The role of repeated imaging in detecting complications in the post-operative period following pancreaticoduodenectomy: Serial CT imaging post-pancreaticoduodenectomy.

BACKGROUND: Post-pancreaticoduodenectomy haemorrhage is a potentially life-threatening complication. Delay in the detection and subsequent management of complications contribute significantly to post-operative mortality and morbidity associated with pancreaticoduodenectomy. METHODS: All patients undergoing pancreaticoduodenectomy at an Australian-based tertiary referral center between 2017 and 2022 were reviewed retrospectively. We identified those patients who suffered a post-pancreaticoduodenectomy haemorrhage and further analysed those patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeated CT imaging performed within 24 h of their previous CT scan. RESULTS: A total of 232 pancreaticoduodenectomies were identified for analysis during the study period, of which 23 patients (9.9%) suffered a post-pancreaticoduodenectomy haemorrhage. We present four patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeat CT scan in the setting of a recent (within 24 h) CT scan which showed no evidence of active haemorrhage or pseudoaneurysm formation. All patients received prompt and definitive endovascular management through stent insertion or coil embolization resulting in successful cessation of bleeding. Three patients made an uncomplicated recovery thereafter. Unfortunately, one patient died as a complication of the bleed despite early and definitive endovascular intervention. CONCLUSION: Our study highlights the importance of having a low threshold for repeated CT imaging in the post-pancreaticoduodenectomy setting, particularly when there remains a high index of suspicion clinically for a post-operative complication, even in the context of previous benign imaging. Given the complexity of pancreaticoduodenectomy, we believe early detection with liberal imaging allows the best chance at successfully managing the morbidity and mortality associated in the post-pancreaticoduodenectomy setting.

Interventional radiology in obstetric patients: A population-based record linkage study of use and outcomes.

INTRODUCTION: Interventional radiology (IR) is a technique for controlling hemorrhage and preserving fertility for women with serious obstetric conditions such as placenta accreta spectrum (PAS) or postpartum hemorrhage. This study examined maternal, pregnancy and hospital characteristics and outcomes for women receiving IR in pregnancy and postpartum. MATERIAL AND METHODS: A population-based record linkage study was conducted, including all women who gave birth in hospital in New South Wales or the major tertiary hospital in the neighboring Australian Capital Territory, Australia, between 2003 and 2019. Data were obtained from birth and hospital records. Characteristics and outcomes of women who underwent IR in pregnancy or postpartum are described. Outcomes following IR were compared in a high-risk cohort of women: those with PAS who had a planned cesarean with hysterectomy. Women were grouped by those who did and those who did did not have IR and were matched using propensity score and other factors. RESULTS: We identified IR in 236 pregnancies of 1 584 708 (15.0 per 100 000), including 208 in the delivery and 26 in a postpartum admission. Two-thirds of women receiving IR in the birth admission received a transfusion of red cells or blood products, 28% underwent hysterectomy and 12.5% were readmitted within 6 weeks. Other complications included: severe maternal morbidity (29.8%), genitourinary tract trauma/repair (17.3%) and deep vein thrombosis/pulmonary embolism (4.3%). Outcomes for women with PAS who underwent planned cesarean with hysterectomy were similar for those who did and did not receive IR, with a small reduction in transfusion requirement for those who received IR. CONCLUSIONS: Interventional radiology is infrequently used in pregnant women. In our study it was performed at a limited number of hospitals, largely tertiary centers, with the level of adverse outcomes reflecting use in a high-risk population. For women with PAS undergoing planned cesarean with hysterectomy, most outcomes were similar for those receiving IR and those not receiving IR, but IR may reduce bleeding.

Staged treatment of placenta accreta spectrum: A combined surgical and radiological approach.

BACKGROUND: Placenta accreta spectrum (PAS) is a rare but serious complication of pregnancy. AIMS: The aim of this study was to determine maternal and neonatal outcomes following a combined surgical and interventional radiology (IR) approach to managing PAS, and the risks associated with this technique. METHODS AND MATERIALS: Retrospective cohort study of all cases of PAS in a tertiary maternity centre between January 2001 and July 2020. Women who underwent caesarean hysterectomy for histologically confirmed PAS with a staged surgical and IR approach were compared with those who underwent caesarean hysterectomy without IR. Maternal, neonatal outcomes, surgical and radiological complications were assessed. RESULTS: Forty-six women were included in the study, and 30/46 (65.2%) underwent the staged surgical and IR approach. Women in the staged group had less overall blood loss (1794 mL vs 3713 mL; P < 0.001), less requirement for blood transfusion (40% vs 75%; P < 0.001), and a lower mean volume of packed red cells transfused (2.5 vs 6.1 units). Anaesthetic and operative times were longer for the staged group (468 vs 189 min: 272 vs 141 min P < 0.001), respectively. There were no differences in rates of neonatal or maternal complications between the two groups. CONCLUSION: This study demonstrates that a staged procedure combining surgery and IR for PAS results in a considerable reduction in blood loss, need for transfusion, and units of packed red cells transfused compared with surgery alone. The staged procedure required significantly longer anaesthetic and operative times; however, there were no differences in maternal and neonatal morbidity.

Value of central review of RECIST v1.1 outcomes in the AGITG INTEGRATE randomised phase 2 international trial for advanced oesophago-gastric cancer.

PURPOSE: Activity estimates should be accurately evaluated in phase 2 clinical trials to ensure appropriate decisions about proceeding to phase 3 trials. RECIST v1.1. progression-free survival (PFS) is a common endpoint in oncology; however, it can be influenced by assessment criteria and trial design. We assessed the value of central adjudication of investigator-assessed PFS times of participants in a double-blind, randomised phase 2 trial evaluating regorafenib versus placebo in advanced gastro-oesophageal cancer (AGITG INTEGRATE) to inform plans for central review in future trials. METHODS: We calculated the proportion of participants with a disagreement between the site investigator assessment and blinded independent central review and in whom central review resulted in a change, then evaluated the effect of central review on study conclusions by comparing hazard ratios (HRs) for PFS based on site review versus central review. Post-progression unblinding was assessed with similar methods. Simulation studies explored the effect of differential and non-differential measurement error on treatment effect estimation and study power. RESULTS: Disagreements between site assessments versus central review occurred in 8/147 (5.4%) participants, 5 resulting in amended date of progression (3.4%). PFS HRs (sites vs central review progression dates) were similar (0.39 vs 0.40). RECIST progression occurred in 82/86 (95%) of cases where post-progression unblinding was requested by the site investigator. CONCLUSIONS: Blinded independent central review was feasible and supported the reliability of site assessments, trial results, and conclusions. Modelling showed that when treatment effects were large and outcome assessments blinded, central review was unlikely to affect conclusions.

Clinical characteristics and outcomes of COVID-19 in a low-prevalence, well resourced setting, Sydney, Australia.

BACKGROUND: The Northern Sydney Local Health District was one of the first health regions to be affected by COVID-19 in Australia. AIMS: To describe the clinical characteristics, risk factors and outcomes in our low-prevalence Australian population. METHODS: This is a retrospective analysis of 517 laboratory-confirmed COVID-19 cases between January and June 2020. Patient information was collected as part of routine care within the COVID-19 Virtual Hospital system. Outcomes examined were death, recovery at 30 days and intensive care unit (ICU) admission. RESULTS: The case fatality rate was 1.8%. Multivariate analysis showed factors independently associated with death, composite outcome of death/ICU admission or incomplete recovery at 30 days were age >80 years and presence of two or more comorbidities. Most cases acquired COVID-19 through international (50.9%) or cruise ship travel (9.1%). Healthcare workers comprised 12.8% of the cohort and represented a disproportionately high percentage of the 'unknown' source group (27.6%). The median incubation period was 5 days (interquartile range 3-8); one patient had an incubation period of 15 days. Hospitalisation was required in 11.8%, ICU admission in 2.1% and ventilation in 1.4%. A Radiographic Assessment of Lung Oedema score on chest X-ray of >10 was independently associated with death. CONCLUSIONS: In this low prevalence, well resourced Australian setting, we report an overall low mortality. Factors associated with adverse patient outcomes on multivariate analysis were age greater than 80 and the presence of two or more comorbidities. These data can assist in early risk stratification of COVID-19 patients, and in surge capacity planning for hospitals.

Phrenic nerve palsy as a complication of superior vena caval stenting.

Superior vena cava obstruction typically results from either primary pulmonary malignancies, lymphoma, or fibrosis related to central catheters. Endovascular stenting of superior vena caval obstruction is a common first approach, due to the rapid clinical improvement typically seen. The commonest complications are recurrence of obstruction and stent migration. We present herein the case of a phrenic nerve palsy secondary to endovascular stenting in a patient with superior vena cava obstruction due to primary small cell lung cancer.

Management of per rectal bleeding is resource intensive.

BACKGROUND: Haematochezia or per rectal (PR) bleeding is the most common presentation of lower gastrointestinal bleeding. This study analyses the hospital resources used in the management of patients with PR bleeding. METHODS: A retrospective analysis was performed on patients who presented with PR bleeding from June 2012 to December 2013 to a single tertiary centre in Sydney, Australia. Age, gender, comorbidities, use of antiplatelet or anticoagulant medications, vital signs, and haematological data were recorded. The objective factors available on initial patient assessment were analysed for their relationship with the following outcomes: use of computed tomography mesenteric angiogram, formal angiography and embolization, transfusion of blood products, endoscopy, operative management and length of stay. RESULTS: There were 523 confirmed presentations of PR bleeding. Four hundred and fifty-two of these presented directly to emergency department, while 71 were referred from another hospital. One in five patients had blood transfusion (19%), 13% had computed tomography mesenteric angiogram, 4% had embolization and 13% underwent diagnostic and/or therapeutic colonoscopy. Patients referred from other facilities were more comorbid (55% versus 30%), more likely to be on antiplatelet or anticoagulant (69% versus 33%) with a higher rate of embolization (28% versus 4%), more packed cell transfusions (2.1 versus 0.7 units) and longer length of stay (7.9 versus 5.7 days) but mortality was the same (1%). CONCLUSIONS: The management of patients with PR bleeding is resource intensive. Better identification and allocation of resources in patients who present with PR bleeding may lead to better efficiency in managing this growing clinical problem.

Density and enhancement of the pancreatic tail on computer tomography predicts acinar score and pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Acinar score calculated at the pancreatic resection margin is associated with postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). The present study evaluates the association between (i) computed tomography (CT) density of the pancreas and the acinar score of the pancreatic resection margin, and (ii) CT density of the pancreas and POPF after PD. METHODS: Consecutive patients who underwent PD were included for analysis. CT densities of the pancreatic head, neck, body and tail were measured in non-contrast (NC), arterial (ART) and portal venous (PV) phases. Histologic slides of the pancreatic resection margin were scored for acinar cell density. RESULTS: Ninety patients were included for analysis. Non-contrast density of the pancreatic tail was a good predictor of POPF (AUROC 0.704, p = 0.036), and a cut-off value of >40 Hounsfield units predicted POPF with 70.0% sensitivity and 73.4% specificity. The ratio of densities between PV and NC phases in the pancreatic tail was also a good predictor of POPF (AUROC 0.712, p = 0.030), and a cut-off value of <2.29 predicted POPF with 70.9% sensitivity and 80% specificity. CONCLUSION: Non-contrast CT density of the pancreatic tail correlates with acinar cell density of the pancreatic resection margin and predicts the development of POPF after PD.

Management of recurrent bleeding after pancreatoduodenectomy.

BACKGROUND: Re-bleeding after management of a first haemorrhage following pancreatic surgery is an ever-present danger and often presents diagnostic and management dilemmas. METHODS: All cases of post-pancreatectomy haemorrhage (PPH) following pancreatoduodenectomy were identified from a tertiary referral, clinical database (April 2004-April 2013). Only those suffering a second re-bleeding episode were included in the final case notes review. RESULTS: A total of 301 patients underwent pancreatoduodenectomy during the study period (most common indication: pancreatic adenocarcinoma; 49.5%). Twenty-two (7.3%) patients suffered a PPH (five early). Of these cases, three suffered a re-bleeding event (one mortality). Endoscopy, interventional radiology and surgery were employed in each case. CONCLUSION: PPH presents major clinical challenges and is associated with significant morbidity and mortality. Early detection of the site and type of bleeding are critical and multimodal therapy is usually required. Interventional radiology techniques are making a major contribution to overall management.

Changing Therapeutic Paradigms: Predicting mCRC Lesion Response to Selective Internal Radionuclide Therapy (SIRT) based on Critical Absorbed Dose Thresholds: A Case Study.

A 65 year old male with metastatic colorectal cancer (mCRC) in the liver was referred for selective internal radionuclide therapy (SIRT) following a history of extensive systemic chemotherapy. 90Y PET imaging was performed immediately after treatment and used to confirm lesion targeting and measure individual lesion absorbed doses. Lesion dosimetry was highly predictive of eventual response in the follow-up FDG PET performed 8 weeks after therapy. The derived radiation dose map was used to plan a second SIRT procedure aiming to protect healthy liver by keeping absorbed dose below the critical dose threshold, whilst targeting the remaining lesions that had received sub-critical dosing. Again, 90Y PET was performed immediately post-treatment and used to derive absorbed dose measures to both lesions and healthy parenchyma. Additional follow-up FDG PET imaging again confirmed the role of the 90Y PET dose map as an early predictor of response, and a tool for safe repeat treatment planning.

Clinical and imaging-based prognostic factors in radioembolisation of liver metastases from colorectal cancer: a retrospective exploratory analysis.

BACKGROUND: The aim of this study was to investigate the relationship between absorbed dose and response of colorectal cancer liver metastases treated with [90Y]-resin microspheres and to explore possible clinical and imaging derived prognostic factors. METHODS: FDG PET/CT was used to measure response of individual lesions to a measured absorbed dose, derived from post-treatment 90Y PET imaging. Predicted dose was also derived from planning [99mTc]-MAA SPECT data. Peak standardised uptake value and total lesion glycolysis (TLG) were explored as response measures, and compared to dose metrics including average dose (D avg), biologically effective dose, minimum dose to 70% of lesion volume and volume receiving at least 50 Gy. Prognostic factors examined included baseline TLG, RAS mutation status, FDG heterogeneity and dose heterogeneity. In an exploratory analysis, response and clinico-pathological variables were evaluated and compared to overall survival. RESULTS: Sixty-three lesions were analysed from 22 patients. Poor agreement was seen between predicted and measured dose values. TLG was a superior measure of response, and all dose metrics were significant prognostic factors, with a D avg of ~50 Gy derived as the critical threshold for a significant response (>50% reduction in TLG). No significant correlation was found between baseline TLG or RAS mutation status and response. Measured dose heterogeneity was a significant prognostic factor and when combined with D avg had a positive predictive value for response >80%. In the exploratory analysis for prognostic factors of survival, low hepatic tumour burden and mean reduction in TLG >65% were independently associated with improved overall survival. CONCLUSIONS: Lesions receiving an average dose greater than 50 Gy are likely to have a significant response. For lesions receiving less than 50 Gy, dose heterogeneity is a significant prognostic factor. Lesions receiving an average dose less than 20 Gy are unlikely to respond. A reduction in TLG may be associated with improved overall survival.

A multireferral centre retrospective cohort analysis on the experience in treatment of metastatic uveal melanoma and utilization of sequential liver-directed treatment and immunotherapy.

Metastatic uveal melanoma is a rare malignancy with a poor prognosis. To date, systemic therapy has been ineffective; however, there are few data on the benefits of anti-CTLA4 or anti-PD-1 antibodies in sequence with liver-directed therapy. A retrospective cohort analysis was carried out on 37 consecutive patients managed in a tertiary referral centre examining the safety and efficacy of treatment; patterns of care; and impact on survival. The sequential treatment with transarterial chemotherapy (TAC), systemic immunotherapy (IT) and systemic chemotherapy was reviewed. In all, 18 patients in the series received sequential therapy. The median overall survival (OS) was 17 months (n=37), which compared favourably with previously reported series. Patients treated with TAC first or second line had an overall progression-free survival (PFS) of 9 months (n=29) and IT PFS 7 months (n=26). The overall response rate (ORR) for TAC first line was 26% and the disease control rate (DCR) was 65% (n=23). ORR for IT first line was 7%, DCR 77% (n=14). Second-line (cross-over) IT ORR was 16%, DCR 58% (n=12). For second-line (cross-over) TAC, ORR was 50% and DCR was 66% (n=6). Toxicity was manageable. There were no cases of autoimmune hepatitis. In this retrospective small series analysis in uveal melanoma, liver-directed therapy and IT in sequence have shown to be active and reasonably well tolerated. Further prospective clinical trials should clarify the role of these treatments and their potential survival benefit.

Endovascular stenting of mesenterico-portal vein stenosis to reduce blood flow through venous collaterals prior to pancreatoduodenectomy.

BACKGROUND: When the mesenterico-portal vein is stenosed due to tumor related compression, venous collaterals develop and flow occurs antegrade towards the portal vein through the collateral tributaries. Undertaking pancreatoduodenectomy for pancreatic cancer in this setting may result in significant blood loss during the process of ligation of these tributaries. DESCRIPTION OF TECHNIQUE: We describe the technique of endovascular stenting of the mesenterico-portal vein to reduce flow within these collateral tributaries and hence blood loss, to facilitate extended pancreatoduodenectomy and vein resection. CONCLUSION: Percutaneous transhepatic placement of endovascular stent into a stenotic mesentero-portal vein facilitates pancreatoduodenectomy by reducing operative time, which would otherwise be required in dealing with the extensive venous collaterals and hence also reducing blood loss.

Dramatic response to selective internal radiation therapy for unresectable hepatocellular carcinoma.

A 54-year-old woman with a known history of multifocal hepatocellular carcinoma was treated with selective internal radiation therapy (SIRT) using yttrium-90 ((90)Y) microspheres, despite disease relapses after surgical resection and transarterial chemoembolization. She developed a dramatic clinical, radiological and metabolic response after 9 weeks. This case provides visual illustration of the potential roles of SIRT in the treatment of hepatocellular carcinoma.

Four-dimensional computed tomography for parathyroid localization: a new imaging modality.

INTRODUCTION: Four-dimensional computed tomography (4DCT) is a new parathyroid localization technique not previously reported in Australia. It provides both functional and anatomical imaging in a single test, with superior sensitivity compared with sestamibi scintigraphy (SeS). This study examines the utility of 4DCT in defined clinical situations. METHODS: This is a retrospective cohort study in a tertiary referral hospital setting. One hundred consecutive operative cases of primary hyperparathyroidism (99 patients) undergoing both preoperative 4DCT and SeS. Localization studies were correlated with operative findings, histopathology and clinical outcomes. The utility of 4DCT was analysed in three common clinical settings: primary cases with positive SeS (Group A, n = 68), primary cases with negative SeS (Group B, n = 21) and re-operative cases (Group C, n = 11). RESULTS: The overall sensitivity of 4DCT was 92% compared with 70% for SeS. The sensitivity of 4DCT was superior to SeS in Groups B and C (76% versus 0% and 91% versus 46%, respectively). The overall cure rate was 98%, with 94% of cases completed as minimally invasive procedures. Up to 62% of Group B cases potentially avoided a bilateral neck exploration owing to a positive 4DCT. CONCLUSIONS: 4DCT is an accurate technique providing both functional and anatomical localization of abnormal parathyroid glands. However, the advantage of speed and simplicity in image acquisition needs to be balanced against the small risk of increased radiation exposure in the younger patient group.

Any detectable thyroglobulin in lymph node biopsy washouts suggests local recurrence in differentiated thyroid cancer.

The sensitivity of local recurrence detection in differentiated thyroid cancer (DTC) is increased by measuring thyroglobulin in needle washouts from lymph node fine-needle aspiration biopsies (FNA-Tg). Recent studies have proposed minimum diagnostic threshold values for FNA-Tg and have reported interference from Tg antibodies (Tg Ab), leading to low or false-negative results. The aim of this study was to assess the utility of FNA-Tg in the diagnosis of local DTC recurrence in patients referred to a single pathology service used by our tertiary teaching hospital, the first such study in an Australian cohort. Data were collected from the pathology service database for FNA-Tg over an 18-month period, and the results of 69 FNA-Tg samples from 57 patients were obtained. FNA-Tg findings were compared with cytology and histology when patients proceeded to surgery. Using the functional sensitivity as the cut-off, detectable FNA-Tg (≥0.9 µg/l) had a sensitivity of 95.7%, specificity of 50% and positive predictive value of 95.7%. Our results suggest that detectable FNA-Tg leads to histological confirmation of local nodal DTC recurrence and would support a decision to proceed to surgery. Serum Tg Ab can, however, interfere with FNA-Tg measurements. Thus, we now recommend routine use of FNA-Tg washouts in all lymph node FNA biopsies for the detection of DTC recurrence.

Intra-arterial infusion and chemo-embolization for melanoma liver metastases.

This article will review the rationale for hepatic arterial administration of agents to treat melanoma liver metastases, the techniques and practical considerations pertinent to hepatic arterial therapy, the variety of agents that have been used and the reported outcomes. Recent and emerging developments will be highlighted and the potential role of liver-directed therapies in the context of molecular advances and improved systemic therapy will be discussed.

Peripancreatic pseudoaneurysms: a management-based classification system.

BACKGROUND: Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms. METHODS: A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed. RESULTS: The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site. CONCLUSION: The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

Portal vein embolization prior to major liver resection.

BACKGROUND: Portal vein embolization (PVE) induces compensatory hypertrophy of the future liver remnant volume (FLRV) to improve the safety of major liver surgery by reducing the risk of post-operative liver failure. The aim was to describe our experience of PVE for patients with large or multifocal malignant liver tumours who initially were deemed unresectable. METHODS: Perioperative data were retrieved from a prospective database and computed tomographic scans were retrospectively reviewed to calculate volume changes and the degree of liver hypertrophy following PVE. RESULTS: PVE was successful in 23 out of 25 patients and resulted in a change in the mean estimated FLRV from 585 to 788 mL following PVE. This represented a 35% increase in the remnant liver parenchymal volume post-embolization (P < 0.01). The procedure was well tolerated and did not compromise the surgical resection in any patient. Nineteen patients went on to have a liver resection following PVE with an in-hospital mortality of 16% (3 out of 19) and a 42% morbidity rate. After a mean follow-up of 31 months (1-130 months), 32% (6 out of 19) of patients are alive and 4 of these (21%) are completely disease-free. CONCLUSIONS: PVE results in an increase in the FLRV prior to major hepatectomy. Failure to develop hypertrophy following PVE is a surrogate marker for underlying liver dysfunction. PVE is safe and may increase the pool of patients suitable for liver resection. Long-term survival is similar to those not requiring embolization prior to liver resection.