Antonio Bruni

Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous

BACKGROUND Complete transection of the common bile duct (CBD) is a dramatic and often extremely difficult-to-repair event after surgery. Abdominal biliary fluid collection or jaundice is the initial symptom, and ERCP is the determinant for diagnosis. OBJECTIVE To evaluate the safety and efficacy of a combined endoscopic-radiologic technique for the reconstruction of the CBD. DESIGN Single-center retrospective study. SETTING Tertiary-care center for biliary surgery. PATIENTS This study involved 22 patients with complete transection of the CBD after cholecystectomy. INTERVENTION A guidewire is passed in the subhepatic space through the endoscopic approach. A snare loop is advanced from the percutaneous entry site to catch the free end of the wire and then pulled outside the body: a percutaneous biliary-duodenal (PTBD) drainage is put in place. After a new contralateral PTBD, 4 plastic stents are inserted. The stents are removed endoscopically after 8 to 12 months. MAIN OUTCOME MEASUREMENTS Success of the rendezvous maneuver, patient recovery, and patient mortality. RESULTS After a mean follow-up period of 4 years, 16 patients are asymptomatic. Two patients are still under treatment, and 4 patients underwent surgery, as was the surgeons choice. LIMITATIONS Single-center, retrospective study with a small population. CONCLUSION Interruption of the biliary tree does not represent an indication for an often-difficult surgical treatment, because the CBD is often thin in the presence of biliary peritonitis. However, the condition can be treated with a rendezvous technique. Surgery can be performed in elective conditions or completely avoided when conservative therapy is selected.

Magnetic resonance imaging of an ileal carcinoid tumor Correlation with CT and US

The authors report the case of an advanced carcinoid tumor located in the distal ileum studied with CT, US and MRI. The lesion was deeply invasive and associated with liver metastases and peritoneal spreading. Imaging findings obtained with the different modalities have been reported, compared and discussed. MRI may play a role in the diagnosis and staging of carcinoid tumors, although CT still remains the investigation of choice.

Stent graft in TIPS: technical and procedural aspects

Transjugular intrahepatic portosystemic shunt (TIPS) is a nonoperative therapeutic option for the management of portal hypertension, variceal bleeding, recurrent ascites, Budd–Chiari syndrome. In view of the many issues surrounding the use of TIPS, in 1994 the US National Digestive Diseases Advisory Board convened a scientific conference to review the current data available and to establish the indications and controindications for this procedure. However there are still unsolved problems especially short primary patency of the shunt due to intimal hyperplasia, which causes a reduction of the shunt lumen thus favoring a return of the portal hypertension with recurrent variceal bleeding. Several study were performed in the last years to evaluate the efficacy of covered stent in order to reduce shunt disfunction secondary to intimal hyperplasia. PTFE seems to be more efficient in the prevention of restenoses. In our experience more then 100 patients were treated with the Viatorr stent–graft. After a follow–up ranging from 1 to 50 months we reported a 1– year primary patency rate of 83.8%. However the use of the stentgraft is correlate with a high rate of hepatic hencefalopathy (46.6 %). In case of hepatic hencefalopathy refractory to the conventional medical therapy, TIPS reduction should be performed.

Endovascular repair for acute mesenteric ischemia: case report

Methods We present a case of a 75-year-old patient with acute occlusive mesenteric ischemia that was successfully treated with endovascular intervention. Angiography revealed high-grade stenosis of the proximal tract of the SMA. Immediate option for endovascular therapy was made, and a MARIS self-expandable 6x40 mm stent was positioned. The patient was discharged 2 days after with full recovery from the symptoms.

Case report: Percutaneous treatment of multiple honeycomb-like liver hydatid cysts (type III CE2, according to WHO classification).

Percutaneous treatment has been developing as a reliable and effective alternative to surgery in the treatment of liver hydatid cysts. However, percutaneous treatment is strongly recommended only for some types of hydatid cysts (types I and II). We report a patient with type III (CE2, according to the WHO classification) multiple liver hydatid cysts treated with the PAIR (puncture–aspiration–injection–reaspiration) technique. The patient developed a secondary biliary fistula, which ultimately healed.

Transcatheter Bronchial Artery Aneurysm Embolization with Onyx

Purpose: Report a case of transcatheteral embolization of a Bronchial Artery Aneurysm (BAA) using Onyx. Case report: A 60 years-old man was hospidalized because mediastinum hematoma related to BAA. Left transsucclavian approach was conducted and the microcatheter was used to reach the BAA. Because vessel caliper and tortuosity aneurism packing was not possible, so why Onyx 34 was released as close as possible to the aneurysmatic sac with “plug and push” technique. The clinical condition of the patient immediatly improved and the 1-month CTA confirmed the complete exclusion of BAA; patient did not claim any particular disturbs after 7-month follow-up. Conclusions: Embolization of BAA using Onyx 34 is feasible and viable.