Minimally Invasive Treatment Options for Hepatic Uveal Melanoma Metastases.

Uveal melanoma is one of the most common primary intraocular malignancies that accounts for about 85% of all ocular melanomas. The pathophysiology of uveal melanoma is distinct from cutaneous melanoma and has separate tumor profiles. The management of uveal melanoma is largely dependent on the presence of metastases, which confers a poor prognosis with a one-year survival reaching only 15%. Although a better understanding of tumor biology has led to the development of novel pharmacologic agents, there is increasing demand for minimally invasive management of hepatic uveal melanoma metastases. Multiple studies have already summarized the systemic therapeutic options available for metastatic uveal melanoma. This review covers the current research for the most prevalent locoregional treatment options for metastatic uveal melanoma including percutaneous hepatic perfusion, immunoembolization, chemoembolization, thermal ablation, and radioembolization.

Percutaneous Ultrasound Guided Gastrostomy Tube Placement: A Prospective Cohort Trial.

BACKGROUND: To compare the safety and efficacy of percutaneous ultrasound guided gastrostomy (PUG) tube placement with traditional fluoroscopic guided percutaneous gastrostomy tube placement (PRG). METHODS: A prospective, observational, non-randomized cohort trial was performed comparing 25 consecutive patients who underwent PUG placement between April 2020 and August 2020 with 25 consecutive patients who underwent PRG placement between February 2020 and March 2020. Procedure time, sedation, analgesia requirements, and complications were compared between the two groups in non-inferiority analysis. RESULTS: Technical success rates were 96% in both groups (24/25) of procedures. Ninety-two percent of patients in the PUG cohort were admitted to the ICU at the time of G-tube request. Aside from significantly more COVID-19 patients in the PUG group (P < .001), there was no other statistically significant difference in patient demographics. Intra-procedure pain medication requirements were the same for both groups, 50 micrograms of IV fentanyl (P = 1.0). Intra-procedure sedation with IV midazolam was insignificantly higher in the PUG group 1.12 mg vs 0.8 mg (P = .355). Procedure time trended toward statistical significance (P = .076), with PRG being shorter than PUG (30.5 ± 14.1 minutes vs 39.7 ± 17.9 minutes). There were 2 non-device related major complications in the PUG group and 1 major and 1 minor complication in the PRG group. CONCLUSION: PUG is similar in terms of complications to PRG gastrostomy tube placement and a safe method for gastrostomy tube placement in the critically ill with the added benefits of bedside placement, elimination of radiation exposure, and expanded and improved access to care.

Evaluation of a three-session biliary dilation protocol following transplant-related biliary stricture in pediatric patients.

To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.

Comparative 13-year meta-analysis of the sensitivity and positive predictive value of ultrasound, CT, and MRI for detecting hepatocellular carcinoma.

PURPOSE: To compare the per-lesion sensitivity and positive predictive value (PPV) of ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) for the diagnosis of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The meta-analysis of sensitivity included 242 studies (15,713 patients); 116 studies (7492 patients) allowed calculation of PPV. Pooled per-lesion sensitivity and PPV for HCC detection were compared using empirical Bayes estimates of a beta-binomial model. RESULTS: The pooled per-lesion sensitivity and PPV of contrast-enhanced CT (73.6%, 85.8%) and gadolinium-enhanced MRI (77.5%, 83.6%) are not significantly different (P = 0.08, P = 0.2). However, if the hepatobiliary agent gadoxetate is used, MRI has significantly higher pooled per-lesion sensitivity and PPV (85.6%, 94.2%) than CT (P < 0.0001) or than MRI with other agents (P < 0.0001). Non-contrast-enhanced US has the lowest overall sensitivity and PPV (59.3%, 77.4%). Pooled per-lesion sensitivity and PPV of contrast-enhanced US (84.4%, 89.3%) are relatively high, but no contrast-enhanced US study used the most rigorous reference standards. CONCLUSION: MRI utilizing the hepatobiliary agent gadoxetate has the highest overall sensitivity and PPV, and may be the single optimal method for diagnosis of HCC. Non-contrast-enhanced US has the lowest sensitivity and PPV. More rigorous reference standards are needed to compare the performance of contrast-enhanced US with CT and MRI. Differences in sensitivity and PPV between CT and conventional gadolinium-enhanced MRI are not statistically significant overall.

Retrieval of a Dislodged Catheter Using Combined Fluoroscopy and Intracardiac Echocardiography.

This report details a method of percutaneous, transluminal retrieval of an intracardiac foreign body using fluoroscopy in combination with intracardiac echocardiography. During retrieval, intracardiac echocardiography (ICE) provided real-time anatomic localization of a constantly moving, almost radiolucent micropuncture coaxial dilator fragment with respect to the tricuspid and pulmonary valves. This method may serve as a crucial aid in retrieval of intracardiac foreign bodies that are difficult to see with fluoroscopy and which may be adjacent to cardiac valves.

Experimental in vivo canine model for gastric prolapse of laparoscopic adjustable gastric band system.

BACKGROUND: The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse. METHODS: The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm(3) was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus. RESULTS: Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve. CONCLUSION: The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

Impact of distal side water and residue 315 on ligand binding to ferric Mycobacterium tuberculosis catalase-peroxidase (KatG).

The catalase-peroxidase (KatG) of Mycobacterium tuberculosis (Mtb) is important for the virulence of this pathogen and also is responsible for activation of isoniazid (INH), an antibiotic in use for over 50 years in the first line treatment against tuberculosis infection. Overexpressed Mtb KatG contains a heterogeneous population of heme species that present distinct spectroscopic properties and, as described here, functional properties. A six-coordinate (6-c) heme species that accumulates in the resting enzyme after purification is defined as a unique structure containing weakly associated water on the heme distal side. We present the unexpected finding that this form of the enzyme, generally present as a minority species along with five-coordinate (5-c) enzyme, is the favored reactant for ligand binding. The use of resting enzyme samples with different proportional composition of 5-c and 6-c forms, as well as the use of KatG mutants with replacements at residue 315 that have different tendencies to stabilize the 6-c form, allowed demonstration of more rapid cyanide binding and preferred peroxide binding to enzyme containing 6-c heme. Optical-stopped flow and equilibrium titrations of ferric KatG with potassium cyanide reveal complex behavior that depends in part on the amount of 6-c heme in the resting enzymes. Resonance Raman and low-temperature EPR spectroscopy clearly demonstrate favored ligand (cyanide or peroxide) binding to 6-c heme. The 5-c and 6-c enzyme forms are not in equilibrium on the time scale of the experiments. The results provide evidence for the likely participation of specific water molecule(s) in the first phases of the reaction mechanism of catalase-peroxidase enzymes.