Unlocking the enigma: Combined percutaneous-transhepatic and endoscopic strategies for retrieval of severed Dormia basket in choledocholithiasis. A case report and literature review.

Choledocholithiasis, characterized by the presence of stones in the common bile duct, poses significant challenges in clinical management, particularly when the stones are massive. While endoscopic methods are often effective in stone removal, complications such as the impaction of foreign bodies like Dormia baskets can occur. These complications may necessitate alternative approaches, including surgical intervention, highlighting the importance of exploring innovative interventional techniques. We report on an 89-year-old patient presenting with massive choledocholithiasis, involving complete filling of the intra- and extrahepatic bile duct system with large stones up to a maximum of 2 cm. The patient underwent interventional removal of a Dormia basket (3.5Fr. Boston Scientific, USA) impacted in the common bile duct. This procedure proved challenging due to the metallic end marker of the basket perforating through the wall of the distal common bile duct, rendering it fixed. Given the complexity of the case, a parallel approach combining percutaneous transhepatic cholangiography and drainage with simultaneous endoscopy was employed to successfully extract the fixed Dormia basket. In cases of severe choledocholithiasis complicated by the impaction of foreign bodies such as Dormia baskets, innovative interventional strategies are crucial for successful management. Our case highlights the effectiveness of a parallel approach involving percutaneous transhepatic cholangiography and drainage alongside simultaneous endoscopy in safely removing the fixed foreign body from the common bile duct. This multidisciplinary approach not only offers a viable alternative to surgical intervention but also underscores the importance of collaboration between interventional radiologists and endoscopists in optimizing patient outcomes in complex biliary interventions.

Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature.

The pancreaticobiliary system is a complex and vulnerable anatomic region. Small changes can lead to severe complications. Pancreaticobiliary disorders leading to severe complications include malignancies, pancreatitis, duodenal ulcer, duodenal diverticula, vascular malformations, and iatrogenic or traumatic injuries. Different therapeutic strategies, such as conservative, interventional (e.g., embolization, stent graft applications, or biliary interventions), or surgical therapy, are available in early disease stages. Therapeutic options in patients with severe complications such as duodenal perforation, acute bleeding, or sepsis are limited. If less invasive procedures are exhausted, an emergency pancreaticoduodenectomy (EPD) can be the only option left. The aim of this study was to analyze a single-center experience of EPD performed for benign non-trauma indications and to review the literature concerning EPD. Between January 2015 and January 2022, 11 patients received EPD due to benign non-trauma indications at our institution. Data were analyzed regarding sex, age, indication, operative parameters, length of hospital stay, postoperative morbidity, and mortality. Furthermore, we performed a literature survey using the PubMed database and reviewed reported cases of EPD. Eleven EPD cases due to benign non-trauma indications were analyzed. Indications included peptic duodenal ulcer with penetration into the hepatopancreatic duct and the pancreas, duodenal ulcer with acute uncontrollable bleeding, and penetration into the pancreas, and a massive perforated duodenal diverticulum with peritonitis and sepsis. The mean operative time was 369 min, and the median length of hospital stay was 35.8 days. Postoperative complications occurred in 4 out of 11 patients (36.4%). Total 90-day postoperative mortality was 9.1% (1 patient). We reviewed 17 studies and 22 case reports revealing 269 cases of EPD. Only 20 cases of EPD performed for benign non-trauma indications are reported in the literature. EPD performed for benign non-trauma indications remains a rare event, with only 31 reported cases. The data analysis of all available cases from the literature revealed an increased postoperative mortality rate of 25.8%. If less invasive approaches are exhausted, EPD is still a life-saving procedure with acceptable results. Performed by surgeons with a high level of experience in hepatobiliary and pancreatic surgery, mortality rates below 10% can be achieved.

Successful heparin-perfusion therapy for complete thrombosis of the intra- and extrahepatic portal and mesenteric vein. A case report and literature review.

The initial treatment of acute and subacute portal vein thrombosis, which is the most common cause of portal vein occlusion, consists of intravenous anticoagulation with heparin, but there is still a huge uncertainty among physicians regarding the role of more invasive therapies. We report a 61-year-old male patient, who presented in our emergency room with a subacute complete thrombosis of the intra- and extrahepatic portal vein, mesenteric vein, with associated venous congestion of 20-30 cm length of the small intestine with a quick and complete remission of the portal vein thrombosis under sole i.v. heparin-perfusor therapy without any complications. Molecular genetic analysis found combined genetic mutations of the gene factor 2 (c.20210G>A, heterozygotic), SERPINE1 (-675 5G>4G, heterozygotic), and the MTHFR gene. Along with this interesting case, we also present the recent status of portal vein thrombosis and portal vein occlusion in the literature.

Clinical effects and safety of different transarterial chemoembolization methods for bridging and palliative treatments in hepatocellular carcinoma.

PURPOSE: We assessed and compared clinical effects and safety endpoints of three methods of transarterial chemoembolization (TACE), conventional (cTACE), with drug-eluting beads (DEB-TACE), and with degradable starch microspheres (DSM-TACE), used in patients with hepatocellular carcinoma (HCC) in the bridging to liver transplant (LT) and the palliative setting. METHODS: In our center, 148 patients with HCC underwent 492 completed TACE procedures between 2008 and 2017 (158 for bridging to LT; 334 for palliative treatment) which we analyzed retrospectively. Of these procedures, 348 were DEB-TACE, 60 cTACE, and 84 DSM-TACE. RESULTS: The cTACE procedure revealed a significantly longer period of hospitalization (p = 0.02), increased occurrence of nausea (p = 0.025), and rise in alanine transaminase (ALT) levels (p = 0.001), especially in the palliative setting. In the bridging to LT cohort, these clinical endpoints did not reach statistical significance. CONCLUSIONS: The clinical safety of different TACE methods for HCC in both the palliative and the bridging to LT setting was equivalent. In the palliative setting, the cTACE procedure revealed an increased risk for adverse clinical effects such as nausea, elevation of ALT, and a prolonged period of hospitalization what might either be related to the systemic effects of the chemotherapeutic agent or to the differences in both collectives. Thus, further studies must be conducted on a larger number of TACE procedures to effectively explore the clinical side effects of the various TACE variants.

Impact of needle positioning on ablation success of irreversible electroporation: a unicentric retrospective analysis.

Irreversible electroporation (IRE) is an ablation procedure in which cell death is induced by ultrashort electrical pulses. In this unicentric retrospective study we investigated the influence of needle positioning on ablation success. 15 IREs with residual tumor after ablation, detected in the first follow-up MRI, were included, and compared with 30 successful ablations. Evaluation of needle geometry revealed significantly higher values for needle divergence (NDiv, 7.0° vs. 3.7°, p = 0.02), tumor-center-to-ablation-center distance (TACD, 11.6 vs. 3.2 mm, p < 0.001), tumor-to-needle distance (4.7 vs. 1.9 mm, p = 0.04), and tumor diameter per needle (7.5 vs. 5.9 mm/needle, p = 0.01) in patients with residual tumor. The average number of needles used was higher in the group without residual tumor after ablation (3.1 vs. 2.4, p = 0.04). In many cases with residual tumor, needle depth was too short (2.1 vs. 6.8 mm tumor overlap beyond the most proximal needle tip, p < 0.01). The use of a stereotactic navigation system in 10 cases resulted in a lower NDiv value (2.1° vs. 5.6°, p < 0.01). Thus, correct needle placement seems to be a crucial factor for success and the assistance of a stereotactic navigation system might be helpful. As most important geometrical parameter TACD could be identified. Main reasons for high TACD were insufficient needle depth and a lesion location out of the needle plane.

Postoperative liver regeneration does not elicit recurrence of colorectal cancer liver metastases after major hepatectomy.

BACKGROUND AND OBJECTIVES: Recurrence is a frequent concern in curatively resected CRC liver metastases. Translational research suggests that regeneration upon hepatectomy may also alleviate metastatic recurrence; however, the significance in patients is unclear. We therefore sought to study the effect of liver regeneration on tumor recurrence in patients. METHODS: In this retrospective cohort study, we included 58 out of 186 potentially eligible patients from our prospectively maintained database of CRC liver metastasis patients between 2001 and 2012 with a median follow-up of 42 months who underwent a formal right or left hemihepatectomy. Liver regeneration in CT volumetry was correlated with recurrence of CRC liver metastases and overall survival. RESULTS: Liver regeneration increased up to 14 months to 21.0% for left and 122.6% for right hemihepatectomy, respectively, with comparable final volumes. Regeneration was independent of initial tumor stage, number of metastases, and preoperative chemotherapy. Patients with lower liver regeneration showed earlier recurrence of CRC liver metastases (p = 0.006). Overall survival did not differ in patients with weak versus strong liver regeneration. CONCLUSIONS: The extent of liver regeneration after major hepatectomy does not impede overall survival. Therefore, our data encourage aggressive therapeutical regimes for CRC liver metastases involving major hepatectomies as part of a curative approach.

Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study.

OBJECTIVE: Percutaneous biliary interventions (PBIs) can be associated with a high patient radiation dose, which can be reduced when national diagnostic reference levels (DRLs) are kept in mind. The aim of this multicentre study was to investigate patient radiation exposure in different percutaneous biliary interventions, in order to recommend national DRLs. METHODS: A questionnaire asking for the dose area product (DAP) and the fluoroscopy time (FT) in different PBIs with ultrasound- or fluoroscopy-guided bile duct punctures was sent to 200 advanced care hospitals. Recommended national DRLs are set at the 75th percentile of all DAPs. RESULTS: Twenty-three facilities (9 interventional radiology depts. and 14 gastroenterology depts.) returned the questionnaire (12%). Five hundred sixty-five PBIs with 19 different interventions were included in the analysis. DAPs (range 4-21,510 cGy·cm2) and FTs (range 0.07-180.33 min) varied substantially depending on the centre and type of PBI. The DAPs of initial PBIs were significantly (p < 0.0001) higher (median 2162 cGy·cm2) than those of follow-up PBIs (median 464 cGy·cm2). There was no significant difference between initial PBIs with ultrasound-guided bile duct puncture (2162 cGy·cm2) and initial PBIs with fluoroscopy-guided bile duct puncture (2132 cGy·cm2) (p = 0.85). FT varied substantially (0.07-180.33 min). CONCLUSIONS: DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. PBI with US-guided bile duct puncture did not reduce DAP, when compared to PBI with fluoroscopy-guided bile duct puncture. National DRLs of 4300 cGy·cm2 for initial PBIs and 1400 cGy·cm2 for follow-up PBIs are recommended. KEY POINTS: • DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. • PBI with US-guided bile duct puncture did not reduce DAP when compared to PBI with fluoroscopy-guided bile duct puncture. • DRLs of 4300 cGy·cm2for initial PBIs (establishing a transhepatic tract) and 1400 cGy·cm2for follow-up PBIs (transhepatic tract already established) are recommended.

Percutaneous hepatic perfusion (chemosaturation) with melphalan in patients with intrahepatic cholangiocarcinoma: European multicentre study on safety, short-term effects and survival.

OBJECTIVES: Cholangiocarcinoma is the second most common primary liver tumour with a poor overall prognosis. Percutaneous hepatic perfusion (PHP) is a directed therapy for primary and secondary liver malignancies, and its efficacy and safety have been shown in different entities. The purpose of this study was to prove the safety and efficacy of PHP in patients with unresectable intrahepatic cholangiocarcinoma (iCCA). PATIENTS AND METHODS: We retrospectively reviewed data from 15 patients with unresectable iCCA treated with PHP in nine different hospitals throughout Europe. Overall response rates (ORR) were assessed according to response evaluation criteria in solid tumours (RECIST1.1). Overall survival (OS), progression-free survival (PFS) and hepatic PFS (hPFS) were analysed using the Kaplan-Meier estimation. Adverse events (AEs) and toxicity were evaluated. RESULTS: Fifteen patients were treated with 26 PHPs. ORR was 20%, disease control was achieved in 53% after the first PHP. Median OS was 26.9 months from initial diagnosis and 7.6 months from first PHP. Median PFS and hPFS were 122 and 131 days, respectively. Patients with liver-only disease had a significantly longer median OS compared to patients with locoregional lymph node metastases (12.9 vs. 4.8 months, respectively; p < 0.01). Haematological toxicity was common, but manageable. No AEs of grade 3 or 4 occurred during the procedures. DISCUSSION: PHP is a standardised and safe procedure that provides promising response rates and survival data in patients with iCCA, especially in non-metastatic disease. KEY POINTS: • Percutaneous hepatic perfusion (PHP) offers an additional locoregional therapy strategy for the treatment of unresectable primary or secondary intrahepatic malignancies. • PHP is a standardised and safe procedure that provides promising response rates and survival data in patients with intrahepatic cholangiocarcinoma (iCCA), especially in non-metastatic disease. • Side effects seem to be tolerable and comparable to other systemic or local treatment strategies.

Survival of Hepatocellular Carcinoma Patients Treated with Sorafenib beyond Progression.

BACKGROUND/AIM: Sorafenib leads to improved survival in advanced hepatocellular carcinoma (HCC) patients. Continuation of sorafenib beyond progression has been a possible treatment strategy when further approved therapeutic agents are lacking. METHODS: We performed a retrospective analysis of all HCC patients at our institution with documented disease progression under treatment with sorafenib. Overall survival (OS) from start of sorafenib treatment was compared between patients who received sorafenib for > 3 weeks beyond progression (group 1) and those who discontinued sorafenib ≤3 weeks after progression (group 2). Group 1 was further subdivided into those patients who received sorafenib for > 3 months (group 1a) and those who received it for ≤3 months (group 1b). RESULTS: A total of 71 patients were analyzed. Median OS for all patients was 15.4 months. OS in group 1 (15.6 months) and 2 (13.0 months) was similar (p = 0.90). Patients in group 1a showed significantly prolonged median OS (19.7 months) compared to that of patients in group 1b (13.6 months, p = 0.004), and they showed a trend towards prolonged OS compared to group 2 (p = 0.126). For patients with a poor prognosis according to their Child-Pugh stage, performance status, alpha-fetoprotein, and response to prior sorafenib treatment, OS was significantly prolonged in group 1 versus group 2 (12.1 vs. 6.4 months, p = 0.019). CONCLUSION: In HCC patients, continuing sorafenib beyond progression for > 3 months is associated with improved survival compared to discontinuing sorafenib within 3 months. Furthermore, patients with a poor prognosis who continue sorafenib beyond progression in general show significantly prolonged survival.

Mobile, real-time, and point-of-care augmented reality is robust, accurate, and feasible: a prospective pilot study.

BACKGROUND: Augmented reality (AR) systems are currently being explored by a broad spectrum of industries, mainly for improving point-of-care access to data and images. Especially in surgery and especially for timely decisions in emergency cases, a fast and comprehensive access to images at the patient bedside is mandatory. Currently, imaging data are accessed at a distance from the patient both in time and space, i.e., at a specific workstation. Mobile technology and 3-dimensional (3D) visualization of radiological imaging data promise to overcome these restrictions by making bedside AR feasible. METHODS: In this project, AR was realized in a surgical setting by fusing a 3D-representation of structures of interest with live camera images on a tablet computer using marker-based registration. The intent of this study was to focus on a thorough evaluation of AR. Feasibility, robustness, and accuracy were thus evaluated consecutively in a phantom model and a porcine model. Additionally feasibility was evaluated in one male volunteer. RESULTS: In the phantom model (n = 10), AR visualization was feasible in 84% of the visualization space with high accuracy (mean reprojection error ± standard deviation (SD): 2.8 ± 2.7 mm; 95th percentile = 6.7 mm). In a porcine model (n = 5), AR visualization was feasible in 79% with high accuracy (mean reprojection error ± SD: 3.5 ± 3.0 mm; 95th percentile = 9.5 mm). Furthermore, AR was successfully used and proved feasible within a male volunteer. CONCLUSIONS: Mobile, real-time, and point-of-care AR for clinical purposes proved feasible, robust, and accurate in the phantom, animal, and single-trial human model shown in this study. Consequently, AR following similar implementation proved robust and accurate enough to be evaluated in clinical trials assessing accuracy, robustness in clinical reality, as well as integration into the clinical workflow. If these further studies prove successful, AR might revolutionize data access at patient bedside.

Transvascular therapy of Hepatocellular Carcinoma (HCC), status and developments.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Only 30-40% of patients diagnosed with HCC are candidates for curative treatment options. The remaining majority of patients undergo local, regional or systemic palliative therapies. Transvascular therapy of HCC takes advantage of the fact that hypervascularized HCCs receive their main perfusion from the hepatic artery. In this context transvascular therapy describes different therapies: bland embolization (transarterial embolization, TAE), cTACE (conventional transarterial chemoembolization), DEB-TACE (TACE with drug-eluting beads, DEB) and SIRT (selective internal radiation therapy, radioembolization). cTACE is the most common type of transvascular treatment and represents a combination of the intra-arterial use of a chemotherapeutic agent and embolization. There is no standardized regimen for cTACE. It remains unclear whether the intra-arterial application of a chemotherapeutic agent is definitely required, because bland embolization alone using very small spherical particles shows tumor necrosis comparable to cTACE. For DEB-TACE microparticles loaded with a chemotherapeutic drug combine the advantages of cTACE and bland embolization.

Safety and Feasibility of Chemoembolization with Doxorubicin-Loaded Small Calibrated Microspheres in Patients with Hepatocellular Carcinoma: Results of the MIRACLE I Prospective Multicenter Study.

PURPOSE: The MIRACLE I pilot study was designed as a preliminary investigation of safety and efficacy of Embozene TANDEM microspheres loaded with doxorubicin for treatment of locally untreatable (i.e., unresectable and not suitable for local thermal ablation) hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Patients with locally untreatable HCC (mono- or bilobar disease, ECOG performance status 0-2, Child-Pugh score < 11) were eligible for this single-arm multicenter study. DEB-TACE was performed with 75 µm Embozene TANDEM loaded with 150 mg of doxorubicin. RESULTS: Twenty-five subjects with 41 tumors were treated (mean age 65 years); 16, 52, and 32% had BCLC A, B, and C status, respectively. Child-Pugh status was A for 64%, B for 32%, and C for 4%; 40% had ascites. About 92% had disease localized to one liver lobe. Most (72%) underwent ≤ 2 DEB-TACE procedures. Average doxorubicin dose was 124.5 ± 36.1 mg (median 150 mg) per procedure. Two patients had procedure-related SAE (liver necrosis, worsening of liver insufficiency) within 30 days of the first DEB-TACE procedure. Six-month freedom from procedure-related SAE or death was 68% (one hepatic encephalopathy, five deaths). Tumor response or stable disease was achieved in 95% (20/21) of subjects. Freedom from tumor progression or death at 6 months was 76%. The one-year survival rate was 56% overall and 73% among patients without ascites at baseline. CONCLUSION: MIRACLE I results suggest that Embozene TANDEM microspheres loaded with doxorubicin can provide good local tumor control in a heterogeneous group of patients with locally untreatable HCC. LEVEL OF EVIDENCE: Level 2b, Individual cohort study.

Occlusion of a Long-Term Transpleural Biliary Drainage Tract Using a Gelatin Pledget (Hep-Plug™).

This case describes a technique used to close a long-term 14F transpleural biliary drainage catheter tract to prevent biliopleural fistula and further complications. We deployed a compressed gelatin foam pledget provided in a pre-loaded delivery device (Hep-Plug™) along the intrahepatic tissue tract for sealing it against the pleural cavity. The device used is easy to handle and gives the Interventional Radiologist the possibility to safely manage and prevent complications after percutaneous transhepatic interventions.

Successful ablation of lymph nodes using irreversible electroporation (IRE) in a porcine survival model.

BACKGROUND: Irreversible electroporation (IRE), a nonthermal injury ablation technique, has been shown to be effective and safe in various organs, such as in the kidney, liver, prostate, or in pancreas. In contrast to radiofrequency or microwave ablation, IRE is also effective in the neighborhood of major vessels. Many human cancers reveal lymphatic spread. The present study aimed to evaluate technical feasibility and safety of IRE in lymphatic tissue. To our knowledge, this is the first report showing successful IRE of lymph nodes in a standardized porcine survival model. METHODS: A total of ten pigs were divided into two study groups. Five animals received ECG-gated IRE of mesenteric lymph nodes of the small bowel and were sacrificed 2 h after ablation. Another five animals were followed up for 7 days. Clinical parameters, laboratory and abdominal imaging by contrast-enhanced computed tomography, as well as histology were obtained from all animals at different time points. RESULTS: During and after IRE ablation, no cardiocirculatory side effects were noted in any of the animals. In the acute phase experiments, no damage to adjacent organs and no thermal injuries were seen following IRE. One hundred twenty minutes after ablation, no significant laboratory changes were observed. In the survival group, all animals recovered quickly and showed normal activity and feeding habits indicating a minimal pain level. Seven days after IRE ablation, a significant increase in white blood cell count was observed, while creatinine, urea, or hemoglobin remained unchanged. Computed tomography revealed a hypodense lesion following IRE already at 2 h. Histopathology showed coagulation necrosis of the treated lymph nodes with preservation of the lymph node capsule. CONCLUSIONS: This porcine survival model shows that IRE can safely and effectively be performed in lymph nodes. Thus, IRE might display a novel approach for therapy of lymph node metastasis. Further clinical studies are needed to evaluate the oncologic outcome of IRE ablation in lymph node metastasis.

Percutaneous Isolated Hepatic Perfusion as a Treatment for Isolated Hepatic Metastases of Uveal Melanoma: Patient Outcome and Safety in a Multi-centre Study.

PURPOSE: Percutaneous isolated hepatic perfusion (PIHP) with Melphalan has been developed as a treatment for patients with isolated hepatic metastases of uveal melanoma. We discuss patient outcome and safety in a retrospective multi-centre study. MATERIALS AND METHODS: Between 2012 and 2016 18 patients with un-resectable isolated hepatic metastases of uveal melanoma received single or repeated PIHP with Melphalan (n = 35) at seven sites. Progression-free time, overall survival time (OS) and tumour response by means of RECIST 1.1 criteria were evaluated. Peri- and post-procedural adverse events (AE) were registered. Patients' life quality was assessed using four-point scale questionnaires. RESULTS: Of 18 patients, initial PIHP treatment resulted in partial response (PR) in eight, stable disease (SD) in seven and progressive disease (PD) in three cases. Nine patients underwent second PIHP with PR in eight cases and PD in one case. Six patients were evaluated after third PIHP with PR in five patients and SD in one patient. Two patients received fourth PIHP with PD in both cases. Median OS was 9.6 months (range 1.6-41.0 months). Median progression-free survival time was 12.4 months (range 0.9-41.0 months) with 1-year survival of 44%. Most common post-procedural AE grade 3 and 4 were temporary leukopenia (n = 11) and thrombocytopenia (n = 8). Patients' self-assessments showed good ratings for overall health and quality of life with only slight changes after PIHP, and a high degree of satisfaction with PIHP treatment. CONCLUSION: PIHP with Melphalan proved to be a relatively safe, minimal-invasive and repeatable treatment for patients with non-resectable hepatic metastases of uveal melanoma.

Treatment Failure After Image-Guided Percutaneous Radiofrequency Ablation (RFA) of Renal Tumors - A Systematic Review with Description of Type, Frequency, Risk Factors and Management.

Background Radiofrequency ablation (RFA) is an established treatment for small renal tumors. The objective of this review is to systematically assess the type, frequency, risk factors and management of treatment failure after image-guided percutaneous RFA of renal tumors. Method 10 studies (967 patients, 1033 tumors) with a mean/median follow-up of ≥ 30 months were systematically identified and analyzed. Results and Conclusion Image-guided percutaneous RFA of localized renal tumors is very effective. The most common type of treatment failure is residual unablated tumor (5.9 %), followed by local tumor progression (4.7 %). De novo tumors in the kidneys occur in 1.3 % of cases and extra-renal metastases in 2.0 %. Local tumor progression, de novo tumors in the kidneys and extra-renal metastases occur predominantly later than 12 months after initial RFA. Tumor size > 3 cm and central tumor location are the major risk factors for treatment failure. In the case of treatment failure, repeated RFA shows high success rates (86.3 % for residual unablated tumors and 87.5 % for local tumor progression). Key Points: · Treatment failure can be subdivided into residual unablated tumor and local tumor progression.. · Residual unablated tumor occurs in 5.9 % of cases.. · Local tumor progression occurs in 4.7 % of cases.. · Tumor size and location are the major risk factors for treatment failure.. · Repeated RFA is effective and commonly used for management.. Citation Format · Vollherbst D, Bertheau R, Kauczor H et al. Treatment Failure After Image-Guided Percutaneous Radiofrequency Ablation (RFA) of Renal Tumors - A Systematic Review with Description of Type, Frequency, Risk Factors and Management. Fortschr Röntgenstr 2017; 189: 219 - 227.

Electrochemical Effects after Transarterial Chemoembolization in Combination with Percutaneous Irreversible Electroporation: Observations in an Acute Porcine Liver Model.

PURPOSE: To evaluate the effects of combined use of transarterial chemoembolization and irreversible electroporation (IRE) for focal tissue ablation in an acute porcine liver model. MATERIALS AND METHODS: Two established interventional techniques were combined: IRE with zones of irreversible and reversible electroporation and chemoembolization with microspheres, iodized oil, and doxorubicin. IRE was performed before chemoembolization in two pigs (pigs 1 and 2; IRE/chemoembolization group), chemoembolization was performed before IRE in two pigs (pigs 3 and 4; chemoembolization/IRE group), and only IRE was performed in two pigs (pigs 5 and 6). Five study groups were defined: IRE/chemoembolization (pigs 1 and 2), chemoembolization/IRE (pigs 3 and 4), IRE only (pigs 5 and 6), chemoembolization only (tissue outside the IRE zones in pigs 1-4), and control (untreated liver tissue outside the IRE zones in pigs 5 and 6). Animals were euthanized 2 hours after intervention. Size and shape of IRE zones on contrast-enhanced computed tomography, cell death on light microscopy, and doxorubicin tissue concentrations on chromatography and fluorescence microscopy were analyzed. RESULTS: Size and shape of IRE zones were not significantly different (eg, P = .067 for volume). A histologic marker for irreversible cell death was positive in IRE/chemoembolization, chemoembolization/IRE, and IRE groups only in the macroscopically visible IRE zones. Doxorubicin tissue concentrations were not significantly different (P = .873). However, in the reversible electroporation (RE) zones, broad areas with intense intranuclear doxorubicin accumulation were observed in IRE/chemoembolization but not in chemoembolization/IRE and chemoembolization groups. CONCLUSIONS: IRE before chemoembolization enhances the intranuclear accumulation of doxorubicin in the RE zone.

The Provision of Interventional Radiology Services in Europe: CIRSE Recommendations.

Interventional Radiology (IR) is an essential part of modern medicine, delivering minimally invasive patient-focused care, which has been proven to be safe and effective in both elective and emergency settings. The aim of this document is to outline the core requirements and standards for the provision of Interventional Radiological services, including training, certification, manpower, and accreditation. The ultimate challenge will be the adoption of these recommendations by different countries and health economies around the world, in turn ensuring equal access to IR treatments for all patients, the appropriate distribution of resources for IR service provision as well as the continued development of safe and high-quality IR services in Europe and beyond.

Towards markerless navigation for percutaneous needle insertions.

PURPOSE: Percutaneous needle insertions are increasingly used for diagnosis and treatment of abdominal lesions. The challenging part of computed tomography (CT)-guided punctures is the transfer of the insertion trajectory planned in the CT image to the patient. Conventionally, this often results in several needle repositionings and control CT scans. To address this issue, several navigation systems for percutaneous needle insertions have been presented; however, none of them has thus far become widely accepted in clinical routine. Their benefit for the patient could not exceed the additional higher costs and the increased complexity in terms of bulky tracking systems and specialized markers for registration and tracking. METHODS: We present the first markerless and trackerless navigation concept for real-time patient localization and instrument guidance. It has specifically been designed to be integrated smoothly into the clinical workflow and does not require markers or an external tracking system. The main idea is the utilization of a range imaging device that allows for contactless and radiation-free acquisition of both range and color information used for patient localization and instrument guidance. RESULTS: A first feasibility study in phantom and porcine models yielded a median targeting accuracy of 6.9 and 19.4 mm, respectively. CONCLUSIONS: Although system performance remains to be improved for clinical use, expected advances in camera technology as well as consideration of respiratory motion and automation of the individual steps will make this approach an interesting alternative for guiding percutaneous needle insertions.

Outcome after a liver resection of benign lesions.

BACKGROUND: Benign liver tumours represent a challenge in clinical management. There is considerable controversy with respect to the indications for surgery as the evidence for surgical treatment is variable. The aim of this retrospective study was to analyse the indication and outcome after resection of benign, solid liver lesions. METHODS: Data of 79 patients, who underwent liver resection between 2001 and 2012, were analysed for demographic and outcome parameters. RESULTS: Thirty-eight patients with focal nodular hyperplasia (48%), 23 patients with haemangioma (29%) and 18 patients with hepatocellular adenoma (23%) underwent a hepatic resection. A major hepatic resection was performed in 23 patients (29%) and a minor resection in 56 patients (71%). The post-operative mortality rate was zero and the 30-day morbidity rate 13.9%. After a median follow-up of 64 months, 75 patients (95%) were alive, and no patient had developed recurrent disease. Fifty-four patients (68%) were pre-operatively symptomatic, of which, 87% had complete or partial relief of symptoms after a liver resection. The incidence of symptoms increased with the lesions' size. DISCUSSION: The management of benign liver lesions necessitates an individualized therapy within a multidisciplinary, evidence-based, treatment algorithm. Resection of benign liver lesions can be performed safely in well-selected patients without mortality and low post-operative morbidity.