Dorico Righi

Brain volumetric abnormalities in patients with anorexia and bulimia nervosa: A Voxel-based morphometry study

Recent studies focussing on neuroimaging features of eating disorders have observed that anorexia nervosa (AN) is characterized by significant grey matter (GM) atrophy in many brain regions, especially in the cerebellum and anterior cingulate cortex. To date, no studies have found GM atrophy in bulimia nervosa (BN) or have directly compared patients with AN and BN. We used voxel-based morphometry (VBM) to characterize brain abnormalities in AN and BN patients, comparing them with each other and with a control group, and correlating brain volume with clinical features. We recruited 17 AN, 13 BN and 14 healthy controls. All subjects underwent high-resolution magnetic resonance imaging (MRI) with a T1-weighted 3D image. VBM analysis was carried out with the FSL-VBM 4.1 tool. We found no global atrophy, but regional GM reduction in AN with respect to controls and BN in the cerebellum, fusiform area, supplementary motor area, and occipital cortex, and in the caudate in BN compared to AN and controls. Both groups of patients had a volumetric increase bilaterally in somatosensory regions with respect to controls, in areas that are typically involved in the sensory-motor integration of body stimuli and in mental representation of the body image. Our VBM study documented, for the first time in BN patients, the presence of volumetric alterations and replicated previous findings in AN patients. We evidenced morphological differences between AN and BN, demonstrating in the latter atrophy of the caudate nucleus, a region involved in reward mechanisms and processes of self-regulation, perhaps involved in the genesis of the binge-eating behaviors of this disorder.

Left atrial appendage morphology and silent cerebral ischemia in patients with atrial fibrillation

BACKGROUND Left atrial appendage (LAA) is the major source of cardiac thrombi in atrial fibrillation (AF) and plays a major role in cardioembolic events. OBJECTIVE To investigate the correlation between LAA morphology and the burden of silent cerebral ischemia (SCI) as a new thromboembolic risk marker in patients with AF. METHODS A total of 348 patients with AF undergoing transcatheter ablation were enrolled. A cerebral magnetic resonance (MR) was performed to assess SCI burden, while LAA morphology was studied by MR or computed tomography and categorized as follows: cactus in 52 (14.9%) patients, chicken wing in 177 (50.9%), wind sock in 101 (29.0%), and cauliflower in 18 (5.2%). RESULTS SCIs were detected in 295 (84.8%) patients, with a median number of lesions of 23. SCI burden was related to LAA complexity: 30.8% and 17.3% patients with cactus, 30.5% and 22.0% with chicken wing, 13.9% and 27.7% with wind sock, and 16.7% and 38.9% with cauliflower LAA morphologies were in the first and fourth quartiles of number of SCI per patient, respectively (P = .035). After adjustment for potential confounders, only age (β 0.12; 95% CI 0.08-0.16; P < .001), chicken wing (β -0.28; 95% CI -0.51 to -0.04; P = .021), wind sock (β 0.38; 95% CI 0.12-0.65; P = .005), and cauliflower (β 0.61; 95% CI 0.07-1.14; P = .026) LAA morphologies were significantly related to SCI burden. CONCLUSION LAA morphology relates to the burden of SCI in AF patients. Future research should corroborate if accessible methods (eg, echocardiography) are able to describe LAA morphology, permitting its use within universal thromboembolic risk predictors in AF patients.

Role of Interventional Radiology in the Treatment of Biliary Strictures Following Orthotopic Liver Transplantation

AbstractPurpose: To evaluate the efficacy and safety of percutaneous treatment of biliary strictures complicating orthotopic liver transplantation (OLT). Methods: Between October 1990 and May 2000, 619 patients underwent 678 liver transplants. Seventy of the 619 (11%) patients were found to be affected by biliary strictures by July 2000. Bilioplasty was performed in 51 of these 70 (73%) patients. A cohort of 33 of 51 (65%) patients were clinically followed for more than 12 months after the last percutaneous treatment and included in the survey results. Results: After one to three treatments 24 of 33 (73%) patients were stricture-free on ultrasound and MR cholangiography follow-up. A delayed stricture recurrence required a fourth percutaneous bilioplasty in two of 33 (6%) patients. A surgical bilioenteric anastomosis was performed in six of 33 (18%) patients. Retransplantation was performed due to ischemic damage in one of 33 (3%) patients. Conclusion: Interventional radiology is an effective therapeutic alternative for the treatment of most biliary strictures complicating OLT. It has a high success rate and should be considered before surgical interventions. Elective surgery may be necessary in a few failed cases or those with more severe and extensive biliary strictures.

Intrinsic Connectivity Networks Within Cerebellum and Beyond in Eating Disorders

Cerebellum seems to have a role both in feeding behavior and emotion regulation; therefore, it is a region that warrants further neuroimaging studies in eating disorders, severe conditions that determine a significant impairment in the physical and psychological domain. The aim of this study was to examine the cerebellum intrinsic connectivity during functional magnetic resonance imaging resting state in anorexia nervosa (AN), bulimia nervosa (BN), and healthy controls (CN). Resting state brain activity was decomposed into intrinsic connectivity networks (ICNs) using group spatial independent component analysis on the resting blood oxygenation level dependent time courses of 12 AN, 12 BN, and 10 CN. We extracted the cerebellar ICN and compared it between groups. Intrinsic connectivity within the cerebellar network showed some common alterations in eating disordered compared to healthy subjects (e.g., a greater connectivity with insulae, vermis, and paravermis and a lesser connectivity with parietal lobe); AN and BN patients were characterized by some peculiar alterations in connectivity patterns (e.g., greater connectivity with the insulae in AN compared to BN, greater connectivity with anterior cingulate cortex in BN compared to AN). Our data are consistent with the presence of different alterations in the cerebellar network in AN and BN patients that could be related to psychopathologic dimensions of eating disorders.

Safety and efficacy of the percutaneous treatment of bile leaks in hepaticojejunostomy or split‐liver transplantation without dilatation of the biliary tree

Biliary leaks complicating hepaticojejunostomy (HJA) or fistulas from cut surface are severe complications after liver transplantation (LT) and split‐liver transplantation (SLT). The aim of the study was to describe our experience about the safety and efficacy of radiological percutaneous treatment without dilatation of intrahepatic biliary ducts. From 1990 to 2006, 1595 LTs in 1463 patients were performed in our center. In 1199 LTs (75.2%), a duct‐to‐duct anastomosis was performed, and in 396 (24.8%), an HJA was performed. One hundred twenty‐nine anastomotic or cut‐surface bile leakages occurred in 115 patients. Sixty‐two biliary leaks occurred in 54 patients with HJA; in 48 cases, an anastomotic fistula was found. Cut‐surface fistulas occurred in 14 cases: 5 in right SLTs and 5 in left SLTs. Twenty‐two patients were treated with 23 percutaneous approaches for 17 HJA fistulas and 6 cut‐surface leaks without intrahepatic bile duct dilatation. Two percutaneous therapeutic approaches were used: percutaneous transhepatic biliary drainage (PTBD) for fistula alone and PTBD with percutaneous drainage of biliary collection in patients with both complications. PTBD was successful in 21 cases (91.3%); the median delay from catheter insertion and leak resolution was 10.3 days (range: 7–41). The median maintenance of drainage was 14.8 days. In 1 patient, fistula recurrence after PTBD needed a surgical approach; after that, an anastomotic fistula was still found, and a new PTBD was successfully performed. In another patient, PTBD was immediately followed by retransplantation for portal vein thrombosis. There were no complications related to the interventional procedure. In conclusion, biliary fistulas after HJA in LT or after SLT can be successfully treated by PTBD. The absence of enlarged intrahepatic biliary ducts should not be a contraindication for percutaneous treatment. Liver Transpl 14:611–615, 2008.

Percutaneous removal of biliary stones

Since 1983 we have performed percutaneous treatment of biliary lithiasis in 97 patients. Previous retrograde endoscopic procedures were incomplete or infeasible in all patients. Immediate results were excellent resulting in complete resolution of lithiasis in 89 of 97 patients (92%). In 4 patients (4%) partial success was obtained (symptoms subsided although there were nonobstructing residual stones). Percutaneous treatment failed in 1 patient (1%). Three patients died. Complications occurred in 14 of 97 patients (14%) and mortality at 30 days was 3%. Long-term results were evaluated in 71 patients who had at least a 6-month follow-up (mean 31 months and range 6–78 months). Eight of 71 patients (11%) had recurrence of stones and 7 of these were successfully retreated transhepatically. Percutaneous removal of biliary stones is efficacious because it has a high cure rate, a low complication rate, and a mortality rate that compares favorably to that of surgery even though the patients are usually older and in poorer general condition.

Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement

PurposeThis retrospective analysis was carried out to assess the feasibility and results of transjugular intrahepatic portal systemic shunt (TIPS) performed with ultrasound (US)-guided percutaneous puncture of the hepatic veins.Material and methodsOver a period of 3 years, 153 patients were treated with TIPS at our centre. In eight cases, a percutaneous puncture of the middle (n=7) or right (n=1) hepatic vein was required because the hepatic vein ostium was not accessible. Indications for TIPS were bleeding (n=1), Budd-Chiari syndrome (n=1), ascites (n=2), reduced portal flow (n=1) and incomplete portal thrombosis (n=3). A 0.018-in. guidewire was anterogradely introduced into the hepatic vein to the inferior vena cava (IVC) through a 21-gauge needle. In the meantime, a 25-mm snare-loop catheter was introduced through the jugular access to retrieve the guidewire, achieving through-andthrough access. Then, a Rosch-Uchida set was used to place the TIPS with the traditional technique.ResultsTechnical success was achieved in all patients. There was one case of stent thrombosis. One patient died of pulmonary oedema. Three patients were eligible for liver transplantation, whereas the others were excluded due to shunt thrombosis (n=1) and previous nonhepatic neoplasms (n=3).ConclusionsThe percutaneous approach to hepatic veins is rapid and safe and may be useful for avoiding traumatic liver injuries.RiassuntoObiettivoScopo del presente lavoro è stato analizzare retrospettivamente fattibilità e risultati della transjugular intrahepatic portal systemic shunt (TIPS) confezionata con puntura percutanea eco-guidata delle vene epatiche.Materiali e metodiNell’arco di 3 anni, 153 pazienti sono stati sottoposti a TIPS. In 8 casi si è resa necessaria la puntura percutanea delle vene epatiche mediana (n=7) o destra (n=1), dopo tentativi fallimentari di cateterismo retrogrado ostiale. Le indicazioni alla TIPS erano: 1 sanguinamento, 1 sindrome di Budd-Chiari, 2 asciti, 1 ipoafflusso portale e 3 trombosi portali incomplete. Attraverso un ago di 21G per via anterograda è stata introdotta dalla vena epatica in vena cava inferiore (VCI) una guida di 0,018 pollici. Contemporaneamente dall’accesso giugulare la guida è stata catturata ed esteriorizzata con un catetere a laccio di 25 mm, per veicolare su di essa il set di Rösch-Uchida e confezionare la TIPS con tecnica classica.RisultatiIl successo tecnico è stato ottenuto in tutti i pazienti. Abbiamo registrato 1 trombosi dello stent. Un paziente è deceduto per edema polmonare; 3 pazienti sono eleggibili per il trapianto epatico, mentre gli altri sono stati esclusi per occlusione dello shunt (n=1) o pregresse neoplasie extraepatiche (n=3).ConclusioniL’approccio percutaneo alle vene epatiche è rapido, sicuro ed utile nell’evitare lesioni epatiche traumatiche.

Emergency transjugular intrahepatic portosystemic shunt (TIPS): results, complications and predictors of mortality in the first month of follow-up

PurposeWe conducted a single-centre retrospective analysis of the results and predictors of early mortality in emergency transjugular intrahepatic portosystemic shunt (TIPS).Materials and methodsBetween 1992 and 2009, 82 patients with refractory variceal bleeding underwent emergency TIPS at our Institution. The success and complications of the procedure were assessed for each patient. Child class, platelet count, prothrombin time, serum creatinine levels and venous pressure before and after TIPS were studied statistically as possible prognostic factors of early mortality.ResultsThe technical, haemodynamic, and clinical success rates were 91.6%, 78% and 86.6%, respectively. Complications occurred in 21 cases (25.6%): eight were major (two stent migrations, one pulmonary embolism, one haemoperitoneum, one haemobilia, three intrahepatic haematomas) and 13 were minor (encephalopathy responsive to medical therapy). Twenty-one patients (25.6%) died due to the following causes: disseminated intravascular coagulation (DIC) (n=2), haemorrhage (n=8), cardiopulmonary failure (n=2) and liver failure (n=9). The predictors of mortality were Child’s class C, high serum creatinine and prolonged prothrombin time.ConclusionsThe technical success of TIPS may not lead to haemodynamic and clinical success. Complications are often due to impaired coagulation and inadequacy of the stent-graft. Early mortality is only influenced by pre-existing clinical and laboratory factors.RiassuntoObiettivoScopo del nostro lavoro è stato procedere ad una analisi retrospettiva monocentrica dei risultati e dei fattori prognostici di mortalità precoce del transjugular intrahepatic portosystemic shunt (TIPS) d’urgenza.Materiali e metodiDal 1992 ad oggi abbiamo eseguito 82 TIPS d’urgenza per sanguinamento varicoso irrefrenabile. Sono stati valutati i risultati della procedura e le relative complicanze. Tra i possibili fattori prognostici di mortalità precoce sono stati studiati statisticamente il Child, la conta piastrinica, il tempo di protrombina, la creatininemia e le pressioni venose pre- e post-TIPS.RisultatiIl successo tecnico, emodinamico e clinico sono stati rispettivamente: 91,6%, 78% e 86,6%. Abbiamo registrato 21 complicanze (25,6%): 8 maggiori (2 migrazioni di stent, un’embolia polmonare, 1 emoperitoneo, 1 emobilia e 3 ematomi intraepatici) e 13 minori (encefalopatia responsiva a terapia medica). Ventuno pazienti (25,6%) sono deceduti per: coagulazione intravasale disseminata (2), emorragia (8), insufficienza cardio-respiratoria (2), insufficienza epatica (9). Sono risultati fattori predittivi di mortalità: la classe C di Child e l’ipercreatininemia e l’allungamento del tempo di protrombina.ConclusioniIl successo tecnico del TIPS può non condurre al successo emodinamico e clinico. Le complicanze sono spesso riconducibili a coagulazione deficitaria ed all’inadeguatezza della protesi. La mortalità precoce è condizionata esclusivamente da fattori clinicolaboratoristici pre-esistenti al TIPS.

Patologia di fegato, vie biliari, pancreas: problematiche della radiologia interventistica

Nei pazienti anziani, nei quali l’intervento chirurgico e spesso controindicato sia per l’eta che per le condizioni cliniche, la radiologia interventistica assume un ruolo di rilievo sia a scopo terapeutico, come nella litiasi delle vie biliari, sia a scopo “palliativo” in caso di tumori primitivi delle vie biliari o lesioni estrinseche che comprimono o infiltrano le vie biliari. Le principali indicazioni al trattamento percutaneo in caso di patologie coinvolgenti le vie biliari intraed extraepatiche sono[1]: – assenza di indicazione o controindicazione al trattamento chirurgico; – decompressione preoperatoria; – impossibilita o fallimento dell’approccio endoscopico; – rischio ponderato accettabile; – effettivo prolungamento della spettanza di vita del paziente senza peggioramento della qualita di vita; – urgenze (colangite, ascesso biliare, mezzo di contrasto MDC nella via biliare).

Selective salpingography and tubaric catheterization in the diagnosis and treatment of fallopian tube obstruction

Fallopian tube catheterization with selective salpingography is a new technique for the diagnosis of tubal factors of sterility and also for the treatment of proximal tubal obstruction (PTO). In this study, 156 women, 20–42 years of age, with a mean duration of infertility of 5.7 years, who presented at conventional hysterosalpingography (HSG) a unilateral or bilateral PTO, were studied. Catheterization and selective salpingography was successful in 93% of the cases. Failures (6.1%) were ascribed to obliterative organic diseases, where it was impossible to overcome the stenosis with the catheter or the guidewire. Fourteen spontaneous pregnancies were obtained (7 full term deliveries, 4 miscarriages, 3 tubal pregnancies) and 11 patients became pregnant after gamete intra-fallopian transfer (GIFT). At follow-up, after 12 monts, four out of ten patients had patent tubes, while six presented a new unilateral or bilateral PTO. No major complications occurred; nevertheless, it is acknowledged that ectopic pregnancy is a possible outcome, due to the mechanical re-establishment of patency in a non-functioning tube.