Charles Edouard Zurstrassen

Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients

The incidence of biliary complications (BCs) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population are limited, and treatment protocols vary. Our aim was to describe the clinical scenario for BCs and treatment approaches after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT procedures were performed. BCs developed in 71 patients (14.5%). Biliary strictures (BSs) developed in 45 (9.2%) patients, and bile leaks (BLs) developed in 33 patients (6.7%). The BL diagnosis was clinical in all cases, and 69.7% of the patients underwent surgery. Nearly half of the BS cases had clinical features or suggestive ultrasound findings. Liver biopsy findings suggested BSs in 51.7%. Percutaneous transhepatic cholangiography was performed in 95.6% of the BS patients. The success rate was 77% [mean number of percutaneous biliary interventions (PBIs) = 3.9 ± 1.98, median drainage time = 8 months]. In conclusion, BL patients can be managed with conservative therapy, even though most of these patients will ultimately be treated with surgery. Diagnosing a BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of cases. A higher number of PBIs and the use of a drainage catheter for a longer time may be required to achieve better results with this technique. Liver Transpl 20:882‐892, 2014.

Endovascular techniques and procedures, methods for removal of intravascular foreign bodies.

INTRODUCTION The incidence of intravascular embolization of venous catheters reported in the world medical literature corresponds to 1% of all the described complications. However, its mortality rate may vary between 24 to 60%. Catheter malfunction is the most likely signal of embolization, since patients are usually asymptomatic. OBJECTIVE To report the method of removing intravascular foreign bodies, catheters with the use of various endovascular techniques and procedures. METHODS This is a two-year retrospective study of 12 patients: seven women and five men. The average age was 29 years (ranging from two months to 65 years). RESULTS Technical performance was 100% successful. Ten port-a-caths, one intra-cath and one PICC were extracted. The most common sites for the lodging of one of the ends of the intravascular foreign bodies were the right atrium (41.6%) and the right ventricle (33.3%). In 100% of the cases, only one venous access was used for extraction of foreign bodies, and in 91.6% of the cases (11 catheters) the femoral access was used. The loop-snare was used in 10 cases (83.3%). The most common cause of intravascular foreign body insertion was a catheter fracture, which occurred in 66.6% of the cases (eight cases). One major complication, the atrial fibrillation, occurred (8.3%), which was related to the intravascular foreign body extraction. The mortality rate in 30 days was zero. CONCLUSION Percutaneous retrieval of intravascular foreign bodies is considered gold standard treatment because it is a minimally invasive, relatively simple, safe procedure, with low complication rates compared to conventional surgical treatment.

Portal vein obstruction after liver transplantation in children treated by simultaneous minilaparotomy and transhepatic approaches: Initial experience

Carnevale FC, Santos ACB, Seda‐Neto J, Zurstrassen CE, Moreira AM, Carone E, Marcelino ASZ, Porta G, Pugliese R, Miura I, Baggio VD, Guimarães T, Cerri GG, Chapchap P. Portal vein obstruction after liver transplantation in children treated by simultaneous minilaparotomy and transhepatic approaches: Initial experience.
Pediatr Transplantation 2011: 15: 47–52.

Computed tomography-guided percutaneous core needle biopsy in pancreatic tumor diagnosis

AIM To evaluate the techniques, results, and complications related to computed tomography (CT)-guided percutaneous core needle biopsies of solid pancreatic lesions. METHODS CT-guided percutaneous biopsies of solid pancreatic lesions performed at a cancer reference center between January 2012 and September 2013 were retrospectively analyzed. Biopsy material was collected with a 16-20 G Tru-Core needle (10-15 cm; Angiotech, Vancouver, CA) using a coaxial system and automatic biopsy gun. When direct access to the lesion was not possible, indirect (transgastric or transhepatic) access or hydrodissection and/or pneumodissection maneuvers were used. Characteristics of the patients, lesions, procedures, and histologic results were recorded using a standardized form. RESULTS A total of 103 procedures included in the study were performed on patients with a mean age of 64.8 year (range: 39-94 year). The mean size of the pancreatic lesions was 45.5 mm (range: 15-195 mm). Most (75/103, 72.8%) procedures were performed via direct access, though hydrodissection and/or pneumodissection were used in 22.2% (23/103) of cases and indirect transhepatic or transgastric access was used in 4.8% (5/103) of cases. Histologic analysis was performed on all biopsies, and diagnoses were conclusive in 98.1% (101/103) of cases, confirming 3.9% (4/103) of tumors were benign and 94.2% (97/103) were malignant; results were atypical in 1.9% (2/103) of cases, requiring a repeat biopsy to diagnose a neuroendocrine tumor, and surgical resection to confirm a primary adenocarcinoma. Only mild/moderate complications were observed in 9/103 patients (8.7%), and they were more commonly associated with biopsies of lesions located in the head/uncinate process (n = 8), than of those located in the body/tail (n = 1) of the pancreas, but this difference was not significant. CONCLUSION CT-guided biopsy of a pancreatic lesion is a safe procedure with a high success rate, and is an excellent option for minimally invasive diagnosis.

Acesso venoso trans-hepático percutâneo para hemodiálise: uma alternativa para pacientes portadores de insuficiência renal crônica

BACKGROUND: Percutaneous transhepatic venous access is an option for hemodialysis patients who have exhausted all traditional sites of venous access. OBJECTIVES: To present a small sample regarding the possibility and the functionality of transhepatic implantation of long-term catheters for hemodialysis in patients with no other possible access routes. METHODS: Retrospective observational analysis was made of the charts of six patients in which nine tunneled dialysis catheters were implanted by the percutaneous transhepatic route. Transhepatic catheters were placed in the absence of an available peripheral venous site. Patients were monitored to evaluate technical success, the complication rate, the infection rate and the duration of catheter patency. RESULTS: Four men and two women aged 31 to 85 years (mean age: 55 years). Technical success was 100%. The mean duration of catheter function was 300.5 days (range: 2 to 814 days). Means of primary and secondary patency were 179.60 and 328.33 days, respectively. The catheter thrombosis rate was 0.05 per 100 catheter-days as the infection rate. There were three early complications (within the first 30 days of catheter implantation): two catheter displacement and one infection. Two late complications were observed: one thrombosis and one migration. Three patients (50%) needed to have their catheters changed. The 30-day mortality rate was 33% but with no relation to the procedure. CONCLUSION: It may be suggested that this technique is safe, however transhepatic hemodialysis catheters may be used in patients with no other options for deep venous access for hemodialysis, albeit as a last resort access route.

Tratamento endovascular de pseudo-aneurisma da artéria subclávia em criança hemofílica

O uso de cateteres venosos centrais em pacientes hemofilicos e muito frequente, devido as proprias caracteristicas terapeuticas da doenca. As complicacoes desses procedimentos, tais como pseudo-aneurisma, geralmente sao mais graves nesses pacientes. A correcao cirurgica do pseudo-aneurisma que acomete a arteria subclavia constitui um dos maiores desafios da cirurgia vascular. Em pacientes hemofilicos, a dificuldade habitual de exposicao cirurgica somam-se os problemas de alteracao no processo normal de coagulacao. Como alternativa ao tratamento cirurgico convencional, a utilizacao de tecnicas endovasculares constitui uma solucao segura e com bons resultados.

Tratamento percutâneo de obstrução biliar maligna: comparação entre os stents nitinol e elgiloy

Objective This study aimed to compare two self-expanding stents, a nitinol stent and an elgiloy stent, both placed percutaneously, in terms of their efficacy in palliating inoperable malignant biliary obstruction. Materials and Methods We retrospectively investigated 99 patients with unresectable malignant biliary obstruction treated with percutaneous placement of a self-expanding metallic stent at our institution between May 2007 and January 2010. Serum bilirubin and liver enzyme levels were measured before and 30 days after stenting. For all procedures using elgiloy or nitinol stents, stent occlusion and patient survival rates were calculated using Kaplan-Meyer analysis. Results All of the patients showed clinical improvement after stent placement, with no difference between the two groups. In both groups, the occlusion-free survival rate was 67% at 30 days, 37% at 90 days, 25% at 180 days, and 10% at 360 days, with no significant difference in relation to the type of stent. Conclusion The two stents evaluated showed comparable efficacy for the percutaneous treatment of unresectable biliary malignancy, with good clinical results.Zurstrassen CE, Bitencourt AGV, Guimaraes MD, Cavalcante ACBS, Tyng CJ, Amoedo MK, Matsushita Junior JPK, Szklaruk J, Marchiori E, Chojniak R.Percutaneous stent placement for the treatment of malignant biliary obstruction: nitinol versus elgiloy stents. Radiol Bras. 20 17 Mar/Abr;50(2):97–102.AbstractResumoObjective: This study aimed to compare two self-expanding stents, a nitinol stent and an elgiloy stent, both placed percutaneously, interms of their efficacy in palliating inoperable malignant biliary obstruction.Materials and Methods: We retrospectively investigated 99 patients with unresectable malignant biliary obstruction treated with percu-taneous placement of a self-expanding metallic stent at our institution between May 2007 and January 2010. Serum bilirubin and liverenzyme levels were measured before and 30 days after stenting. For all procedures using elgiloy or nitinol stents, stent occlus ion andpatient survival rates were calculated using Kaplan-Meyer analysis.Results: All of the patients showed clinical improvement after stent placement, with no difference between the two groups. In both grou ps,the occlusion-free survival rate was 67% at 30 days, 37% at 90 days, 25% at 180 days, and 10% at 360 days, with no significantdifference in relation to the type of stent.Conclusion: The two stents evaluated showed comparable efficacy for the percutaneous treatment of unresectable biliary malignancy,with good clinical results.Keywords: Radiology, interventional; Drainage; Stents; Biliary tract/pathology; Oncology.Objetivo: Este estudo procurou comparar a eficacia do implante percutâneo do stent autoexpansivel de nitinol versus o stent de elgiloypara paliacao da obstrucao biliar maligna irressecavel.Materiais e Metodos: Nos investigamos, retrospectivamente, 99 pacientes com obstrucao maligna irressecavel tratada com implantepercutâneo de stent metalico autoexpansivel em nossa instituicao, de marco de 2007 ate janeiro de 2010. Os niveis sericos de bilirru-bina e enzimas hepaticas foram medidos antes e 30 dias apos o implante do stent. Para os procedimentos em que foi utilizado o stentde elgiloy ou o stent de nitinol, as taxas de oclusao dos stents e as taxas de sobrevida dos pacientes foram calculadas pela analise deKaplan-Meyer.Resultados: Os pacientes mostraram melhora clinica apos o implante dos stents, sem diferenca entre os dois grupos. As taxas desobrevida livre de oclusao foram 67% aos 30 dias, 37% aos 90 dias, 25% aos 180 dias e 10% aos 360 dias para ambos os grupos,sem diferenca significativa em relacao ao tipo de stent.Conclusao: Os dois stents mostraram eficacias comparaveis no tratamento da doenca biliar maligna irressecavel, com bons resultadosclinicos.Unitermos: Radiologia intervencionista; Drenagem; Stents; Trato biliar; Oncologia.

BRAZILIAN CONSENSUS FOR MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 3: CONTROVERSIES AND UNRESECTABLE METASTASES

ABSTRACT In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

Safety and efficacy of HepaSphere 50–100 μm in the treatment of hepatocellular carcinoma

Abstract Aim: To evaluate the effects of HepaSphere 50–100 μm (Merit Medical) as a doxorubicin carrier and embolization agent for the treatment of hepatocellular carcinoma (HCC). Material and methods: A prospective analysis of 18 patients recruited from a national cancer center was conducted. This analysis evaluated the efficacy and safety of HepaSphere, as expressed by the treatment response rate (measured by the modified Response Evaluation Criteria in Solid Tumors, mRECIST) and by the prevalence of treatment-related adverse events, respectively. Results: The cohort was predominantly male, with a mean age of 69 years. The objective response rate (complete + partial response) was 53.3%. The variable most likely to be associated with objective response was Barcelona Clinic Liver Cancer (BCLC) staging. The most prevalent adverse events were nausea, vomiting and abdominal pain. Conclusion: HepaSphere chemoembolization yielded a substantial objective response rate with an acceptable toxicity profile and should be considered an option for HCC treatment.

A New CT-Guided Modified Trocar Technique for Drainage of Difficult Locations Abscesses

PurposeComputed tomography (CT) is commonly used to guide drainage of deep-seated abdominal fluid collections. However, in some cases, these collections seem to be inaccessible due to surrounding organs or their being in difficult locations. The aim of this study is to describe a modified Trocar technique to drain collections in difficult locations, especially those in the subphrenic space, without passing through intervening organs.Materials and MethodsThis retrospective case series study describes seven inpatients who underwent CT-guided drainage using a modified Trocar technique for abscesses that are difficult to access percutaneously. All patients provided written informed consent prior to the procedure. After placement of a 12–14F catheter inside the peritoneum, the Trocar stylet was removed so that the tip of the catheter became blunt and flexible to avoid injury to organs and structures in the catheter route, and the catheter was slowly advanced towards the collection using CT guidance and tactile sensation. After reaching the target, the stylet was reintroduced to enter the abscess wall.ResultsAll procedures were performed using an anterior abdominal wall access with adequate catheter positioning and resulted in clinical status improvement in the days after the drainage. No complications related to the procedure were identified in any of the patients.ConclusionsThe modified Trocar technique for percutaneous CT-guided drainage of abdominal abscesses may be feasible for lesions that are difficult to access with conventional methods.