Olivier Meyrignac

Acute Pancreatitis: Extrapancreatic Necrosis Volume as Early Predictor of Severity

PURPOSE To determine the volume of extrapancreatic necrosis that predicts severe acute pancreatitis and to assess the reliability of this threshold in predicting severe acute pancreatitis compared with current scoring systems and C-reactive protein (CRP) levels. MATERIALS AND METHODS This institutional review board-approved, HIPAA-compliant retrospective study included patients with acute pancreatitis who were examined with computed tomography (CT) 2-6 days after disease onset. Extrapancreatic necrosis volume, Balthazar score, and CT severity index (CTSI) were calculated. CRP levels 48 hours after the onset of symptoms were reviewed. Outcome parameters included organ failure, infection, need for surgery or percutaneous intervention, duration of hospitalization, and/or death. Receiver operating characteristic (ROC) curves were constructed to determine the optimal threshold for predicting clinical outcomes. Pairwise comparisons of areas under ROC curves (AUCs) from the different grading systems were performed. Interobserver and intraobserver agreement in the grading of extrapancreatic necrosis was assessed by using κ statistics. RESULTS In 264 patients, significant relationships were found between extrapancreatic necrosis volume and organ failure, infection, duration of hospitalization, need for intervention, and death (P < .001 for all). The optimal threshold for predicting severe acute pancreatitis was 100 mL. Sensitivity and specificity were 95% (19 of 20) and 83% (142 of 172), respectively, for predicting organ failure (vs 100% [20 of 20] and 46% [79 of 172] for the Balthazar score and 25% [five of 20] and 95% [163 of 172] for the CTSI). The extrapancreatic necrosis AUC was the highest for all systems. Interobserver and intraobserver agreement based on the 100-mL threshold was considered to be excellent. CONCLUSION A simple grading system based on an objective criterion such as a threshold of 100 mL of extrapancreatic necrosis provides more reliable information for predicting acute pancreatitis outcomes than do the current scoring systems.

Orthotopic branched endovascular aortic arch repair in patients who cannot undergo classical surgery

OBJECTIVES Our goal was to assess the results after orthotopic branched endovascular aortic arch repair using a new double-branch endoprosthesis in patients with thoracic aortic disease affecting the aortic arch who cannot undergo classical surgery. METHODS Within a 4-year period, 15 patients with thoracic aortic disease affecting the aortic arch were treated with the Bolton Relay plus double-branch endoprosthesis (Bolton Medical, Sunrise, FL, USA). We assessed clinical outcome, occurrence of endoleaks and the need for secondary interventions. The median logistic EuroSCORE I level was 13.6 (4.2; 22.8). RESULTS The in-hospital mortality rate was 6.7%. A disabling stroke was observed in 1 (6.7%) patient, whereas non-disabling strokes occurred in 2 (13.3%) patients. Type I and III endoleaks occurred in 6.7%. The median follow-up period was 263 (1st quartile 84; 2nd quartile 564) days. Four patients died during the follow-up period. Aortic-related survival was 100%. CONCLUSIONS Orthotopic branched endovascular aortic arch repair using the Bolton Relay Plus double-branch endoprosthesis is a safe and feasible technique enriching the armamentarium to treat patients with thoracic aortic disease who cannot undergo classical surgery. Aortic-related survival is excellent, and the occurrence of disabling stroke and endoleaks warranting treatment is low. Further studies are needed to assess the long-term durability of this new method.

Non-contrast-enhanced MR angiography using time-spin labelling inversion pulse technique for detecting crossing renal vessels in children with symptomatic ureteropelvic junction obstruction: comparison with surgical findings.

ObjectivesInvestigate the feasibility and evaluate the accuracy of non-contrast-enhanced MR angiography (NC-MRA) using time-spin labelling inversion pulse (time-SLIP)to identify crossing renal vessels (CRVs) in children requiring surgical treatment of ureteropelvic junction (UPJ) obstructionand compare to laparoscopic findings.Materials and methodsNineteen children ranging from 6 to 16 years of age underwent NC-MRA using the time-SLIP technique before surgery. Two independent readers analysed the MRA images. Number of renal arteries and presence or absence of CRVs were identified and compared with surgicalfindings. Image quality was assessed, as well as the presence of CRVs and measurement of renal pelvis diameter. Intra and inter-reader agreement was calculated using Cohen’s kappa coefficient and Bland–Altman plots.ResultsThe overall image quality was fair or good in 88% of cases. NC-MRA demonstrated CRVs at the level of the obstruction in 10 children and no CRV in 9 children. All were confirmed intra-operatively except in one of the nine children. Sensitivity, specificity, NPV, PPV for predicting CRVs were 92%, 100%, 100% and 87.5%, respectively, for both readers.ConclusionNC-MRA is a good alternative to contrast-enhanced MRA and CT scanning for identifying CRVs in children with symptomatic UPJ.Key points• Time-SLIP technique offers acceptable imaging quality for identifying crossing renal vessel.• Time-SLIP technique is easy to apply to the renal MRA examination.• Time-SLIP technique is an alternative to contrast-enhanced MRA and CT scanning.

Other non-surgical treatments for liver cancer

Interventional radiology plays a major role in the modern management of liver cancers, in primary hepatic malignancies or metastases and in palliative or curative situations. Radiological treatments are divided in two categories based on their approach: endovascular treatment and direct transcapsular access. Endovascular treatments include mainly three applications: transarterial chemoembolization (TACE), transarterial radioembolization (TARE) and portal vein embolization (PVE). TACE and TARE share an endovascular arterial approach, consisting of a selective catheterization of the hepatic artery or its branches. Subsequently, either a chemotherapy (TACE) or radioembolic (TARE) agent is injected in the target vessel to act on the tumor. PVE raises the volume of the future liver remnant in extended hepatectomy by embolizing a portal vein territory which results in hepatic regeneration. Direct transcapsular access treatments involve mainly three techniques: radiofrequency thermal ablation (RFA), microwave thermal ablation (MWA) and percutaneous ethanol injection (PEI). RFA and MWA procedures are almost identical, their clinical applications are similar. A probe is deployed directly into the tumor to generate heat and coagulation necrosis. PEI has known implications based on the chemical toxicity of intra-tumoral injection with highly concentrated alcohol by a thin needle.