Greater cost without greater benefit: The need to refine transfer criteria for patients with severe acute pancreatitis.

BACKGROUND: Appropriate and timely care is essential in the management of severe acute pancreatitis (SAP). We hypothesized that transferred patients with SAP undergoing procedural intervention would have higher mortality compared to those managed directly at academic centers. METHODS: This was a retrospective analysis of Maryland's statewide claims database from 2009 to 2022 of adult patients admitted with a primary diagnosis of SAP (acute pancreatitis with organ failure). Patients were divided into three groups: those admitted directly from the emergency room to academic facilities (AD), non-academic facilities (NA), or transferred to academic facilities (TR). Procedural intervention included endoscopic, percutaneous image-guided, or surgical. The primary outcome was in-hospital mortality. Secondary outcomes were admission costs, length of stay (LOS), and intensive care unit (ICU) admission. RESULTS: There were 7,648 (48.9%) in the NA group, 6,682 (42.7%) in the AD group and 1,316 (8.4%) in the TR group. On regression analysis, odds of death were 0.57x lower in the NA group and 0.67x lower in the AD group compared to transfers (<0.001). Procedural intervention was not associated with increased mortality. Transferred patients had longer median LOS (11 vs NA = 5, AD = 6, p < 0.001), increased median cost of admission ($41k vs NA = $12k, AD = $17k, p < 0.001) and greater ICU admission (45.6% vs NA = 20.6%, AD = 23.9%, p < 0.001). CONCLUSION: Transferred patients have greater burden of illness and cost of care without evidence of improved outcomes in the management of SAP regardless of procedural intervention. Transfer criteria for patients with SAP must be further refined to reduce unnecessary transfers.

Percutaneous Image-guided Cryoneurolysis: Applications and Techniques.

The expansion and dissemination of interventional cryoneurolysis in recent years has been fueled by the integration of advanced imaging guidance, the evolution of our understanding of neuropathologic processes after exposure of nerves to cold, and opportunities for its use beyond pain management. The clinical translation of cryoneurolysis through interventional radiology requires consideration of many factors, including (a) the supply and composition of target nerves, (b) the value of diagnostic injection with imaging guidance for confirmation, (c) the integration of advanced imaging guidance that allows safe ablation, (d) the difference between neoplastic and nonneoplastic causes of pain, (e) the phenomenon of percutaneously induced neuroregeneration, (f) the potential to manage conditions other than pain, (g) the consideration of protocols, (h) the limitations of current technology, and (i) the potential complications and adverse effects. Cryoneurolysis has societal and legislative endorsement as an effective nonopioid option for pain palliation. The Centers for Medicare and Medicaid Services (CMS) approved three new category III Current Procedural Terminology (CPT) codes specifically for the cryoablation of nerves with advanced imaging guidance. Interventional radiologists who are aware of nerve-directed strategies see eligible patients in their daily practice and have opportunities to bundle procedures (eg, celiac plexus block at the time of a biliary drain for pancreatic cancer with low bile duct obstruction), offering an avenue to serve the patient, reduce opioid dependence, allow faster discharge, and establish name recognition of interventional radiologists. Also, the ability to use CT to target deep structures accurately and swiftly, often with only local anesthesia, compared with the usual monitored anesthesia care in a surgical setting, may provide another avenue to build a cryoneurolysis practice. ©RSNA, 2022.

Response assessment methods for patients with hepatic metastasis from rare tumor primaries undergoing transarterial chemoembolization.

PURPOSE: This study assessed the response to conventional transarterial chemoembolization (cTACE) in patients with liver metastases from rare tumor primaries using one-dimensional (1D) and three-dimensional (3D) quantitative response assessment methods, and investigate the relationship of lipiodol deposition in predicting response. MATERIALS AND METHODS: This retrospective bicentric study included 16 patients with hepatic metastases from rare tumors treated with cTACE between 2002 and 2017. Multi-phasic MR imaging obtained before and after cTACE was used for assessment of response. Response evaluation criteria in solid tumors (RECIST) and modified-RECIST (mRECIST) were utilized for 1D response assessment, and volumetric RECIST (vRECIST) and enhancement-based quantitative European Association for Study of the Liver EASL (qEASL) were used for 3D response assessment. The same day post-cTACE CT scan was analyzed to quantify intratumoral lipiodol deposition (%). RESULTS: The mean and standard deviation (SD) of diameter of treated lesions per targeted area was 7.5 ± 5.4 cm, and the mean and SD of number of metastases in each targeted area was 4.2 ± 4.6. cTACE was technically successful in all patients, without major complications. While RECIST and vRECIST methods did not allocate patients with partial response, mRECIST and qEASL identified patients with partial response. Intratumoral lipiodol deposition significantly predicted treatment response according qEASL (R2 = 0.470, p < 0.01), while no association was shown between lipiodol deposition within treated tumor area and RECIST or mRECIST (p > 0.212). CONCLUSION: 3D quantitative volumetric response analysis can be used for stratification of response to cTACE in patients with hepatic metastases originating from rare primary tumors. Lipiodol deposition could potentially be used as an early surrogate to predict response to cTACE.

The radiologist's guide to duplex ultrasound assessment of chronic mesenteric ischemia.

OBJECTIVE: This article reviews the relevant anatomy and physiology of the mesenteric vasculature, familiarizes the radiologist with the accepted diagnostic criteria for mesenteric artery stenosis and its role in the diagnosis of chronic mesenteric ischemia, describes Doppler imaging techniques, and provides protocols for the assessment and surveillance of the mesenteric vasculature before and after revascularization. It also discusses expected changes following revascularization and reviews common post-procedural complications. RESULTS: Duplex sonography plays an important role in the diagnosis and management of chronic mesenteric ischemia (CMI). Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient expertise in image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive [computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive (digital subtraction angiography (DSA)] imaging modalities for assessment of the mesenteric vasculature, a new era of "imaging wisely" raises legitimate concerns about the effects of ionizing radiation as well as potential effects of CT and MR contrast agents. These concerns are obviated by the use of ultrasound, and recently developed techniques, such as contrast-enhanced ultrasound and vascular applications focused on the evaluation of slow flow, have revealed the vast potential of vascular ultrasound in the evaluation of chronic mesenteric ischemia. CONCLUSION: Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system post revascularization.

Modeling of implementation of the new Organ Procurement and Transplantation Network/United Network for Organ Sharing policy for patients with hepatocellular carcinoma.

Aim: To simulate effects of the new Organ Procurement and Transplantation Network/United Network for Organ Sharing policy on the patients' characteristics and post orthotopic liver transplantation (OLT) outcome. Materials & methods: The United Network for Organ Sharing database was used to identify patients with hepatocellular carcinoma who were listed for OLT 2002-2014. All patients (actual group) versus simulated group with new 6-month delay in assigning Model for End-Stage Liver Disease score exception and Model for End-Stage Liver Disease exception cap of 34 were compared. Results & conclusion: With the new policy, 7,745 (30.4%) of the transplanted patients would have received a delayed transplantation or not be transplanted. The simulated group also showed significantly higher mean overall survival after OLT (p < 0.002) and received more locoreginal treatments (p < 0.001).