Study of the intra-prostatic arterial anatomy and implications for arterial embolization of benign prostatic hyperplasia.

INTRODUCTION: Prostatic arterial embolization (PAE) is an experimental therapy for benign prostatic hyperplasia. Its feasibility is based on the knowledge of the pelvic arterial anatomy, and more specifically the prostate. The aim of this study was to describe the prostatic arterial supply: origins, distribution and variability. MATERIAL AND METHODS: We reviewed retrospectively, with two radiologists, 40 arteriographies of patients who underwent PAE in our center. With these observations of 80 hemipelvics, we described the number of prostatic arteries, their origins, their distributions and eventually their anastomoses with other pelvic arteries. RESULTS: There was one prostatic artery in 70% of the cases. It came from a common trunk for the prostate and the bladder in 55% of the cases, from the obturator artery in 17.5% of the cases, from the pudendal artery in 25% of the cases, from the intern iliac artery in 1% of the cases, and from the superior gluteal artery in 1% of the cases. The prostatic artery splitted in two branches (medial and lateral), with no anastomoses in 37% of the cases. Anastomoses with penile and rectal arteries were observed in 29% of the cases. CONCLUSIONS: For our 40 patients, we observed many variations of arterial prostatic anatomy. We proposed a classification in order to increase security and efficacy of PAE, and it should be validated with more patients. LEVEL OF EVIDENCE: 2.

Comparison of Two Endovascular Steerable Robotic Catheters for Percutaneous Robot-Assisted Fibroid Embolization.

PURPOSE: To compare outcomes of percutaneous robot-assisted uterine fibroid embolization (UFE) using two different endovascular robotic catheters. METHODS: Twenty-one patients with a symptomatic uterine fibroid were prospectively enrolled in a single-center study to be treated with a percutaneous robot-assisted embolization using the Magellan system. Fourteen patients were treated using a first generation steerable robotic catheter, version 1.0 (group 1), and seven were treated using the new version 1.1 (group 2). Demographic, pathologic, and procedural variables were recorded. Dose Area Product (DAP) and physician equivalent doses were registered for each procedure. Procedural related complications and clinical midterm outcomes were also evaluated. RESULTS: Successful robot-assisted UFE was obtained in eight patients (57.1%) in group 1 and 7 patients (100%) in group 2 (p = 0.01). A successful robot-assisted catheterization of the internal iliac artery anterior branch was performed in all patients of both groups. Median selective target vessel catheterization time was 21.0 ± 12.8 vs 13.4 ± 7 min (p = 0.04) and total fluoroscopy time was 30.3 ± 11.2 vs 19.3 ± 5.9 min, respectively, in group 1 and 2. Mean DAP decreased from 18472.6 ± 15622 to 5469.1 ± 4461.0 cGy·cm2 (p = 0.04). All patients obtained a symptoms relief at 6 months follow-up. CONCLUSIONS: Robot-assisted uterine fibroid embolization is safe and effective. New version of steerable robotic catheter allows performing a faster procedure without related adverse events compared to old version.

Percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma under C-arm cone beam CT guidance.

PURPOSE: The aim of this study was to assess the feasibility, safety and efficacy of percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma using C-arm cone beam computed tomography (CBCT) guidance. MATERIAL AND METHODS: This single-center prospective observational study was performed from August 2013 to August 2016, and included consecutive patients referred for radiofrequency ablation of lung metastases from colorectal cancer. Radiofrequency ablation procedures were performed under C-arm CBCT guidance. Feasibility was assessed by probe accuracy placement, time to accurate placement and number of C-arm CBCT acquisitions to reach the target lesion. Safety was assessed by the report of adverse event graded using the common terminology criteria for adverse events (CTCAE-V4.0). Efficacy was assessed by metastases response rate using RECIST 1.1 and 18FDG-PET-CT tumor uptake at 6months. RESULTS: Fifty-four consecutive patients (32 men, 22 women) with a mean age of 63±8 (SD) years (range: 51-81years) with a total of 56 lung metastasis from colorectal metastases were treated in a single session. The mean tumor diameter was 25.6±4.5 (SD)mm (range: 17-31mm). Median time to insert the needle into the target lesion was 10min (range: 5-25min). Median number of needles repositioning and C-arm CBCT acquisition per patient was 1 (range: 0-3) and 4 (range: 3-6) respectively. The accuracy for radiofrequency ablation probe placement was 2±0.2 (SD)mm (range: 0-9mm). Pneumothorax requiring chest tube placement occurred in one patient (CTCAE-V4.0 grade 3). At 6months, all patients were alive with tumor response rate of -27% and had no significant activity on the 18FDG-PET CT follow-up. CONCLUSION: Percutaneous radiofrequency ablation of lung metastases from colorectal cancer under C-arm CBCT guidance is feasible and safe, with immediate and short-term results similar to those obtained using conventional CT guidance.

Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease.

AIM: The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery. METHODS: Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n = 23) or with a failure of instrumental or surgical treatment (n = 7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life. RESULTS: Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5 months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%). CONCLUSION: Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.

Usefulness of endoscopic ultrasonography in patients with "idiopathic" acute pancreatitis.

PURPOSE: No underlying cause is found in as many as 30% of patients with acute pancreatitis. The aim of this study was to evaluate the usefulness of endoscopic ultrasonography in the diagnosis of biliary tract pathology or chronic pancreatitis in these patients. SUBJECTS AND METHODS: We evaluated 168 patients who were referred with idiopathic pancreatitis. Diagnoses obtained by endoscopic ultrasonography were prospectively compared with those obtained at surgery in 101 patients, by endoscopic cholangiopancreatography in 49 patients, or by bile crystal analysis and medical follow-up in 18 patients. RESULTS: Endoscopic ultrasonography was abnormal in 135 (80%) patients, 124 of whom had biliary tract disease. When the results of endoscopic ultrasonography were compared with those made after multidisciplinary investigations, endoscopic ultrasonography correctly identified the cause-most commonly biliary tract disease-of the "idiopathic" pancreatitis in 155 (92%) of the 168 patients. CONCLUSIONS: Endoscopic ultrasonography is valuable in determining the cause of acute pancreatitis in patients initially considered to have idiopathic pancreatitis.

Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration.

BACKGROUND: The rate of spontaneous migration of bile duct stones through the duodenal papilla is not well known. Endoscopic retrograde cholangiography (ERC) has been the standard method to diagnose bile duct stones, but accumulating data show there is a good agreement between ERC and endoscopic ultrasonography (EUS). The aim of the study was to evaluate the incidence and time course of stone migration in patients with bile duct stones by analyzing discrepancies between EUS and ERC as a function of the elapsed time between these two procedures. Stone migration was considered as the absence of stones at time of ERC regardless of the number of stones seen at EUS. METHODS: The main criterion for inclusion was the presence of bile duct stone as shown by EUS. Ninety-two consecutive patients were prospectively included in this study. RESULTS: Choledocholithiasis was absent at ERC in 12 patients. In univariate analysis, presence of gallbladder was significantly associated with an increased rate of stone migration (correction for multiple testing would remove this statistical significance). The size of the stone was the only independent factor to predict migration. CONCLUSION: Migration occurred in about 21% of cases within 1 month. Our study emphasizes the need to analyze carefully the results of comparative imaging studies of bile duct stones.

[Comparison of color Doppler ultrasonography and endoscopic ultrasonography for preoperative evaluation of the mesenteric-portal axis in pancreatic lesions]. / Comparaison de l'échodoppler couleur et de l'échoendoscopie pour l'évaluation préopératoire de l'axe mésentéricoportal dans les lésions pancréatiques.

AIM OF THE STUDY: This prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseases. MATERIAL AND METHODS: The study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectability or potential resectability (n = 34) and irresectability (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy. RESULTS: For endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar. CONCLUSIONS: Imaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.

[Contribution of imaging of gastric cancers]. / Apport de l'imagerie dans les cancers gastriques.

Medical imaging techniques have gradually lost their place in the diagnosis of gastric neoplastic tumors since endoscopic ultrasonography appears. Today, classical esophageal gastric duodenum barium examination is only practiced in preoperative staging. Anyway, endoscopic ultrasonography and transabdominal sonography have a great part in the staging of locoregional and general extension, as well as in patients observation.

[Guided fine needle puncture in the diagnosis of pancreatic disorders]. / La ponction guidée à l'aiguille fine dans le diagnostic des affections pancréatiques.

Fine-needle aspiration (FNA) of pancreatic disorders with ultrasound or computed tomographic, and recently echo-endocopic guidance has become commonplace to diagnose the nature of a pancreatic lesion. It is specially usefull in diagnosing solid neoplasms. Most often, FNA is performed to confirm a diagnosis of ductal adenocarcinoma. The aspirate shows cellular clusters with high nuclear-to cytoplasmic ratio, overlapping nuclei and prominant macronucleoli. The cytologic features that permit a diagnosis of neuroendocrin neoplasm are loose cellular aggregates with round nuclei, evently dispersed nuclear chromatin, a moderate amount of amphophilic cytoplasm and rosette formation. Immunocytochemistry can provide additional confirmatory information. Difficulties are encountered in diagnosing cystic neoplasms. The major cytologic differences between serous and mucinous tumors are the absence of mucin and presence of low cuboidal glycogen-containing cells in the microcystic adenoma vs the presence of goblet cells in the mucinous tumors. Except for the presence of necrotic debris, and in the absence of obvious malignant cytologic features, it is impossible to predict the behaviour of mucinous neoplasms. The lower accuracy for cystic neoplasm can be attributed to predominantly bloody specimens and limited cellularity. These problems illustrate the importance of knowing the clinical and radiological features of pancreatic cystic neoplasms.

Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography.

The aim of this study was to prospectively evaluate endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis not detected by conventional ultrasonography. Forty five consecutive patients (26 females, 19 males, mean age: 50 years) with suspected cholecystolithiasis and at least two normal transcutaneous ultrasonography examinations were included. Endoscopic ultrasonographic criteria for the diagnosis of cholecystolithiasis were the presence of stones with or without acoustic shadowing or sludge. Criteria of microscopic examination of bile were cholesterol or bilirubinate crystals or spheroliths. Thirty three patients underwent cholecystectomy and lithiasis was found in gall bladder bile in 24. Twelve patients who were not operated on and were followed up (median: 17 months), had no evidence of cholecystolithiasis. Endoscopic ultrasonography and duodenal bile examination were 96% and 67% sensitive, respectively (p < 0.03). The specificity was not different (86 and 91%, respectively). None of the 16 patients with negative results in both procedures had evidence of cholecystolithiasis. It was found that for the diagnosis of cholecystolithiasis in patients with normal conventional ultrasonography, the sensitivity of endoscopic ultrasonography is higher than that of microscopic examination of duodenal bile. If endoscopic ultrasonography and microscopic examination of duodenal bile are negative, the risk of underdiagnosing cholecystolithiasis is negligible.

Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common-bileduct lithiasis.

BACKGROUND: Endoscopic sphincterotomy is sometimes done unnecessarily in patients with suspected choledocholithiasis. Our aims were to assess the diagnostic accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography (ERC) and to find out whether endoscopic ultrasonography may help to prevent unnecessary sphincterotomy or surgical explorations. METHODS: We recruited 119 patients aged 70.4 (SD 16.1) years with strongly suspected choledocholithiasis who presented to our endoscopy unit between January, 1994, and January, 1995. During the same spell of sedation or within 2 h of each other, endoscopic ultrasonography and ERC were carried out by investigators unaware of the patient's history. Endoscopic sphincterotomy with instrumental exploration was then done as the gold standard for the presence or the absence of stones. FINDINGS: 78 (66%) patients had choledocholithiasis; 17 (14%) had other bileduct diseases; 24 (20%) had a clear bileduct or did not require an invasive endoscopic procedure. The sensitivity of endoscopic ultrasonography was 93%, specificity 97%, positive predictive value 98%, and negative predictive value 88%. The corresponding values for ERC were 89%, 100%, 100%, and 83%. There were five false-negative cases by endoscopic ultrasonography (of which three were also negative with ERC) and one false-positive. The morbidity rate was 4.1%. INTERPRETATION: We conclude that endoscopic ultrasonography is at least as sensitive as ERC. Endoscopic ultrasonography may prevent inappropriate invasive explorations of the common bileduct.

Endoscopic ultrasonography in gallbladder stones.

The frequency of gallbladder stones is as high as 10% in the general population over 50 years. Nevertheless, only 10% to 20% of patients become symptomatic. The diagnosis of symptomatic forms is important because treatment must be early before the advent of severe complications. This brief article describes technologic points and semeiologic endoscopic ultrasound (EUS) finding of gallbladder stones, analyzes the studies, and describes specific situations warranting the use of EUS.

Localization of gastrinomas by endoscopic ultrasonography in patients with Zollinger-Ellison syndrome.

BACKGROUND: Preoperative localization of gastrinomas by current imaging techniques such as computed tomography (CT) scan and angiography is still difficult because of the small size of tumor(s) in most patients undergoing operation. This study evaluated the diagnostic value of endoscopic ultrasonography. METHODS: Twenty-two patients presenting with Zollinger-Ellison syndrome underwent exploratory laparotomy after preoperative attempts to identify the gastrinoma(s) by CT scan, upper gastrointestinal endoscopy, and endoscopic ultrasonography. Surgery included intraoperative ultrasonography and duodenal transillumination in all cases. The sensitivity and specificity of imaging techniques were then evaluated. RESULTS: At least one tumor was found in 19 patients (four had two tumors and one had multiple tumors). Duodenal, lymph node, and pancreatic gastrinomas were found in 42%, 38%, and 17% of the patients, respectively. Sensitivity of endoscopic ultrasonography was 50% for duodenal wall tumors (conventional endoscopy, 40%), 75% for pancreatic tumors (CT scan, 25%), and 62.5% for tumoral lymph nodes (CT scan, 0%). The specificity of all techniques was excellent. Correct diagnosis was made by endoscopic ultrasonography alone in 41% of the patients. The combination of conventional endoscopy and endoscopic ultrasonography provided correct diagnosis in 60% of the patients. CONCLUSIONS: Endoscopic ultrasonography should be considered as a first-choice imaging technique for preoperative detection of gastrinomas. Although small duodenal gastrinomas are still obviously difficult to detect, an accurate exploration of the pancreatic area was provided by this technique.

[Diagnosis of cystadenomas and cystadenocarcinomas of the pancreas. Study of 35 cases]. / Diagnostic des cystadénomes et cystadénocarcinomes du pancréas. Etude de 35 cas.

OBJECTIVES: The aims of this study were to assess the circumstances of diagnosis and accuracy of imaging procedures in patients with cystic pancreatic tumours. METHODS: Thirty-five consecutive patients with cystic pancreatic tumours (serous cystadenomas: n = 19, mucinous cystadenomas: n = 9, cystadenocarcinomas: n = 7) were studied from 1988 to 1993. Respective diagnostic values of ultrasonography, endoscopic ultrasonography, CT scan and analysis of cyst fluid were evaluated. RESULTS: The circumstances of diagnosis were abdominal pain (74%), weight loss (23%), jaundice (8%), abdominal mass (6%), asymptomatic (6%). Initial diagnosis of cystadenoma was correctly made by ultrasonography, CT scan and endoscopic ultrasonography in 63%, 77% and 84%, and the type of cystadenoma was correctly diagnosed in 20%, 51% and 55%. A pseudocyst was falsely diagnosed in 28%, 12% and 3%, respectively. After blind review of CT scans and endoscopic ultrasonography records, the type of cystadenoma was correctly diagnosed in 82% by both procedures. Cytological examination of cyst fluid of 18 cystic tumours gave correct diagnosis in 10 cases with sufficient material. A low CEA (P < 0.002), Ca 19.9 (P < 0.003) and absence of mucins (P < 0.002) in cyst fluid was evocative of serous cystadenoma. CONCLUSIONS: Abdominal pain was the main circumstance of diagnosis in cases of pancreatic cystadenomas. The type of cystadenoma was correctly diagnosed in 82% by CT scan and endoscopic ultrasonography. Cytological examination, tumoural marker and mucin levels in cyst fluid were helpful for an accurate diagnosis of cystic tumours.

[Imaging of cancer of the esophagus: ultrasound-endoscopy or computed tomography?]. / Imagerie du cancer de l'oesophage: échoendoscopie ou tomodensitométrie?

The aim of this retrospective study, in 100 patients who had an esophagectomy from 1987 to 1992 for squamous cell carcinoma of the thoracic esophagus, was to determine the accuracy of endoscopic ultrasonography (EUS) and computed tomography (CT) in the preoperative staging of esophageal squamous cell carcinoma (SCC). The EUS report were compared to the pathological findings for the T stage. Both EUS and CT reports were compared with surgical and pathological findings for N stage (N0/N1) and mediastinal extension. In the 100 patients, EUS accuracy for T stage was 80%; EUS was more accurate for N stage than CT (71% vs 55% respectively; p < 0.02), and as accurate as CT for mediastinal extension (86% vs 85%). In the 26 SCC estimated superficial by EUS (all passed through), EUS accuracy was 92% for T stage and 77% for the distinction between mucosal and submucosal tumours; for N stage, EUS and CT accuracies were equivalent (77% vs 81%). In the 44 SCC passed and estimated advanced by EUS, EUS accuracy for T stage was 68%; EUS was more accurate than CT for N stage (77% vs 48%, p < 0.01) and as accurate as CT for mediastinal extension (86 vs 84%). In the 30 SCC not passed by EUS, accuracies of EUS and CT were equivalent for N stage (57% vs 47%) and for mediastinal extension (73% vs 73%). This study suggests that: a) for SCC estimated superficial by EUS, EUS does not differentiate reliably mucosal from submucosal tumors and CT is useless; b) routine EUS seems unnecessary for SCC not passed through by endoscopy; c) CT is still useful in patients with advanced SCC, mainly for detection of distant metastases.

Diagnosis of choledocholithiasis by endoscopic ultrasonography.

BACKGROUND/AIMS: Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis. Accuracy for the diagnosis of choledocholithiasis by ultrasonography and computed tomography were prospectively compared with endoscopic ultrasonography in 62 consecutive patients. METHODS: Final diagnosis was determined by endoscopic retrograde cholangiography with or without sphincterotomy or intraoperative cholangiography with or without choledochoscopy. All of the patients had abdominal ultrasonography, computed tomography, endoscopic ultrasonography, and either an endoscopic retrograde (n = 40) or intraoperative cholangiography (n = 32) performed. RESULTS: Choledocholithiasis was confirmed in 22 patients. Thirteen patients had a stone with a diameter < 1 cm, and 14 had a nonenlarged common bile duct. Endoscopic ultrasonography was more sensitive (97%) than ultrasonography (25%; P < 0.0001) and computed tomography (75%; P < 0.02). Specificity and positive predictive value were not significantly different. Negative predictive value of endoscopic ultrasonography (97%) was better than that of ultrasonography (56%; P < 0.0001) and computed tomography (78%; P < 0.02). Results were unchanged after six patients in whom the absence of choledocholithiasis was considered probable after follow-up were excluded. Endoscopic ultrasonography results did not depend on stone diameter or common bile duct dilatation. CONCLUSIONS: Endoscopic ultrasonography appears to be the best diagnostic tool for the diagnosis of choledocholithiasis compared with other noninvasive procedures.

[Aneurysm of the portal vein associated with aneurysm of the splenic artery]. / Anévrysme de la veine porte associé à un anévrysme de l'artère splénique.

Portal vein aneurysm is very rare. A case of portal vein aneurysm without symptoms of portal hypertension is described. Ultrasonography demonstrated a hypoechoic mass at the isthmic region of the pancreas. Computed tomography demonstrated the vascular origin of the mass. Angiography showed a portal vein aneurysm, measuring 3 cm in diameter, at the junction of portal vein trunk and splenic vein. The association with a splenic artery aneurysm and absence of portal hypertension lead us to suggest that our case is congenital. Non-invasive diagnostic methods are useful to recognize the pathology of portal vein aneurysm and prevent complications especially those related to a possible portal hypertension.

Hypertrophic gastropathy with gastric adenocarcinoma: Menetrier's disease and lymphocytic gastritis?

Lymphocytic gastritis is a form of gastric inflammation characterised by a pronounced increase in lymphocytes in gastric surface and foveolar epithelium. Lymphocytic gastritis is often associated with endoscopic evidence of 'varioliform gastritis'. Lymphocytic gastritis has recently been reported to be associated with other forms of hypertrophic gastropathies. We present a case of hypertrophic gastropathy with gastric adenocarcinoma, with both Menetrier's disease and lymphocyte gastritis. Immunohistochemical studies showed that the intraepithelial lymphocytes were predominantly alpha/beta T cells as in the normal stomach and not gamma/delta T cells as in coeliac sprue. This case together with the six recently published cases suggests that Menetrier's disease and lymphocytic gastritis may be part of the same disease spectrum.