Selective venous sampling in primary hyperparathyroidism: Is it worth doing?

BACKGROUND: Accurate preoperative localization of the culprit gland is the key point for the surgical treatment of primary hyperparathyroidism. Conventional imaging techniques (ultrasound and Tc99m sestamibi scintigraphy) are usually adequate for preoperative localization. However, in some patient groups, additional imaging modalities may be required since noninvasive techniques may fail. In this study, we aimed to evaluate the diagnostic value of selective parathyroid venous sampling in patients with unclear noninvasive localization tests. METHODS: Among 513 cases who underwent parathyroidectomy due to primary hyperparathyroidism, twelve cases (2.3%) were undergone selective parathyroid venous sampling and were included in the study. Age, sex, presenting symptom, presence of a genetic disease, medical and surgical history, serum calcium (Ca)-parathormone (PTH) levels (preoperative, intraoperative, and postoperative), imaging reports (US, SM, and SVS), surgery reports, pathology reports, and complications were retrospectively reviewed. RESULTS: Seven cases (58.3%) had persistent primary hyperparathyroidism and one patient (8.3%) had past surgical history of total thyroidectomy. The remaining four patients (33.3%) had no previous neck surgery. T he sensitivity of selective venous sampling was 75%. According to the medical history, accurate localization was achieved in 85.7% of persistent cases and 60% of primary cases. Eight cases (66.6%) underwent unilateral neck exploration and four cases (33.3%) underwent four gland exploration. A single adenoma was detected in ten cases (90.9%) while one patient (9.1%) had double adenoma.

Percutaneous Intraductal Microwave Ablation and Self-expandable Metallic Stenting: A New Treatment Method for Malignant Extrahepatic Biliary Obstruction.

PURPOSE: To evaluate the patency and clinical efficacy of percutaneous intraductal microwave ablation (PIMWA) and uncovered self-expandable metallic stents (USEMs) in inoperable malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: The procedures to be performed on patients with malignant inoperable extrahepatic biliary obstruction were decided by a multidisciplinary team including an interventional radiologist. In our study, 141 patients were evaluated retrospectively. Twenty-one patients who underwent PIMWA + USEMs with the MedWaves AveCure microwave system (AveCure® Intelligent Controller and Super-Flex Smart Catheter) and met the inclusion criteria were included in the study. Complications related to the intervention, stent patency, survival time, serum bilirubin levels, and the general condition of the patients were noted. RESULTS: The median stent patency and the median survival time were 108 and 143 days, respectively. The rates of 30-day, 2-month, 6-month and 8-month survival were 95.2%, 85.7%, 38.1%, and 14.3%, respectively. CONCLUSION: The PIMWA + USEMs procedure is a safe, effective, and minimally invasive alternative palliative treatment method in patients with malignant inoperable extrahepatic biliary obstruction.

Percutaneous Treatment of Giant Cystic Echinococcosis in Liver: Catheterization Technique in Patients with CE1 and CE3a.

PURPOSE: This study aimed to evaluate the efficacy, safety, and follow-up results of the percutaneous treatment of cystic echinococcosis (CE) patients with giant hepatic cysts (at least one diameter > 10 cm). METHODS: Between January 2013 and 2018, 31 CE patients with 34 giant cysts classified as CE1 or CE3a (Gharbi type 1 or 2) according to the World Health Organization criteria and treated with the catheterization technique were analyzed retrospectively. RESULTS: Thirty-four giant hepatic cysts were treated using the catheterization technique. Technical success was 100%. One procedure was sufficient for 27 of these cysts, while six patients underwent a second procedure due to recurrence, recollection or complications; one did not accept a repeat procedure and decided to refer to surgery due to pain. Ten (29%) major complications developed. The overall clinical success was 97%. The mean follow-up period was 20 months (5-61 months), and the total reduction in the cyst volume was 92%. CONCLUSION: The catheterization technique is effective in treating giant CE with acceptable complication rates. LEVEL OF EVIDENCE: Level 4, Clinical Investigation.

Implementation of the EXOSEAL Vascular Closure Device in the Transpopliteal Arterial Approach.

PURPOSE: To investigate the feasibility and safety of the EXOSEAL vascular closure device (VCD) in achieving hemostasis in transpopliteal arterial interventions. MATERIALS AND METHODS: Between May 2014 and May 2016, 46 procedures involving transpopliteal arterial access in 28 patients (18 bilateral and 10 unilateral) were analyzed retrospectively. Popliteal arterial puncture was performed under ultrasonographic (US) and fluoroscopic guidance by using a micropuncture access set with a 21-gauge needle. Six-French sheaths were used in 45 procedures, and a 7-F sheath was used in 1 procedure. Hemostasis was achieved with the EXOSEAL VCD. All patients were examined for any access-related complications with US at 6 and 24 hours after the procedure. One week later, all patients were followed up in the outpatient clinic. RESULTS: In 44 of the 46 procedures, the EXOSEAL VCD was applied successfully. The technical failure rate was 4.4%. An excessively steep angle of the introducer sheath and improper placement of the EXOSEAL plug in the setting of high blood pressure (220/120 mm Hg) were the reasons for the 2 failures. Among the 44 successful procedures, 1 (2.3%) minor 3-cm hematoma was found to be associated with the VCD. In 1 of the 46 procedures, an arteriovenous fistula (2.2%) was observed as a puncture-related complication and treated with a stent graft. CONCLUSIONS: The EXOSEAL VCD can be safely used for hemostasis in interventions that use transpopliteal arterial approaches, with a high technical success rate and a low rate of entry-site complications.

Percutaneous cholecystostomy for delayed laparoscopic cholecystectomy in patients with acute cholecystitis: analysis of a single-centre experience and literature review.

INTRODUCTION: Percutaneous cholecystostomy (PC) has been used as a relatively safe and efficient temporising measure in the treatment of acute cholecystitis (AC) in high-risk patients with serious co-morbidity and in elderly patients. AIM: To assess the effectiveness, possible advantages, and complication of delayed laparoscopic cholecystectomy (LC) following PC in patients with AC. MATERIAL AND METHODS: A total of 52 LC for AC were divided into two groups: the first group consisted of patients who had PC followed by LC (PCLC group, n = 12), and the second group consisted of patients who had conservative treatment followed by LC (non-PCLC group, n = 40). Eight of these patients were males and four were female. The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conservation, and complication rates. PC was performed via the transhepatic route under ultrasound guidance using local anaesthesia. RESULTS: Percutaneous cholecystostomy was technically successful in 12 patients with no attributable mortality or major complications. Upon the regression of cholecystitis and the decrease in APACHE-II scores, the PC catheter was unplugged and elective LC was scheduled for after 8 weeks. Ninety-two percent had complete resolution of symptoms within 48 h of intervention while 8% had partial resolution. All of the patients in PCLC and non-PCLC groups recovered well from cholecystectomy. CONCLUSIONS: This study suggests that PCLC would not significantly improve the outcome of LC as assessed by conversion and morbidity rate and hospital stay compared with non-PCLC. Percutaneous cholecystostomy is a valid alternative for patients with acute cholecystitis. And our study shows that the laparoscopic cholecystectomy is a good option in high-risk patients who have been treated by percutaneous cholecystostomy for acute cholecystitis.

Risk factors for hemorrhage requiring embolization after percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the primary surgical intervention in kidney stone management. Even though it is performed quite often, the complication rates are also high. Arteriovenous fistulas following extended hemorrhages after PCNL are one of the most serious complications of this operation. Our main objective was to review the data of patients who required angiography and embolization. METHODS: In total, we included 1405 patients who underwent PCNL between 2007 and 2014. All patient data were retrospectively reviewed. All patients went under PCNL using fluoroscopy. Following informed consent, all hemorrhagic patients underwent angiography in the interventional radiology department and embolization was performed in patients with a hemorrhage focus point. RESULTS: A total of 147 patients (10.4%) required transfusion for post-PCNL hemorrhages. Of them, 14 (0.99%) underwent angiography and embolization (9 [64.2%] were male and 5 [35.8%] were female, with a mean age of 39.4 ± 10.2). The remaining 133 patients were conservatively managed (81 [60.9%] males and 52 [39.1%] females, with a mean age of 42.3 ± 12.4). When the predicting factors for angiography and embolization were reviewed, renal abnormalities and the mean size of stones were significant in both univariate and multivariate analysis (p < 0.001). CONCLUSION: Patients with extended and intermittent hematuria should be monitored closely for hemodynamics; if there is an ongoing necessity for transfusion, angiography should be considered.

Angiographic assessment of variants of basal vein of Rosenthal in idiopathic subarachnoid hemorrhage.

Previous studies have reported the possible contribution of a primitive variant of the basal vein of Rosenthal (BVR) in the cause of idiopathic subarachnoid hemorrhage (ISAH). The purpose of this study was to assess the drainage patterns of the BVR among ISAH patients. The venous phase at cerebral angiography was retrospectively analyzed in 19 patients with ISAH and then compared with patients with unruptured aneurysms as controls. A relationship was found between ISAH and the presence of a primitive variant. However, the venous configuration effect on bleeding is still unknown.

Multidetector CT of left atrium.

MDCT angiography has enabled visualization of left atrium in addition to coronary arteries. CT images can be utilized to demonstrate normal anatomy and pathologies. Left atrium variations and pathologies include atrial septal pouch, patent foramen ovale, atrial septal defect, atrial band, lipomatous hypertrophy, cor triatriatum, diverticulum, accessory appendages, atrial thrombus and masses. Left atrium should be carefully evaluated in patients undergoing coronary CT angiography. MDCT is becoming an alternative modality for the evaluation of left atrium.

Clinical applications of gadobenate dimeglumine-enhanced magnetic resonance cholangiography: an expanded pictorial review.

Gadobenate dimeglumine (Gd-BOPTA) is taken up by functioning hepatocellular cells and is partially excreted into the biliary system; therefore, it can be used as a potential intrabiliary contrast agent for magnetic resonance cholangiography applications for various clinical conditions such as obstructive disorders (e.g., choledocholithiasis, hepatolithiasis), inflammatory disorders (e.g., acute cholecystitis, cholangitis), benign biliary disorders, and pre- and postprocedural evaluation of the biliary system. In this pictorial review, we aimed to demonstrate the clinical applications of Gd-BOPTA as an intrabiliary contrast agent for imaging various biliary pathologies.

Is there an alternative to TIPS? Ultrasound-guided direct intrahepatic portosystemic shunt placement in Budd-Chiari syndrome.

Budd-Chiari syndrome is a spectrum of manifestations which develops as a result of hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive vascular and interventional radiological procedure indicated in the management of refractory ascites in such patients. Conventional TIPS requires the presence of a patent hepatic vein and reasonable accessibility to the portal vein, and in patients with totally occluded hepatic veins, this procedure is technically challenging. Direct intrahepatic portosystemic shunt (DIPS) or so called "percutaneous TIPS" involves ultrasound-guided percutaneous simultaneous puncture of the portal vein and inferior vena cava followed by introduction of a guidewire through the portal vein into the inferior vena cava, as a deviation from conventional TIPS. Described here is our experience with DIPS. Three patients with BCS who had refractory ascites but were unsuitable for conventional TIPS due to occlusion of the hepatic veins were chosen to undergo the DIPS procedure. Our technical success was 100%. The shunts placed in two patients remain patent to date, while the shunt in a third patient with underlying antiphospholipid syndrome was occluded a month after the procedure. The percutaneous TIPS procedure seems to be technically feasible and effective in the management of refractory ascites as a result of BCS, particularly in the setting of occluded hepatic veins.

Initial experience on utility of gadobenate dimeglumine (Gd-BOPTA) enhanced T1-weighted MR cholangiography in diagnosis of acute cholecystitis.

PURPOSE: To investigate the feasibility of the use of gadobenate dimeglumine (also known as Gd-BOPTA) -enhanced T1-weighted MR cholangiography in diagnosis of acute cholecystitis. MATERIALS AND METHODS: This prospectively designed institutional review board-approved HIPAA-compliant study was done between January and November 2007. We included 11 consecutive patients (7 male, mean age 59 years) who presented to the emergency room with acute right upper quadrant pain and with equivocal physical examination and/or ultrasound findings. The control group included 15 patients who underwent liver MRI with Gd-BOPTA. All patients underwent contrast-enhanced (CE) MR cholangiography examinations. CE-MR cholangiography was performed on a 1.5 Tesla magnet using 3D T1-weighted high resolution isotrophic volume examination (THRIVE) obtained at the 90th min after intravenous injection of Gd-BOPTA. Imaging features detected on CE-MR cholangiography were correlated with operative and histopathologic findings. RESULTS: In the control group, GD-BOPTA was visualized within the gallbladder in all subjects. For the study group, gallstones were present in nine patients (n = 7 both in gallbladder and cystic duct, n = 1 only in gallbladder, n = 1 only in cystic duct) on MRCP. Hydropic gallbladder was detected in seven patients, significant wall thickening in seven patients, and pericholecystic free fluid in 6 patients. On delayed phase CE cholangiography, significant enhancement of gallbladder wall was seen in 10 patients, and contrast agent excretion into gallbladder was absent in all patients. Surgery was performed in 10 patients, and cholecystostomy was done in 1 patient. Surgery and histopathology findings were consistent with cholecystitis in all patients. CONCLUSION: In addition to anatomical assessment, Gd-BOPTA-enhanced MR cholangiography can provide functional evaluation similar to HIDA scintigraphy in diagnosing acute cholecystitis in patients with acute right upper quadrant pain and equivocal findings.

Multidetector computed tomography diagnosis of fusion of pancreas and spleen confirmed by magnetic resonance imaging.

We report multidetector computed tomography findings of fusion between the spleen and the distal pancreas with magnetic resonance imaging findings, which has not been reported before. Diagnosis of splenopancreatic fusion can be important in patients who will undergo splenectomy or distal pancreatectomy to avoid possible complications.