David J. Glickerman

Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study.

BACKGROUND The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD. DESIGN Multicenter, prospective, single-arm phase 2 study. SETTING Six academic medical centers. PATIENTS We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture. INTERVENTIONS Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment. MAIN OUTCOME MEASURES Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months. RESULTS We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%. CONCLUSIONS This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.

Steady-state free precession MRA of the renal arteries: breath-hold and navigator-gated techniques vs. CE-MRA.

To explore the use of breath‐hold and navigator‐gated noncontrast Steady State Free Precession (SSFP) MR angiography (MRA) protocols for the evaluation of renal artery stenosis (RAS).

Results of percutaneous transluminal angioplasty for atherosclerotic renal artery stenosis: A follow-up study with duplex ultrasonography

PURPOSE The short and long-term anatomic results of percutaneous transluminal renal angioplasty (PTRA) in the treatment of atherosclerotic renovascular disease have been poorly documented because of a lack of follow-up arteriography. The purpose of this study was to evaluate the anatomic results of PTRA with serial duplex examinations. METHODS The records of 41 patients who underwent 52 primary PTRA procedures and had subsequent duplex follow-up of at least 6 months were reviewed. After PTRA, renal arteries were classified as normal, < 60% stenosis, > or = 60% stenosis, or occluded on the basis of previously validated duplex criteria. RESULTS The study group included 26 men and 15 women with a mean age of 65 years, who were observed for a mean interval of 34 months. Endovascular stents were placed in 12 of the 52 arteries. The initial post-PTRA renal artery stenosis classification (based on arteriography or duplex scan) was normal in 23, < 60% in 19, and > or = 60% in 10. The cumulative incidence of restenosis from normal to > or = 60% was 13% at 1 year and 19% at 2 years. The cumulative incidence of restenosis from < 60% to > or = 60% was 44% at 1 year and 55% at 2 years. The cumulative incidence of progression from > or = 60% to occlusion was 10% at 2 years. Although 83% of the 12 stented arteries and only 33% of the 40 nonstented arteries were normal immediately after PTRA, after 1 year the stented renal arteries showed a 44% restenosis rate, whereas the nonstented renal arteries showed a 18% restenosis rate (p = 0.087). CONCLUSIONS Restenosis after PTRA for atherosclerotic disease is relatively common and correlates with the initial anatomic result. Although PTRA with stent placement yields superior immediate technical results, the high early restenosis rate is disturbing.

Navigator-Gated MR Angiography of the Renal Arteries: A Potential Screening Tool for Renal Artery Stenosis

OBJECTIVE The purpose of our study was to determine how well unenhanced navigator-gated steady-state free precession (Nav SSFP) MR angiography (MRA) performs as a screening test for the detection of renal artery stenosis. SUBJECTS AND METHODS Forty patients referred to rule out renal artery stenosis were imaged using an optimized Nav SSFP MRA sequence before conventional contrast-enhanced MRA (CE-MRA). Two radiologists evaluated Nav SSFP for maximum stenosis measurement, and comparison was made with CE-MRA results. RESULTS Fifteen of the 40 patients had greater than 50% renal artery stenosis as determined on CE-MRA. Sensitivity for detecting renal artery stenosis with Nav SSFP was 100%; specificity, 84%; negative predictive value, 100%; and positive predictive value, 79%. The average mean stenosis difference between Nav SSFP and CE-MRA was 10% +/- 9%. CONCLUSION Sensitivity and negative predictive value for the detection of renal artery stenosis using Nav SSFP were perfect, with an acceptable specificity of 84%. This suggests Nav SSFP is a promising technique for simple unenhanced screening for the detection of renal artery stenosis.

Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation.

Obstruction of the IVC occurs in only 1-2% of patients after liver transplantation. The mortality of this complication can be as high as 66%. This case report describes the use of a Wallstent for an IVC obstruction that was unresponsive to conventional balloon angioplasty.

Cardiopulmonary consequences of transjugular intrahepatic portosystemic shunts: Role of increased pulmonary artery pressure

Goals: To determine whether increased pulmonary artery pressure (PAP) following transjugular intrahepatic portosystemic shunting (TIPSS) results in short-term mortality or cardiorespiratory complications. Background: TIPSS is frequently performed for complications of cirrhosis. PAP increases following TIPSS; however consequences of this phenomenon are unknown. Study: Demographics, disease severity and etiology were recorded among patients undergoing TIPSS. PAP before and following TIPSS were measured and the relationship between PAP before and after TIPSS, and subsequent cardiorespiratory complications and mortality was examined. Results: Thirty-one patients were enrolled (mean age 53 years, 74% men, 55% Child-Pugh class C cirrhosis). TIPSS was performed for variceal bleeding in 84% of cases. Ten patients (32%) died 5–20 days following TIPSS. PAP increased significantly following TIPSS (mean 20.8 mm Hg pre-TIPSS (95% CI 18.2–23.4) to 26.9 mm Hg post-TIPSS (95% CI 24.2–29.6, P = 0.0016). Congestive heart failure developed in 4 patients (13%), sepsis in 4 (13%), and ARDS in 8 (26%). Increased PAP following TIPSS was not associated with early mortality (P = 0.13), CHF (P = 0.31), or ARDS (P = 0.43). ARDS was the only significant predictor of short-term mortality following TIPSS (OR 18.7, P = 0.02 (95% CI: 1.5–232). Conclusion: PAP increases after TIPSS and cardiorespiratory complications are common, yet unrelated to increased PAP. ARDS is independently associated with increased risk of mortality after TIPSS.

The gallbladder also secretes.

The gallbladder is traditionally regarded as an absorptive organ. There is increasing evidence that the gallbladder mucosa can have a secretory function. We studied a patient with primary sclerosing cholangitis whose gallbladder was excluded from his extrahepatic bile ducts by stricture formation. He was admitted into hospital because of cholecystitis and cholangitis and required separate drainage tubes into his gallbladder and common hepatic duct. This unique combination of drains afforded the opportunity to examine hepatic bile and gallbladder secretion. We analyzed samples for fluid volume, protein, electrolyte concentrations and biliary lipids. The simultaneous, yet separate, drainage from the gallbladder and the liver had a striking difference. The former was colorless to opalescent; the latter always golden brown. Hepatic bile flow was continuous but gallbladder drainage was variable in volume, intermittent, and occurred only after a meal. The gallbladder fluid had no bilirubin, bile salts, cholesterol, or phospholipids and had the ionic profile of an extracellular fluid. It was alkaline and contained abundant bicarbonate. We have shown that the gallbladder can secrete. In addition, these observations may also have important implications in the pathogenesis and prevention of gallbladder sludge and stones.

Transluminal Treatment of a Celiac Artery Pseudoaneurysm with a Stent Graft Occlusion Device

Abstract This report describes the transluminal placement of a stent graft occlusion device to treat a celiac bypass graft pseudoaneurysm which was causing biliary and duodenal obstruction.

Development of an Intrabiliary MR Imaging-monitored Local Agent Delivery Technique: A Feasibility Study in Pigs

PURPOSE To investigate the feasibility of using magnetic resonance (MR) imaging to monitor intrabiliary delivery of motexafin gadolinium (MGd) into pig common bile duct (CBD) walls. MATERIALS AND METHODS Animal studies were approved by the Institutional Animal Care and Use Committee. Initially, human cholangiocarcinoma cells were treated with various concentrations of MGd, a compound serving as a T1-weighted MR imaging contrast agent, chemotherapy drug, and cell marker. These cells were then examined by means of confocal microscopy to confirm the intracellular uptake of MGd. In addition, an MGd/trypan blue mixture was locally infused into CBD walls of six cadaveric pigs using a microporous balloon catheter. CBDs of six pigs were infused with saline to serve as controls. Ex vivo T1-weighted MR imaging of these CBDs was performed. For in vivo technical validation, the microporous balloon catheter was placed in the CBD by means of a transcholecytic access to deliver MGd/trypan blue into CBD walls of six living pigs. T1-weighted images were obtained with both a surface coil and an intrabiliary MR imaging guidewire, and contrast-to-noise ratios of CBD walls before and after MGd/trypan blue infusions were compared in the two groups by means of paired t test, with subsequent histologic analysis to confirm the penetration and distribution of the MGd/trypan blue agent into CBD walls. RESULTS In vitro experiments confirmed uptake of MGd by human cholangiocarcinoma cells. The ex vivo experiments demonstrated the penetration of MGd/trypan blue into the CBD walls. The in vivo experiment confirmed the uptake of MGd/trypan blue, showing an increased contrast-to-noise ratio for the CBD after administration of the mixture, compared with images obtained prior to MGd/trypan blue administration (11.6 ± 4.2 [standard deviation] vs 5.7 ± 2.8; P = .04). Histologic results depicted the blue dye stains and red fluorescence of MGd in CBD walls, confirming the imaging findings. CONCLUSION It is feasible to use MR imaging to monitor the penetration of locally delivered MGd into pig CBD walls.

Successful treatment of early postoperative aortic graft infection by percutaneous catheter drainage

Successful treatment by percutaneous catheter drainage of an acute aortic graft infection with an associated pancreatic fistula is reported. Percutaneous catheter drainage can be considered in selected patients when the risk of reoperation is deemed unacceptable or when other reasonable treatment options do not exist.