Randomized Trial Comparing Radiologic Pigtail Gastrostomy and Peroral Image-Guided Gastrostomy: Intra- and Postprocedural Pain, Radiation Exposure, Complications, and Quality of Life.

PURPOSE: To prospectively compare radiologically created pigtail gastrostomy (PG), in which the tube is inserted directly through the abdominal wall, versus peroral image-guided gastrostomy (POG), in which the tube is inserted through the mouth. Pain profiles (primary outcome measure), fluoroscopy times, total room times, technical success, complications, and quality of life (QOL) were measured. MATERIALS AND METHODS: Sixty patients were prospectively randomized to receive 14-F PG or 20-F POG tubes. All patients received prophylactically created gastrostomies before radiation therapy for head and neck squamous-cell carcinoma. Patients receiving palliative treatment were excluded, as were those with established pharyngeal obstruction. Pain was measured by numeric rating scale (NRS) scores for 6 weeks after the procedure and by intraprocedural fentanyl and midazolam doses and postprocedural 24-h morphine doses. Fluoroscopy times, total room times, technical success, complications up to 6 months, and gastrostomy-related QOL (using the Functional Assessment of Cancer Therapy-Enteral Feeding questionnaire) were determined. RESULTS: Fifty-six patients underwent the randomized procedure. The POG group required significantly higher intraprocedural midazolam and fentanyl doses (mean, 1.2 mg and 67 µg, respectively, for PG vs 1.9 mg and 105 µg for POG; P < .001) and had significantly longer fluoroscopy times (mean, 1.3 min for PG vs 4.8 min for POG; P < .0001). NRS scores, morphine doses, total room times, technical success, complication rates, and QOL did not differ significantly between groups. The one major complication, a misplaced PG in the peritoneal cavity, followed a technical failure of POG creation. CONCLUSIONS: Despite the differences in insertion technique and tube caliber, the measured outcomes of POG and PG are comparable.

Endoscopic or percutaneous biliary drainage for Klatskin tumors?

PURPOSE: Controversy exists regarding the preferred biliary drainage technique in patients with Klatskin tumors because few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD). MATERIALS AND METHODS: Consecutive patients (N = 129) with Klatskin tumors treated with initial EBD or PTBD were identified, and their clinical histories were retrospectively reviewed. The primary endpoint was the time to therapeutic success (TTS), defined as the time between the first drainage and a total bilirubin measurement of 40 µmol/L or lower. RESULTS: EBD was the first biliary decompression procedure performed in 87 patients; PTBD was performed first in 42. Technical success rates (78% with EBD vs 98% with PTBD; P = .004) and therapeutic success rates (49% vs 79%, respectively; P = .002) were significantly lower in the EBD group than in the PTBD group. Forty-four patients in the EBD group (51%) subsequently underwent PTBD before therapeutic success was achieved or antitumoral treatment was started. Median TTSs were 61 days in the EBD group and 44 days in the PTBD group, and multivariate analysis showed a hazard ratio of 0.63 (95% confidence interval, 0.41-0.99; P = .045). In patients treated with surgery or chemotherapy with or without radiation therapy, median times to treatment were 76 and 68 days in the EBD and PTBD groups, respectively (P = .76). Cholangitis occurred in 25% and 21% of patients in the EBD and PTBD groups, respectively (P = .34). CONCLUSIONS: PTBD should be seriously considered for biliary decompression when treating patients with Klatskin tumor.

Pain after percutaneous liver biopsy for diffuse hepatic disease: a randomized trial comparing subcostal and intercostal approaches.

PURPOSE: To compare pain levels as measured by visual analog scale (VAS) and analgesic requirement between intercostal and anterior subcostal ultrasound (US)-guided biopsy. MATERIALS AND METHODS: Seventy consecutive patients were randomized to undergo biopsy via an intercostal (n = 33) or subcostal (n = 37) approach. The groups were matched with regard to baseline characteristics: mean age, 44 years; age range, 20-70 years; sex, 43 male and 27 female; and indications of hepatitis C in 69%, hepatitis B in 16%, and others in 15%. The VAS score was obtained immediately after biopsy and hourly for 4 hours until the patients were discharged. Analgesic requirements and postprocedural complications were documented. RESULTS: No significant difference in VAS scores was seen between the groups. At hours 0, 1, 2, 3, and 4, the VAS scores (on a scale of 100) in the intercostal and subcostal groups were 10.3 +/- 16.7 versus 11.8 +/- 16.0 (P = .70), 19.1 +/- 24.0 versus 13.9 +/- 16.2 (P = .30), 11.5 +/- 14.8 versus 11.8 +/- 15.1 (P = .93), 6.2 +/- 8.9 versus 7.5 +/- 11.5 (P = .63), and 5.4 +/- 8.2 versus 4.7 +/- 8.5 (P = .72), respectively. The average VAS was less than 10. In the intercostal biopsy group, 36.4% of patients required additional analgesia after biopsy, compared with 27.0% in the subcostal biopsy group (P = .64). One patient in the intercostal group refused to have future follow-up biopsy even if it was clinically indicated, compared with no such patients in the subcostal biopsy group. No differences in diagnostic samples or major complications were seen in either group. CONCLUSION: US-guided percutaneous liver biopsy performed with fentanyl and midazolam premedication is a well-tolerated procedure with minimal patient discomfort. The location of the biopsy does not influence the outcome of the procedure.

Needle tract seeding after radiofrequency ablation of hepatic tumors.

PURPOSE: To determine the incidence and risk factors associated with needle tract seeding after radiofrequency ablation (RFA) of liver tumors. MATERIALS AND METHODS: A prospective data base of patients with hepatic tumors treated by RFA from December 1999 until August 2003 was reviewed to identify patients with needle tract seeding. During this period, 200 patients (148 men, 52 women) with 299 lesions underwent 298 treatment sessions. Patients with both primary (153 hepatocellular carcinoma, two cholangiocarcinoma) and a variety of secondary tumors (35 colorectal, 10 other) were treated. RFA was performed percutaneously with computed tomography (CT) and/or ultrasound (US) guidance, or with US guidance at laparoscopy or laparotomy. All procedures were performed with a LeVeen needle electrode. The needle tract was not routinely coagulated or embolized. RESULTS: Eight patients out of 200 (4%) were identified with needle tract seeding, based on imaging findings or surgical reintervention. This corresponds to a rate of eight of 298 (2.7%) per treatment session and eight of 299 (2.7%) per lesion. Statistically significant risk factors for neoplastic seeding included treatment of a subcapsular lesion (OR = 11.57, P = .007), multiple treatment sessions (OR = 2.0, P = .037), and multiple electrode placements (OR = 1.4, P = .006). CONCLUSIONS: Neoplastic seeding may occur after RFA of liver tumors. The results show that the frequency of this complication is not insignificant, and are at the upper end of rates reported in the literature of 0.5% to 2.8%. Specific risk factors identified in this study include treatment of subcapsular lesions, patients treated in multiple sessions, and lesions requiring more than one electrode placement.