Risk of pulmonary aspiration during semaglutide use and anesthesia in a fasting patient: a case report with tomographic evidence.

Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.

Radiological characteristics of hepatocellular carcinoma that achieved complete response after chemoembolization with drug-eluting beads for liver transplantation planning.

OBJECTIVE: To describe the radiological characteristics of hepatocellular carcinoma (HCC) lesions that achieved a complete response following drug-eluting bead transarterial chemoembolization (DEB-TACE) preceding liver transplantation. METHODS: This single-center case-control study enrolled patients with hepatocellular carcinoma who underwent neoadjuvant DEB-TACE therapy, were followed up with contrast-enhanced magnetic resonance imaging or computed tomography, and were successively evaluated according to the modified Response Evaluation Criteria in Solid Tumors. The HCCs were divided into two groups based on their diameter (Group A: ≤3cm; Group B: 3cm). Viability was assessed using the Kaplan-Meier method according to tumor size categories. The relationship between tumor variables was analyzed using bivariate Cox regression. RESULTS: Three-hundred and twenty-eight patients with 667 hepatocellular carcinomas who underwent their first DEB-TACE session were enrolled. A total of 105 hepatocellular carcinomas in 59 patients exhibited complete response after the initial DEB-TACE session and were divided into Group A (92 HCCs) and Group B (13 HCCs). The diameter in Group A decreased significantly compared to the pre-procedure size until the second assessment (p<0.001), with no subsequent reduction in diameter, despite maintaining a complete response. In Group B, the reduction in diameter remained significant compared with the initial value until the sixth imaging evaluation (p=0.014). The average reduction was 45.1% for Group B and a maximum of 14.9% in Group A. CONCLUSION: HCCs >3cm exhibited a greater reduction in size and a longer time to recurrence. HCCs ≤3cm had a shorter relapse time. The recurrence rates were similar. These findings may aid in planning for liver transplantation.

Transarterial Selective Internal Radiation Therapy with Yttrium-90 for Liver Metastatic Urothelial Carcinoma of the Ureter as a Bridging Therapy to Immunotherapy: A Case Report with a 10-Year Follow-Up.

Primary transitional cell carcinoma of the ureter is a rare type of cancer with metastasis presented in approximately 25% at diagnosis. Due to its rarity and poor prognosis, the management of this neoplasm is still controversial, and the development of new therapies is of uttermost importance. Herein, we describe a case of a 54-year-old patient diagnosed with transitional cell carcinoma of the left ureter submitted to left nephroureterectomy (pT3N2M0) and methotrexate, vinblastine, doxorubicin, and cisplatin adjuvant chemotherapy. A single liver metastasis was detected and combination chemotherapy with gemcitabine and carboplatin was initiated along with stereotactic body radiation therapy. Despite these 2 previous chemotherapy regimens, the patient presented disease progression and transarterial selective internal radiation therapy (SIRT) with yttrium-90 was indicated. This locoregional treatment was performed with the administration of 1.2 GBq yttrium-90 resin microspheres (SIR-Spheres®, Sirtex Medical Limited, Sydney, NSW, Australia) into the right hepatic artery. Another systemic treatment was immunotherapy using nivolumab with excellent tolerability. After 10 years of follow-up, at the last clinical evaluation, the patient had no clinical symptoms and the last imaging follow-up using positron emission tomography-computed tomography scan showed complete response. This report introduces upper urinary tract urothelial carcinoma as a distinct type of malignancy in which SIRT can be safely implemented. As a transition method to nivolumab, it was successful. There might be a potential therapeutic synergism between these 2 treatment modalities.

Complication rates of transrectal and transperineal prostate fusion biopsies - is there a learning curve even in high volume interventional center?

ABSTRACT Purpose To analyze the learning curve regarding complication rates of transrectal prostate biopsy (TRPB) versus transperineal prostate biopsy (TPPB), using real time software-based magnetic resonance imaging ultrasound (MRI-US) fusion techniques, along with first year experience of transperineal approach. Materials and Methods retrospective unicentric cohort study at a quaternary care hospital. Medical records of all consecutive patients that underwent TPPB between March 2021 and February 2022, after the introduction of MRI-US fusion device, and those who underwent TRPB throughout the entire years of 2019 and 2020 were analyzed. All complications that occurred as consequences of the procedure were considered. Descriptive statistics, Chi-squared and Fisher tests were used to describe complications and compare the two groups. Results A total of 283 patients were included in the transperineal group and 513 in the transrectal group. The analysis of a learning curve for the transperineal method showed lower complications rates comparing the first six months of TPPB procedures (group 1); The complication rate for TPPB was lower than that of TRPB (55.1% versus 81.9%, respectively; p<0.01). TPPB showed specifically lower rates of hematuria (48.8% versus 66.3%;p<0.001) and rectal bleeding(3.5% versus 18.1%; p<0.001). There were no cases of prostatitis after transperineal biopsies and three cases (0.6%) after transrectal procedures. Conclusions We evidenced the learning curve for performing the transperineal biopsy, with a lower rate of complications for the experienced team, after 142 cases after 6 months of practice. The lower complication rate of TPPB and the absence of infectious prostatitis imply a safer procedure when compared to TRPB.

The iceberg technique: an innovative approach for radiofrequency ablation of diving thyroid nodules.

Diving thyroid nodules are a limitation of radiofrequency ablation because the mediastinal component cannot be adequately identified by ultrasound (US). We aim to describe a new technique, the iceberg technique, to overcome this issue and explain our three-year experience of using this novel method. The iceberg technique consists of a two-stage treatment. First, the ablation of the cervical portion of the nodules (easily visualized during the initial US exam) using trans-isthmic access is performed using the moving-shot technique. After three to six months, there is a volumetric reduction of the treated portion, leading to retraction of the thyroid parenchyma. This brings the mediastinal component to the cervical region, thereby enabling a perfect visualization by US. Then, the second stage of treatment is carried out with complete nodule ablation, and the region that was treated first is looked at a second time. From April 2018 to April 2021, nine patients with nine benign nodules were submitted for the iceberg technique. No complications occurred during the entire follow-up period. The patients displayed normal hormonal levels after the procedures, and there was a significant volume reduction of the nodules until three months post-ablation. The iceberg technique is an effective and safe option for the radiofrequency treatment of diving goiters.

Embolization of the Superior Rectal Arteries versus Closed Hemorrhoidectomy (Ferguson Technique) in the Treatment of Hemorrhoidal Disease: A Randomized Clinical Trial.

PURPOSE: To compare short-term and medium-term results of superior rectal artery embolization versus surgical hemorrhoidectomy in the treatment of patients with hemorrhoidal disease. MATERIAL AND METHODS: This study was a prospective randomized clinical trial following 33 patients with symptomatic hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups: the superior rectal artery embolization group (n = 15) and Ferguson closed hemorrhoidectomy surgical group (n = 14). Four patients were excluded from the analysis. Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7 days of the postoperative period. Recurrent symptoms and satisfaction with treatment were also evaluated in the subsequent first, third, sixth, and twelfth months. RESULTS: The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in the embolization group (P = .001). The mean use of pain medication was higher in the surgery group (28.92 doses ± 15.78 vs 2.4 doses ± 5.21; P < .001). In the embolization group, the most prevalent preprocedural symptom was bleeding in 14 patients, with complete improvement in 12 (83.3%) patients. Mucus, skin tag, and pruritus were symptoms that showed little improvement in both groups. The frequency of symptoms (bleeding, pain, prolapse, and pruritus) was similar between the groups at 12 months (P = .691). No severe adverse events were observed in both groups. CONCLUSIONS: Despite no difference in outcomes, embolization of the superior rectal arteries for the treatment of hemorrhoidal disease showed pain levels lower than those observed after surgical treatment.

Radiological characteristics of hepatocellular carcinoma that achieved complete response after chemoembolization with drug-eluting beads for liver transplantation planning

ABSTRACT Objective To describe the radiological characteristics of hepatocellular carcinoma (HCC) lesions that achieved a complete response following drug-eluting bead transarterial chemoembolization (DEB-TACE) preceding liver transplantation. Methods This single-center case-control study enrolled patients with hepatocellular carcinoma who underwent neoadjuvant DEB-TACE therapy, were followed up with contrast-enhanced magnetic resonance imaging or computed tomography, and were successively evaluated according to the modified Response Evaluation Criteria in Solid Tumors. The HCCs were divided into two groups based on their diameter (Group A: ≤3cm; Group B: 3cm). Viability was assessed using the Kaplan-Meier method according to tumor size categories. The relationship between tumor variables was analyzed using bivariate Cox regression. Results Three-hundred and twenty-eight patients with 667 hepatocellular carcinomas who underwent their first DEB-TACE session were enrolled. A total of 105 hepatocellular carcinomas in 59 patients exhibited complete response after the initial DEB-TACE session and were divided into Group A (92 HCCs) and Group B (13 HCCs). The diameter in Group A decreased significantly compared to the pre-procedure size until the second assessment (p<0.001), with no subsequent reduction in diameter, despite maintaining a complete response. In Group B, the reduction in diameter remained significant compared with the initial value until the sixth imaging evaluation (p=0.014). The average reduction was 45.1% for Group B and a maximum of 14.9% in Group A. Conclusion HCCs >3cm exhibited a greater reduction in size and a longer time to recurrence. HCCs ≤3cm had a shorter relapse time. The recurrence rates were similar. These findings may aid in planning for liver transplantation.

Risk of pulmonary aspiration during semaglutide use and anesthesia in a fasting patient: a case report with tomographic evidence

ABSTRACT Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.

Transafferent nodal embolization for lymphocele treatment: case report.

Lymphoceles are collections of lymphatic fluid, mainly caused by major surgical approaches. Most lymphoceles are asymptomatic and limited, but some cases may require a medical management. Among the different techniques, transafferent nodal embolization has emerged as a minimally invasive option, with low morbidity and high resolubility, although it is not widespread in the Brazilian scenario. In this study, we report a case of lymphocele drained percutaneously, with maintenance of high output and requiring transafferent nodal embolization.

Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review.

OBJECTIVE: To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. METHODS: A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. RESULTS: A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. CONCLUSION: Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

Spontaneous renal artery dissection: angioplasty with stent implantation in one-year follow-up.

Spontaneous renal artery dissection is an unusual and idiopathic condition in most cases. In young, mildly symptomatic patients, diagnosis may be difficult, frequently culminating in delay in treatment. This report presents the case of a 40-year-old male patient, with severe hypertension of sudden onset, and difficult management of oral medication. In etiological investigation, Echo-Doppler of renal arteries showed signs of hemodynamically relevant right renal artery stenosis. Arteriography showed presence of double-lumen and thrombus in the vessel lumen, indicating dissection. The proposed treatment was endovascular approach after failure of isolated medical treatment, option which included the aspiration of the thrombus by Penumbra System® device and balloon angioplasty, followed by right renal artery stenting. Improvement of immediate sonographic control of peak systolic velocity and renal-aortic ratio was shown, with a consequent reduction of systemic arterial blood pressure and stabilization of renal function. Within the following year, the patient presented in-stent stenosis and was successfully treated with balloon angioplasty.

Omental lipoma in pediatric age group: clinical presentation, image findings and management.

A 2-year-old female patient, admitted in the emergency room, presented diarrhea for 5 days and bloody stools in the last 24 hours. Physical examination revealed no significant findings. Ultrasound was initially performed, showing an elongated, well delimited and solid mass occupying since right hypocondrium until left iliac fossa, displacing adjacent structures. In sequence, magnetic resonance imaging was performed for confirmation of findings suggestive of omentum lipoma. After 1 week, the surgical resection was performed by videolaparoscopic acess. During 2-year follow-up, there was no sign of recurrence.

Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review

ABSTRACT Objective To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. Methods A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. Results A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. Conclusion Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

Transafferent nodal embolization for lymphocele treatment: case report

ABSTRACT Lymphoceles are collections of lymphatic fluid, mainly caused by major surgical approaches. Most lymphoceles are asymptomatic and limited, but some cases may require a medical management. Among the different techniques, transafferent nodal embolization has emerged as a minimally invasive option, with low morbidity and high resolubility, although it is not widespread in the Brazilian scenario. In this study, we report a case of lymphocele drained percutaneously, with maintenance of high output and requiring transafferent nodal embolization.

Omental lipoma in pediatric age group: clinical presentation, image findings and management

ABSTRACT A 2-year-old female patient, admitted in the emergency room, presented diarrhea for 5 days and bloody stools in the last 24 hours. Physical examination revealed no significant findings. Ultrasound was initially performed, showing an elongated, well delimited and solid mass occupying since right hypocondrium until left iliac fossa, displacing adjacent structures. In sequence, magnetic resonance imaging was performed for confirmation of findings suggestive of omentum lipoma. After 1 week, the surgical resection was performed by videolaparoscopic acess. During 2-year follow-up, there was no sign of recurrence.

Evaluation of the blood-oxygen-level-dependent (BOLD) sequence with 3 Tesla device in renal transplant patients in the assessment of early allograft disfunction, correlated with biopsy.

OBJECTIVE: To evaluate the ability of blood-oxygen-level-dependent (BOLD) magnetic resonance imaging at 3 Tesla to measure tissue oxygen bioavailability based on R2* values, and to differentiate between acute tubular necrosis and acute rejection compared to renal biopsy (gold standard). METHODS: A prospective, single-center study, with patients submitted to renal transplantation between 2013 and 2014, who developed graft dysfunction less than 4 weeks after transplantation. All patients were submitted to abdominal magnetic resonance imaging at 3 Tesla using the same protocol, followed by two BOLD sequences and kidney biopsy. RESULTS: Twelve male (68.75%) and three female (31.25%) patients were included. A total of 19 percutaneous renal biopsies were performed (four patients required a second biopsy due to changes in clinical findings). Pathological findings revealed ten cases of acute tubular necrosis, four cases of acute rejection, and five cases with other (miscellaneous) diagnoses. Comparison between the four groups of interest failed to reveal significant differences (p=0.177) in cortical R2* values, whereas medullary R2* values differed significantly (p=0.033), with lower values in the miscellaneous diagnoses and the acute tubular necrosis group. CONCLUSION: BOLD magnetic resonance imaging at 3 Tesla is a feasible technique that uses indirect tissue oxygen level measurements to differentiate between acute rejection and acute tubular necrosis in renal grafts.