Marco Milella

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.

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.

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.

Spontaneous massive necrosis of a hepatocellular carcinoma.

A case of hepatocellular carcinoma that underwent total necrosis without previous chemotherapy is described. Histologic examination of the neoplasm revealed massive thrombosis of numerous peritumoral venous vessels in the adjacent normal liver. Although the importance of a newly formed arterial blood supply for the maintenance of the viability of hepatocellular carcinoma is unquestionable, this case suggests a similar importance of the venous drainage of the surrounding liver.

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.

Pancreatic tumor imaging by III generation CT, gray-scale ultrasound and improved angiography.

Thanks to computed tomography (CT) and gray-scale ultrasounds the possibilities of morphological diagnosis in pancreatic disease have improved. Nevertheless, only a part of the potenial performances of this practice is known and especially for ultrasounds, where only an expert eye can properly read the resulting images. With the help of pictures we hereby deal with the above-mentioned procedures in the demonstration of a pancreatic neoplasm. The possible integration with other more invasive methods was verified compared to pancreatic angiography. The latter is irreplaceable in the presurgical stage, and the method proposed by the authors can be useful when other methods cannot be employed.

Self-expanding metal stents in gastrointestinal interventional radiology: technical problems.

Aims and background To analyze the procedural difficulties in the placement of metal stents in stenoses of the digestive tract and optimize the technique. Methods Twenty-nine patients with digestive tract stenoses were treated from January 1999 to December 2004. In 14 cases the stricture was anastomotic (9 colorectal, 3 esophageal, 1 gastroesophageal and 1 gastrojejunal), in 13 esophageal, in 1 gastric and in 1 duodenal. The stenosis was due to scarring in 5 patients and was malignant in 24 patients (primary in 17 cases and secondary in 7 cases). Results The procedure achieved technical success in all cases but 2. For each of the different segments the technical difficulties and the adopted procedural solutions were analyzed. Conclusions The interventional radiology approach yielded results comparable to those reported for the endoscopic method and was always well tolerated. The need to rely on materials mostly designed for endoscopic use can make radiological use difficult in some cases.

Intraarterial injection of CO2 in US imaging of hepatocellular carcinoma (echo carbography)

Contrast-enhanced us with CO2 can improve us liver sensitivity, detecting daughter nodules of HCC not visible with normal us Examination and CT.

COLOR-DOPPLER ULTRASOUND IN OVARIAN MASSES : ANATOMO-PATHOLOGIC CORRELATION

Background and aims In the radiologic assessment of ovarian masses, the major difficulty consists in the late recognition and lack of parameters for a differential diagnosis between benign and malignant lesions, especially in the post-menopause when the incidence of cancer is higher. The use of a transvaginal probe and the color-Doppler examination have recently improved the study of the female pelvis. This study is aimed to verify the possibility of the color-Doppler imaging to differentiate between malignant and benign ovarian lesions during transvaginal echographies, on the basis of the qualitative and quantitative characteristics of the vascular pattern of the ovarian lesions. Results Twenty-six expansive ovarian lesions were studied: 8/26 showed no vascular signals and were considered benign as confirmed at histology. In the remaining lesions with some vascularization, the resistance index (RI) was evaluated: those with RI > 0.40 were considered benign, those with RI < 0.40 malignant. In 8/9 benign lesions and in 7/9 malignant neoplasms, the results of color-Doppler were coherent with histology. The results showed a sensibility of 87.5 % and a specificity of 88.8 % for the transvaginal examination. Conclusions The main advantages of the color-Doppler transvaginal examination are: the high frequency of visualization of the ovaries, even in postmenopausal patients; the definition of small lesions; the visualization of small parenchymal vessels, both physiologic and pathologic, and their quantitative analysis. The importance of the RI cutoff was critical for the differential diagnosis between benign and malignant lesions: we think that a cutoff of 0.50, instead of 0.40 proposed by other authors, would be far more appropriate.