Transjugular liver biopsy after transjugular intrahepatic portosystemic shunt (TIPS) or direct intrahepatic portocaval shunt (DIPS): Is it feasible, effective, and safe?

PURPOSE: To evaluate our experience with transjugular liver biopsies (TJLB) in patients with previously placed transjugular intrahepatic portosystemic shunt (TIPS) or direct intrahepatic portocaval shunt (DIPS). MATERIAL AND METHODS: A single-institution retrospective review was performed looking at all TJLBs in patients with previously placed TIPS or DIPS over the past seven years. There were six men and one woman (mean age 57.9±8.8 [SD] years; range: 47-71 years). Patient demographics, indications, procedural details, laboratory data, complications, and pathology were recorded. Patients with occluded TIPS were excluded from this study. RESULTS: Seven TJLBs were performed, five in patients who had a TIPS and two who had a DIPS. Of the patients with TIPS, biopsies were performed from the same hepatic vein as TIPS in three procedures and from a different hepatic vein in two procedures. In DIPS patients, both biopsies were performed from the right hepatic vein. The reasons for the transjugular rather than the percutaneous approach to liver biopsy included ascites, coagulopathy, or need for concurrent TIPS/DIPS evaluation and/or revision. All procedures were technically successful with adequate samples obtained. There were no immediate or delayed complications. CONCLUSION: Our results suggest that if needed a TJLB can safely and effectively be performed in patients with previously placed TIPS or DIPS.

Obstructive sleep apnoea and perioperative complications in bariatric patients.

BACKGROUND: The objective of this study was to determine the relationship between perioperative complications and the severity of obstructive sleep apnoea (OSA) in patients undergoing bariatric surgery who had undergone preoperative polysomnography (PSG). METHODS: The records of 797 patients, age >18 yr, who underwent bariatric operations (442 open and 355 laparoscopic procedures) at Mayo Clinic and were assessed before operation by PSG, were reviewed retrospectively. OSA was quantified using the apnoea-hypopnoea index (AHI) as none (≤ 4), mild (5-15), moderate (16-30), and severe (≥ 31). Pulmonary, surgical, and 'other' complications within the first 30 postoperative days were analysed according to OSA severity. Logistic regression was used to assess the multivariable association of OSA, age, sex, BMI, and surgical approach with postoperative complications. RESULTS: Most patients with OSA (93%) received perioperative positive airway pressure therapy, and all patients were closely monitored after operation with pulse oximetry on either regular nursing floors or in intensive or intermediate care units. At least one postoperative complication occurred in 259 patients (33%). In a multivariable model, the overall complication rate was increased with open procedures compared with laparoscopic. In addition, increased BMI and age were associated with increased likelihood of pulmonary and other complications. Complication rates were not associated with OSA severity. CONCLUSIONS: In obese patients evaluated before operation by PSG before bariatric surgery and managed accordingly, the severity of OSA, as assessed by the AHI, was not associated with the rate of perioperative complications. These results cannot determine whether unrecognized and untreated OSA increases risk.

Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series.

Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.

Optional inferior vena caval filters: where are we now?

With the advent of newer optional/retrievable inferior vena caval filters, there has been a rise in the number of filters inserted globally. This review article examines the currently available approved optional filter models, outlines the clinical indications for filter insertion and examines the expanding indications. Additionally, the available evidence behind the use of optional filters is reviewed, the issue of anticoagulation is discussed and possible future filter developments are considered.

Recent advances and novel methods in pancreatic imaging.

Traditional imaging studies for evaluating pancreatic disease including abdominal ultrasound (US) and computerized tomography (CT) are widely utilized due to their availability, non-invasiveness, and familiarity to practitioners. The addition of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) has contributed significantly to the clinician's the ability to safely sample tissue, stage malignancy, evaluate the pancreatic ductal anatomy, and look for subtle parenchymal changes in the setting of chronic pancreatitis. The role of endoscopic retrograde cholangiopancreatography (ERCP) has diminished with the use of these less invasive modalities. Limitations in these conventional techniques include a lack of sensitivity and specificity in diagnosing early chronic pancreatitis, difficulties in differentiating malignancy from chronic or focal pancreatitis, and accuracy of staging pancreatic malignancy, particularly with regard to vascular involvement. Several recent advances in traditional imaging techniques have been described, which may improve our ability to accurately diagnose and stage pancreatic disease. Advances have been made in the standard modalities for imaging the pancreas such as multidetector CT, micro-bubble contrast enhanced ultrasound, and secretin stimulated MRCP. Other novel methods of pancreatic imaging have recently been described including EUS elastography, optical coherence tomography, diffusion weighted MRI, and MR spectroscopy. This article will review the recent advances in both traditional pancreatic imaging modalities as well as some of the emerging technologies for imaging evaluating diseases of the pancreas. As experience and clinical evidence accumulate, the role of these imaging techniques will continue to evolve.

Clinical impact of conventional endosonography and endoscopic ultrasound-guided fine-needle aspiration in the assessment of patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma who have been referred for endoscopic ablation therapy.

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett's esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. PATIENTS AND METHODS: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. RESULTS: Baseline pathology in the 25 patients (mean age 70, range 49-85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20%) were deemed to be unsuitable candidates for endoscopic therapy. CONCLUSIONS: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.

The role of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in diagnosis and treatment of acute pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool for diagnosis and therapy in acute and recurrent pancreatitis. While treatment of biliary disorders leading to pancreatitis is common practice, over the past several years many specialized centers have been directing traditional biliary techniques such as sphincterotomy and stenting towards the pancreas. A justifiable fear of pancreatitis and other complications has caused many endoscopists to shy away from pancreatic endotherapy, but refinements in technique, extensive experience, and most notably the routine use of pancreatic stenting to prevent post-ERCP pancreatitis has opened up the field and allowed for endoscopists in specialized centers around the world to perform diagnostic and therapeutic ERCP of the pancreas safely and effectively. In acute gallstone pancreatitis, the benefit of therapeutic ERCP including biliary sphincterotomy has been proven in randomized controlled trials. There are also data to support the role of ERCP directed at the pancreatic sphincters and ducts in treatment of acute relapsing pancreatitis due to pancreas divisum, sphincter of Oddi dysfunction, smoldering pancreatitis, pancreatic ductal disruptions, and perhaps even in evolving pancreatic necrosis. Many causes of apparently idiopathic pancreatitis can be discovered after an extensive evaluation with endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP) and ERCP with sphincter of Oddi manometry. ERCP often allows treatment of the underlying cause. Because of the inherent risks associated with ERCP, particularly when directed toward the pancreas, the role of ERCP in acute and especially recurrent pancreatitis should be primarily therapeutic with attempts to establish diagnosis whenever possible by less risky techniques including EUS and MRCP. With the added techniques, devices, skill-sets, and experience required, pancreatic endotherapy should preferably be performed in high volume tertiary referral settings. ERCP for diagnosis and treatment of severe or acute relapsing pancreatitis is also best performed using a multidisciplinary approach involving endoscopy, hepatobiliary-pancreatic surgery, and interventional radiology.

Integral role of interventional radiology in the development of a pediatric liver transplantation program.

The aim of this study was to examine the role of interventional radiology (IR) in the pretransplant evaluation of potential living-related liver transplantation (LRLT) donors and in the post-transplant management of pediatric liver transplant recipients. Medical records and procedural reports were reviewed of 12 potential donors and five recipients for left lateral segment liver transplants. Procedures performed by the IR Division, clinical indications, and complications were tabulated. Retrospective calculation of radiation exposure to the skin and gonads of the donors and recipients were made. Three-dimensional ultrasound (3D US) was used in all 12 potential donors to screen for the donor with the most appropriately sized left lateral segment. The four optimal donor candidates underwent contrast angiography in order to measure the diameter and screen for variant arterial supply to the left lateral segment. Pretransplantation, one recipient underwent mesenteric angiography with indirect portography to confirm thrombosis of the portal vein and to prove patency of the splenomesenteric venous confluence. Three children underwent LRLT and two children received split livers from cadaveric donors. Thirty-two IR procedures were performed after transplantation (Tx) in the four transplant survivors (one child died following Tx). These IR procedures included: ultrasound-guided percutaneous liver biopsy to evaluate the pathologic cause of liver dysfunction (seven); placement of nasal jejunal feeding tubes (three) or a peripherally inserted central catheter (four) for nutritional and pharmacologic support; large-volume diagnostic and therapeutic paracentesis (two) and thoracentesis (one); percutaneous catheter drainage of symptomatic large pleural effusions (two), large-volume chylous ascites (one) (with later drain removal [one]), and a large biloma (one); percutaneous biliary drain placement (three), biliary drain replacement (two), and balloon cholangioplasty (four) to relieve obstructive jaundice from biliary enteric anatomic strictures; and mesenteric arteriography (one) for suspected thrombosis of the hepatic artery. No complications occurred. Mean skin and gonadal radiation doses were 193 mGy and 27 mGy, respectively, for donors, and 164 mGy and 60 mGy, respectively, for recipients. Even in a program such as this, with a limited series of pediatric liver Txs, it is apparent that IR plays an integral role in optimizing the clinical outcome and use of resources. Specific benefits included: selection of optimal donors; accurate mapping of the donor and occasionally recipient hepatic vasculature; and, most importantly, providing relatively safe minimally invasive procedures for nutritional support and diagnosis and management of untoward events after Tx. When possible, ultrasound guidance should be used to avoid excessive cumulative fluoroscopic exposure to recipients.

Silent infarction as a risk factor for overt stroke in children with sickle cell anemia: a report from the Cooperative Study of Sickle Cell Disease.

OBJECTIVE: To determine whether children with homozygous sickle cell anemia (SCD) who have silent infarcts on magnetic resonance imaging (MRI) of the brain are at increased risk for overt stroke. METHODS: We selected patients with homozygous SCD who (1) enrolled in the Cooperative Study of Sickle Cell Disease (CSSCD) before age 6 months, (2) had at least 1 study-mandated brain MRI at age 6 years or older, and (3) had no overt stroke before a first MRI. MRI results and clinical and laboratory parameters were tested as predictors of stroke. RESULTS: Among 248 eligible patients, mean age at first MRI was 8.3 +/- 1.9 years, and mean follow-up after baseline MRI was 5.2 +/- 2.2 years. Five (8.1%) of 62 patients with silent infarct had strokes compared with 1 (0.5%) of 186 patients without prior silent infarct; incidence per 100 patient-years of follow-up was increased 14-fold (1.45 per 100 patient-years vs 0.11 per 100 patient-years, P =.006). Of several clinical and laboratory parameters examined, silent infarct was the strongest independent predictor of stroke (hazard ratio = 7.2, P =.027). CONCLUSIONS: Silent infarct identified at age 6 years or older is associated with increased stroke risk.

Fatal paradoxic embolism occurring during IVC filter insertion in a patient with chronic pulmonary thromboembolic disease.

A patient diagnosed with chronic thromboembolic disease experienced a fatal intraprocedural paradoxic embolism during inferior vena cava (IVC) filter insertion. The frequency of patent intra-atrial shunts in patients with chronic thromboembolic disease is surprisingly high, occurring in approximately 29.5% of patients with chronic thromboembolic disease. Prevention of embolic events during venous interventions in such cases requires that the operator recognize that central shunts may be present and strictly adhere to meticulous technique during IVC filter insertion.

Direct US-guided puncture of the innominate veins for central venous access.

Maintenance of functioning venous access is recognized as the Achilles heel of long-term hemodialysis treatment. In patients who require catheter-directed hemodialysis, the internal jugular veins are recognized as the optimal veins for insertion of dialysis catheters. When these sites are no longer available, alternative venous access sites are required. The authors describe two hemodialysis patients with limited access sites in whom hemodialysis catheters were successfully inserted directly into the innominate veins with use of ultrasound-guided punctures.

The influence of sex, gender, self-discrepancies, and self-awareness on anger and verbal aggressiveness among U.S. college students.

Among a sample of 445 U.S. college students, the authors examined the extent to which individual differences (e.g., sex, gender, self-discrepancies, self-awareness) explained anger tendencies and verbal aggressiveness. Regression analyses showed that (a) the tendency to repress anger (anger-in) was explained by masculinity, desire to be masculine, and public self-awareness, R2 = .19, F(11, 433) = 8.44, p < .001; (b) the tendency to express anger (anger-out) was explained by sex, masculinity, and public self-awareness, R2 = .17, F(11, 433) = 7.38, p < .001; and (c) willingness to be verbally aggressive was explained by sex, femininity, and private self-awareness, R2 = .32, F(11, 433) = 16.94, p < .001. In addition, different types of individual difference variables accounted for anger tendencies and verbal aggressiveness across sex and gender categories, suggesting that anger and verbal aggressiveness may be driven by different psychological processes across types of participants.

Skin and nail changes in children with sickle cell anemia receiving hydroxyurea therapy.

Skin and nail changes from long-term hydroxyurea therapy are reported in adults. Skin and nail changes, including nail hyperpigmentation, longitudinal bands, and hyperpigmentation of the palms and other skin surfaces, developed in 7 children with sickle cell anemia after 6 to 16 weeks of hydroxyurea therapy. Cutaneous and nail changes may occur in children receiving hydroxyurea.

Value of three-dimensional US for optimizing guidance for ablating focal liver tumors.

PURPOSE: To determine if three-dimensional ultrasound (3D US), by nature of its ability to simultaneously evaluate structures in three orthogonal planes and to study relationships of devices to tumor(s) and surrounding anatomic structures from any desired orientation, adds significant additional information to real-time 2D US used for placement of devices for ablation of focal liver tumors. MATERIALS AND METHODS: Sixteen patients underwent focal ablation of 23 liver tumors during two intraoperative cryoablation (CA) procedures, three intraoperative radiofrequency ablation (RFA) procedures, 11 percutaneous ethanol injections (PEI) procedures, and six percutaneous RFA procedures. After satisfactory placement of the ablative device(s) with 2D US guidance, 3D US was used to reevaluate adequacy to device position. Information added by 3D US and resultant alterations in device deployment were tabulated. RESULTS: 3D US added information in 20 of 22 (91%) procedures and caused the operator to readjust the number or position of ablative devices in 10 of 22 (45%) of procedures. Specifically, 3D US improved visualization and confident localization of devices in 13 of 22 (59%) procedures, detected unacceptable device placement in 10 of 22 (45%), and determined that 2D US had incorrectly predicted device orientation to a tumor in three of 22 (14%). CONCLUSIONS: Compared to conventional 2D US, 3D US provides additional relationship information for improved placement and optimal distribution of ablative agents for treatment of focal liver malignancy.

Pulmonary embolism from pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts: urokinase versus heparinized saline.

PURPOSE: To compare the frequency and extent of pulmonary embolism (PE) occurring during pulse-spray pharmacomechanical thrombolysis (PSPMT) of clotted hemodialysis grafts with use of either urokinase (UK) or heparinized saline (HS). Postintervention primary patency and complication rates were compared for each method of thrombolysis. METHODS AND MATERIALS: Twenty-seven patients were enrolled in this prospective, randomized, double-blind study evaluating PE with two PSPMT agents. The doses of heparin were similar between groups. The only variable was that one group of patients received UK and the other received HS. In two cases, the venous anastomosis could not be crossed. Eleven patients were treated with UK and 14 with HS. Nuclear medicine perfusion lung scans were performed before treatment and after graft declotting procedures. Lung perfusion was quantified to 10% of a pulmonary segment (0 = normal perfusion, 1 = segmental perfusion defect), with nine segments counted for each lung. RESULTS: Baseline nuclear medicine perfusion lung scan results were abnormal (> or = 20% segmental perfusion defect) in 19 patients (70.4%). New PE (one or more pulmonary segments) occurred in two patients treated with UK (18.2%) and nine patients treated with HS (64.3%; P = .04). All cases of PE were asymptomatic. Quantitative global pulmonary perfusion analyses revealed that treatment with UK improved flow to 0.2 +/- 2.0 pulmonary segments, whereas treatment with HS decreased perfusion to 1.0 +/- 1.7 segments (P = .16, NS). Although postintervention primary patency rates were similar according to life-table analysis (P = .76, NS), complication rates were higher with use of HS (n = 4, 28.6%) than with use of UK (n = 2, 18.2%) (P = .6, NS). CONCLUSIONS: All PE were asymptomatic during PSPMT, but treatment with UK reduced the rate of PE and tended to result in smaller defects in lung scan results. Most patients undergoing hemodialysis have abnormal baseline perfusion scan results, but PSPMT with UK improved many of them. The postintervention primary patency rates were similar between groups, but complications were more frequent after treatment with HS.

Early rethrombosis of clotted hemodialysis grafts: graft salvage achieved with an aggressive approach.

OBJECTIVE: The purpose of this study was to assess the efficacy of repeated pulsed spray pharmacomechanical thrombolysis for salvage of early rethrombosis of hemodialysis grafts and to identify factors that predict successful outcome. MATERIALS AND METHODS: Thirty-four patients with initial successful thrombolysis were referred for repeated thrombolysis because of early rethrombosis. Repeated thrombolysis occurred within 1 month of initial thrombolysis. Technical success and patency rates were calculated. Causes of graft thrombosis and procedural modifications were analyzed. RESULTS: The 39 rethrombosed grafts were successfully treated using pharmacomechanical thrombolysis, and patients underwent subsequent hemodialysis. The underlying flow-limiting stenoses were treated with balloon angioplasty using a larger balloon (41%), a same-size angioplasty balloon (18%), stent placement (15%), or increased anticoagulation (5%). A new stenosis location was discovered in 18%. Mean primary patency was 80.9 days (2.6 months) and secondary patency was 235.4 days (7.8 months). With life table analysis, 1-, 3-, 6-, and 12-month primary patency rates were 72%, 31%, 23%, and 15%, and secondary patency rates were 77%, 62%, 51%, and 31%, respectively. Graft patency rates in our study were compared with our institutional historic graft patency rates, with no significant difference noted (p = 0.76). No major procedural complications occurred. CONCLUSION: Adequate technical success and patency rates for pharmacomechanical thrombolysis occur even for hemodialysis grafts that rethrombose within 1 month. After thrombolysis, aggressive search for and treatment of additional stenoses are warranted.

Adjunctive 3D US for achieving portal vein access during transjugular intrahepatic portosystemic shunt procedures.

PURPOSE: To evaluate the usefulness of information provided by three-dimensional ultrasound (3D US) and to determine whether 3D US decreased the number of passes required to obtain portal vein (PV) access during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Intermittent 3D US volume acquisitions were obtained during creation of TIPS in 20 patients. Useful information provided by 3D US was tabulated. The number of passes required to achieve PV access was recorded and results were compared retrospectively to 25 patients who underwent TIPS without 3D US. RESULTS: 3D US documented that the operator's opinion of which hepatic vein had been selected was incorrect in nine patients (45%), detected unfavorable PV anatomy that required modification of equipment or technique in seven patients (35%), permitted estimation of the trajectory required to access the targeted PV in all patients (100%), assisted in selecting the optimal point along the hepatic vein for origination of the needle pass in 11 patients (55%), allowed avoidance of a large hepatocellular carcinoma in one patient (5%), and confirmed that access into the main PV was intrahepatic in four patients (20%). The mean number of needle passes decreased from 10.4 in the historic control group to 4.6 in the 3D US group (P = .0001). CONCLUSION: 3D US provided imaging information that detected technical errors and altered anatomy, and provided positional and directional information to significantly improve needle pass efficiency.