Clinical features and natural history of hepatocellular adenomas: the impact of obesity.

BACKGROUND: Hepatocellular adenoma is a benign tumour associated with bleeding and malignant transformation. Obesity has been linked to hepatic tumourigenesis. AIM: To evaluate the presentation of hepatocellular adenoma in obesity, and the impact of obesity on the clinical course. METHODS: Records of 60 consecutive patients (between 2005 and 2010) with a diagnosis of hepatocellular adenoma from a single tertiary centre were analysed. RESULTS: Fifty six of 60 patients were women, median age was 36years, 75% had history of contraceptive use, 18% were overweight and 55% were obese (BMI ≥30kg/m(2) ). Majority (63%) were asymptomatic; seven patients presented with bleeding. Single (28%) and multiple adenomas (72%) were encountered; size ranged from 1 to 19.7cm. Obesity was more often associated with multiple adenomas (85% vs. 48%, P=0.005), bilobar distribution (67% vs. 33%, P=0.01), lower serum albumin (P=0.007) and co-morbidities of fatty liver (P=0.006), diabetes (P=0.003), hypertension (P=0.006) and dyslipidemia (P=0.03). During median follow-up of 2.6years, there were no instances of bleeding, malignant transformation or death. Thirty four patients underwent therapeutic intervention (17 surgical resection, nine transarterial embolization and eight both interventions sequentially). The rate of complete resection of adenoma(s) was significantly lower in obese patients (8% vs. 69%, P=0.004). In the 26 patients without intervention, tumour size progression was more frequently observed in obese patients (33% vs. 0%, P=0.05). Three of 15 obese patients (20%) lost ≥5% body weight and there was no progression in the liver lesions. CONCLUSIONS: Obesity and features of metabolic syndrome were frequently observed in hepatocellular adenoma. Multiple and bilobar adenomas were more frequent in obese patients. Among patients who were conservatively managed, tumour progression was more often associated with obesity.

Delivery of encapsulated Doxorubicin by ultrasound-mediated size reduction of drug-loaded polymer contrast agents.

Low delivery efficiency combined with systemic toxicity of traditional chemotherapy provides a need for improved chemotherapeutic delivery. Within our laboratory, we have developed polymer ultrasound contrast agents (1.2-1.8 mum in diameter) containing doxorubicin (Dox) within the shell (100-150 nm). In vivo this platform is expected to circulate through the vasculature until activated at the tumor site with external focused ultrasound (US). In vitro, the agent is responsive to US and when insonated at peak positive pressure amplitudes of 0.69 MPa and above, shows dramatic size reduction, eventually reaching a mean particle size of 350 nm, presumably due to fragmentation of, or gas release from the agent. The resulting Dox-polymer particles retain the drug and are small enough to pass through the leaky pores (350-400 nm) within the tumor vasculature, providing a sustained intratumoral release of chemotherapeutic as the polymer degrades. In vivo studies using a VX2 liver tumor model have shown that the combination of the agent and US results in nearly 50% less drug delivered to the nontargeted, healthy liver ( p = 0.009) and a 110% increase ( p = 0.004) in Dox delivery to the viable peripheral tissue of the tumor, relative to the uninsonated controls. This study shows how US-mediated destruction of drug-loaded polymer contrast agent can be used to deliver encapsulated drug for potential sustained release. Penetration mechanisms of these resulting particles and their ability to provide a sustained release from the tumor interstia will be explored in the future.

Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival.

PURPOSE: To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival. MATERIALS AND METHODS: A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables. RESULTS: None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P =.030), coagulopathy (OR, 0.36; P =.026), and bleeding subsequent to trauma (OR, 7.1; P =.040) or invasive procedures (OR, 6.5; P =.009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54-39.2; P =.000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014-0.229; P =.000). CONCLUSION: Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

Predictors of long-term patency after femoropopliteal angioplasty: results from the STAR registry.

PURPOSE: To identify variables predictive of long-term patency after femoropopliteal angioplasty. MATERIALS AND METHODS: The primary patency of 219 limbs in 205 patients from a multicenter registry who underwent femoropopliteal angioplasty between January 1, 1992, and December 31, 1994, was prospectively monitored with a combination of angiography, noninvasive hemodynamic testing, and clinical outcome. Patient demographic, angiographic, and hemodynamic variables were examined alone and in combination to determine effect on long-term primary patency. Each limb was graded as Category 1-4 according to the American Heart Association (AHA) criteria for arterial lesions, and differences in outcome for each category were examined. Primary patency and intergroup analysis were determined with use of the Kaplan-Meier method and log-rank test, respectively. Cox proportional hazards models were used to calculate relative risks for predictive variables. RESULTS: Primary patency rates for all limbs (on an intent-to-treat basis) at 12, 24, and 36 months were 87% +/- 3%, 80% +/- 3%, and 69% +/- 5%, respectively. Primary patency at 48 and 60 months was 55% +/- 7%. Poor tibial runoff (single tibial vessel with 50%-99% stenosis or occlusion) was most predictive of occlusion (relative risk 8.5, P <.0001). The presence of diabetes or renal failure was associated with lower long-term patency (relative risk 5.5 and 4.0, P <.0001 and.0002, respectively). Long-term patency was higher with AHA Category 1 lesions (P =.006), and no significant difference in patency was observed between Category 2 and 3 lesions (P =.65). A multivariate Cox proportional hazards model showed only the stratified runoff score and the presence of diabetes to be significant determinants of long-term patency. CONCLUSION: Poor tibial runoff is most predictive of lower long-term patency rates. Diabetes is also independently associated with lower long-term patency rates. The criteria that distinguish Category 2 and 3 lesions do not predict differences in long-term patency, nor do they serve to identify lesions best treated with surgical bypass. This suggests that indications for femoral angioplasty can be extended to include longer and more complex Category 3 lesions.

Risk factors for liver abscess formation after hepatic chemoembolization.

PURPOSE: To assess the frequency and risk factors for liver abscess after hepatic chemoembolization. MATERIALS AND METHODS: The authors performed retrospective analysis of 397 chemoembolization procedures in 157 patients. All patients received prophylactic intravenous antibiotics before the procedure and 5 days of oral antibiotics after the procedure. The association between abscess formation and risk factors was determined with use of chi(2) analysis and the Fisher exact test and expressed as an odds ratio. RESULTS: Liver abscess occurred in seven of 157 patients (4.5%) after eight of 397 procedures (2.0%) at a mean of 19 d +/- 7 after chemoembolization. No patients had neutropenia. Organisms isolated reflected intestinal flora. Six patients required percutaneous drainage for 35 d +/- 29. The seventh patient required drainage for the remainder of life as a result of a nonhealing biliary fistula. Three of 24 patients with neuroendocrine tumors had abscesses (12.5%; odds ratio, 4.6; 95% CI, 0.96-22.1; P =.07), as did three of 14 patients with gastrointestinal sarcomas (21%; odds ratio, 9.5; 95% CI, 1.9-47.8; P =.016), and one of two with pancreatic adenocarcinoma. Six of the seven patients with abscesses underwent a Whipple procedure before chemoembolization. Only one patient with a history of a Whipple procedure did not develop an hepatic abscess. In the absence of a bilioenteric anastomosis, abscess occurred in only one of 150 patients (0.7%), or one of 383 procedures (0.3%). The odds ratio for liver abscess among patients with a bilioenteric anastomosis was 894 (95% CI, 50-16,000; P <.0001). CONCLUSION: Earlier bilioenteric anastomosis is the major determinant of liver abscess formation after hepatic chemoembolization. The prophylaxis regimen used failed to prevent abscess formation in patients with earlier bilioenteric anastomosis.

Balloon embolization of the internal iliac artery before aneurysm endograft deployment.

Six patients, ranging from 69 to 81 years of age, underwent iliac artery embolization with use of Detachable Silicon Balloons (DSB) 11-14 days before stent-graft repair of aneurysms. Balloons of 8.8-mm, 9.4-mm, and 9.9-mm sizes were used with 20-30 g of release force. Deployment difficulty was experienced in three cases. Five of six cases were successful, with the iliac artery remaining occluded at the time of endografting; one case required subsequent coil replacement. The average operative time for balloon embolization (75 min +/- 28) was shorter than that in 18 cases of coil embolization performed within the same time period (111 min +/- 105), but the difference was not significant (P = .21). Postoperatively, one patient (17%) reported buttock claudication after the procedure. Use of the DSB represents an alternative to use of coils for embolization of large and tortuous iliac arteries.

Determinants of postembolization syndrome after hepatic chemoembolization.

PURPOSE: Postembolization syndrome (PES) occurs in the majority of patients undergoing hepatic chemoembolization, and is the major reason for hospitalization after the procedure. The ability to identify which groups of patients are at increased or decreased risk of PES would be useful to better counsel patients, to minimize toxicity, and to plan inpatient versus outpatient therapy. MATERIALS AND METHODS: Seventy hepatic chemoembolization procedures were performed in 29 patients using cytotoxic drugs mixed with Ethiodol and polyvinyl alcohol. The following procedural variables were retrospectively assessed and evaluated for association with PES and length of postprocedural hospitalization: gallbladder embolization, lobe embolized, percentage liver volume embolized, percentage embolized volume occupied by tumor, previous embolization of the same territory, and dose of chemoembolic emulsion. Logistic regression was used to quantify the relative effect of each procedural variable. RESULTS: Gallbladder embolization and dose administered were associated with an increased risk of PES and an extended hospitalization, with odds ratios of 2.8 and 3.0, and 3.0 and 4.6, respectively. Previous embolization was associated with a decreased risk of both PES and extended hospitalization, with odds ratios of 0.5 and 0.4, respectively. There was a statistical trend toward significance for gallbladder embolization (P = .06), dose administered (P = .07), and previous embolization (P = .14). CONCLUSION: Clinically relevant predictors of the severity of PES and length of postprocedural hospitalization may exist. Avoiding embolization of the gallbladder reduces the risk of PES. Re-embolization of previously treated vessels is associated with decreased toxicity and may assist in selecting patients for treatment on an outpatient basis, especially when a reduced dose is required.

Percutaneous radiofrequency ablation of liver tumors with the LeVeen probe: is roll-off predictive of response?

PURPOSE: The LeVeen radiofrequency (RF) probe uses roll-off of electrical impedance as the endpoint for RF cautery of hepatic tumors. The purpose of this study is to determine the relation of roll-off to local control of hepatic tumors. MATERIALS AND METHODS: Twenty hepatic tumors, including 10 hepatomas and 10 metastases, were treated. Lesions ranged from 1.4 cm to 6.0 cm in diameter; 13 (57%) were smaller than 3.0 cm. Each lesion was ablated with use of the LeVeen 15-gauge RF needle according to the manufacturer's protocol. Five patients underwent chemoembolization the day before. Patients were followed up with contrast-enhanced computed tomography or magnetic resonance imaging at 1 month and every 3 months thereafter. RESULTS: Among the 20 lesions, roll-off was achieved at all burn locations in 11 (55%), no burn locations in eight (40%), and two of three burn locations in one (5%). Roll-off was observed in all patients who had undergone chemoembolization the day before. Six local recurrences occurred, five after RF ablation without roll-off and one after RF ablation with roll-off. According to life-table analysis, the local recurrence rate at 6 months without roll-off was 43% and with roll-off was 15% (P =.024; OR = 8.3; 95% CI = 0.93-66). CONCLUSION: Roll-off is a significant predictor of local control after RF ablation. Strategies to enhance roll-off, such as concurrent embolization, may be important to optimize the therapeutic effect of this device.

Sarcomas metastatic to the liver: response and survival after cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol chemoembolization.

PURPOSE: To evaluate the response to and survival after chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol for patients with sarcomas metastatic to the liver that are surgically unresectable. MATERIALS AND METHODS: Sixteen patients were treated. Primary tumors included 11 gastrointestinal leiomyosarcomas, two splenic angiosarcomas, one leiomyosarcoma of the broad ligament, one leiomyosarcoma of the inferior vena cava, and one malignant fibrous histiocytoma of the colon. Chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol particles was performed 1-5 times at approximately monthly intervals (mean, 2.8). Pre- and posttreatment cross-sectional imaging was performed 1 month after completion of treatment and then every 3 months. Thirty-day response was graded according to World Health Organization/Eastern Cooperative Oncology Group criteria. Survival was calculated with use of Kaplan-Meier analysis. RESULTS: Two patients (13%) exhibited partial morphologic response, 11 patients (69%) were morphologically stable, and three (19%) demonstrated progression of disease 30 days after completion of treatment. Among the 13 responders, two underwent partial hepatectomy after initial treatment. Seven developed intrahepatic progression at a mean of 10 months and a median time of 8 months. The remaining four patients had no documented intrahepatic progression at the time of last imaging follow-up. Nine patients developed extrahepatic progression at a mean time of 6.3 months and a median time of 6 months, of whom four underwent additional surgical resection. Response to therapy was based on time of first intervention. Cumulative survival from time of diagnosis with use of Kaplan-Meier analysis was 81% at 1 year, 54% at 2 years, and 40% at 3 years. Median survival time was 20 months. Cumulative survival from initial chemoembolization was 67% at 1 year, 50% at 2 years, and 40% at 3 years, with a median survival time of 13 months. The thirty-day mortality rate was zero. CONCLUSION: Durable tumor response with chemoembolization is possible in this form of metastatic disease, which is highly resistant to systemic chemotherapy.

Limb kinking in supported and unsupported abdominal aortic stent-grafts.

PURPOSE: The occurrence of kinking of stent-graft limbs depends on the patient's anatomy and the device used. The purpose of this investigation was to determine the rates of limb kinking in supported and unsupported aortic stent-grafts. MATERIALS AND METHODS: The authors performed a retrospective review of patients undergoing placement of either a Guidant Ancure/EGS or Medtronic Talent aortic stent-graft for the treatment of abdominal aortic aneurysm as part of separate phase II and phase III clinical trials. The records of 91 consecutive patients with 149 limbs were reviewed. The type and configuration of each device and any procedure performed specifically relating to limb patency was recorded. An analysis was then performed comparing the rates of kinking in supported and unsupported groups. A review of the literature was also performed. RESULTS: Overall, there was kinking in 18 of 149 limbs (12%). In the supported stent-graft group, 48 bifurcated and 26 aortomonoiliac grafts were placed, with a total of 122 limbs at risk. Six limbs (5%) in five patients required intervention as a result of limb kinking. Stents were placed intraoperatively in two limbs (2%) and postoperatively in four limbs (3%) for thrombosis or severe stenosis. In the unsupported group, 12 bifurcated and three aortomonoiliac grafts were placed, with a total of 27 limbs at risk. Twelve limbs (44%) in eight patients required some type of intervention as a result of limb kinking. Stents were placed intraoperatively in seven limbs (26%) and postoperatively in five limbs (19%) for thrombosis or severe stenosis. Rates of limb kinking were significantly different between the supported and unsupported groups (P < .0001). CONCLUSIONS: The use of supported versus unsupported stent-grafts impacts the occurrence of limb kinking. A direct comparison of the groups suggests that an unsupported stent-graft will be more than 15 times more likely than a supported system to require intervention because of kinking.

Diagnosis and treatment of inferior mesenteric arterial endoleaks after endovascular repair of abdominal aortic aneurysms.

PURPOSE: To review the incidence and repair of inferior mesenteric arterial (IMA) type II endoleaks after endovascular repair of abdominal aortic aneurysms. MATERIALS AND METHODS: Fifty patients who underwent endovascular repair of abdominal aortic aneurysms were examined. If an endoleak was identified at 30-day postoperative computed tomography, conventional arteriography was performed to identify and eliminate its source. After the exclusion of attachment site leaks, a catheter was placed selectively in the superior mesenteric artery (SMA). If retrograde filling of the IMA and aneurysm was identified, coil embolization was attempted through the SMA and middle colic artery. Intrasac pressures were measured at embolization. RESULTS: Eight of 50 patients (16%) had type II endoleaks that were attributed to retrograde flow in the IMA. Intrasac measurements demonstrated systemic pressure in six patients and one-half systemic pressure in two patients. The IMA was embolized through the SMA and left colic artery in seven patients and through the translumbar aorta in one patient. CONCLUSION: Retrograde flow in the IMA is responsible for many type II endoleaks. Systemic pressures are transmitted into the aneurysm sac from the IMA. The IMA can be embolized successfully with an SMA approach in most patients.

Minimally invasive treatment of malignant hepatic tumors: at the threshold of a major breakthrough.

Six existing minimally invasive techniques for the treatment of primary and secondary malignant hepatic tumors--radio-frequency ablation, microwave ablation, laser ablation, cryoablation, ethanol ablation, and chemoembolization--are reviewed and debated by noted authorities from six institutions from around the world. All of the authors currently believe that surgery remains the treatment of choice for patients with resectable hepatic tumors. However, the clinical results of each of the minimally invasive techniques presented have exceeded those obtained with conventional chemotherapy or radiation therapy. Thus, for nonsurgical patients, these techniques are becoming standard independent or adjuvant therapies. In addition, with continued improvement in technology and increasing clinical experience, one or more of these minimally invasive techniques may soon challenge surgical resection as the treatment of choice for patients with limited hepatic tumor.

Cutaneous complications of hepatic chemoembolization via extrahepatic collaterals.

PURPOSE: To report cutaneous complications occurring after chemoembolization of hepatic tumors via extrahepatic collaterals. METHODS: Five patients underwent chemoembolization via the internal mammary (n = 3), intercostal (n = 1), or multiple extrahepatic collateral vessels supplying liver metastases. RESULTS: Painful induration and discoloration of the skin in the distribution of the superior epigastric or intercostal arteries occurred in four patients, with transmural necrosis in two. One required surgical excision. One patient developed a radiation burn after 12 procedures and eventually developed a squamous cell carcinoma at the site, which required resection and skin grafting. CONCLUSION: Cutaneous injury can occur after chemoembolization of extrahepatic collaterals. Scrupulous technique is required to avoid nontarget embolization of chemotherapeutic drugs. High cumulative radiation doses to localized areas of skin can occur in patients undergoing multiple procedures.

Chemoembolization of hepatocellular carcinoma with cisplatin, doxorubicin, mitomycin-C, ethiodol, and polyvinyl alcohol: prospective evaluation of response and survival in a U.S. population.

PURPOSE: To evaluate response and survival after hepatic chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol in a U.S. population of patients with hepatocellular carcinoma. MATERIALS AND METHODS: Thirty-eight consecutive patients were treated: 35% stage I, 62% stage II, 3% stage III. Fifty-one percent had cirrhosis. Chemoembolization was performed at approximately monthly intervals for one to seven sessions (mean, 2.2). Pretreatment and posttreatment cross-sectional imaging and alpha-fetoprotein (AFP) levels were obtained prospectively 1 month after treatment and then every 3 months. Thirty-day response was calculated by means of the the World Health Organization/Eastern Cooperative Oncology Group criteria. RESULTS: One patient was lost to follow-up. In seven patients, lesions became resectable after chemoembolization. Among 13 evaluable patients with initially elevated AFP level, 70% had a partial biologic response (>50% decrease in AFP), 15% had a minor response (25-50% decrease), and the remaining 15% remained stable. Among 25 patients evaluable for morphologic response, 36% had a partial response, 32% had a minor response, and 32% remained stable. No patients had progression of disease while receiving therapy. The cumulative survival was 60% at 1 year, 41% at 2 years, and 16% at 3 years. Two patients developed progressive hepatic failure. Thirty-day mortality was 3% (one patient). CONCLUSION: These results compare favorably to published response and survival data for chemoembolization of advanced hepatocellular carcinoma from Asia and Europe.

Impact of screening MR angiography on referrals for percutaneous intervention in renovascular disease.

PURPOSE: Concern about contrast- and catheter-induced complications inhibits liberal use of catheter angiography to screen for renal artery stenosis. The authors evaluated the impact on interventional practice growth of offering magnetic resonance angiography (MRA) as an alternative screening test for renovascular disease. MATERIALS AND METHODS: A retrospective analysis of 339 patients with renovascular disease identified with MRA from January 1, 1993 through December 31, 1997, and the subsequent utilization of follow-up catheter angiography and/or intervention was performed. The number of patients treated per year with percutaneous techniques for renovascular disease was recorded, and was correlated with screening MRA. The impact of screening MRA on percutaneous management of renovascular disease was evaluated through comparisons of the number of percutaneous procedures performed among the individual years during the 5-year period, and with the number of procedures performed during the 5-year period (1988-1992) immediately preceding 1993, prior to the use of screening MRA. RESULTS: The number of annual screening MRA examinations increased six-fold during the 5-year period, from 17 per year initially to approximately 100 per year for each of the last 3 years. One hundred thirty-five (40%) of screening MRA examinations were positive for renal artery stenosis or occlusion, and 111 (33%) patients had anatomy potentially suitable for percutaneous intervention. Fifty-two patients with positive screening MR angiograms underwent arteriography: 34 underwent renal angioplasty or stent placement, seven had surgery, seven with stenosis determined with MRA had occlusion on catheter angiography, and four had false-positive results of MRA (<50% stenosis). Three additional patients with negative screening MR angiograms were also referred for arteriography, which confirmed the MRA findings. The percentage of positive catheter angiograms was 50% greater among patients with a screening MRA, and the number of renal artery angioplasties performed annually doubled. Moreover, comparison with the 5-year period from 1988 to 1992 (immediately prior to the use of MRA as a screening tool), demonstrates that the average number of renal artery percutaneous procedures performed per year increased nearly 350% from an average of three per year to 15 per year. These findings are entirely attributable to referrals from screening MRA. CONCLUSIONS: Marketing of renal artery MRA as a safe, noninvasive outpatient screening technique can lead to improved utilization of catheter angiography in evaluation of renovascular disease, and can secondarily increase the volume of renal artery angioplasty and stent placement procedures for treatment of renovascular disease.

Renal artery stenosis: evaluation with conventional angiography versus gadolinium-enhanced MR angiography.

PURPOSE: To evaluate the interobserver and intermodality variability of conventional angiography and gadolinium-enhanced magnetic resonance (MR) angiography in the assessment of renal artery stenosis. MATERIALS AND METHODS: Fifty-four patients underwent conventional angiography and gadolinium-enhanced three-dimensional gradient-echo MR angiography. Three angiographers blinded to each other's interpretations and the MR angiographic findings assessed the conventional angiograms for renal artery stenosis. Similarly, three blinded MR imagers evaluated the MR angiograms. RESULTS: Interobserver variability for the degree of renal artery stenosis in the 107 kidneys evaluated was not significantly different between the two modalities. The mean SD of the degree of stenosis was 6.9% at MR angiography versus 7.5% at conventional angiography (alpha < or = .05, P > .05). In 70 kidneys (65%), the average degree of stenosis reported by the readers for the two modalities differed by 10% or less. In 22 cases (21%), the degree of stenosis was overestimated with MR angiography by more than 10% relative to the results of conventional angiography. In 15 cases (14%), the degree of stenosis was underestimated with MR angiography by more than 10%. CONCLUSION: Gadolinium-enhanced MR angiography permits evaluation of renal artery stenosis with an interobserver variability comparable with that of conventional angiography.

Direct percutaneous jejunostomy: techniques and applications--ten years experience.

PURPOSE: To present 10 years experience with direct fluoroscopically guided percutaneous jejunostomy. MATERIALS AND METHODS: Percutaneous jejunostomy was performed in 62 patients, most of whom had undergone major abdominal surgery. A new or replacement jejunostomy was created for alimentation in 20 and 21 patients, respectively. Jejunostomy was performed for interventional procedures of the bile ducts or intestine in 13 patients and for retrograde gastroesophageal drainage in eight. The distended jejunum was accessed with a 21-gauge needle, immobilized with a gastric anchor, and catheterized with a 10-14-F locking loop drain. RESULTS: The technical success rate was 19 of 20 (95%) for new feeding jejunostomy and 17 of 21 (81%) for replacement feeding jejunostomy. Jejunostomy facilitated drainage, dilation, stone extraction, and recanalization in the bile ducts or intestine in all 13 patients. Retrograde jejunoesophagogastrostomy suction effectively replaced painful nasogastric suction in all eight patients. Two patients who underwent replacement jejunostomy required laparotomy for possible leakage; there was no important procedure-related morbidity and no procedure-related mortality. CONCLUSION: The technical success and complication rates of feeding percutaneous jejunostomy compare favorably with those of surgery or endoscopy. Percutaneous jejunostomy is a useful and underused approach to managing bowel and biliary obstruction.