better survival rates compared to those diagnosed after development of symptoms (HR = 0.58, 95%CI: 0.33-1.01, P < 0.05). CONCLUSIONS: TACE is safe and efficient for unrespectable HCC. Alcohol abuse, tumor burden, response criteria, Child-Pugh and AFP prior to the session were identified as independent predictors of survival whereas, adherence to surveillance programs resulted in significantly better survival in these patients.

Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric procedure, and data regarding the learning curve are scarce. The aim of this study is to assess how the procedure can be safely implanted in a newly established bariatric unit and to define the learning curve. METHODS: Proctorship and mentorship in bariatric surgery were attended by two surgeons who were previously experienced in advanced laparoscopic surgery. The first consecutive 102 patients who underwent LSG in our newly established bariatric center were included. Patients were divided into three groups of 34 (groups 1, 2, and 3) according to case sequence. Data on demographics, operative time, conversion rate, hospital stay, morbidity, mortality, and excess weight loss (EWL) over time were compared between the groups. RESULTS: The operative time was significantly lower in groups 2 (p = 0.016) and 3 (p = 0.003) compared to group 1. The learning curve was flat up to the 68th case. A significant decrease in hospital stay was noted for group 3 compared to groups 1 (p < 0.001) and 2 (p = 0.002). The conversion rate, mortality and morbidity rates, and EWL did not differ significantly between the groups. Mortality was 0.98% and procedure-related morbidity was 7.8%. CONCLUSIONS: LSG can be safely and efficiently performed in a newly established bariatric center following a mentorship procedure. Proficiency seems to require 68 cases. The operative time and hospital stay may significantly decrease with experience early in the learning curve, as opposed to mortality and morbidity rates, conversion rate, and EWL.

Experimental animal study of a novel radiofrequency endovascular occlusion device.

BACKGROUND: The purpose of this study was to present a radiofrequency (RF) endovascular occlusion device (ie, Habib VesCoag Catheter; EMcision Ltd, London, UK) and to evaluate safety and efficacy of the device for complete occlusion of normal porcine vessels. METHODS: The study included 20 pigs. In each pig, a segmental branch of the right hepatic artery, a branch of the splenic artery, and a branch of one of the renal arteries were catheterized. A single or multiple applications of RF energy were performed until vessel occlusion was achieved. Fifteen days later, angiography was repeated to assess vessel patency. The vessels were then excised for pathological analysis. RESULTS: Vessels 2.5 to 6 mm in diameter were treated. Complete occlusion with a single attempt was achieved using a mean amount of energy of 110.67 J in vessels 2.5 to 3 mm, 111.67 J in vessels 3.5 to 4 mm, and 116.63 J in vessels 5 to 6 mm in diameter and was confirmed by angiography at the 15-day follow-up. CONCLUSIONS: Vascular occlusion can be effectively and safely achieved by endovascular application of RF energy to normal porcine arteries using the Habib VesCoag catheter.

A novel experimental animal model of arterial stenosis based on endovascular radiofrequency energy application.

PURPOSE: To develop a new rabbit model of arterial stenosis using endovascular radiofrequency (RF) energy. MATERIALS AND METHODS: Ten rabbits were used for multiple endovascular RF applications to the aorta and left common carotid artery through the Habib™ VesCoag™ catheter. Angiography and color Doppler ultrasound were used to assess vessel patency immediately following the procedure and six weeks later. One rabbit was sacrificed following the procedure for histopathologic analysis of the vessel wall. Two rabbits died of aortic and carotid rupture, respectively, immediately after the procedure. The remaining seven rabbits were sacrificed after six-week follow-up for histopathological analysis. RESULTS: Optimal RF generator settings to induce significant arterial stenosis (>50%) without complications were standardized at 24-26 watts (W) for 1.5 min for the aorta and 6 W for 1 min for the common carotid artery. The six-week follow-up showed permanent results in all surviving rabbits. Histopathology revealed intima and medial smooth muscle layer necrosis. CONCLUSION: We have developed a novel rabbit model of arterial stenosis using endovascular RF energy. Our model is fast, safe, inexpensive, and reproducible. It would be useful for experimental investigations and new therapeutic devices.

Radiofrequency-assisted hemostasis in a trauma model: a new indication for a bipolar device.

BACKGROUND: Hemorrhage control in severe splenic and hepatic injuries remains a challenge, despite recent improvements in equipment technology. Radiofrequency (RF) energy-assisted surgery for the spleen and liver has been recently reported; however, the technique has not gained wide acceptance, mainly due to surgeons' unfamiliarity with the technique and the risk of complications caused by uncontrolled disseminated energy. In this study, the safety and efficacy of the Habib 4X (AngioDynamics, Latham, NY), a hand-held bipolar RF energy device, was evaluated in a porcine trauma model. MATERIALS AND METHODS: Five white male Landrace pigs were included in the study. Multiple stab wounds were inflicted to the splenic and hepatic parenchyma, both centrally and peripherally. Hemostasis was achieved by using the Habib 4X RF bipolar device. The pigs were humanely sacrificed 6 weeks postoperatively, and histology of the ablated spleen and liver was evaluated. RESULTS: Hemorrhage was successfully controlled at all bleeding sites, using appropriate RF generator settings. The splenic artery and vein, as well as the hepatic veins, were successfully ligated using the device. No complications were noted immediately postoperatively or 6 weeks following the procedure. CONCLUSIONS: The bipolar Habib 4X device delivers RF energy that can achieve hemostasis of the injured splenic and hepatic parenchyma. The method is feasible and safe. Clinical studies are warranted to assess short- and long-term results of this promising technique and compare it to the gold standards.