Assessment of needle guidance devices for their potential to reduce fluoroscopy time and operator hand dose during C-arm cone-beam computed tomography-guided needle interventions.

PURPOSE: To assess whether the use of needle guidance devices can reduce fluoroscopy time and operator hand dose during cone-beam computed tomography-guided needle interventions. MATERIALS AND METHODS: The freehand technique was compared with techniques employing two distinct needle holders and a ceiling-mounted laser guidance technique. Laser guidance was used either alone or in combination with needle holders. Four interventional radiologists were instructed to reach predetermined targets in an abdominal phantom using these techniques. Each operator used all six techniques three times. Fluoroscopy time, procedure time, operator hand dose, and needle tip deviation were obtained for all simulated needle interventions. All data are presented as median (ranges). RESULTS: All procedures were successfully completed within 2-4 minutes, resulting in a deviation from target of 0.8 mm (0-4.7). In freehand procedures, the fluoroscopy time to reach the target was 50 seconds (31-98 s). Laser guidance, used alone or in combination with needle holders, reduced fluoroscopy time to 31 seconds (14-68 s) (P<.02). The operator hand dose in freehand procedures was 275 µSv (20-603 µSv). Laser guidance alone or in combination with needle holders resulted in a reduction of the hand dose to<36 µSv (5-82 µSv) per procedure (P<.001). There were no statistically significant effects on hand dose levels or fluoroscopy time when the needle holders were employed alone. CONCLUSIONS: Compared with the freehand technique, all three tested needle guidance devices performed with equivalent efficiency in terms of accuracy and procedure time. Only the addition of laser guidance was found to reduce both fluoroscopy time and operator hand dose.

Hemobilia as a late complication after blunt abdominal trauma: a case report and review of the literature.

BACKGROUND: Bleeding within the biliary tree, called hemobilia, is a rare complication after blunt hepatic trauma. OBJECTIVES: To report on a patient who developed hemobilia 1 month after a blunt abdominal injury and to discuss the diagnosis and treatment of hemobilia. CASE REPORT: A 17-year-old boy presented with upper gastrointestinal bleeding caused by hemobilia 1 month after a blunt liver injury. Angiography revealed a pseudoaneurysm of the right hepatic artery, which was successfully treated with embolization. CONCLUSIONS: The diagnosis of hemobilia first requires consideration of the diagnosis, particularly in patients with previous abdominal trauma. Hemobilia should be included in the differential diagnosis of upper gastrointestinal bleeding. Investigations of choice include computed tomography scan followed by angiography. During angiography, treatment can be done by endovascular embolization.

Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography.

To assess the variability in accuracy of contrast media introduction, leakage, required time and patient discomfort in four different centres, each using a different image-guided glenohumeral injection technique. Each centre included 25 consecutive patients. The ultrasound-guided anterior (USa) and posterior approach (USp), fluoroscopic-guided anterior (FLa) and posterior (FLp) approach were used. Number of injection attempts, effect of contrast leakage on diagnostic quality, and total room, radiologist and procedure times were measured. Pain was documented with a visual analogue scale (VAS) pain score. Access to the joint was achieved in all patients. A successful first attempt significantly occurred more often with US (94%) than with fluoroscopic guidance (72%). Leakage of contrast medium did not cause interpretative difficulties. With US guidance mean room, procedure and radiologist times were significantly shorter (p < 0.001). The USa approach was rated with the lowest pre- and post-injection VAS scores. The four image-guided injection techniques are successful in injection of contrast material into the glenohumeral joint. US-guided injections and especially the anterior approach are significantly less time consuming, more successful on the first attempt, cause less patient discomfort and obviate the need for radiation and iodine contrast.

Axillary recurrence after a negative sentinel node biopsy for breast cancer: incidence and clinical significance.

BACKGROUND: Sentinel lymph node biopsy (SLNB) carries the inherent risk of approximately 5% false-negative sampling. Undetected tumor-positive nodes of clinical importance are those that lead to axillary recurrence. This survey aims at clarifying the extent of this problem in current practice and literature. METHODS: In a regional teaching hospital, 696 consecutive breast cancer patients underwent SLNB between January 1998 and July 2003, and data were entered in a prospective database. PubMed and the Cochrane library were searched for a systematic review of the literature. Thirteen studies dealt with the follow-up of a cohort of sentinel lymph node (SLN)-negative patients or presented a case report. RESULTS: The SLN identification rate was 97.1%. The SLN was tumor free in 439 (65%) of the 676 patients. After a median follow-up of 26 months, axillary recurrence was detected in 2 of 439 patients 4 and 27 months after the SLNB. The incidence of clinically apparent false-negative SLNB is .46%. The systematic review resulted in 3184 SLNB-negative patients with a median follow-up of 25 months. Axillary recurrence occurred in eight patients after a median of 21 months. The axillary recurrence rate in the literature is .25%. One third of these patients present with synchronous systemic metastases. CONCLUSIONS: Axillary recurrences after a negative SLNB occur, but at a much lower rate than would be expected on the basis of historical figures and the false-negative SLN findings. The natural history of axillary relapse after negative SLNB resembles the locoregional recurrence of breast cancer.

Sentinel lymph node biopsy performed under local anesthesia is feasible.

BACKGROUND: A sentinel lymph node (SLN) biopsy in breast cancer patients, performed under local anesthesia (LA), could have advantages such as more efficient use of operating room time and pathologist time. It also provides a histologic diagnosis before definitive breast surgery is undertaken. The aim of this study was to assess feasibility by comparing the results of SLN procedures performed under LA versus general anesthesia (GA). METHODS: The SLN procedure was performed in 50 consecutive outpatients and 167 inpatients with clinical T1-2N0 breast cancer while they were under LA and GA, respectively. The SLN detection rate, a comparison of mapped and harvested SLNs, was compared for both groups. The duration of the SLN biopsies performed under LA was also measured. RESULTS: For both groups a median of 2 SLNs/patient were harvested. The detection rate was 1.00 for the LA group and 0.99 for the GA group. The learning curve for SLN procedures under LA showed a decrease in duration for the consecutive months (not significant). CONCLUSIONS: SLN biopsy can be safely and adequately performed with the patient under LA. It allows early diagnosis of the lymph node status, acquired on an outpatient basis, with minimal discomfort to the patient. The learning curve demonstrated that the LA procedure can quickly be mastered if the surgeon is experienced in performing SLN biopsies.