Ten-Year Experience with Percutaneous Cryoablation of Renal Tumors: Tumor Size Predicts Disease Progression.

Introduction: Percutaneous cryoablation (PCA) has emerged as an alternative to extirpative management of small renal masses (SRMs) in select patients, with a reduced risk of perioperative complications. Although disease recurrence is thought to occur in the early postoperative period, limited data on long-term oncologic outcomes have been published. We reviewed our 10-year experience with PCA for SRMs and assessed predictors of disease progression. Materials and Methods: We reviewed our prospectively maintained database of patients who underwent renal PCA from March 2005 to December 2015 (n = 308). Baseline patient and tumor variables were recorded, and postoperative cross-sectional imaging was examined for evidence of disease recurrence. Disease progression was defined as the presence of local recurrence or new lymphadenopathy/metastasis. Results: Mean patient age was 67.2 ± 11 years, mean tumor size was 2.7 ± 1.3 cm, and mean nephrometry score was 6.8 ± 1.7. At mean follow-up of 38 months, local recurrence and new lymphadenopathy/metastasis occurred in 10.1% (31/308) and 6.2% (19/308) of patients, respectively. Excluding patients with a solitary kidney and/or von Hippel-Lindau, local recurrence and new lymphadenopathy/metastasis occurred in 8.6% (23/268) and 1.9% (5/268) of cases, respectively. Kaplan-Meier estimated disease-free survival was 92.5% at 1 year, 89.3% at 2 years, and 86.7% at 3 years post-PCA. Increasing tumor size was a significant predictor of disease progression (hazard ratio 1.32 per 1-cm increase in size, p = 0.001). Conclusions: PCA is a viable treatment option for patients with SRMs. Increasing tumor size is a significant predictor of disease progression following PCA.

A Phase II Study of Tumor Ablation in Patients with Metastatic Sarcoma Stable on Chemotherapy.

LESSONS LEARNED: Ablation therapy appears to be a reasonably safe and effective approach to obtain a significant treatment-free interval for a subset of patients with limited sites of metastatic disease for which systemic control can be obtained with six cycles of chemotherapy. BACKGROUND: Metastatic sarcoma often becomes resistant to treatment by chemotherapy. There is sometimes prolonged stable disease from active chemotherapy that provides a window of opportunity for an intervention to prolong disease-free survival. MATERIALS AND METHODS: We performed a phase II study in patients with metastatic sarcoma who had been stable on six cycles of chemotherapy who then received ablation therapy to their residual disease. Histologies captured in this study included leiomyosarcoma, malignant peripheral nerve sheath tumor, pleiomorphic rhabdomyosarcoma, and myxoid liposarcoma. Sites ablated included lung metastases and retroperitoneal metastatic deposits. In this study, up to three lesions were ablated in any given interventional radiology session. After ablation, patients were not treated with any further therapy but were followed by surveillance imaging to determine progression-free rate (PFR). RESULTS: Although terminated early because of slow accrual, this study demonstrated a 3-month PFR of 75% for this cohort of eight patients treated with ablation performed after completion of six cycles of chemotherapy with stable disease. Median progression-free survival (PFS) was 19.74 months, and the median overall survival (OS) was not reached. CONCLUSION: Our data are the first prospective study to suggest that ablation therapy in selected patients who are stable on chemotherapy can provide a significant progression-free interval off therapy and warrants further study in a randomized trial.

Assessment of the Albumin-Bilirubin (ALBI) Grade as a Prognostic Indicator for Hepatocellular Carcinoma Patients Treated With Radioembolization.

OBJECTIVE: As the utility of Child-Pugh (C-P) class is limited by the subjectivity of ascites and encephalopathy, we evaluated a previously established objective method, the albumin-bilirubin (ALBI) grade, as a prognosticator for yttrium-90 radioembolization (RE) treatment for patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 117 patients who received RE for HCC from 2 academic centers were reviewed and stratified by ALBI grade, C-P class, and Barcelona Clinic Liver Cancer stage. The overall survival (OS) according to these 3 criteria was evaluated by Kaplan-Meier survival analysis. The utilities of C-P class and ALBI grade as prognostic indicators were compared using the log-rank test. Multivariate Cox regression analysis was performed to identify additional predictive factors. RESULTS: Patients with ALBI grade 1 (n=49) had superior OS than those with ALBI grade 2 (n=65) (P=0.01). Meanwhile, no significant difference was observed in OS between C-P class A (n=100) and C-P class B (n=14) (P=0.11). For C-P class A patients, the ALBI grade (1 vs. 2) was able to stratify 2 clear and nonoverlapping subgroups with differing OS curves (P=0.03). Multivariate Cox regression test identified alanine transaminase, Barcelona Clinic Liver Cancer stage, and ALBI grade as the strongest prognostic factors for OS (P<0.10). CONCLUSIONS: ALBI grade as a prognosticator has demonstrated clear survival discrimination that is superior to C-P class among HCC patients treated with RE, particularly within the subgroup of C-P class A patients. ALBI grade is useful for clinicians to make decisions as to whether RE should be recommended to patients with HCC.

Chemoembolization of Hepatocellular Carcinoma with Extrahepatic Collateral Blood Supply: Anatomic and Technical Considerations.

Transarterial chemoembolization (TACE) is considered a standard local-regional treatment for intermediate-stage hepatocellular carcinoma (HCC) and the most common bridging therapy. This treatment is offered to more than 70% of patients who are on the waiting list for liver transplantation in the United States. HCC typically receives its blood supply from the hepatic artery; however, it can recruit a parasitic supply from extrahepatic collateral (EHC) arteries. The development of an EHC arterial blood supply can interfere with the therapeutic efficacy of TACE and result in treatment failure and poor outcome. Cross-sectional imaging-specifically computed tomography and magnetic resonance imaging-has some limitations in depicting the presence or absence of an EHC arterial supply during the pre-TACE evaluation. Catheterization and angiography of every possible EHC artery during a routine TACE procedure would be time consuming and technically challenging and would not always be feasible. Therefore, the prediction of a potential EHC arterial supply on the basis of tumor location before, during, and after TACE is fundamental to achieving optimal therapeutic efficacy. To perform TACE through EHC arteries, special considerations are necessary to avoid potentially serious complications. The authors review the factors influencing the development of an EHC arterial blood supply to HCC and describe a systematic approach to enhance the ability to predict the presence of EHC arteries. They also describe the proper technique for TACE of each EHC artery and how to avoid potential technique-related complications. ©RSNA, 2017.

Neoadjuvant Locoregional Therapy and Recurrent Hepatocellular Carcinoma after Liver Transplantation.

BACKGROUND: Neoadjuvant locoregional therapies (LRTs) have been widely used to reduce tumor burden or to downstage hepatocellular carcinoma (HCC) before orthotopic liver transplantation (OLT). We examined the impact of LRT response on HCC recurrence after OLT. STUDY DESIGN: We performed a retrospective study of 384 patients with HCC treated by OLT. Tumor necrosis was determined by pathologic evaluation. The vascular and lymphatic vessels were localized by immunofluorescence staining in formalin-fixed, paraffin-embedded tissue; expressions of vascular endothelial growth factor receptor (VEGFR)-2 and VEGFR-3 were analyzed by Western blot. Plasma vascular endothelial growth factor (VEGF)-A and VEGF-C levels of a consecutive cohort of 171 HCC patients were detected by ELISA. RESULTS: Of the 384 patients with HCC, 268 had undergone pretransplantation neoadjuvant LRTs. Patients with no tumor necrosis (n = 58; 5.2% recurrence) or complete tumor necrosis (n = 70; 6.1% recurrence) had significantly lower 5-year recurrence rates than those with partial tumor necrosis (n = 140; 22.6% recurrence; p < 0.001). Lymphatic metastases were significantly more numerous in patients with partial tumor necrosis than in those without tumor necrosis after OLT (p < 0.001). With immunofluorescence staining of peritumor zone, lymphatics were visualized around partially necrotic tumors, but not around tumors without necrosis. Plasma levels of VEGF-A and VEGF-C were elevated significantly in patients with evidence of tumor necrosis (n = 102) compared with those without necrosis (n = 69; p < 0.001). By Western blot, VEGFR-2 and VEGFR-3 expression in the peritumoral tissue associated with partially necrotic tumors was significantly higher than in peritumoral tissue of non-necrosis tumors (n = 3/group, p < 0.020 and p < 0.006, respectively). CONCLUSIONS: Locoregional therapy-induced or spontaneous partially necrotic HCC was associated with increased risk of lymphatic metastases compared with tumors with no or complete tumor necrosis. Anti-lymphangiogenic agents with neoadjuvant LRTs can decrease the pattern of lymphatic metastasis after OLT.

Liver Transplantation for Advanced Hepatocellular Carcinoma after Downstaging Without Up-Front Stage Restrictions.

BACKGROUND: The incidence of hepatocellular carcinoma (HCC) continues to increase dramatically worldwide. Liver transplantation (LT) is now the standard and optimal treatment for patients with HCC in the setting of cirrhosis, but only for tumors within Milan criteria. In patients presenting beyond Milan criteria, locoregional therapy (LRT) can downstage to within Milan criteria for consideration for LT. Although controversial, the current study aims to evaluate the outcomes of LT in patients presenting with advanced-stage HCC who underwent downstaging and compare these outcomes with those of patients who met Milan criteria at presentation. STUDY DESIGN: Our protocol does not set a priori limitations as long as HCC is confined to the liver. In this retrospective study between January 1, 2002 and December 31, 2014, we reviewed outcomes associated with 284 patients who presented within Milan criteria and patients who presented with more-advanced stage tumor who were potential transplantation candidates. The patients with advanced disease were then subdivided into those who were within or beyond University of California San Francisco criteria. Imaging, details of LRT, recurrence, and survival were compared between the groups. RESULTS: Sixty-three of 210 (30%) eligible patients were downstaged and underwent transplantation; 14 additional downstaged and listed patients were withdrawn for the following reasons: death while waiting (n = 4), disease progression (n = 8), development of other malignancy (n = 1), and declined LT (n = 1). Twelve patients underwent resection after downstaging and did not require LT. Survival for patients who were downstaged was similar to those who were within Milan criteria initially. Recurrence of HCC at 5 years was similar between groups (10.9% vs 10.8%; p = 0.84). CONCLUSIONS: Patients with beyond-Milan criteria HCC who are otherwise candidates for LT should undergo aggressive attempts at downstaging without a priori exclusion. This highly selective approach allows for excellent long-term results, similar to patients presenting with earlier-stage disease.

Process improvement for the safe delivery of multidisciplinary-executed treatments-A case in Y-90 microspheres therapy.

PURPOSE: To develop a safe and robust workflow for yttrium-90 (Y-90) radioembolization procedures in a multidisciplinary team environment. METHODS AND MATERIALS: A generalized Define-Measure-Analyze-Improve-Control (DMAIC)-based approach to process improvement was applied to a Y-90 radioembolization workflow. In the first DMAIC cycle, events with the Y-90 workflow were defined and analyzed. To improve the workflow, a web-based interactive electronic white board (EWB) system was adopted as the central communication platform and information processing hub. The EWB-based Y-90 workflow then underwent a second DMAIC cycle. Out of 245 treatments, three misses that went undetected until treatment initiation were recorded over a period of 21 months, and root-cause-analysis was performed to determine causes of each incident and opportunities for improvement. The EWB-based Y-90 process was further improved via new rules to define reliable sources of information as inputs into the planning process, as well as new check points to ensure this information was communicated correctly throughout the process flow. RESULTS: After implementation of the revised EWB-based Y-90 workflow, after two DMAIC-like cycles, there were zero misses out of 153 patient treatments in 1 year. CONCLUSIONS: The DMAIC-based approach adopted here allowed the iterative development of a robust workflow to achieve an adaptable, event-minimizing planning process despite a complex setting which requires the participation of multiple teams for Y-90 microspheres therapy. Implementation of such a workflow using the EWB or similar platform with a DMAIC-based process improvement approach could be expanded to other treatment procedures, especially those requiring multidisciplinary management.

Chemoembolization versus radioembolization for the treatment of unresectable intrahepatic cholangiocarcinoma in a single institution image-based efficacy and comparative toxicity.

AIM: Compare radioembolization (Y90) and chemoembolization (CE) for the treatment of unresectable intrahepatic cholangiocarcinoma (UICC). MATERIALS & METHODS: Institutional Review Board-approved, retrospective search was performed. Forty patients with UICC were treated with either Y90 (n = 25, 39 treatments) or CE (n = 15, 35 treatments). Comparative analysis was performed using Student's t and fisher-exact tests. Multivariable-logistic regression was also performed. RESULTS: Median ages were 60 and 64 years for CE and Y90 groups, respectively (p = 0.798). Patient variables including age, Eastern Cooperative Oncology Group score, tumor burden, extra-hepatic disease, prior chemotherapy and prior surgery were similar between groups. Adverse events were similar in both groups (CE 20%, Y90 26%; p > 0.9). Overall response rate (CE 6%, Y90 4%; p > 0.9) and disease control rate (CE 46%, Y90 48%; p > 0.9) were statistically similar. Multilogistic regression did not identify any variables that correlated with disease control rate, including Eastern Cooperative Oncology Group score and tumor burden. CONCLUSION: Our observation shows that CE and Y90 display similar toxicity and disease control in the treatment of UICC.

Colorectal liver metastases: disappearing lesions in the era of Eovist hepatobiliary magnetic resonance imaging.

BACKGROUND: Hepatobiliary contrast enhanced MRI is known to be the most sensitive imaging modality for detection of colorectal hepatic metastasis. To date no study has investigated the rate of disappearing lesions with gadoxetic acid MR (Eovist/Primovist), or characterized the pathologic response of lesions which disappear on gadoxetic acid MR. METHODS: Retrospective review of hepatic resections for colorectal metastases between 01/2008 and 01/2014 was performed to evaluated the rate of disappearance of lesions on gadoxetic acid MR and the rate of complete pathologic response in the lesions that disappear. "Disappearing lesions" were lesions on baseline imaging that were not identifiable on pre-operative Eovist MRI. Complete pathologic response was defined as no viable tumor on pathology or by lack of recurrence within 1 year. RESULTS: In 23 patients, 200 colorectal metastases were identified on baseline imaging. On pre-operative Eovist MR 77 of the 200 lesions (38.5%) were "disappearing" lesions. At surgical pathology or 1 year follow-up imaging, 42 of 77 lesions (55%) demonstrated viable tumor (21) or recurrence (21). Thirty of 77 lesions (39%) were nonviable at pathology (10) or without evidence of recurrence at 1 year (20). 5 lesions were indeterminate. DISCUSSION: Despite disappearance on Eovist MR imaging (the most sensitive available imaging modality), 38.5% of all colorectal metastases disappeared and of those, 55% were viable.

PET/MRI of Hepatic 90Y Microsphere Deposition Determines Individual Tumor Response.

PURPOSE: The purpose of our study is to determine if there is a relationship between dose deposition measured by PET/MRI and individual lesion response to yttrium-90 ((90)Y) microsphere radioembolization. MATERIALS AND METHODS: 26 patients undergoing lobar treatment with (90)Y microspheres underwent PET/MRI within 66 h of treatment and had follow-up imaging available. Adequate visualization of tumor was available in 24 patients, and contours were drawn on simultaneously acquired PET/MRI data. Dose volume histograms (DVHs) were extracted from dose maps, which were generated using a voxelized dose kernel. Similar contours to capture dimensional and volumetric change of tumors were drawn on follow-up imaging. Response was analyzed using both RECIST and volumetric RECIST (vRECIST) criteria. RESULTS: A total of 8 hepatocellular carcinoma (HCC), 4 neuroendocrine tumor (NET), 9 colorectal metastases (CRC) patients, and 3 patients with other metastatic disease met inclusion criteria. Average dose was useful in predicting response between responders and non-responders for all lesion types and for CRC lesions alone using both response criteria (p < 0.05). D70 (minimum dose to 70 % of volume) was also useful in predicting response when using vRECIST. No significant trend was seen in the other tumor types. For CRC lesions, an average dose of 29.8 Gy offered 76.9 % sensitivity and 75.9 % specificity for response. CONCLUSIONS: PET/MRI of (90)Y microsphere distribution showed significantly higher DVH values for responders than non-responders in patients with CRC. DVH analysis of (90)Y microsphere distribution following treatment may be an important predictor of response and could be used to guide future adaptive therapy trials.

Biphenotypic Primary Liver Carcinomas: Assessing Outcomes of Hepatic Directed Therapy.

BACKGROUND: Primary liver carcinomas with hepatocellular and cholangiocellular differentiation (b[HB]-PLC) are rare. Surgery offers the best prognosis, but there is a paucity of literature to guide therapy for patients with advanced or unresectable disease. This study aimed to evaluate outcomes of hepatic-directed therapy compared with those of systemic chemotherapy and surgery. METHODS: A retrospective evaluation of patients with b(HB)-PLC from 1 January 2008 to 1 September 2014 was conducted. The patients were divided into the following four groups: transplantation (TX) group, surgical resection (SX) group, hepatic directed (HD) group, and systemic chemotherapy alone (SC) group. Overall and progression-free survival, treatment response, and clinicopathologic data were analyzed. RESULTS: The study included 79 patients (37 females) with an average age of 62 years. The number of patients in each group were as follows: TX group (n = 6), SX group (n = 27), HD group (n = 18), and SC group (n = 28). The mean follow-up periods were 33 months for the TX group, 17 months for the SX group, 14 months for the HD group, and 7 months for the SX group. Overall, 28 % of the patients had cirrhosis and 35 % had viral hepatitis. The candidates for surgery comprised 42 % of the patients. The HD group (n = 18) had a significantly greater objective response than the SC group (n = 28) (47 vs. 6 %; p = 0.02). Two patients who underwent hepatic arterial infusion pump treatment were downstaged to resection. A trend toward improved OS/PFS was observed in the HD group versus the SC group, although statistically significant. The SX group had significantly improved survival (p < 0.001) as did the transplanted patients. CONCLUSIONS: Although surgery offers the best survival for b(HB)-PLC patients, only a minority are candidates for surgery. Because HD therapy showed a superior objective response over SC therapy, it may offer a survival advantage and may downstage patients for surgical resection or transplantation.

Imaging approach to hepatocellular carcinoma, cholangiocarcinoma, and metastatic colorectal cancer.

Liver imaging is a highly evolving field with new imaging contrast agents and modalities. Knowledge of the different imaging options and what they have to offer in primary and metastatic liver disease is essential for appropriate diagnosis, staging, and prognosis in patients. This review summarizes the major imaging modalities in liver neoplasms and provides specific discussion of imaging hepatocellular carcinoma, cholangiocarcinoma, and colorectal liver metastases. The final sections provide an overview of presurgical imaging relevant to planning hepatectomies and ablative procedures.

Comparison of laparoscopic and percutaneous cryoablation for treatment of renal masses.

OBJECTIVE: To compare perioperative and oncologic outcomes between laparoscopic (LCA) and percutaneous cryoablation (PCA) and identify predictors of treatment failure after cryoablation. METHODS: Retrospective analysis was performed on 145 patients undergoing LCA and 118 patients undergoing PCA at our institution between July 2000 and June 2011. RESULTS: LCA and PCA were performed on 167 and 123 tumors, respectively. Perioperative complication rates were 10% for both the groups. Mean length of stay was significantly shorter for the PCA group (2.1 ± 0.5 vs 3.5 ± 3.1 days, P <.01). Both groups had a comparable decline in estimated glomerular filtration rate at most recent follow-up (LCA 3.8 ± 18.5 mL/min/1.73 m(2) vs PCA 6.6 ± 17.1 mL/min/1.73 m(2), P = .21). Mean oncologic follow-up was 71.4 ± 32.1 months for LCA and 38.6 ± 19.6 months for PCA. Kaplan-Meier estimated 5-year overall and recurrence-free survival were 79.3% and 85.5%, respectively, for LCA and 86.3% and 86.3%, respectively, for PCA. Multivariate Cox proportional hazards analysis demonstrated that cryoablation approach (LCA vs PCA) was not predictive of overall mortality or disease recurrence (P = .36 and .82, respectively). Predictors of overall mortality included age-adjusted Charlson comorbidity index ≥ 6 (P = .01) and preoperative estimated glomerular filtration rate <60 mL/min/1.73 m(2) (P = .02). Predictors of recurrence included tumor size ≥ 3 cm (P <.01), body mass index ≥ 30 kg/m(2) (P = .01), and endophytic growth (P = .04). CONCLUSION: Mean length of stay was shorter for patients undergoing PCA as compared with LCA. Complication rates and decline in renal function at most recent follow-up were similar between groups. Oncologic outcomes were influenced by baseline patient and tumor characteristics rather than the cryoablation approach.

Stomal varices: management with decompression tips and transvenous obliteration or sclerosis.

Stomal or parastomal varices are extraperitoneal ectopic mesenteric varices. Parastomal varices are not common but can be a source of considerable bleeding. They usually occur in the setting of portal hypertension, although, in theory, they can occur because of vascular thrombosis of the mesentery. An obstructive element (not necessarily venous thrombosis, but a constrictive effect) most likely exists and thus localizes the bleeding to the stomal mesenteric varices. This obstruction can be due to postsurgical changes associated with the stoma creation itself. Bleeding is the main presentation of stomal varices. Bleeding can be life threatening; however, most of it can be controlled by manual compression by patients who are consciously aware. Anecdotally, there are 2 pathologic bleeding presentations. Certain stomas are diffusely congested and ooze blood diffusely, and others bleed focally from a particular site (from a particular mesenteric varix). The focal bleeders are the ones that respond favorably to manual compression by the patient. The stomas that are diffusely congested or engorged with diffuse venous oozing do better with transjugular intrahepatic portosystemic shunt (TIPS) decompression. Bleeding from focal varices in the stoma (with the rest of the stomal mucosa looking normal and not engorged) can be treated with TIPS (if the portal or mesenteric vein or both are patent) or with transvenous obliteration utilizing 1% sodium tetradecyl sulfate (not 3% sodium tetradecyl sulfate). Balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration, trans-TIPS balloon-occluded antegrade transvenous obliteration can all be adequate approaches to transvenous obliteration. However, the least invasive (in the authors' opinion) and simplest is the direct mesenteric venous stick (balloon-occluded antegrade transvenous obliteration-type) approach with ultrasound-guided compression of the systemic outflow vein.

Validation of organ procurement and transplant network (OPTN)/united network for organ sharing (UNOS) criteria for imaging diagnosis of hepatocellular carcinoma.

BACKGROUND: Imaging diagnosis of hepatocellular carcinoma (HCC) presents an important pathway for transplant exception points and priority for cirrhotic patients. The purpose of this retrospective study is to evaluate the validity of the new Organ Procurement and Transplant Network (OPTN) classification system on patients undergoing transplantation for HCC. METHODS: One hundred twenty-nine patients underwent transplantation for HCC from April 14, 2006 to April 18, 2011; a total of 263 lesions were reported as suspicious for HCC on pretransplantation magnetic resonance imaging. Magnetic resonance imaging examinations were reviewed independently by two experienced radiologists, blinded to final pathology. Reviewers identified major imaging features and an OPTN classification was assigned to each lesion. Final proof of diagnosis was pathology on explant or necrosis along with imaging findings of ablation after transarterial chemoembolization. RESULTS: Application of OPTN imaging criteria in our population resulted in high specificity for the diagnosis of HCC. Sensitivity in diagnosis of small lesions (≥1 and <2 cm) was low (range, 26%-34%). Use of the OPTN system would have resulted in different management in 17% of our population who had received automatic exception points for HCC based on preoperative imaging but would not have met criteria under the new system. Eleven percent of the patients not meeting OPTN criteria were found to have T2 stage tumor burden on pathology. CONCLUSIONS: The OPTN imaging policy introduces a high level of specificity for HCC but may decrease sensitivity for small lesions. Management may be impacted in a number of patients, potentially requiring longer surveillance periods or biopsy to confirm diagnosis.

Management of iatrogenic bile duct injuries: role of the interventional radiologist.

Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.

Percutaneous cryoablation of renal masses: Washington University experience of treating 129 tumours.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: For patients who are unfit for extirpative surgery, percutaneous cryoablation (PCA) presents a minimally-invasive alternative for the treatment of renal masses. PCA has been demonstrated to be safe, with complication rates <10% being reported consistently. Studies have suggested that a minimal and insignificant decline in renal function can occur after PCA. Finally, among studies with a follow-up >20 months, treatment success rates range from 75% to 96%. However, longer-term oncological and functional results for patients treated with PCA are relatively limited. The present study profiles one of the largest reported experiences with PCA for renal masses: 129 tumours in 124 patients. Our complication rate was comparable to that observed in other reported studies. At a mean follow-up of 30 months, treatment success was achieved in 87% of tumours, which is in line with published PCA success rates. On multivariable analysis, tumour size >3.0 cm was found to be significantly associated with treatment failure. A minimal but statistically significant renal functional decline was observed, with 20% of patients experiencing a progression in National Kidney Foundation-Chronic Kidney Disease stage. On multivariable analysis, age >70 years, hilar tumour location and postoperative day 1 estimated glomerular filtration rate <60 mL/min/1.73 m(2) were found to be significantly associated with renal functional decline. The present study confirms that PCA of renal masses represents a safe alternative to surgery in patients with substantial medical comorbidities. In the present cohort, baseline patient and tumour characteristics probably impact the risk of tumour recurrence, as well as renal disease progression, after PCA. OBJECTIVE: To evaluate perioperative, oncological and functional outcomes after percutaneous cryoablation (PCA) for renal masses based on our single-centre experience. PATIENTS AND METHODS: We retrospectively identified 124 patients who underwent PCA for 129 renal tumours between March 2005 and June 2011. Patient demographics and baseline clinical characteristics, tumour features, perioperative information, and postoperative outcomes were recorded. Oncological outcomes were defined by radiographic evidence of recurrence on follow-up computed tomography or magnetic resonance imaging. Renal disease progression was defined by a change in National Kidney Foundation-Chronic Kidney Disease stage. RESULTS: Patients had mean (sd) age of 72.6 (10.2) years; mean (sd) tumour size and nephrometry score were 2.7 (1.1) cm and 6.5 (1.7), respectively. Our overall complication rate was 9% (11/124), whereas the major (greater than Clavien II) complication rate was 2% (2/124). Significant predictors of renal disease progression following PCA included age ≥ 70 years (odds ratio [OR], 4.31, P = 0.03), hilar tumour location (OR, 4.67, P = 0.04), and post operative day 1 estimated glomerular filteration rate ≤60 mL/min/1.73 m(2) (OR, 7.09, P = 0.02). Our treatment success rate was 87% (112/129) at a mean (sd) follow-up of 30.2 (18.8) months. Tumour size ≥3.0 cm was significantly associated with PCA failure (hazard ratio, 3.21, P = 0.03). CONCLUSION: PCA provides a safe and oncologically effective alternative to extirpative surgery for renal masses in patients with significant medical comorbidities.

Pancreaticoportal fistula and disseminated fat necrosis after revision of a transjugular intrahepatic portosystemic shunt.

A 59-year old man with alcohol related cirrhosis and portal hypertension was referred for transjugular intrahepatic portosystemic shunt (TIPS) to treat his refractory ascites. Ten years later, two sequential TIPS revisions were performed for shunt stenosis and recurrent ascites. After these revisions, he returned with increased serum pancreatic enzyme levels and disseminated superficial fat necrosis; an iatrogenic pancreaticoportal vein fistula caused by disruption of the pancreatic duct was suspected. The bare area of the TIPS was subsequently lined with a covered stent-graft, and serum enzyme levels returned to baseline. In the interval follow-up period, the patient has clinically improved.