Cozzi G

Percutaneous Transhepatic Biliary Drainage in the Management of Postsurgical Biliary Leaks in Patients with Nondilated Intrahepatic Bile Ducts

PurposeTo assess the feasibility of percutaneous transhepatic biliary drainage (PTBD) for the treatment of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts, its efficacy in restoring the integrity of bile ducts, and technical procedures to reduce morbidity.MethodsSeventeen patients out of 936 undergoing PTBD over a 20-year period had a noncholestatic liver and were retrospectively reviewed. All patients underwent surgery for cancer and suffered a postsurgical biliary leak of 345 ml/day on average; 71% were in poor condition and required permanent nutritional support. An endoscopic approach failed or was excluded due to inaccessibility of the bile ducts.ResultsEstablished biliary leaks and site of origin were diagnosed an average of 21 days (range 1–90 days) after surgery. In all cases percutaneous access to the biliary tree was achieved. An external (preleakage) drain was applied in 7 cases, 9 patients had an external–internal fistula bridging catheter, and 1 patient had a percutaneous hepatogastrostomy. Fistulas healed in an average of 31 days (range 3–118 days ) in 15 of 17 patients (88%) following PTBD. No major complications occurred after drainage. Post-PTBD cholangitis was observed in 6 of 17 patients (35%) and was related to biliary sludge formation occurring mostly when drainage lasted >30 days and was of the external–internal type. Median patient survival was 17.7 months and in all cases the repaired biliary leaks remained healed.ConclusionsPTBD is a feasible, effective, and safe procedure for the treatment of postsurgical biliary leaks. It is therefore a reliable alternative to surgical repair, which entails longer hospitalization and higher costs.

Role of home parenteral nutrition in chronic radiation enteritis

OBJECTIVES:The management of chronic radiation enteritis (CRE) is difficult and often controversial. The aim of the study was to compare long-term outcome of patients with radiation-induced intestinal obstruction treated either surgically or with intestinal rest and home parenteral nutrition (HPN).METHODS:Thirty patients, with mechanical bowel obstruction due to CRE, were retrospectively included in the study and divided in two groups according to the first treatment approach. Seventeen patients underwent surgery (S group) and 13 patients were supported with HPN (HPN group). Survival, nutrition autonomy, number of surgeries, related complications and persistence of symptoms were evaluated in the two groups. Associations between factors and treatment group were assessed by means of the Wilcoxon rank sum test for continuous variables and the Fisher exact test for categorical variables. Overall survival was calculated using the Kaplan-Meier method.RESULTS:The two groups were similar in terms of age, dose of radiation therapy, time of occurrence and degree of signs and symptoms. 7/13 patients in the HPN group resolved the obstruction without surgery. 10/17 patients of the S group developed intestinal failure which required HPN. Nutrition autonomy was achieved in 100% and 58.8% of HPN and S group respectively (p = 0.01). The overall five-year survival was 90.0% and 68.4% respectively in the HPN and S group (p = 0.0231).CONCLUSIONS:Both HPN and surgery are often necessary in patients with chronic radiation-induced intestinal obstruction. However, the long term nutrition autonomy and survival seem to be better in patients initially treated with intestinal rest and HPN.

TP53 mutations and mdm2 protein overexpression in cholangiocarcinomas.

Tumor suppressor protein p53 is a positive regulator of MDM2 gene expression and the mdm2 protein can bind to p53, preventing the transactivation of p53 responsive genes, thus mimicking TP53 mutation. The authors looked for alterations that could affect, directly and indirectly, p53 function in 13 patients with extrahepatic cholangiocarcinoma. Molecular analysis by single strand conformation polymorphism and DNA sequencing revealed that TP53 gene mutations occurred in only 2 of 13 cholangiocarcinomas. High levels of mdm2 protein were found, by immunohistochemical staining, in 61% of the cholangiocarcinomas and in almost all specimens (70%) displaying stabilized p53 protein in the absence and in the presence of TP53 mutations. The finding of co-overexpressed mdm2 and p53 proteins in cholangiocarcinomas indicates that they can upregulate the expression of mdm2 protein to a level sufficient for binding and accumulating p53 in a presumably inactive complexed form. The presence of TP53 mutations or upregulation of MDM2 gene expression in 9 of the 13 cholangiocarcinomas strongly supports that the impairment of the p53 pathway is an important and specific step in cholangiocarcinoma pathogenesis. At variance with other authors, no alteration of p16ink4/CDKN2 gene was observed in all 13 cholangiocarcinomas.

Interventional radiology and radiotherapy for inoperable cholangiocarcinoma of the extrahepatic bile ducts

AIMS AND BACKGROUND To evaluate the effectiveness of external radiation therapy (ERT), alone or combined with endoluminal brachytherapy (BRT), following percutaneous transhepatic biliary drainage (PTBD) in the treatment of patients affected by inoperable cholangiocarcinoma. METHODS & STUDY DESIGN From September 1980 to June 1996, 130 jaundiced patients affected by inoperable cholangiocarcinoma were submitted to PTBD at the Division of Radiology C of the National Cancer Institute of Milan. Nineteen were excluded from the present analysis due to the short survival after PTBD (< 30 days). The other 111 patients were divided into three groups according to the following therapy: no further treatment after palliative PTBD in 89 patients (80%, group 1); ERT in 10 patients (9%, group 2); ERT plus BRT in 12 patients (11%, group 3). All the ERT + BRT patients were enrolled after 1990 and were treated with high-energy photon beams followed by endobiliary insertion of one or two iridium-192 wires. RESULTS Median overall survival among the 111 assessable patients was 126 days; for groups 1, 2 and 3 it was 108, 345 and 428 days, respectively. The patients submitted to radiotherapy (ERT alone or ERT + BRT) were evaluated by radiologic examinations after the end of radiation. In group 2, a partial remission in 3 cases, a progression of disease in 1 case, and no change in 6 cases were observed. Among the patients of group 3, complete remission in 5 and partial remission in 7 patients were achieved. In all the patients achieving complete remission, the PTBD could be removed. CONCLUSIONS The combination of ERT plus BRT improves survival and quality of life of the patients submitted to PTBD for cholangiocarcinoma. Under the technical point of view, radiation treatment is easy to perform, but much caution is required in defining clinical and planning target volumes. Moreover, drainage during the radiation treatment has to be submitted to a very meticulous surveillance.

Percutaneous gastrostomy in oncologic patients: analysis of results and expansion of the indications

AbstractBackground: Percutaneous gastrostomy is generally performed for permanent enteral nutrition or gastric decompression. Methods: In our series of oncologic patients, percutaneous gastrostomy was also used temporarily in some patients for enteral nutrition while awaiting functional recovery of swallowing, in preparation for surgery, or for the treatment of fistulas in the upper digestive tract. Fifty-one procedures were performed in 50 patients: 42 for feeding, eight for decompression, and one for transgastric drainage of a duodenal fistula. Results: Of the 35 patients treated for permanent enteral nutrition, four are still alive, with a total survival time of 2167 days. In three patients, gastrostomy was performed for temporary feeding and was removed once the ability to swallow was restored. In four patients, it was created to restore metabolic balance before surgery. In the patient with a duodenal fistula, healing was achieved in 19 days. The seven patients in whom the procedure was performed for decompression survived for a mean of 19.2 days. There was only one major procedure-related complication (peritonitis). Conclusions: Percutaneous gastrostomy is a safe, low-cost method that allows the patient to maintain essential nutrition without the discomfort of a nasogastic tube and therefore warrants wider and earlier use. We feel that its application should also be extended to temporary feeding of patients about to undergo long courses of chemotherapy and radiotherapy, which can lead to severe deterioration of nutritional status.

Diagnostic accuracy of the double-contrast enema for colonic polyps in patients with or without diverticular disease.

The accuracy of the double-contrast enema for the diagnosis of polypoid lesions in the presence or absence of diverticula was evaluated by retrospectively reviewing the medical records of 202 patients subjected to examination and endoscopy. Analysis of the data on 215 polypoid lesions showed that (a) the diagnostic accuracy of the examination is not affected significantly by the presence of diverticula; (b) the sensitivity of the examination is highly dependent on the size of the polyps (smaller or larger than 0.5 cm) but not on the form (sessile or pedunculated); and (c) the positive predictive value is higher in patients without diverticula. The doublecontrast enema was confirmed to be a valid method for the diagnosis of polypoid lesions.

The role of interventional radiology in biliary complications after orthotopic liver transplantation: a single-center experience

This study evaluated interventional radiological experience in the management of biliary complications of OLT at the National Cancer Institute of Milan. Seventeen patients who had undergone orthotopic liver transplantation in various hospital were referred to our unit with biliary complications. Group I consisted of 8 patients with anastomotic biliary fistula who came to our attention a short time after transplantation. Group II consisted of 9 patients with anastomotic strictures who came to our attention in a longer period. Two different interventional radiological approaches were used: (a) percutaneous transhepatic biliary drainage (PTBD) in the presence of fistulas in patients of group I; and (b) percutaneous transhepatic biliary drainage combined with dilatation of the strictures with a balloon catheter in patients of group II. On the whole resolution of the biliary complications was achieved in 13 of the 17 cases treated (76.5%), 5 of 8 in group I and 8 of 9 in group II. No secondary stenosis after PTBD were observed in group I, whereas two patients of group II needed a second dilatation. Percutaneous biliary drainage is indicated as a valid treatment in the management of biliary complications, either to allow closure of the fistula either to perform balloon dilatation of stenosis.

Double-contrast barium enema and computerised tomography in the pre-operative evaluation of rectal carcinoma: are they still useful diagnostic procedures?

Purpose In modern management of rectal carcinoma, the preoperative evaluation of disease parameters is important for selection of therapeutic options. Such parameters are currently defined through endorectal ultrasonography or endoscopic ultrasonography. A retrospective analysis of the parameters obtained with double-contrast barium enema (DCBE) and endorectal balloon computed tomography (CT) was conducted to verify the diagnostic reliability of the radiological techniques and to establish whether there is still an indication for their use. Methods 53 consecutive patients with adenocarcinoma of the distal half of the rectal ampulla underwent double contrast barium enema examination and CT of the pelvis with endorectal balloon. On the basis of the DCBE and CT assessment we evaluated: 1) the distance between the cranial extremity of the anal canal and the distal margin of the neoplasm; 2) the radial diffusion of the tumor; 3) the metastatic involvement of the perirectal and inferior mesenteric lymph nodes. Results 1) CT and DBCE measurements of the distal margin tended to coincide, but both tended to overestimate the measurement when compared to the pathologic examination; 2) in the identification of neoplastic infiltration of perirectal fat (T3) CT had 100% sensitivity, 78.7% specificity and 86.8% accuracy; 3) the CT sensitivity for detecting lymph node metastasis was 52.6%, specificity 85.3% and accuracy 73.6%. Conclusions The diagnostic information provided by the radiological examinations is comparable to that of clinical and instrumental methods currently employed for staging of rectal carcinoma, although the latter are preferred because they are more readily accessible and less costly. DCBE and CT can therefore be usefully employed for staging of cancer of the rectum in those cases in which there are limitations of the current standard methods.

The Outcome of Cholangitis After Percutaneous Biliary Drainage in Neoplastic Jaundice

The purpose of this paper is to evaluate factors affecting the outcome of cholangitis after PTBD in jaundiced cancer patients. Twenty nine patients with neoplastic jaundice (male/female ratio 13/16, median age 55 years) with full clinical data, were treated by PTBD and developed cholangitis at a median of 9 days later. Four patients (14%) died of biliary sepsis a median of one month after PTBD while the other 25 survived a median of 6 months, with one week median duration of cholangitis. The probability of the cholangitis resolving was analyzed by time to resolution and it was found that 50% and 100% of the recoveries occurred 5 and 9 months respectively from the onset of the complication. The series was analyzed to determine the role of several variables (disease/patient/treatment related) in the resolution of cholangitis. Only a low stricture site, a large initial drainage catheter (10F) and a temperature increase exceeding 39° C were correlated with a positive outcome. We conclude that PTBD-related cholangitis has, in our experience, a good chance of cure, low mortality rate and satisfactory 6 months median survival.

Diagnostic and interventional radiology in the post-operative period and follow-up of patients after rectal resection with coloanal anastomosis

Abstract. Surgical treatment of carcinoma of the distal third of the rectum with anal sphincter preservation is increasingly used in accredited cancer centers. This study aimed to evaluate the diagnostic usefulness of radiological investigations in the management of patients who had undergone resection with coloanal anastomosis for carcinoma of the rectum, in the immediate post-operative period, during closure of the protective colostomy and in the follow-up of symptomatic recanalized patients. A total of 175 patients who had undergone total rectal resection with end-to-side anastomosis for carcinoma of the distal third of the rectal ampulla, most of whom had received postoperative radiotherapy, were evaluated radiologically. In the postoperative period radiological investigation was ordered only for symptomatic patients to detect pathology of the anastomosis and the pouch sutures and was used direct film abdominal radiography and contrast-enhanced radiography of the rectal stump with a water-soluble radio-opaque agent. Before closure of the colostomy, 2 months after rectal excision or approximately 4 months after if postoperative radiotherapy was given, the anastomosis and pouch of all patients, even asymptomatic ones, were studied with water-soluble contrast enema to check for normal canalization. In the follow-up after recanalization radiological examinations were done to complete the study of the large intestine if the endoscopist was not able to examine it up to the cecum. Of the 175 patients examined radiologically during the postoperative period and/or subsequent follow-up, 95 showed no pathological findings. Seventy-nine patients had fistulas of the coloanal anastomosis or the pouch, 23 of which supplied a presacral collection. In the absence of severe sepsis, the only therapeutic measures were systemic antibiotics and washing of the surgical catheters to maintain efficient operation. In 2 patients in whom transanal drainage was performed radiologically the fistula was cured in 1 week. In 36 cases of cicatricial stenosis, 17 at the coloanal anastomosis and 19 at the pouch, radiological examination always detected the lesion, correctly defining its anatomical characteristics, nature and extension. Of the 19 cases of stenosis treated radiologically, 15 recovered an adequate intestinal calibre for normal evacuation. During follow-up of the 175 patients operated on, 21 cases of recurrence were detected. Radiological examination was requested as the first investigation in only one of these cases, for a patient with subocclusion. Radiological investigations in patients who have undergone coloanal anastomosis are of real diagnostic value in the immediate post-operative period, during closure of the protective colostomy and in the follow-up of symptomatic recanalized patients.