Onyx®, A New Tool for Intraoperative Localization of Liver Lesions.

BACKGROUND: Precise preoperative localization of liver tumors facilitates successful surgical procedures, Intraoperative ultrasonography is a sensitive imaging modality. However, the presence of small non-palpable isoechoic intraparenchymal lesions may be challenging intraoperatively. METHODOLOGY AND MATERIAL DESCRIPTION: Onyx® is a non-adhesive liquid agent comprised of ethylene-vinyl alcohol usually used dissolved in dimethyl-sulfoxide and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy and ultrasonography and a macroscopic black shape. This embolization material has been increasingly used for the embolization of intracranial arteriovenous malformations. We present the novel application of Onyx® on liver surgery. CURRENT STATUS: We present the case of a female, 55 years-old, whose medical history revealed an elective sigmoidectomy (pT3N1a). After 17 months of follow up, by PET-CT scan, the patient was diagnosed of a small intraparenchymal hypo-attenuated 13 mm tumor located at segment V consistent with metachronous colorectal liver metastasis. Open metastasectomy was performed, ultrasonography-guided Onyx® infusion was delivered the day after, intraoperative ultrasonography showed a palpable hyperechoic material with a posterior acoustic shadowing artifact around the lesion. Onyx® is a promising new tool, without any previous application on liver surgery, feasible with advantages in small not palpable intraparenchymal liver lesions.

Impact of percutaneous cholecystostomy in the management of acute cholecystitis: a retrospective cohort study at a tertiary center.

Laparoscopic cholecystectomy is the gold standard for the treatment of acute cholecystitis (AC). Percutaneous cholecystostomy (PC) for management of AC is increasing; safe and less invasive than laparoscopic cholecystectomy and is very useful in selected patients with severe comorbidities, not suitable for surgery/general anesthesia. We conducted a retrospective observational study between 2016 and 2021 of patients treated with PC for AC, based on the application of the Tokyo guidelines 13/18. The aim was to analyse the clinical results and management of PC in patients undergoing elective or emergency cholecystectomy. Subsequently, a retrospective analytical study was designed to compare various cohorts: elective or emergency surgery and management with PC alone; patients with/without a high surgical risk; and elective vs emergency surgery. Hundred and ninety five patients with AC were treated with PC. Mean age was 74 years, 59.5% were ASA class III/IV, and the mean Charlson comorbidity index was 5.5. Adherence to Tokyo guidelines regarding indication of PC was 50.8%. The rate of complications associated to PC was 12.3% and the 90-day mortality rate was 14.4%. Mean length of time using PC was 10.7 days. Emergency surgery was performed in 4.6%. The overall success rate using PC was 66.7%, and the 1-year readmission rate due to biliary complications after PC was 28.2%. The rate of scheduled cholecystectomy after PC was 22.6%. Conversion to laparotomy and open approach was more frequent in patients who underwent emergency surgery (p = 0.009). No differences were found in 90-day mortality or in the complication rate. PC achieves improvements in the inflammation and infection associated with AC. In our series, it proved to be an effective and safe treatment during the acute episode of AC. Mortality in patients treated with PC is high due to their older age, greater morbidity, and higher Charlson comorbidity index scores. After PC, emergency surgery is uncommon but readmission due to biliary events is high. Cholecystectomy after PC is the definitive treatment and the laparoscopic approach is feasible. Clinical trial registery: The study was registered in the public accessible database clinicaltrials.gov with the ClinicalTrials.gov ID: NCT05153031. Public release date: 12/09/2021.

Ultrasound-guided skeletal biopsies.

OBJECTIVE: Percutaneous biopsy of skeletal lesions is a widely used diagnostic technique that involves fluoroscopic or computerized tomography guidance. The objective of this report is to describe the use of ultrasonography in the guidance of percutaneous biopsy of skeletal lesions. DESIGN AND PATIENTS: We employed ultrasound to guide percutaneous biopsy in 65 skeletal lesions in 63 patients (30 male and 33 female) whose ages ranged from 1 to 82 years (mean 47.2 years ). The lesions were divided into four groups: group 1 ( n=41) were lytic with a soft tissue mass, group 2 ( n=14) were lytic with a disrupted cortex without a soft tissue mass, group 3 ( n=4) were lytic with an intact cortex and group 4 ( n=6) were sclerotic lesions. Different techniques and materials were used in each group. RESULTS: Cytologic assessment obtained the diagnosis in 50 cases, (success rate 76.9%), histology in 56 cases (86.1%) and a combination of both in 60 cases (92.3%). There were no complications. CONCLUSIONS: Ultrasound is a highly accurate and safe method of guidance in percutaneous biopsy of bone lesions, either lytic or sclerotic, because it can identify subtle changes in the cortical and the associated soft tissue component.