Risk factors to differentiate between benign proximal biliary strictures and perihilar cholangiocarcinoma.

BACKGROUND: The aim of this study was to evaluate potential risk factors associated with benign lesions and perihilar cholangiocarcinoma (PHC) in patients presenting with proximal biliary strictures (PBS). METHODS: Patients with PBS who were referred to a specialist HPB centre between 2008 and 2016 were identified. Patients with primary sclerosing cholangitis, metastatic PHC or hilar obstruction by a peripheral tumour were excluded. The final diagnosis was determined either by (1) resection histology or (2) combination of biopsy and clinical course. Multivariable analysis of clinical, laboratory and radiological data was undertaken to identify independent predictors of benign and malignant lesions. RESULTS: 155 consecutive patients were identified, including 25 patients (16%) with benign PBS. Abdominal pain (odds ratio [OR] 3.36; p = 0.027), serum CA19.9 < 100 U/ml (OR 10.35; p = 0.001), and absence of mass on imaging (OR 4.66; p = 0.004) were all associated with the presence of benign lesions on multivariable analysis. CONCLUSIONS: This study has identified several independent variables that may differentiate between benign and malignant proximal biliary strictures. A larger multi-institutional study would be warranted to validate these findings, and to develop a risk score to stratify patients with suspected PHC.

Percutaneous transhepatic cholangiographic endobiliary forceps biopsy versus endoscopic ultrasound fine needle aspiration for proximal biliary strictures: a single-centre experience.

BACKGROUND: Endoscopic ultrasound fine needle aspiration (EUS-FNA) and percutaneous transhepatic cholangiographic endobiliary forceps biopsy (PTC-EFB) are valid procedures for histological assessment of proximal biliary strictures (PBS), but their performances have never been compared. This study aimed to compare the diagnostic performance of these two techniques. METHOD: The diagnostic performances of EUS-FNA and PTC-EFB were compared in a retrospective cohort of patients assessed for PBS from 2011 to 2015 at a single tertiary centre. An inverse probability of treatment weighting (IPTW) was performed to adjust for covariate imbalance. RESULTS: A total of 102 EUS-FNAs and 75 PTC-EFBs (performed in 137 patients) were compared. Patients in the PTC-EFB group had higher preoperative bilirubin (243 versus 169 µmol/l, p = 0.005) and a higher incidence of malignancy (87% versus 67%, p = 0.008). Both techniques showed specificity and positive predictive value of 100%, and similar sensitivity (69% versus 75%, p = 0.45), negative predictive value (58% versus 38%, p = 0.15) and accuracy (78% versus 79%, p = 1.00). After IPTW, the diagnostic performance of the two techniques remained similar. CONCLUSION: Compared to EUS-FNA, PTC-EFB provides similar sensitivity, negative predictive value and accuracy. It should therefore be considered as the preferred tissue-sampling procedure, if biliary drainage is indicated.

Radiological insertion of automated low flow ascitic pump (alfapump®) system for management of medically refractory ascites.

Ascites is well-documented sequelae of liver cirrhosis with significant impact on survival in this group of patients. Among the many established management strategies for the same is the use of an implantable mechanical device, called alfapump® (Sequana Medical, Zurich, Switzerland), that removes ascitic fluid by pumping it from the peritoneal cavity to the urinary bladder. Until recently, this device has been surgically placed under general anaesthesia. We describe successful interventional radiological implantation under conscious sedation in three patients with minimal complications. This device can serve as an alternative to transjugular intrahepatic portosystemic shunt for the management of refractory ascites; however, further studies are required to understand the device better.

Long-term follow-up after endovascular treatment of hepatic venous outflow obstruction following liver transplantation.

Hepatic venous outflow obstruction (HVOO) is a rare complication after liver transplantation (LT) associated with significant morbidity and reduced graft survival. Endovascular intervention has become the first-line treatment for HVOO, but data on long-term outcomes are lacking. We have analysed outcomes after endovascular intervention for HVOO in 905 consecutive patients who received 965 full-size LT at our unit from January 2007 to June 2014. There were 27 (3%) patients who underwent hepatic venogram for suspected HVOO, with persistent ascites being the most common symptom triggering the investigation (n = 19, 70%). Of those, only 10 patients demonstrated either stricture or pressure gradient over 10 mmHg on venogram, which represents a 1% incidence of HVOO. The endovascular interventions were balloon dilatation (n = 3), hepatic vein stenting (n = 4) and stenting with dilatation (n = 3). Two patients required restenting due to stent migration. The symptoms of HVOO completely resolved in all but one patient, with a median follow-up period of 74 (interquartile range 39-89) months. There were no procedure-related complications or mortality. In conclusion, the incidence of HVOO in patients receiving full-size LT is currently very low. Endovascular intervention is an effective and safe procedure providing symptom relief with long-lasting primary patency.

A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy.

BACKGROUND: Various factors are related to the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD). Some of the strongest are identified intra- or postoperatively, which limits their utility in predicting this complication. The preoperative prediction of POPF permits an individualized approach to patient consent and selection, and may influence postoperative management. This study sought to develop and test a score to predict POPF. METHODS: A post hoc analysis of a prospectively maintained database was conducted. Consecutive patients were randomly selected to modelling and validation sets at a ratio of 2 :1, respectively. Patient data, preoperative blood tests and physical characteristics of the gland (assessed from preoperative computed tomography images) were subjected to univariate and multivariate analysis in the modelling set of patients. A score predictive of POPF was designed and tested in the validation set. RESULTS: Postoperative pancreatic fistula occurred in 77 of 325 (23.7%) patients. The occurrence of POPF was associated with 12 factors. On multivariate analysis, body mass index and pancreatic duct width were independently associated with POPF. A risk score to predict POPF was designed (area under the receiver operating characteristic curve: 0.832, 95% confidence interval 0.768-0.897; P < 0.001) and successfully tested upon the validation set. CONCLUSIONS: Preoperative assessment of a patient's risk for POPF is possible using simple measurements. The present risk score is a valid tool with which to predict POPF in patients undergoing PD.

The Role of Interventional Radiology in Treating Complications following Liver Transplantation.

Liver transplantation (LT) is used to treat both adult and pediatric patients with end-stage liver disease or acute liver failure. It has become more prevalent as both the surgical technique and postoperative care have improved resulting in a reduced morbidity and mortality. As a result, there are more patients surviving longer after liver transplantation. Despite this, there remain serious complications from the procedure that have a significant outcome on the patient and may result in retransplantation. At the same time, there have been significant advances in the field of interventional radiology both in terms of technology and how these apply to the patients. In this paper, we review the commonest complications, diagnostic tests, and interventional management options available.

The role of interventional radiology in the management of deep vein thrombosis.

Deep venous thrombosis is a common life-threatening disorder with a significant mortality rate. The current standard anticoagulation therapy has proven inadequate in prevention of long-term post-thrombotic symptoms in patients with large clot burdens. Over the last two decades, advances in endovascular therapies have delivered a range of new treatment options including catheter-directed thrombolysis, percutaneous mechanical thrombectomy, venoplasty and stenting and inferior vena caval filter devices. Although there has been growing experience and guidelines in the treatment of deep vein thrombosis, there remains a wide variation in clinical practice nationally. This paper aims to raise the awareness of these emerging therapies and reviews the available evidence for their use.

Transhepatic embolisation of a traumatic broncho-biliary fistula: a novel approach.

Bronchobiliary fistula is a rare and challenging condition that most commonly presents worldwide following infection with hydatid cystic disease of the liver but is increasingly seen in cases of trauma involving the right upper quadrant. The most common presenting complaint is biliptysis. Treatment is initially aimed at decompressing the biliary tree which allows a considered approach for closure of the fistulous tract. Options range from conservative management to endoscopic and percutaneous approaches. Traditionally definitive treatment would have been surgical and may ultimately have resulted in hepatic and/or pulmonary segmentectomy. Current management strategies of this potentially serious condition are variable. We describe a particularly challenging case in which interventional embolisation with microcoils was used in an attempt to treat persistent post-traumatic bronchobiliary fistula in a tertiary centre. We describe this technique and hope that it is may be of useful reference for those contemplating a similar approach.

The treatment of a dural carotid cavernous fistula (CCF) using Onyx via a transorbital approach: a technical note.

We report the successful case of embolisation of a Barrow D (White et al. in Am J Neuroradiol 28:1415-1417, 2007) dural carotid cavernous fistula (CCF) with bilateral external carotid artery and internal carotid arterial supply, using a direct percutaneous transorbital approach with the embolic agent Onyx. In particular, we highlight the properties of Onyx which make it suitable to treat the multi-compartmental nature of CCFs. The patient developed transient complications which may be related to the volume of embolic agent used, and we discuss this point further. This is still a developing technique, and we present our case as a technical note to aid those contemplating embolisation via a transorbital approach with Onyx.

Reminder of an important clinical lesson in the presentation of an inguinoscrotal bladder hernia and its CT findings.

Inguinoscrotal bladder hernias are still a rare finding in clinical practice. The present report describes the case of a patient who presented with minimal symptoms and was found to have an inguinoscrotal bladder hernia that was confirmed on CT. The CT findings include very clear and interesting images, and the case is discussed further.

A new classification system for retrosternal goitre based on a systematic review of its complications and management.

INTRODUCTION: There is no standard definition for thyroid glands extending below the thoracic inlet, and there are no clear guidelines for pre-operatively identifying those patients that may require an intrathoracic approach. We therefore reviewed the current literature in order to establish the current practices regarding the management of retrosternal goitres (RSGs), and propose a classification system to aid pre-operative planning for this important group of patients. MATERIALS AND METHODS: A PubMed Medline search was conducted using the search terms 'retrosternal', 'substernal', 'intrathoracic', 'mediastinal', 'goitre' and 'goiter', resulting in 626 hits. Exclusion criteria reduced the number of papers to the 34 used for this review. RESULTS: A total of 34 papers totaling 2426 patients were included. Eighty-four percent of patients operated on for RSG were achieved via a cervical approach, with the remainder also requiring manubriotomy (3.1%), full sternotomy (6.6%) or thoracotomy (4%). Tracheomalacia occurred in 1% of patients and Superior Vena Cava syndrome (SVC) in 3.2%. There was a clear and highly significant association between the extent and definition of RSG and reported complications, as well as the approach used, with the incidence of tracheomalacia, SVC and need for intrathoracic approach increasing more than 10-fold in cases of RSG reaching the aortic arch. DISCUSSION: There is a clear need to establish a common standard in the definition and description of the extent of RSG. Using our findings, we propose a new, simple, 3-grade classification system of RSGs, based on their relation with the aortic arch and the right atrium.