Future of IR: Emerging Techniques, Looking to the Future and Learning from the Past.

Innovation has been the cornerstone of interventional radiology since the early years of the founders, with a multitude of new therapeutic approaches developed over the last 50 years. What is the future holding for us? This article presents an overview of the in-coming developments that are catching on at this moment, particularly focusing on three items: the new applications of existing techniques, particularly embolotherapy and interventional oncology; the cutting-edge devices; the imaging technologies at the forefront of the image-guidance. Besides this, clinical vision and patient relation remain crucial for the future of the discipline.

Double cancer of the gallbladder and common bile duct associated with anomalous junction of pancreaticobiliary ductal system.

We report a 64-year-old woman with double cancer of the gallbladder and the common bile duct associated with anomalous junction of the pancreaticobiliary ductal system. Eleven previous cases have been reported to date. From analysis of the 12 cases reviewed, including our patient, double cancer of the gallbladder and the common bile duct accompanied by anomalous junction of the pancreaticobiliary ductal system is characterized by the predominance of well-differentiated and superficial cancer.

Biliary tract cancer accompanied by anomalous junction of pancreaticobiliary ductal system in adults.

BACKGROUND: Anomalous junction of the pancreaticobiliary ductal system (AJPBDS) is a congenital anomaly in which the junction is located outside the duodenal wall. Recently, attention has been focused on the high incidence of malignancy in this anomaly. The purpose of this study was to clarify the clinicopathological features of this anomaly and to determine the appropriate surgical approach for biliary tract cancer associated with AJPBDS. METHODS: The data for 38 patients with AJPBDS, including 14 who had been treated for biliary tract cancer (2 with bile duct cancer and 12 with gallbladder cancer), were retrospectively reviewed. We assessed the clinical features, characteristics of the tumor, operative procedure, and outcome for each patient. RESULTS: The incidence of malignancy in AJPBDS was 17.8% (2 patients with bile duct cancer and 3 with gallbladder cancer) in the bile duct dilatation group (n = 28) and 90% (9 patients with gallbladder cancer) in the no-dilatation group (n = 10) . The mean length of the common channel was 24.7 mm (range 20 to 35 mm) . Resection with lymphadenectomy was performed in 9 (64.3%) of 14 patients, and curative resection in 5 of these 9 patients. Ten (71%) of the 14 patients had lymph node involvement noted either at the time of initial diagnosis or at surgery. The incidence of lymph node metastasis was closely related to the depth of tumor involvement. Ten patients died of recurrence or primary cancer, from 3 to 30 months after operation. Four patients are still alive without recurrent disease from 2.5 to 13 years after operation. CONCLUSION: For patients with AJPBDS without bile duct dilatation, prophylactic cholecystectomy is recommended even if no malignant lesion is found in the gallbladder because of the high incidence of gallbladder cancer and the poor prognosis. Both early detection and curative resection of the tumor are essential for successful treatment of biliary tract cancer.

Amelioration of intestinal dysmotility and stasis by octreotide early after small-bowel autotransplantation in dogs.

BACKGROUND: Intestinal dysmotility and stasis after intestinal transplantation are considered to promote bacterial overgrowth and translocation. Two prokinetic agents, KW5139 (13-leu-motilin) and the somatostatin analogue octreotide acetate, were studied to determine whether they can ameliorate intestinal dysmotility during the early postoperative period. MATERIALS AND METHODS: Motility was recorded by multiple extraluminal strain-gauge transducers in 6 dogs on postoperative days 1, 3, 7, and 14. A barium meal study was performed with a separate group of 8 dogs on postoperative days 3 and 7. RESULTS: The agent KW5139 induced brief, weak contractions in the graft and had little effect on the dilated bowel; however, octreotide induced motor activity that propelled accumulated intestinal contents into the colon and reduced dilation of the transplanted bowel. CONCLUSION: Octreotide, but not KW5139, ameliorates intestinal dysmotility associated with bowel autotransplantation during the early postoperative period. Short-term administration of octreotide may be useful for the treatment of dysmotility following intestinal transplantation.

Effect of rejection on electrophysiologic function of canine intestinal grafts: correlation with histopathology and Na-K-ATPase activity.

To investigate whether electrophysiologic changes can detect the early onset and progress of intestinal rejection, changes in in vitro electrophysiologic function, intestinal histopathology, and Na-K-ATPase activity were studied in dogs. Adult mongrel dogs of both sexes, weighing 18-24 kg, were used for auto and allo small bowel transplantation. The entire small bowels, except for short segments at the proximal and distal ends, were switched between a pair of dogs (allograft). Animals receiving intestinal autotransplantation were used as controls. Allograft recipients were sacrificed 3, 4, 5, 7, or 9 days after transplantation, and autograft recipients were sacrificed 3, 7, or 14 days after transplantation. Immunosuppression was not used. Electrophysiologic measurements were done with an Ussing chamber. Histological analysis was performed blindly using whole thickness sections. Na-K-ATPase activity in the mucosal tissue, which is said to regulate the potential difference, was also measured. Potential difference, resistance, and Na-K-ATPase activity of the allograft intestine decreased with time and were significantly lower 7 and 9 days after transplantation compared to host intestine, normal intestine, and graft intestine of controls (autograft). Potential difference, resistance, and Na-K-ATPase activity of the native intestinal tissue and the autografts did not decrease with time. Detection of histologically mild rejection of the intestine, which is important for appropriate immunosuppressive treatment in clinical cases, could not be achieved based on electrophysiology or Na-K-ATPase activity. Deterioration of electrophysiologic function during rejection correlated with the histological rejection process and Na-K-ATPase activity; however, electrophysiology may not be a reliable tool for monitoring grafts, since it cannot detect early intestinal rejection.

Small bowel rejection in isolated small bowel transplantation and in multivisceral transplantation: a comparative study in a large animal model.

The proposition that a combined graft including the liver protects other organ allografts from the same donor is well known. However, it is not evident in the clinical results. The present experiments were undertaken to compare acute small bowel rejection in isolated small bowel transplantation with multivisceral transplantation. Using 36 outbred, male Large-White pigs, isolated small bowel transplantation (SBTX: n = 9) and abdominal multivisceral transplantation (MVTX: n = 9) were performed without immunosuppression. The survival rate and blood serum samples were monitored postoperatively. In order to compare acute small bowel rejection, sequential biopsy specimens from Thiry-Vella loops were also monitored daily beginning on me 3rd day after transplantation. The specimens were scored from 0 to 3 according to the severity of the rejection. The survival rate was not significantly different. However, significant differences were noted in the cause of the death and in the pathologic changes of the small bowel. In contrast to SBTX, the small bowel rejection of MVTX was significantly delayed and less severe. The rejection score of MVTX was significantly better than SBTX from 5 postoperative days (POD) to 1 lPOD (P < 0.05). The present study demonstrated mat acute small bowel rejection of MVTX graft including the liver was delayed and less severe than that of SBTX in an outbred large animal model.

Influence of the flow rate during flushing on porcine multivisceral preservation.

The effect of flushing flow rate during multiple organ procurement (MOP) on viability of the liver, pancreas, and intestine were investigated in porcine multivisceral transplantation. Splanchnic organs were flushed in situ with 50 ml/kg of 4 degrees C UW solution via the aorta using a pump at a flow rate of 10, 30, or 50 ml/kg/min. After storage and transplantation, we assessed the clearance of hyaluronic acid (CHA) for hepatic endothelial cells function, liver enzymes, amylase, and histology. Two-day survival was 17% in the 10 ml/kg/min group and 67% in other groups. The former group had inadequate flushing out of the hepatic and intestinal grafts, resulting in aggravation of CHA and intestinal tissue injury. At the flow rate of 30 ml/kg/min, the viability and integrity of all organs were well maintained. We conclude that the optimal flushing flow rate would differ for each organ, therefore the common flow rate acceptable for any of the individual grafts should be applied in MOP.

A multipurpose grasping forceps for retrieval of an embolized catheter fragment.

Transjugular removal of an embolized catheter fragment from the right atrium of a 6-month-old infant was successfully performed using a multipurpose grasping forceps. All procedures for the retrieval were completed in only 10 minutes without complications or difficulty.

Technique for procurement of heart, liver and kidneys from a single donor for transplantation.

The purpose of this report is to present a safe, simple technique for procurement of the heart, liver, and kidneys from a single donor with no warm ischemic time. Twenty mongrel dogs were divided into 5 groups of 3 recipients and 1 donor each. Liver and kidney mobilization was performed when the core temperature of the liver reached 27 degrees C, a result of ice slush in the abdominal cavity. As the core temperature of the liver reached 20-22 degrees C, the aorta and inferior vena cava were clamped just above the diaphragm. After excision of the liver and kidneys, another team harvested the heart as it continued to beat. The heart and liver were transplanted orthotopically after simple preservation for 12 and 6 hours, respectively. The kidney was transplanted heterotopically after simple 12-hour preservation. The maximum survival time was 7 hours for heart transplantation and 16 days for liver transplantation. Kidney homogenate ATP levels decreased to 19% of baseline after preservation and were restored to 68% one hour after reperfusion. Our method is simple and safe for harvesting the heart, liver, an kidneys for transplantation and may offer a definite possibility for clinical application.

A case of lipodystrophia centrifugalis abdominalis infantilis with morphea.

A 5-year-old female developed three depressed lesions sequentially on her left hip, left upper arm and left Achilles tendon; we diagnosed them as lipodystrophia centrifugalis abdominalis infantilis (LCAI). She also developed two sclerotic lesions, at almost the same time, on her left upper arm and left forearm; we diagnosed them as morphea. Clinical and histopathological examination revealed that the LCAI and morphea seen in our case were completely different. Although two other cases of co-existing LCAI and morphea have already been reported, they were not described in detail and their morphea lesions were adjacent to their LCAI lesions. We herein report a case of LCAI with morphea in which the lesions were not adjacent.

Pedunculated basal cell epithelioma which is not Pinkus tumor.

A 33-year-old female with pedunculated basal cell epithelioma was reported. She had noticed a cutaneous tumor on the scalp for two years before admission. It developed gradually and clinically resembled fibroma or pigmented nevus. Total resection was performed, and its histopathology revealed the solid or cystic type of basal cell epithelioma.

Portal vein obstruction accompanied by intrahepatic stones.

This study was conducted to clarify the pathogenesis of portal vein obstruction (PVO) associated with intrahepatic stones. Five cases with PVO and intrahepatic stones were studied retrospectively. The coincidence rate of PVO in intrahepatic stones was 5.8% (5 of 86 cases), and that of intrahepatic stones in PVO, 45.5% (5 of 11 cases). All cases had one or more symptoms of cholangitis, such as high-grade fever, abdominal pain, and jaundice prior to diagnosis of PVO. The portal vein was occluded at the main trunk in 4 and in the left branch in 1. Intrahepatic stones were found in bilateral hepatic lobes in 3 and in the left lobe in 2. Numerous calcium bilirubinate stones were packed in dilatated intrahepatic bile ducts of an excised specimen of the liver. Microscopically, arterial structures could be seen, but the portal vein ceased to be evident about the involved bile duct. Based on the results of this study, persistent cholangitis and packed gallstones were concluded essential to the development of PVO accompanied by intrahepatic stones.

[Left-sided gallbladder with accessory liver accompanied by intrahepatic cholangiocarcinoma].

A 66-year-old female of left-sided gallbladder with accessory liver was reported. These anomalies were recognized during an operation of intrahepatic cholangiocarcinoma. The gallbladder was located with its liver bed at the lateral segment of the liver. The cystic duct branched from the right side of the common bile duct, and turned in hairpin form in the left direction. The cystic artery branched from the right hepatic artery. There was the accessory liver on the wall of the gallbladder. A careful identification of the cystic duct and the portal vein was advocated in surgery of the left-sided gallbladder.

[An experimental study on the rejection phenomenon of multi-visceral allografts in pigs].

Multi-visceral allografts including the liver, pancreas and gastrointestinal tract were transplanted in 10 pigs. Eight of them survived for 7 to 21 days. Histopathological changes were studied in the liver, pancreas and gastrointestinal tract. An en bloc transplantation revealed no particular course after transplantation than those individual organ transplantation. The status of rejection was assessed by our histological criteria, which are divided into 5 grades about the liver and 4 grades about other organs according to the severity of the acute rejection. A higher grade of rejection was apparently in the small and large intestine especially after the 10th post-transplanted day (Grade II to III in the small and large intestine v. Grade 0 to II in the liver, stomach and pancreas). The study suggests the existence of organ specific susceptibility to rejection in multi-visceral organ transplantation.