Righi D

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

PurposeThe authors present a retrospective analysis of a large series of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement.Materials and methodsBetween March 1992 and December 2006, 658 patients were referred to our centre for TIPS placement. Indications for the procedure were digestive tract bleeding (52.8%), refractory ascites (35.3%), preservation of portal vein patency prior to liver transplantation (3.0%) and thrombosis of the suprahepatic veins (2.3%). Other indications (6.6%) included pleural ascites, portal thrombosis and hepatorenal and hepatopulmonary syndromes. All patients were evaluated with colour Doppler ultrasonography and in a few cases with computed tomography. The portal system was punctured under sonographic guidance. Wallstent, Palmaz and Nitinol thermosensitive stents were used. Embolisation of persistent varices was performed in 6.8% of cases.ResultsTechnical success was 98.9%. During a 1,500-day follow-up, the cumulative incidence of stent revision was 25.7% (Nitinol), 32.9% (Wallstent) and 1.8% (Palmaz). Mortality rates were 31.1%, 38.5% and 56.4%, respectively. The technical complications included six cases of heart failure, six of haematobilia, three of stent migration, two of intrahepatic haematoma and one of haemoperitoneum. Eight patients with severe portosystemic encephalopathy (PSE) were treated with a reduction stent.ConclusionsTIPS placement is safe and effective and may act as a bridge to liver transplantation. Ultrasonography plays a fundamental role in the preliminary assessment, in portal vein puncture and during the follow-up. Stent patency is satisfactory.RiassuntoObiettivoGli autori presentano un’analisi retrospettiva di un’ampia casistica di pazienti sottoposti a TIPS.Materiali e metodiSono giunti al nostro centro per la TIPS 658 pazienti tra il marzo 1992 e il dicembre 2006. Le indicazioni alla procedura erano: sanguinamento digestivo (52,8%), ascite refrattaria (35,3%), “tutela” della pervietà portale pre-trapianto epatico (3,0%), trombosi delle vene sovraepatiche (2,3%). Altre indicazioni (6,6%) erano ascite pleurica, trombosi portale, sindrome epato-renale ed epato-polmonare. I pazienti sono stati studiati con ecocolor doppler, raramente con tomografia computerizzata; la puntura portale è stata ecoguidata. Sono stati impiegati stent Palmaz, Wallstent e termoespandibili. Nel 6,8% dei casi sono state embolizzate varici persistenti.RisultatiIl successo tecnico è stato del 98,9%. Durante un follow-up di 1500 giorni, l’incidenza cumulativa di reintervento sugli stent è stata del 25,7% (Nitinol), 32,9% (Wallstent) e 1,8% (Palmaz); la mortalità è stata rispettivamente 31,1%, 38,5% e 56,4%. Le complicanze tecniche sono state: 6 insufficienze cardiache, 6 emobilie, 3 migrazioni di stent, 2 ematomi intraepatici ed 1 emoperitoneo. Otto pazienti con encefalopatia portosistemica (PSE) grave sono stati trattati con stent riduttore.ConclusioniLa TIPS è sicura ed efficace, può rappresentare un ponte all’OLT. L’ecografia ha un ruolo fondamentale nello studio preliminare, durante la puntura portale e nel follow-up. La pervietà degli stent è soddisfacente.

Interventional procedures for biliary drainage with bilioplasty in paediatric patients: dosimetric aspects

Purpose . This study was undertaken to evaluate patient dose in paediatric liver transplant recipients treated by percutaneous biliary drainage and bilioplasty proceduresMaterials and methods . Effective dose rates and entrance skin-dose (ESD) rates per minute of fluoroscopy were measured by using a plexiglas phantom (thickness 10 cm) simulating the patient and by varying the exposure parameters (type of pulsed fluoroscopy, image intensifier diameter, presence of diaphragms) to identify the technique delivering the lowest patient dose. In vivo measurements were performed during three interventional proceduresResults . The effective dose rate proved to be lowest for a particular type of pulsed fluoroscopy, with maximum magnification and with field-limiting diaphragms. The in vivo measurements showed a maximum ESD value of around 50 mGy (the threshold for transient erythema is 2,000 mGy, ICRP 60). The effective dose values were in the range of 0.9–1.5 mSvConclusions . We established exposure parameters providing the desired image quality with the lowest dose for the equipment used and for a specific type of interventional procedure. The measured ESD values allow us to exclude the risk of deterministic effects on the skin. The effective dose values and considerations regarding the likelihood of radiation-induced cancer led to the conclusion that the radiological risk for the patient is largely justified by the benefits of these kinds of procedureRiassuntoObiettivo . Valutazione della dose al paziente per procedure di drenaggio biliare e bilioplastica percutanea in pazienti pediatrici trapiantati di fegatoMateriali e metodi . Sono stati misurati i ratei di dose efficace e di dose superficiale in ingresso (ESD) per minuto di scopia, simulando la presenza del paziente con fantoccio in plexiglass di 10 cm di spessore e variando i parametri di esposizione (tipo di scopia pulsata, diametro IB, presenza di diaframmi) al fine di individuare le modalità che consentono di minimizzare la dose. Nel corso di tre procedure sono state effettuate misure in vivoRisultati . I valori di rateo di dose efficace sono risultati minimi per un particolare tipo di scopia pulsata, per il massimo ingrandimento e in presenza di diaframmatura. I risultati delle misure in vivo mostrano un valore massimo di ESD di circa 50 mGy (valore soglia per eritema temporaneo 2000 mGy, ICRP 60). I valori di dose efficace sono compresi tra 0,9 e 1,5 mSvConclusioni . Sono stati stabiliti i parametri di esposizione che consentono di ottenere la qualità di immagine desiderata con la minima dose, per l’apparecchiatura utilizzata e per questa tipologia di procedure. I valori di ESD misurati permettono di escludere il rischio di insorgenza di danni deterministici alla cute. I valori di dose efficace e le considerazioni conseguenti relative alla probabilità di induzione di tumori letali consentono di affermare che i benefici associati a questo tipo di procedure giustificano ampiamente l’esposizione del paziente al rischio radiologico associato

The radiologist’s role in managing paediatric liver transplantation: personal experience with 40 patients

AbstractPurpose.The aim of our study was to evaluate the radiologists role in managing paediatric orthotopic liver transplantation (OLT) through a retrospective review of our experience in diagnosing and treating post-OLT complications.Materials and methods.Forty children (mean age 4.6 years) underwent 44 OLTs over 71 months. The follow-up period (mean 724 days) was divided into three phases: hospital stay, up to three months after discharge and subsequent period. The number and type of radiological examinations, radiologically detectable complications and interventional procedures were analysed.Results.Most examinations were carried out with ultrasound (US) (859/931 of all radiological studies performed during the first two phases, 92.3%). Colour-Doppler US enabled early detection and treatment of all vascular complications (9/40, 22.5% of patients; 13 complications in nine patients, eight arterial and five portal complications; 1.4 for each patient with complications). Computed tomography (CT) or angiography was very rarely employed. US also detected biliary complications (11 patients, 27.5%: three cases of segmental ducts excluded from the anastomosis, four cases of stenosis of the biliodigestive anastomosis, one lithiasis, three stenoses associated with lithiasis), which were successfully managed in 75% of the cases treated with interventional radiology procedures (percutaneous bilioplasty and/or lithotripsy). At the time of writing this paper, the patient survival rate was 100%, and the organ survival rate was 91% (40/44). There were four retransplantations: three due to hepatic artery thrombosis and one to biliary stenosis with lithiasis.Conclusions.The radiologists role is fundamental for early sonographic diagnosis of post-OLT complications in children. Vascular complications are often associated in a single patient, and early treatment may improve the prognosis. Interventional radiology represents a safe and effective treatment for many biliary complications.

Interventional radiology in the treatment of early postoperative biliary complications

PurposeWe sought to evaluate the feasibility and efficacy of percutaneous treatment of early postoperative biliary complications. The primary aims were to evaluate clinical and technical success and complications and perioperative mortality, and secondary aims were to evaluate treatment duration and recurrence rate.Materials and methodsBetween March 2007 and March 2010, 75 patients (42 men and 33 women; age range, 17–88 years; mean age, 60.8 years) underwent interventional radiology procedures to treat early postoperative biliary complications of biliary and pancreatic-duodenal surgery with biliodigestive anastomosis (37.7%), laparoscopic cholecystectomy (30.6%), hepatic resection (21.1%) and several other surgical procedures (10.6%). Complications included fistulas (73%), stenoses (20%) and complete bile duct transections (7%).ResultsInterventional radiology achieved complete clinical success in 74 cases (85.9%) and in particular in 95.2% of fistulas, 76.5% of stenoses and 33.3% of complete bile duct transections. Mean indwelling catheter time was 34.9 days, with an average of 4.1 procedures. There were two cases of severe haemobilia (2.3%). Minor complications occurred in 7% of cases. Perioperative mortality rate was 1.2% and overall recurrence rate 6.7% (range, 1–18 months; mean, 10 months), with recurrences occurring predominantly in stenoses. All patients were retreated successfully.ConclusionsPercutaneous procedures are feasible, effective and safe for treating early postoperative biliary complications. They provide a valuable alternative to presendoscopy, which is precluded in many of these patients, and to surgery, which has higher morbidity and mortality rates.RiassuntoObiettivoScopo del nostro lavoro è stato valutare fattibilità ed efficacia del trattamento percutaneo transepatico delle complicanze precoci post-operatorie delle vie biliari. Obiettivo primario è stato la valutazione del successo tecnico e clinico, delle complicanze e della mortalità perioperatoria. Obiettivi secondari sono stati valutare la durata del trattamento e le recidive a distanza.Materiali e metodiTra marzo 2007 e marzo 2010, 75 pazienti (42 maschi e 33 femmine, età compresa tra 17 e 88 anni, età media 60,8 anni), sottoposti ad interventi di chirurgia biliare e pancreatico-duodenale con anastomosi bilio-digestiva (ABD) (37,7%), colecistectomia laparoscopica (CL) (30,6%), resezione epatica (RE) (21,1%) e vari (VV) (10,6%) sono stati trattati con procedure di radiologia interventistica (RI) in quanto portatori di complicanze precoci post-operatorie delle vie biliari (fistole 73%; stenosi 20%; distacchi completi 7%).RisultatiAbbiamo registrato un successo clinico complessivo (guarigione della complicanza ottenuta con le procedure interventistiche) in 74/85 casi (85,9%): 95,2% nelle fistole, 76,5% nelle stenosi e 33,3% nei distacchi completi. Il tempo medio di permanenza del catetere è stato di 34,9 giorni con una media di 4,1 procedure eseguite. Abbiamo riportato 2 emobilie severe (2,3%); complicanze minori sono insorte nel 7% dei casi. La mortalità perioperatoria è stata dell’1,2%. L’incidenza complessiva di recidive a distanza è stata del 6,7% (1–18 mesi, media 10 mesi) con netta prevalenza delle stenosi. Tutti i pazienti sono stati ritrattati con successo.ConclusioniLe procedure percutanee sono fattibili, efficaci e sicure nel trattamento delle complicanze precoci post-operatorie delle vie biliari; rappresentano una valida alternativa al trattamento endoscopico, non eseguibile in molti di questi pazienti, ed alla chirurgia, gravata da tassi di morbilità e mortalità più elevati.