Michael S. Rosenberg

Intraoperative Fragment Detection During Percutaneous Nephrolithotomy: Evaluation of High Magnification Rotational Fluoroscopy Combined With Aggressive Nephroscopy

PURPOSE Percutaneous nephrolithotomy effectively treats large volume renal calculi but relies on postoperative imaging to judge success. We evaluated the effectiveness of maximizing intraoperative imaging through combined high resolution fluoroscopy and flexible nephroscopy. MATERIALS AND METHODS Percutaneous nephrolithotomy was performed cooperatively with a radiologist in an interventional radiology suite equipped with a ceiling mounted, high resolution C-arm. Aggressive rigid and flexible nephroscopy was performed. At the conclusion patients were prospectively classified as radiologically and/or endoscopically stone-free. Postoperative noncontrast CT allowed fragment classification as stone-free, 2 mm or less, 2 to 4 mm and greater than 4 mm. RESULTS The average stone dimension +/- SEM was 579 +/- 77 mm(2) in 25 consecutive renal units. CT demonstrated that 15 renal units (60%) were stone-free after the primary procedure, while 2 (8%), 5 (20%) and 3 (12%) had fragments 2 or less, 2 to 4 and greater than 4 mm, respectively. Of 21 renal units considered endoscopically and fluoroscopically stone-free postoperative CT demonstrated that 6 had residual fragments, of which all were less than 4 mm. All 4 renal units not considered radiologically and endoscopically stone-free had fragments on CT. Intraoperative fluoroscopy after nephroscopy demonstrated fragments in 36% of renal units, of which after further nephroscopy 78% were stone-free on CT. The sensitivity of intraoperative imaging with reference to the gold standard of postoperative CT was 40%, 38% and 100% at thresholds of 0, 2 and 4 mm, respectively. Specificity was 100%, 94% and 95%, respectively. CONCLUSIONS Flexible nephroscopy combined with high magnification rotational fluoroscopy allows sensitive and specific intraoperative detection of residual fragments, enabling immediate removal or the planning of necessary second look nephroscopy.

Confident Intraoperative Decision Making During Percutaneous Nephrolithotomy: Does This Patient Need a Second Look?

OBJECTIVES To evaluate intraoperative decision making regarding the necessity of second-look nephroscopy after percutaneous nephrolithotomy. METHODS Percutaneous nephrolithotomy was performed cooperatively by a urologist and radiologist equipped with a high-resolution C-arm. Ultrasonic lithotripsy was performed followed by thorough flexible nephroscopy and fluoroscopy. At conclusion patients were prospectively classified as radiologically and/or endoscopically stone free. If confident that complete stone clearance had been atraumatically achieved, a ureteral stent was placed. If there was suspicion of trauma or residual calculi, a nephrostomy tube was inserted. Postoperative CT was performed and allowed fragment classification as stone free, less than 2 mm, 2 to 4 mm, or 4 mm or greater. RESULTS Average stone dimensions were 640.2 +/- 412.5 mm2 in 39 consecutive renal units. Computed tomographic imaging demonstrated that 26 renal units (66.7%) were stone free after primary procedure, with 5 (12.8%), 5 (12.8%), and 3 (7.7%) having fragments less than 2 mm, 2 to 4 mm, and greater than 4 mm, respectively. Of the 34 renal units considered endoscopically and fluoroscopically stone free, postoperative CT demonstrated 9 with residual fragments, all less than 4 mm. Of the 5 renal units not considered radiologically and endoscopically stone free, 4 had fragments on CT. Nephrostomy tubes were avoided in 33 patients. This intraoperative decision was supported by negative predictive values of 100%, 88%, and 73% at postoperative CT fragment detection thresholds of 4 mm, 2 mm, and 0 mm, respectively. CONCLUSIONS Rigorous fragment detection allows confident intraoperative decision making regarding the necessity of second-look nephroscopy.

Tracheobronchial metal stents: Effects of covering a bronchial ostium in pigs

RATIONALE AND OBJECTIVES The purpose of this study was to examine the effects of placing a metal stent across a bronchial orifice. MATERIALS AND METHODS Nine pigs were used as test subjects, because the right upper lobe bronchus comes directly off the trachea in these animals. One of three types of metal stents was placed into the trachea of each pig and covered the orifice of the right upper lobe bronchus. Follow-up studies were performed at 1 and 3 months to evaluate the right upper lobe for signs of bronchial obstruction, infection, and atelectasis. The animals were sacrificed at 3 months to study the histopathologic changes of the trachea and lungs. RESULTS Two upper lobe bronchi remained patent; seven were obstructed by granulation tissue or plugs of mucus and inflammatory cells. Right upper lobe infiltration and atelectasis were seen in eight animals. Interestingly, radiographic opacities were also common in other lung segments. There was a tendency toward fewer and less extensive lung opacities at 3 months compared with that at 1 month. At histopathologic examination, areas of both acute and chronic pneumonia were found in the right upper lobe of all animals. The segment of trachea covered by the stent was lined with a thin layer of granulation tissue containing neutrophils, monocytes, and lymphocytes. The stent luminal surface was covered with columnar, cuboidal, and stratified squamous epithelium. Tracheal stenosis was seen in three animals because of excessive granulation tissue in two and a collapsed stent in one. CONCLUSION Placement of metal stents in pig trachea covering the orifice of the right upper lobe bronchus resulted in retention of secretions and secondary infection in the right upper lobe and other distant lung segments.

Vacuum-Assisted Thrombectomy of Massive Pulmonary Embolism

Figure 4. Axial gadolinium-enhanced T1-weighted magnetic resonance imaging of a 63-year-old man with hepatocellular carcinoma 1month after treatment with IRE. Note the zone of ablation (arrows) extending beyond the unenhanced tumor (#). Asterisk indicates contracted gallbladder. Arrowheads (˄) indicate perfusional changes adjacent to the zone of ablation and not tumor recurrence. Young et al ’ JVIR 1094 ’ Letters to the Editor

Treatment of peristomal hemorrhage: A review of outcomes and comparison of two minimally invasive techniques

PURPOSE The purpose of this study was to review and compare outcomes between percutaneous sclerotherapy and transjugular intrahepatic portosystemic shunt (TIPS) treatments in patients with peristomal variceal bleeding. MATERIALS AND METHODS Ten patients who underwent sclerotherapy (n = 3 patients), TIPS placement (n = 5 patients) or both (n= 2 patients) for peristomal variceal bleeding were retrospectively reviewed. There were 6 women and 4 men, with a mean age of 62.6 years (range: 44-84 years). Data pertaining to the technical aspects of the procedure, demographics, and information regarding the underlying cause of ostomy and portal hypertension were collected. Treatment was considered a primary success if no further hemorrhage occurred. RESULTS No differences in primary success were found between TIPS cohort (100%) and sclerotherapy cohort (40%) (P=0.4). Sclerotherapy patients had a poorer nutritional status (mean albumin serum level of 2.04g/dL in the sclerotherapy group and 2.95g/dL in theTIPS group; P=0.04) and worse liver function (mean total bilirubin serum level of 4.9mg/dL in the sclerotherapy group and 1.6mg/dL in the TIPS group; P=0.07). CONCLUSION While further investigation is needed, TIPS may be more effective than sclerotherapy in treating peristomal variceal bleeding. However, sclerotherapy may serve as an effective bridging mechanism in critically ill patients.

Percutaneous gastric tube placement: Comparison of trans-abdominal and trans-oral approach in patients with chronic ascites

PURPOSE The purpose of this study was to compare the trans-abdominal (TA) and trans-oral (TO) approaches for fluoroscopic-guided gastrostomy tube placement in patients with chronic ascites. MATERIALS AND METHODS A 10-year review of clinical imaging and medical records at a single institution identified 29 patients with chronic recurrent ascites who underwent gastrostomy (GT) or gastro-jejunostomy tube (GJT) placement. In 22 patients (18 women, 4 men) aged from 22 to 76 years of age (mean age, 57.7±13.1 years), a GT or GJT was placed with the TO approach, and in 7 (7 women) from 31 to 86 years of age (mean age, 63±16.8 years) with the TA approach. RESULTS Technical success was 100% in both groups with one (1/22; 5%) immediate complication in the TO group. Fluoroscopy time was significantly greater in the TO group (P=0.002). Leakage of ascites was significantly more frequent in the TA group (P=0.04). There was no significant difference in bleeding or inflammation (P=0.14 and P=0.43, respectively). The cumulative tract related complication rate was significantly greater in the TA group (P=0.03). CONCLUSION Fluoroscopy times and the overall incidence of tract-related complications, in particular leakage of ascites from the stoma, are more frequent in patients in chronic ascites who underwent TA gastrostomy tube placement compared to those who underwent TO placement.