Renan Uflacker

Transpapillary stenting of proximal biliary strictures: does biliary sphincterotomy reduce the risk of postprocedure pancreatitis?

BACKGROUND Pancreatitis after biliary stenting is a rare complication. To reduce this risk, some endoscopists routinely perform biliary sphincterotomy before stenting, but the value of this practice is not established. METHODS The incidence of pancreatitis was reviewed in patients undergoing biliary stenting with and without a biliary sphincterotomy. RESULTS Postprocedure pancreatitis occurred in 4 of 83 (4.8%) patients treated with transpapillary biliary stents. Patients with proximal biliary strictures were at significantly increased risk for postprocedure pancreatitis (4 of 24) versus those with distal or no strictures (0 of 59) (p = 0.006). The four patients with pancreatitis after stenting had not undergone sphincterotomy. Of those treated conservatively, two cases were graded severe (one fatal), and one was mild. The other patient was markedly symptomatic from pancreatitis, but improved dramatically after treatment with a needle-knife sphincterotomy done within 24 hours of the original ERCP. CONCLUSION The risk of pancreatitis following transpapillary biliary stenting is increased in patients with proximal biliary strictures. Such lesions (malignant or benign) may serve as a fulcrum, leading to medial deflection of the stent and compression of the pancreatic orifice. The hypothesis that sphincterotomy may decrease the risk of biliary stent-induced obstructive pancreatitis should be tested in patients with proximal biliary strictures.

Isolated Right Segmental Hepatic Duct Injury Following Laparoscopic Cholecystectomy

PurposeLaparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.MethodsTwelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients’ demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2–90 months).ResultsThree patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed.ConclusionSuccessful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.

Hemobilia: Transcatheter occlusive therapy and long-term follow-up

Eight patients with life-threatening hemobilia were treated by percutaneous transcatheter occlusive therapy. The bleeding was caused by a traumatic pseudoaneurysm of the hepatic artery in 6 cases (auto accident in 4, surgery in 1, biliary drainage in 1) and a true aneurysm of the hepatic artery in 2 (unknown etiology in 1 and mycotic in 1). Arterial catheterization was used in all cases except for one in which a direct percutaneous puncture was performed. Gelfoam alone was used as embolic material in 3 patients. In 1 patient each, the material used was gelfoam plus coils, coils alone, blood clot, n-butyl-cyanoacrylate and an occluding balloon catheter. In all cases the bleeding stopped and did not recur during the follow-up period which ranged from 9 months to 14 years. This experience indicates that transcatheter occlusive therapy is an effective method for the treatment of severe hemobilia.

Stent-Graft Treatment of Pseudoaneurysms and Arteriovenous Fistulae in the Carotid Artery

The purpose of this study was to assess the safety and efficacy of stent-graft placement in the management of arteriovenous fistulae (AVF) and pseudoaneurysms (PAs) involving the carotid artery (CA). Twenty-two patients (16 men, 6 women) with a CA AVF (n = 5) or PA (n = 17) owing to a gunshot or stab wound, carotid endarterectomy, blunt trauma, a tumor, spontaneous dissection, or a central venous catheter were treated with percutaneous placement of stent grafts. The patients presented with tumor, bruit, headache, mouth and tracheostomy bleeding, transitory hemiparesis, seizure, or stroke. Diagnoses were made by using computed tomographic angiography (CTA) and digital subtraction angiography. Fourteen lesions were in the common CA; eight were in the internal CA. Homemade devices and stent grafts from a variety of manufacturers were employed. Follow-up evaluations included clinical, CTA, and Doppler ultrasound assessments. All patients had resolution of the PA or AVF. In one patient with a large petrous PA, acute occlusion of the CA developed after placement of three balloon-expandable stent grafts, but there were no neurologic complications because the circle of Willis was functional. During follow-up ranging from 2 months to 13 years, asymptomatic 90% stenosis owing to stent compression was observed on Doppler ultrasound and angiographic examinations in a patient with an autologous vein–covered stent graft in the internal CA. Three other patients died of causes unrelated to stent-graft placement. In all other patients, the stent graft remained patent. Our results indicate that stent grafting is an acceptable alternative to surgery in the treatment of AVF and PAs in the CA.

Treating complications of subclavian vein puncture by embolization of the internal mammary artery

Embolization therapy is reported in 2 patients who had vascular complications following percutaneous subclavian vein catheterization. One had an arteriovenous fistula between the right internal mammary artery (IMA) and the brachiocephalic vein. The other patient presented with a pseudoaneurysm of the IMA with life-threatening hemorrhage and a large thoracic hematoma. A detachable latex balloon was used for occlusion of the arteriovenous fistula in the first patient and a steel spring coil was used to embolize the IMA and the pseudoaneurysm in the second patient. The lesions were successfully treated on follow-up of 30 months for the first patient and 37 months for the other.

Comparative results of doppler sonography after TIPS using covered and bare stents

OBJECTIVE Our purpose was to evaluate the role of sonography in the early follow-up of patients with a covered transjugular intrahepatic portosystemic shunt (TIPS). CONCLUSION Routine baseline Doppler sonography should occur 7-14 days after shunt placement unless malfunction or procedural complications are suspected.

Lipiodol retention within hepatic cavernous hemangioma

Intraarterial injection of Lipiodol has been recommended to differentiate hepatocellular carcinoma from benign lesions such as cavernous hemangioma, because uptake and prolonged retention of the contrast medium is a characteristic of the malignant tumors. In two cases of cavernous hemangioma of the liver in which we injected Lipiodol, uptake and retention up to 3 months was demonstrated. We conclude that the intraarterial injection of Lipiodol may not be reliable in differentiating hepatocellular carcinoma from cavernous hemangioma of the liver.

Percutaneous Transhepatic Biliary Drainage: Alternatives in Left Hepatic Duct Obstruction

The left-lobe subxiphoid approach has been the standard way to drain left hepatic duct occlusion. A new, right-side biliary drainage approach is described.Five patients, among 25 patients with bilateral biliary obstruction, were treated by an internalinternal drainage system. Three types of internalinternal drainage techniques are described: internal-internal luminal, type 1; internal-internal luminal, type 2; and internal-internal transductal, type 3.All 5 patients succeeded in biliary drainage. The internal-internal biliary drainage technique, performed from the right-side approach, is effective, avoids additional liver puncture and tract dilatation, and allows the combination of several biliary drainage techniques, adding greatly to the flexibility when treating intrahepatic obstruction. No complications were observed in our small series but special precaution should be taken with the transductal technique due to the possibility of bleeding.

Angiographic and Histologic Comparison of Injectable, Expansile Hydrogel Embolic and Pushable AZUR Embolic Devices in Porcine Arteries

PURPOSE To compare an injectable hydrogel embolic device with a pushable AZUR device procedurally, angiographically, and histologically in the embolization of porcine arteries. MATERIALS AND METHODS In 12 pigs, embolization of renal, gluteal, and hepatic or thoracic arteries was performed with either injectable hydrogel embolic devices (two arteries per pig) or an AZUR device (one artery per pig). Follow-up angiography was performed before sacrifice in five pigs at 7 days after embolization and seven pigs at 90 days after embolization. The harvested tissues were evaluated histologically. Continuous and ordinal results were compared using analysis of variance and χ(2) tests. RESULTS For the sites with embolization performed with injectable hydrogel, complete angiographic occlusion was obtained in 21 of 24 (88%) sites after treatment, 10 of 10 (100%) sites at 7 days, and 10 of 14 (72%) sites at 90 days. For the sites with embolization performed with AZUR devices, complete angiographic occlusion was obtained in 10 of 12 (83%) sites after treatment, 4 of 5 (80%) sites at 7 days, and 5 of 7 (72%) sites at 90 days. Statistically significant differences in angiographic occlusion were not observed at 7 days (P = .13) or 90 days (P = .35). The embolization time of the injectable hydrogel group (14 minutes ± 8) was significantly reduced (P = .02) compared with the AZUR group (22 minutes ± 12). Differences between the groups in arterial wall damage were not evident at either 7 days or 90 days, although greater damage was observed in both groups at 90 days. In both groups, inflammation was nonexistent to minimal at 7 days and minimal to mild at 90 days. CONCLUSIONS Embolization of porcine arteries was as effective with injectable hydrogel embolic devices as pushable AZUR devices, as evidenced by the procedural, angiographic, and histologic results.