Desiree E. Morgan

Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique

BACKGROUND Complications of endoscopic transmural drainage of pancreatic fluid collections arise from entry through the gastrointestinal wall. We describe transmural drainage of these collections using the Seldinger technique without electrocautery. METHODS From January 1995 to September 1997, we attempted endoscopic transmural drainage of 94 consecutive pancreatic fluid collections without EUS guidance (needle-knife entry in 51, Seldinger entry technique in 43). Success of entry and complications were compared. RESULTS Successful entry was achieved in 95.3% using the Seldinger technique and 92.1% using the needle-knife entry technique (p = NS). Complications of bleeding and perforation were seen in 4.6% of patients in the Seldinger group and 15.7% in the needle-knife entry group. CONCLUSIONS The Seldinger technique of endoscopic transmural drainage of pancreatic fluid collections appears effective and safer than entry using the needle-knife. Collections as small as 3 cm in diameter can be entered using the Seldinger technique without EUS guidance.

Endoscopic Stent Therapy in Advanced Chronic Pancreatitis: Relationships Between Ductal Changes, Clinical Response, and Stent Patency

OBJECTIVE:Pancreatic duct stenting is now recognized as a treatment option for a number of pancreatic disorders. Although stent-induced ductal changes may result, there is little information regarding the frequency of these stent-induced changes in chronic pancreatitis and their relationship to stent occlusion and clinical response. Our objectives were to evaluate pancreatic ductal changes after endoscopic stenting in patients with preexisting radiographic evidence of chronic pancreatitis and to evaluate the relationships between ductal changes, pain response, and stent patency.METHODS:Twenty-five consecutive patients had 40 stent placement episodes. Main pancreatic duct diameter, pancreatitis grade, preexisting obstructive lesions, and stent-induced strictures were recorded. Pain response and stent patency were correlated with main pancreatic duct caliber change using χ2 analysis.RESULTS:In 28 (70%) of 40 episodes, main pancreatic duct caliber increased or was unchanged after stenting; pain improved in 20 (71%) of 28. Pain improved in six (50%) of 12 patients with smaller ducts after stenting. Stent patency was documented upon retrieval in 34 episodes; most stents were occluded. Stent-induced strictures developed in 18% of 40 stent episodes.CONCLUSION:Main pancreatic duct caliber after endoscopic stenting was not a good indicator of pain response or stent patency; main pancreatic duct was often larger, and even with stent occlusion, patients’ symptoms were frequently improved. Stent-induced strictures were infrequent, compared with values previously reported in the literature.

The Diagnosis and Management of Fluid Collections Associated with Pancreatitis

Pancreatitis may be acute or chronic, mild or severe. Acute necrotizing pancreatitis remains the most serious form of acute pancreatitis and accounts for the majority of complications. Although there is an established nomenclature for pancreatitis and pancreatic fluid collections, such as pancreatic pseudocysts, it is not widely understood or recognized by physicians, including gastroenterologists. Because nonspecialists will be increasingly called upon to treat and appropriately refer patients with pancreatitis and its complications for more specialized care, it is important to understand the evolving treatment options for managing these patients. This article addresses and summarizes pancreatitis and its complications, particularly pancreatic collections.

Single-source dual-energy spectral multidetector CT of pancreatic adenocarcinoma: Optimization of energy level viewing significantly increases lesion contrast

AIM To evaluate lesion contrast in pancreatic adenocarcinoma patients using spectral multidetector computed tomography (MDCT) analysis. MATERIALS AND METHODS The present institutional review board-approved, Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant retrospective study evaluated 64 consecutive adults with pancreatic adenocarcinoma examined using a standardized, multiphasic protocol on a single-source, dual-energy MDCT system. Pancreatic phase images (35 s) were acquired in dual-energy mode; unenhanced and portal venous phases used standard MDCT. Lesion contrast was evaluated on an independent workstation using dual-energy analysis software, comparing tumour to non-tumoural pancreas attenuation (HU) differences and tumour diameter at three energy levels: 70 keV; individual subject-optimized viewing energy level (based on the maximum contrast-to-noise ratio, CNR); and 45 keV. The image noise was measured for the same three energies. Differences in lesion contrast, diameter, and noise between the different energy levels were analysed using analysis of variance (ANOVA). Quantitative differences in contrast gain between 70 keV and CNR-optimized viewing energies, and between CNR-optimized and 45 keV were compared using the paired t-test. RESULTS Thirty-four women and 30 men (mean age 68 years) had a mean tumour diameter of 3.6 cm. The median optimized energy level was 50 keV (range 40-77). The mean ± SD lesion contrast values (non-tumoural pancreas - tumour attenuation) were: 57 ± 29, 115 ± 70, and 146 ± 74 HU (p = 0.0005); the lengths of the tumours were: 3.6, 3.3, and 3.1 cm, respectively (p = 0.026); and the contrast to noise ratios were: 24 ± 7, 39 ± 12, and 59 ± 17 (p = 0.0005) for 70 keV, the optimized energy level, and 45 keV, respectively. For individuals, the mean ± SD contrast gain from 70 keV to the optimized energy level was 59 ± 45 HU; and the mean ± SD contrast gain from the optimized energy level to 45 keV was 31 ± 25 HU (p = 0.007). CONCLUSION Significantly increased pancreatic lesion contrast was noted at lower viewing energies using spectral MDCT. Individual patient CNR-optimized energy level images have the potential to improve lesion conspicuity.

Breast Tumor Xenografts: Diffusion-weighted MR Imaging to Assess Early Therapy with Novel Apoptosis-Inducing Anti-DR5 Antibody

PURPOSE To measure the early therapeutic response to a novel apoptosis-inducing antibody, TRA-8, by using diffusion-weighted magnetic resonance (MR) imaging in a mouse breast cancer model. MATERIALS AND METHODS Animal experiments had institutional animal care and use committee approval. Four groups of nude mice bearing luciferase-positive breast tumors (four to five mice with eight to 10 tumors per group) were injected intravenously with 0 mg (group 1), 0.025 mg (group 2), 0.100 mg (group 3), or 0.200 mg (group 4) of TRA-8 on days 0 and 3. Diffusion-weighted imaging, anatomic MR imaging, and bioluminescence imaging were performed on days 0, 3, and 6 before dosing. Averaged apparent diffusion coefficients (ADCs) for both whole tumor volume and a 1-mm peripheral tumor shell were calculated and were compared with tumor volume and living tumor cell changes. After imaging at day 6, proliferating and apoptotic cell densities were measured with Ki67 and terminal deoxynucleotidyl transferase mediated dUTP nick end labeling, or TUNEL, staining, respectively, and were compared with cleaved caspase-3 density. RESULTS The ADC increase at day 3 was dependent on TRA-8 dose level, averaging 6% +/- 3 (standard error of mean), 19% +/- 4, 14% +/- 4, and 34% +/- 7 in the whole tumor volume and 1% +/- 2, 9% +/- 5, 13% +/- 5, and 30% +/- 8 in the outer 1-mm tumor shell only for groups 1, 2, 3, and 4, respectively. The ADC increase in group 4 was significantly higher (P = .0008 and P = .0189 for whole tumor volume and peripheral region, respectively) than that in group 1 on day 3, whereas tumor size did not significantly differ. At day 3, the dose-dependent ADC increases were linearly proportional to apoptotic cell and cleaved caspase-3 densities and were inversely proportional to the density of cells showing Ki67 expression. CONCLUSION Diffusion-weighted imaging enabled measurement of early breast tumor response to TRA-8 treatment, prior to detectable tumor shrinkage, providing an effective mechanism to noninvasively monitor TRA-8 efficacy. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/248/3/844/DC1.

Dual-energy CT of the abdomen

Although conceived of in the 1970s, practical use of dual-energy CT in the clinical setting did not come to fruition until 2006, and since that time an ever expanding exploration of the technology has been underway. This article will discuss technical aspects of the two commercially available CT scanners, review the recent literature, and provide an organ-based description of abdominal dual-energy CT applications for the practicing radiologist.

Imaging of Acute Pancreatitis and Its Complications

Patients with acute pancreatitis may present with mild or severe disease, the latter comprising a minority of cases but accounting for most of the morbidity and mortality associated with this disease. Contrast-enhanced computed tomography is the mainstay of imaging patients with acute pancreatitis and is widely used in both the community and academic settings. A variety of retroperitoneal morphologic changes are readily depicted, and the correct assessment of these abnormalities is imperative for management. The purpose of this review is to describe the imaging evaluation of patients with acute pancreatitis by using the 1992 Atlanta Symposium classification and definitions to describe local complications depicted on contrast-enhanced computed tomography. Correlation with the proposed revision of Atlanta Symposium definitions set forth by the Acute Pancreatitis Working Group will be discussed.

Early Therapy Evaluation of Combined Anti–Death Receptor 5 Antibody and Gemcitabine in Orthotopic Pancreatic Tumor Xenografts by Diffusion-Weighted Magnetic Resonance Imaging

Early therapeutic efficacy of anti-death receptor 5 antibody (TRA-8) combined with gemcitabine was measured using diffusion-weighted magnetic resonance imaging (DWI) in an orthotopic pancreatic tumor model. Groups 1 to 4 of severe combined immunodeficient mice (n = 5-7 per group) bearing orthotopically implanted, luciferase-positive human pancreatic tumors (MIA PaCa-2) were subsequently (4-5 weeks thereafter) injected with saline (control), gemcitabine (120 mg/kg), TRA-8 (200 mug), or TRA-8 combined with gemcitabine, respectively, on day 0. DWI, anatomic magnetic resonance imaging, and bioluminescence imaging were done on days 0, 1, 2, and 3 after treatment. Three tumors from each group were collected randomly on day 3 after imaging, and terminal deoxyribonucleotidyl transferase-mediated dUTP nick end labeling staining was done to quantify apoptotic cellularity. At just 1 day after starting therapy, the changes of apparent diffusion coefficient (ADC) in tumor regions for group 3 (TRA-8) and group 4 (TRA-8/Gem) were 21 +/- 9% (mean +/- SE) and 27 +/- 3%, respectively, significantly higher (P < 0.05) than those of group 1 (-1 +/- 5%) and group 2 (-2 +/- 4%). There was no statistical difference in tumor volumes for the groups at this time. The mean ADC values of groups 2 to 4 gradually increased over 3 days, which were concurrent with tumor volume regressions and bioluminescence signal decreases. Apoptotic cell densities of tumors in groups 1 to 4 were 0.7 +/- 0.4%, 0.6 +/- 0.2%, 3.1 +/- 0.9%, and 4.7 +/- 1.0%, respectively, linearly proportional to the ADC changes on day 1. Further, the ADC changes were highly correlated with the previously reported mean survival times of animals treated with the same agents and doses. This study supports the clinical use of DWI for pancreatic tumor patients for early assessment of drug efficacy.

Reversed Diastolic Flow in the Renal Transplant: Perioperative Implications Versus Transplants Older Than 1 Month

OBJECTIVE The purpose of our study was to evaluate the causes, waveform morphology, and clinical outcomes of high-resistance reversed diastolic flow in transplanted kidneys. MATERIALS AND METHODS To identify patients with reversed diastolic flow, we performed a review of 5,089 renal transplant Doppler sonograms obtained over a 10-year period. Waveform morphology was correlated with surgical-histologic findings and clinical outcomes. RESULTS Fifty-nine patients (33 male, 26 female; age range, 14-69 years) with reversed diastolic flow fell into three chronologic groups: acute group (six patients), transplant < 24 hours; perioperative group (34 patients), transplant < or = 30 days; and long-term group (19 patients), transplant > 30 days. Acute reversed diastolic flow was associated with higher likelihood of graft survival (p = 0.001, Fishers exact test) compared with reversed diastolic flow discovered in the perioperative or long-term group. In the acute group, hematoma, acute tubular necrosis, renal vein thrombosis, and vascular kink produced reversed diastolic flow. The causes of reversed diastolic flow for the perioperative group were acute tubular necrosis, rejection, and renal vein thrombosis; for the long-term group, reasons for diastolic reversal were rejection, glomerulosclerosis, low cardiac output, and diabetic nephrosclerosis. The causes of reversed diastolic flow were not differentiated by waveform morphology. CONCLUSION The causes of reversed diastolic flow cannot be distinguished by waveform morphology. Patients with reversed diastolic flow < 24 hours after transplantation warrant emergent exploration because correction of treatable causes may lead to recovered function. Long-standing renal transplants with reversed diastolic flow are not likely salvageable.

Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management.

OBJECTIVES:With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS.METHODS:All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded.RESULTS:A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures (n=331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01–0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipples procedure. The two other patients remained alive and well 12 and 22 months after the procedure.CONCLUSIONS:CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS.