Comparative Analysis of Percutaneous Drainage versus Operative Drainage of Intra-Abdominal Abscesses in a Resource-Limited Setting: The Tanzanian Experience.

Background: Intra-abdominal abscesses (IAAs) are a major cause of morbidity and mortality worldwide. While image-guided percutaneous abscess drainage (PAD) has become the standard of care in many countries, over half of the global population does not have access to interventional radiology (IR) and are left with surgery as the only option for source control. Objective: The purpose of this study is to evaluate the development, implementation, and role of a PAD service in a resource-limited setting. Method: A retrospective cohort study was performed on all patients who underwent percutaneous or surgical abscess drainage (SAD) of IAAs at Tanzania's national referral hospital from 10/2018 to 4/2021. Patients were identified through a match case search of institutional records and inclusion was confirmed through manual chart review. Demographics, patient presentation, procedural data, and clinical outcomes were recorded in a password-encrypted database and compared between groups. Findings: Sixty-three patients underwent abscess drainage: 32 percutaneously and 31 surgically. In the PAD group, there was a 100% technical success rate and a 0% complication rate. In the SAD group, there was a 64.5% technical success rate and ten deaths within 30 days (32.3%), and one additional complication requiring major therapy (3.2%) (p < 0.001). Conclusion: Results from this study demonstrate that PAD can be performed with high technical success and without complication by trained IR physicians in Tanzania. The development of a successful PAD program exemplifies the drastic need to support the growth of IR services in this setting.

A Prospective Clinical Study of a Percutaneous Vascular Access System for Hemodialysis Catheters.

INTRODUCTION: Dysfunctional or infected hemodialysis polyester-cuffed catheters often require removal and are dissected out. The DermaPort™, percutaneous vascular access system (PVAS) permanently integrates a titanium mesh with the skin forming a stable, sterile barrier that allows for catheter placement, adjustment, or catheter exchange. This study aimed to describe the use and clinical outcomes of the DermaPort PVAS. METHODS: Thirty-eight patients who were receiving hemodialysis via a tunneled catheter were enrolled in this prospective open-label study. Assessments were performed biweekly for the first month and monthly thereafter, which included physical examination of the site of implantation for infection, catheter blood flow, and need for interventions to maintain catheter patency. Patient satisfaction was assessed with a visual analog score. RESULTS: Implantation of technical success was 100% with the implantation site demonstrating early tissue incorporation after 2 weeks and full incorporation within 4 weeks. The DermaPort™ successfully enabled 31 catheter exchanges and 10 repositions thru the port without dissection in 18 patients with nine repositions (90%) performed at bedside. The mean primary patency of the DermaPort™ was 172 ± 150 days, and mean secondary patency was 430 ± 203 days. There were no reportable serious adverse events in 12,100 catheter days of use and zero explantations of the device attributed to infection. The observed catheter infection rate was 0.33/1000 days. CONCLUSIONS: The DermaPort™ system can be effectively implanted and facilitates catheter interventions in hemodialysis patients requiring long-term catheter use and has a lower infection rate than historical catheter infection rates. Clinical Trial Protocol Number DermaPort-001 (no clinicaltrials.gov number as study was performed 9 years ago). Health Canada Reference Application Number: 118393.

Perception of radiation exposure and risk among patients, medical students, and referring physicians at a tertiary care community hospital.

BACKGROUND: It is important for physicians to be aware of the radiation doses as well as the risks associated with diagnostic imaging procedures that they are ordering. METHODS: A survey was administered to patients, medical students, and referring physicians from a number of specialties to determine background knowledge regarding radiation exposure and risk associated with commonly ordered medical imaging tests. RESULTS: A total of 127 patients, 32 referring physicians, and 30 medical students completed the survey. The majority of patients (92%) were not informed of the radiation risks associated with tests that they were scheduled to receive and had false perceptions about the use of radiation and its associated risks. Physicians and medical students had misconceptions about the use of ionizing radiation in a number of radiologic examinations; for example, 25% and 43% of physicians and medical students, respectively, were unaware that interventional procedures used ionizing radiation, and 28% of physicians were unaware that mammography used ionizing radiation. Computed tomographies and barium studies were thought to be associated with the least ionizing radiation among physicians. CONCLUSION: There is a need for educating the public, medical students, and referring physicians about radiation exposure and associated risk so that (1) patients receiving multiple medical imaging tests are aware of the radiation that they are receiving and (2) physicians and future physicians will make informed decisions when ordering such tests to limit the amount of radiation that patients receive and to promote informed consent among patients.

Pathologic assessment of radiofrequency ablation of pulmonary metastases.

PURPOSE: To evaluate pathologically the effectiveness of radiofrequency (RF) ablation in the treatment of pulmonary metastases. MATERIALS AND METHODS: Patients with multiple pulmonary metastases scheduled for surgical resection were prospectively enrolled. Patients underwent RF ablation of one percutaneously accessible tumor and within 2-4 weeks underwent surgical resection of the ablated tumor and any additional lesions. Resected tumors all were assessed by routine light microscopy, and selected tumors were assessed by immunohistochemistry with MIB1 and proliferative cell nuclear antigen (PCNA). Relationship of ablation zone to the tumor and viability of the ablated tumors were assessed. RESULTS: Nine patients (four men and five women) 46-76 years of age were included in the study. Four patients had metastatic colorectal carcinoma, and five patients had metastases from soft tissue sarcomas. Ablated tumors ranged from 1.0-3.0 cm in diameter. Each target lesion was completely encompassed by the ablation zone. All tumor tissue within the ablation zone showed characteristic changes of coagulative necrosis with hematoxylin and eosin staining. Tumors showed preservation of MIB1 staining but loss of PCNA protein staining. RF ablation resulted in complete coagulative necrosis of all the pulmonary metastases treated in the study. CONCLUSIONS: Although this series is small, it provides histologic support for RF ablation as an effective treatment for selected pulmonary metastases.

Role of radiology in geriatric care: a primer for family physicians.

OBJECTIVE: To present family physicians with the options available for diagnosing and treating a selection of common diseases in the elderly using diagnostic and interventional radiology. QUALITY OF EVIDENCE: Articles providing level I or II evidence were included in our review. Most articles presented results from randomized or other case-controlled studies. MAIN MESSAGE: Geriatric care has become a complicated, multidisciplinary effort, with the family physician often leading the team. The expanding cohort of patients is not only better informed than their predecessors, but also more demanding of better care through cutting-edge technology and treatment. Specifically, the role of radiology has expanded quickly in geriatric medicine. Because of complex clinical presentations and rising costs, it is essential for primary care physicians to understand the appropriate use of imaging and radiological intervention. CONCLUSION: There are a number of new and innovative radiological techniques and procedures available for elderly patients. This review aims to inform primary care physicians of a selected number of these techniques.

Imaging and transcatheter arterial embolization for traumatic splenic injuries: review of the literature.

The spleen is the most commonly injured visceral organ in blunt abdominal trauma in both adults and children. Nonoperative management is the current standard of practice for patients who are hemodynamically stable. However, simple observation alone has been reported to have a failure rate as high as 34%; the rate is even higher among patients with high-grade splenic injuries (American Association for the Surgery of Trauma [AAST] grade III-V). Over the past decade, angiography with transcatheter splenic artery embolization, an alternative nonoperative treatment for splenic injuries, has increased splenic salvage rates to as high as 97%. With the help of splenic artery embolization, success rates of more than 80% have also been described for high-grade splenic injuries. We discuss the role of computed tomography and transcatheter splenic artery embolization in the diagnosis and treatment of blunt splenic trauma. We review technical considerations, indications, efficacy and complication rates. We also propose an algorithm to guide the use of angiography and splenic embolization in patients with traumatic splenic injury.

Interdisciplinary Canadian guidelines on the use of metal stents in the gastrointestinal tract for oncological indications.

OBJECTIVE: To provide evidence-based guidelines regarding the appropriate use of gastrointestinal stents for oncologic indications. This document describes the use of gastrointestinal stents by appropriately trained physicians. METHODS: This document is based on a review of the published evidence and supplemented by consensus expert opinion. Gastrointestinal stenting has been evaluated in terms of technical success, complications, patient satisfaction, clinical outcome, and cost-benefit analysis. This document was approved by the Canadian Interventional Radiology Association; approval from the other relevant Canadian societies is pending. CONCLUSION: Gastrointestinal stenting has a valuable role in the management of gastrointestinal malignancy. The decision to use such devices should be taken after comprehensive multidisciplinary clinical, endoscopic, and radiologic evaluation.

Performance of carotid stenting, vertebroplasty, and EVAR: how many are we doing and why are we not doing more? A survey by the Canadian Interventional Radiology Association.

OBJECTIVE: To determine the percentage of interventional radiologists who currently perform 3 interventional procedures: carotid stenting, vertebroplasty, and endovascular aneurysm repair (EVAR) in Canada, and impediments to their future performance by other interventional radiologists. METHODS: An anonymous online survey was emailed to all members of the Canadian Interventional Radiology Association (CIRA). The survey was open for a period of 2 months. RESULTS: A total of 75 survey responses were received (of an estimated 247). Carotid stenting, vertebroplasty, and EVAR were performed at 40%, 59%, and 46% of respondents' centres respectively. Wait times, from referral to consultation, and from consultation to procedure, were both typically between 2 to 4 weeks, longer for EVAR. Of respondents currently not performing these procedures, 26%, 28%, and 16% anticipated beginning to perform carotid stenting, vertebroplasty, and EVAR, respectively, in the proceeding year from time of survey. Of respondents who wished to perform the procedure, the greatest impediments were a lack of training, lack of a referral base, and lack of support from their radiology department and (or) colleagues. CONCLUSIONS: Although carotid stenting, vertebroplasty, and EVAR were being performed at about one-half of respondent's centres, and there will likely be greater adoption of the procedures in the near future, there remain substantial impediments. The greatest impediments to additional radiologists performing these procedures were a lack of training, lack of referral base, and lack of support from their radiology department and (or) colleagues. The former impediment suggested an unmet need for additional training courses.

Safety and efficacy of gastrointestinal stents in cancer patients at a community hospital.

OBJECTIVE: Increasing scientific evidence supports the use of self-expanding metallic gastrointestinal (GI) stents. The commonly accepted primary indications are their usefulness as a bridge to surgery and for palliation to avoid surgery. These stents have been shown to have high technical success and low complication rates, leading to improved quality of life for patients. They have also been shown to be cost-effective when compared with alternative therapies. The objective of this study is to present a retrospective review of our local experience. METHODS: Attempts were made to place 23 GI stents in 16 patients for palliative cancer indications. RESULTS: Follow-up was 5-352 days (mean 81.9 d). Presenting symptoms included abdominal distention or pain (81%), nausea or vomiting (69%), constipation (31%) and weight loss (19%). Stents were placed in the colon (11 patients), duodenum (4 patients) or esophagus (1 patient). The technical success rate was 91.3%, the clinical success rate (defined as any improvement in symptoms in patients successfully receiving a stent) was 85.7%, and the complication rate was 21.4% among patients successfully receiving a stent, or 18.8% overall. Of 14 patients successfully receiving at least 1 stent, 10 (71%) were discharged home after a mean of 11.5 days (range 1-26 d). Of patients successfully receiving at least 1 stent, 12 (86%) had passed away at the time of last follow-up. Patients who successfully received a stent but who have since passed away (either in hospital or out of hospital) had their stent(s) in situ for a mean of 57 days (range 5-180 d). CONCLUSION: On the basis of our data, we believe that GI stents may be safely and effectively used in a community hospital setting and that they provide benefit in the palliative care population.

Uterine fibroid embolization: CME update for family physicians.

OBJECTIVE: To review evidence supporting the use of uterine fibroid embolization (UFE) as an alternative to hysterectomy and myomectomy for managing uterine fibroids. QUALITY OF EVIDENCE: MEDLINE was searched using the MeSH terms embolization, therapeutic; leiomyoma; treatment outcome; pregnancy; and clinical trials. Most published studies on use of UFE for management of uterine fibroids provide level II evidence. MAIN MESSAGE: For 71% to 92% of patients, UFE is effective at alleviating fibroid-related symptoms. After UFE, fibroids are reduced in size by 42% to 83%. Patients' satisfaction with the procedure is high (>90%), and UFE is safe and has a low rate of major complications (1.25%). When compared with hysterectomy, UFE is associated with fewer major complications, shorter hospital stays, and faster recovery. Although successful pregnancy following UFE is possible, there is insufficient evidence to advocate use of UFE over myomectomy for management of uterine fibroids in women wishing to preserve fertility. CONCLUSION: For treatment of symptomatic uterine fibroids, UFE is a safe and effective nonsurgical alternative to hysterectomy and myomectomy.