Radiofrequency Ablation of Parathyroid Adenomas: Safety and Efficacy in a Study of 10 Patients.

PURPOSE: To evaluate safety and effectiveness of ultrasound-guided percutaneous radiofrequency ablation of parathyroid adenoma in surgically unfit patients with hypercalcemia because of hyperparathyroidism. MATERIALS AND METHODS: A retrospective review of hospital records from Jan 2012 to Dec 2018 revealed 10 patients, who had undergone ablation for solitary parathyroid adenoma. All 10 patients suffered from hyperparathyroidism because of parathyroid adenoma, resulting in hypercalcemia. These patients were surgically unfit because of comorbidities. Pre-ablation serum calcium and serum parathormone levels were measured and compared with the levels after the ablation. RESULTS: Mean serum calcium level decreased significantly from 2.81 ± 0.17 mmol/L pre-ablation to 2.42 ± 0.17 mmol/L 72 h after ablation and parathyroid hormone levels became normal in all patients within 7 days. Seven patients remained normo-calcaemic at 6 months follow-up with no signs and symptoms of hyperparathyroidism. One patient with pancreatitis died after 15 days because of pre-existing multi-organ failure. Two patients were lost to follow-up before 6 months. CONCLUSION: Radiofrequency ablation of parathyroid adenoma is a safe and effective alternate treatment method for symptomatic hypercalcemia in surgically unfit patients suffering from primary hyperparathyroidism because of parathyroid adenoma.

Outcome of 200 Pediatric Living Donor Liver Transplantations in India.

OBJECTIVE: To describe our experience of pediatric living donor liver transplantation from India over a period of 12 years. MATERIALS AND METHODS: A retrospective analysis of 200 living donor liver transplantation in children (18 years or younger) was done for demographic features, indications, donor and graft profile and outcome. RESULTS: Between September 2004 and July 2016, 200 liver transplants were performed on 197 children. Fifty transplants were done in initial 6 years and 150 in next 6 years. All donors (51% mothers) were discharged with a mean stay of 7 days. The leading indications of liver transplants were cholestatic liver disease (46%) followed by metabolic liver disease (33%) and acute liver failure/acute on chronic liver failure (28.5%). Biliary leakage (8.5%), biliary stricture (9%), hepatic artery thrombosis (4.5%) and portal vein thrombosis (4%) were the most common surgical complications; all could be managed by surgical or interventional radiological measures, except in one child who died. Sepsis, acute rejection and CMV hepatitis in first 6 months were seen in 14.5%, 25% and 17% cases, respectively. Post-transplant lymphoproliferative disease was seen in only 1.5%. Re-transplant rate was 1.5%. The overall 1 year survival rate was 94% and 5 year actuarial survival was 87% with no statistically significant difference between children weight <10 kg vs. >10 kg. Outcome in acute liver failure did not differ significantly between those with acute on chronic liver failure vs. those with chronic liver disease. CONCLUSIONS: Advances in medical and surgical techniques associated with multidisciplinary teams including skilled pediatric liver transplant surgeons, anesthetists, dedicated pediatric hepatologists, pediatric intensivists, interventional radiologists and pathologists resulted in an excellent outcome of living related liver transplants in children. Low age and weight of the baby does not seem to be a contraindication for liver transplantation as outcome were comparable in our experience.

Non-invasive quantification of hepatic steatosis in living, related liver donors using dual-echo Dixon imaging and single-voxel proton spectroscopy.

AIM: To evaluate the diagnostic implications of hepatic fat fraction calculated using dual-echo Dixon imaging and (1)H magnetic resonance spectroscopy (MRS) to detect hepatic steatosis in potential liver donors using histopathology as the reference standard. MATERIALS AND METHODS: One hundred and forty-five potential liver donors were included in the study. Magnetic resonance imaging (MRI) was performed using a 1.5 T system using a three-dimensional dual-echo MRI sequence with automated reconstruction of in-phase (IP), out-of-phase (OP), fat-signal-only, and water-signal-only images. Hepatic fat fraction was calculated by drawing 15 regions of interest on the IP, OP, fat-only, and water-only images. Single-voxel MRS was performed at echo times (TEs) of 30 ms in the right and left lobes of liver. Liver fat fraction was calculated from water and fat peaks. One hundred and forty-five biopsies were prospectively evaluated for steatosis by a pathologist using traditional determination of the cell-count fraction. MRI and pathology values of steatosis were correlated using Pearson's correlation coefficient. The sensitivity and specificity of each of these methods was calculated using histopathology as the reference standard. Reproducibility was assessed in 40 patients who had repeat scanning within 4-40 days. Measurement error was calculated from the coefficient of variation (CoV) with histopathologically proven <5% fat (n=112). RESULTS: The Bland-Altman limits of agreement with 95% confidence intervals (CI) was -2.9 to 5.3%. The intraclass correlation coefficient (ICC) for interobserver variability and reproducibility was 0.94 (95% CI: 0.91-0.97), 0.92 (95% CI: 0.91-0.97). The CoV was 7.6% (95% CI: 3.4-11.85). The area under the receiver operating characteristic (ROC) curve (AUC) for Dixon imaging 0.89 (95% CI: 0.87-0.91), for MRS 0.88 (95% CI: 0.86-0.90). The sensitivity for detecting <5% fat was 84% and specificity was 90%. CONCLUSION: Combination of dual-echo Dixon imaging and proton MRS is a useful tool for the preoperative diagnosis of hepatic steatosis in potential living liver donors. This can help avoid unnecessary biopsies in these patients.

Esophageal bronchus: case report and review of the literature.

Communicating bronchopulmonary foregut malformation (CBPFM) is a rare abnormality that is characterized by persistent communication between the bronchial tree and the gastrointestinal tract. We report a case of CBPFM in a young girl, with a description of the imaging and surgical details and a short review of the relevant literature.

Endovascular management of pseudoaneurysms of the splenic artery: experience with six patients.

The purpose of this paper was to describe our experience with the endovascular management of splenic artery pseudoaneurysms (SAPA). Seven patients with documented SAPA on CT and/or angiography were considered for endovascular treatment. The pseudoaneurysms were located in the main splenic artery (n = 4) or its branches (n = 3). In one patient in whom the pseudoaneurysm was located in a hilar branch, selective catheterization of splenic artery failed. Metallic coils (n = 1), gelfoam and hydrogel particles (n = 1), metallic coils and gelfoam (n = 2), metallic coil, gelfoam and acrylic glue (n = 2) were used as embolization material in the remaining six patients. These patients were followed for a mean period of 11.3 months. Transcatheter embolization was successful in five patients with no procedure-related complications. In one patient, embolization was incomplete and the patient underwent surgery, but died on the 10th postoperative day because of irreversible shock. Another patient, after successful embolization, underwent surgery for management of an associated pseudocyst. Endovascular treatment is a safe and effective method of management of SAPA.

Intra-arterial embolization of lumbar artery pseudoaneurysm following percutaneous nephrolithotomy.

The management of a patient with haematuria following percutaneous nephrolithotomy is described. The patient underwent renal angiography to assess the cause of bleeding. A pseudoaneurysm arising from first left lumbar artery was incidentally discovered, which was then successfully embolized using an indigenously fabricated metallic coil and gel foam particles in the same sitting.

Pseudoaneurysm of gastroduodenal artery associated with mitral valve prolapse presenting as haemobilia.

Pseudoaneurysms of the hepatic or gastroduodenal arteries may cause Haemobilia. Mitral valve prolapse associated with mycotic pseudoaneurysm of cerebral and extracerebral arteries have been reported. We report a case of gastroduodenal artery pseudoaneurysm presenting as haemobilia. The patient was successfully treated with indigenously fabricated steel coil embolization followed by surgery.

Biliary ascariasis complicating endoscopic sphincterotomy for choledocholithiasis in India.

Endoscopic sphincterotomy is the treatment of choice for patients with choledocholithiasis. Biliary ascariasis has been reported from many parts of the world but is common in Kashmir, India. We report five cases of biliary ascariasis of which four were the result of post-endoscopic sphincterotomy for choledocholithiasis. Therefore, biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy.

Spontaneous passage of gallbladder calculi--facilitation by endoscopic sphincterotomy.

After endoscopic sphincterotopy (ES) gallbladder motility increases leading to expulsion of crystals and stones. But this is not a universal phenomenon. We evaluated cholangiographic findings in patients emptying their gallbladder after ES for common bile duct (CBD) stones. Cholangiographic features of twenty patients expelling gallbladder calculi after ES were studied. Controls included 20 age and sex matched patients with gallstones and CBD stones, who did not expel gallstones after ES. Of 20 cases in study group, 9 recovered more than 20 stones each in the stool within 7 days of ES. Repeat ERCP showed empty gallbladder in all, whereas CBD was full of stones in 11 of the 20 cases. In the study group, low insertion of the cystic duct was more common (10 vs 0, p < 0.04), the cystic duct made a narrow angle (20 +/- 5 degrees vs 50 +/- 10 degrees, p < 0.04) with CBD before insertion and cystic duct diameter was higher (5 mm vs 2.5 mm, p < 0.04) as compared to controls. We conclude that in patients undergoing ES with intact gallbladder and small gallbladder calculi, spontaneous emptying of gallbladder calculi occurs, if cystic duct is wider, has low insertion and makes narrow angle with CBD before insertion.

Biliary stenting for management of common bile duct stones.

Large and multiple common bile duct stones may defy extraction despite an adequate endoscopic papillotomy. We treated 65 patients with symptomatic bile duct stones with endoscopic stents after failed attempts at stone extraction. Of the 65 patients, bile duct stones were extracted in eight at a second attempt, 29 underwent elective surgery and 28 patients were followed with the stent in situ for 21-52 months (median 42 months). During follow up, two patients had recurrent pain and two required surgery. The remaining 24 patients remained asymptomatic. Biliary stenting is a safe and effective mode of treatment for common bile duct stones in patients who have failed stone extraction after endoscopic papillotomy.

Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy.

BACKGROUND & AIMS: Biliary cholesterol supersaturation, rapid nucleation of cholesterol, and altered gallbladder motility are prerequisite for gallstone formation. However, the pathogenesis of microlithiasis is not clear. The aim of this study was to determine the abnormalities of gallbladder emptying and bile composition in patients with microlithiasis. METHODS: Nucleation time, cholesterol saturation index (CSI), and gallbladder emptying were studied in patients with microlithiasis (n = 10), patients with gallstones (n = 10), and healthy volunteers (n = 10). Bile analysis was repeated in 6 patients with microlithiasis treated with ursodeoxycholic acid (UDCA) for 8 weeks. RESULTS: Nucleation time was shorter in patients with microlithiasis and those with gallstones than in healthy volunteers (P < 0.0001). Patients with microlithiasis had longer nucleation time than those with gallstones (P < 0.001). There was no difference in cholesterol levels and CSI in gallstone and microlithiasis patients. However, healthy volunteers had lower cholesterol levels (P < 0.01) and CSI (P < 0.01). Patients with microlithiasis had prolongation of nucleation time (P < 0.001) and lowering of CSI (P < 0.001) after UDCA therapy. Gallbladder ejection fraction was higher in microlithiasis patients than in gallstone patients (P < 0.01) but lower than in healthy volunteers (P < 0.01). CONCLUSIONS: Patients with microlithiasis have longer nucleation time and better gallbladder emptying than patients with gallstones. Bile abnormalities can be successfully corrected with UDCA therapy in patients with microlithiasis.

Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility.

BACKGROUND: Endoscopic sphincterotomy has been shown to inhibit stone formation in the gall bladder of experimental animals. AIMS: To investigate the alterations in bile composition and gall bladder motility after endoscopic sphincterotomy. PATIENTS: A study was performed of gall bladder bile composition and gall bladder motility in patients with gallstone disease ((n = 20; age 40-60 years, median age 55 years: seven men), with gall bladder calculi (n = 12) and with diseased gall bladder (chronic inflammation) without gall bladder calculi (n = 8)), who had received endoscopic sphincterotomy for common bile duct stones. Age and sex matched disease controls comprised 20 patients with gallstone disease but without stones and an intact sphincter of Oddi (with gall bladder calculi (n = 10) and diseased gall bladder without gall bladder calculi (n = 10)). METHODS: Gall bladder motility was assessed by ultrasound. Duodenal bile collected by nasoduodenal tube after stimulation of gall bladder by intravenous ceruletid infusion was analysed for cholesterol, phospholipid, and bile acid concentrations, cholesterol saturation index, and nucleation time. RESULTS: There was a significant reduction in mean (SEM) fasting volume (12.5 (1.7) ml v 26.4 (2.5) ml; p < 0.001) and mean (SEM) residual volume (4.34 (0.9) ml v 14.7 (0.98) ml; p < 0.001), and increase in mean (SEM) ejection fraction (65.7 (4.2)% v 43.6 (5.52)%; p < 0.001) and mean (SEM) rate constant of gall bladder emptying (-0.031/min v -0.020/min; p < 0.01) in patients who had been subjected to endoscopic sphincterotomy. Median nucleation time was significantly longer (17 days v 6 days; p < 0.006) in treated patients. There was a reduction in total mean (SEM) lipid concentrations (6.73 (0.32) g/dl v 7.72 (0.84) g/dl; p < 0.05), cholesterol (5.6 (1.5) mmol/l v 10.3 (2.23) mmol/l; p < 0.001) and CSI (0.72 (0.15) v 1.32 (0.31); p < 0.001). There was no significant change in mean (SEM) phospholipid (25.6 (3.5) mmol/l v 23.4 (6.28) mmol/l) and bile acid (93.7 (7.31) mmol/l v 105.07 (16.6) mmol/l) concentrations. CONCLUSIONS: After endoscopic sphincterotomy there was enhanced contractility of the gall bladder, accompanied by a prolongation of nucleation time and reduction in cholesterol saturation index.

Pravastatin has no effect on bile lipid composition, nucleation time, and gallbladder motility in persons with normal levels of cholesterol.

Pravastatin dissolves gallstones in patients with hypercholesterolemia by reducing the cholesterol saturation index (CSI) of bile. There are few reports on effect of pravastatin on bile lipids, CSI and nucleation time (NT) in patients with gallstones and normal plasma lipid levels, or on the effect of pravastatin on gallbladder motility. Therefore we studied the effect of pravastatin on bile lipids, CSI, NT, and gallbladder motility in persons with normal cholesterol levels. We included 10 patients (ages 32 +/- 8 years; 6 men) with symptomatic gallstones and normal plasma lipid profiles. Estimation of bile lipids, CSI, and NT in duodenal bile and gallbladder motility were done using standard methods. Subsequently each patient was given 40 mg pravastatin daily for 1 month. At completion of pravastatin therapy, bile lipids and gallbladder motility studies were repeated. After pravastatin therapy, we found no significant reduction in bile cholesterol (11.2 +/- 3.2 vs. 10.4 +/- 2.8 mmol/l), bile acids (114.6 +/- 7.4 vs. 133 +/- 16 mmol/l), phospholipids (23 +/- 3.5 vs. 24 +/- 6.2 mmol/l), CSI (1.28 +/- 0.4 vs. 1.22 +/- 0.3), and nucleation time (7 +/- 3 vs. 7 +/- 3 days). In addition, there was no significant change in gallbladder fasting volume (26 +/- 3 vs. 26.6 +/- 3 ml), residual volume (14.6 +/- 1.1 vs. 15.08 +/- 1.4 ml), ejection fraction (44% vs. 43%), and rate constant of gallbladder emptying (0.018/min vs. 0.022/min). One-month therapy with pravastatin does not alter bile lipids, CSI, NT, and gallbladder contractility in persons with normal levels of cholesterol.

Effect of endoscopic sphincterotomy on gallbladder motility.

In experimental animals, sphincterotomy facilitates passage of solids from the gallbladder and inhibits gallstone formation apparently by improvement in gallbladder emptying. In humans, however, gallbladder emptying has not been studied following endoscopic sphincterotomy (ES) in patients with gallstones. We therefore prospectively studied resting and cerulin-stimulated gallbladder volumes by real time ultrasonography in 15 patients of choledocholithiasis with gallbladder in situ (eight with and seven without gallbladder calculi) before and after (after bile duct clearance) ES. ES significantly lowered resting gallbladder volume (21.2 +/- 10.6 vs 11.1 +/- 5.0; P < 0.0001) and cerulin-stimulated residual gallbladder volume (10.8 +/- 5.6 vs 4.4 +/- 2.1; P < 0.0001). ES also significantly increased the gallbladder ejection fraction (47.3 +/- 12.1% vs 58.8 +/- 11.1%; P < 0.0001). The rate constant for gallbladder emptying after cerulin infusion also increased significantly after ES (-0.022/min vs -0.031/ min; P < 0.0001). Significant improvement in gallbladder motility was observed in both groups of patients with and without gallbladder calculi. ES significantly improves gallbladder motility in humans.

Intraoperative ultrasonography for insulinoma: a preliminary experience.

BACKGROUND: A majority of insulinomas are benign and intrapancreatic. Because surgery is curative in 90% of cases, and almost 60% are not detected by preoperative imaging studies, precise intraoperative localization is essential. Recently, the use of high-resolution real-time ultrasonography has facilitated intraoperative detection. METHODS: Intraoperative ultrasonography using a high-frequency probe was performed in four patients with biochemically proven insulinomas. RESULTS: Ultrasonography helped to localize the insulinomas, and also helped in surgical decision-making by accurately documenting the relationship of the tumor to vital structures. CONCLUSION: Besides its ability to find islet cell tumors, intraoperative ultrasonography also affects surgical decision-making.

Iatrogenic renal vascular injuries and their radiological management.

Twenty-nine patients with significant haematuria after a renal invasive procedure (27 of whom had undergone a percutaneous renal procedure and 2 surgical pyelolithotomy) were investigated with angiography. Out of the 21 patients with evidence of arterial injury, 19 were treated by transarterial embolization with gelfoam with or with hydrogel particles; (n = 11), steel coils with gelfoam (n = 4), hydrogel particles (n = 1), surgicel (n = 2), silk with gelfoam (n = 1). The efficacy and technique of the therapeutic embolization procedure is emphasized.

Renal artery stenosis in aortoarteritis: spectrum of disease in children and adults.

Nonspecific aortoarteritis is the commonest cause of renovascular hypertension (RVH) accounting for 87% of the patients in the present study. We compared the clinical and radiographic features and outcome in children (n = 16) and adult (n = 24) patients with aortoarteritis. Children have a shorter duration of disease and present more commonly with constitutional symptoms. All the patients were hypertensive; however, malignant hypertension and hypertensive encephalopathy were more common in children. Abdominal bruit and asymmetry of pulses were present only in 75 and 35% of the patients, respectively. Asymmetric kidney size on ultrasound was present in 15 of 24 adults, whereas 9 of 16 children had equal sized kidneys. Captopril renography had a better sensitivity for detection of RVH in children (13 of 16 in children vs. 12 of 24 in adults showing positive results). On intra-arterial digital substraction angiography, abdominal aortic involvement was invariable, whereas the thoracic aorta was involved less frequently in both age groups. Angiographic scores for the severity of vascular involvement was significantly lesser in children (6.87+/-4.8) as compared to adults (11.32+/-4.5). Thirteen of the 15 children were found suitable for revascularization, whereas 12 of 24 adults were not considered for revascularization as their kidneys were small and contributed to less than 10% of total function. Six of the adult patients underwent nephrectomy for the control of blood pressure. Results of angioplasty were also better in children than adults. We conclude that children present earlier with less severe vascular disease and respond better to revascularization, as compared to adults.