CT Fluoroscopy-Guided Drain Placement to Treat Infected Gastric Leakage after Sleeve Gastrectomy: Technical and Clinical Outcome of 31 Procedures.

PURPOSE: To observe the technical and clinical outcome as well as safety of CT fluoroscopy-guided drain placement in the multimodal clinical complication management of superinfected gastric leakage after sleeve gastrectomy. MATERIALS AND METHODS: All consecutive patients who underwent CT fluoroscopy-guided drain placement to treat superinfected postoperative leakage after sleeve gastrectomy in our department between 2007 and 2014 were included in this retrospective study. All interventions were performed on a 16- or 128-row CT scanner under intermittent CT fluoroscopy guidance (15-25 mAs, 120 kV). The technical and clinical success rates as well as complications, additional therapies and patient radiation dose were analyzed. RESULTS: 14 patients (mean age: 43.8 ±â€Š11.3 years, mean BMI: 52.9 ±â€Š13.5, 7 women) who underwent a total of 31 CT fluoroscopy-guided drain placement procedures were included. 30 of 31 interventions (96.8 %) were technically successful. 7 patients underwent more than one intervention due to drain obstruction or secondary dislocation or as further treatment. During and after the intervention no procedure-associated complications occurred. In all patients, inflammation parameters decreased within days after the CT-guided intervention. The total interventional dose length product (DLP) was 1561 ±â€Š1035 mGy*cm. CONCLUSION: CT fluoroscopy-guided drain placement has been shown to be a safe minimally invasive procedure that rarely leads to complications for treating superinfected gastric leakage occurring after sleeve gastrectomy. We assume that operative revisions in a high-risk patient group can be avoided using this procedure. KEY POINTS: · CT fluoroscopy-guided drain placement in obese - often medically highly complex - patients is a technically feasible procedure.. · Multimodal treatment (CT intervention, endoscopy and surgery) is required to successfully treat gastric leakage after bariatric surgery.. · High-risk surgery might be avoided by the CT-guided drain placement.. CITATION FORMAT: · Schwarz J, Strobl FF, Paprottka PM et al. CT Fluoroscopy-Guided Drain Placement to Treat Infected Gastric Leakage after Sleeve Gastrectomy: Technical and Clinical Outcome of 31 Procedures. Fortschr Röntgenstr 2020; 192: 163 - 170.

CT fluoroscopy guided percutaneous gastrostomy or jejunostomy without (CT-PG/PJ) or with simultaneous endoscopy (CT-PEG/PEJ) in otherwise untreatable patients.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) are substantial for patients with swallowing disorders to maintain enteral nutrition or to decompress palliatively intractable small bowel obstruction. Endoscopic placement can be impossible due to previous (gastric) operation, obesity, hepato-splenomegaly, peritoneal carcinosis, inadequate transillumination, or obstructed passage. Computed tomography (CT)-fluoroscopic guidance with or without endoscopy can enable placement of CT-PG/CT-PJ or CT-PEG/CT-PEJ if endoscopically guided placement fails. In this retrospective study, we will evaluate the feasibility and safety of this method. METHODS: A total of 101 consecutive patients were referred to our department for feeding support (n = 87) or decompression (n = 14). Reasons were: ENT tumor (n = 51), esophageal cancer (n = 19), mediastinal mass (n = 2), neurological disorder (n = 15). Decompression tubes were placed because of cancer (n = 13) or Crohn's disease (n = 1). The following approaches were chosen: CT fluoroscopy and simultaneous gastroscopy (n = 61), inflation of the stomach via nasogastric tube (n = 29), and direct puncture under CT-fluoroscopic guidance (n = 11). RESULTS: CT fluoroscopy-guided gastrostomy was feasible in 89 of 101 patients. No procedure-related mortality was observed. One tube was misplaced into the colon in a patient with a history of gastrectomy. No complication was seen after removal. Minor complications: dislodgement (n = 17), peristomal leakage (n = 7), wound infection (n = 1), superficial skin infection (n = 6), tube obstruction (n = 2). CONCLUSIONS: CT fluoroscopy-guided PG/PJ or PEG/PEJ is feasible and safe and provides adequate feeding support or decompression. It offers the benefits of minimally invasive therapy even in patients with contraindications to established endoscopic methods, combining the advantages of both techniques. Long-term complications-mainly tube-related problems-are easily treated.

Relation of gallbladder motility to viscosity and composition of gallbladder bile in patients with cholesterol gallstones.

BACKGROUND/AIMS: Increased viscosity and supersaturation of cholesterol in gallbladder bile, as well as an impaired motility of the gallbladder, are considered to be important factors in the pathogenesis of cholesterol gallstones. However, the relation of these parameters has not yet been determined. MATERIAL AND METHODS: Bile viscosity (mPa s) was measured by rotation viscosimetry and the composition of gallbladder bile was determined using standard methodology. Gallbladder motility was calculated as ejection fraction in percent of total volume 45 min after a test meal using ultrasonography in patients with gallstones prior to elective cholecystectomy. RESULTS: The study included 35 patients with cholesterol gallstones. Viscosity of gallbladder bile ranged between 0.9 and 12.5 mPa s (median 2.2 mPa s) and an ejection fraction of the gallbladder of 55.4 +/- 18.3% (mean +/- SD) was determined. No significant correlation (r = 0.19, p < 0.2) between the 2 parameters could be calculated. Analysis of the composition of gallbladder bile revealed a positive correlation of all components to biliary viscosity but not to the motility of the gallbladder, with the exceptions of a negative correlation (r = 0.39, p < 0.02) between mucin concentration and the ejection fraction at 45 min after the test meal. CONCLUSIONS: The motility of the gallbladder appears to be unrelated to the viscosity of gallbladder bile or gallbladder bile composition. The negative correlation between the ejection fraction of the gallbladder and mucin concentration of gallbladder bile suggests that chronic inflammation of the gallbladder wall is associated with both an impaired motility of the gallbladder and increased mucin release into gallbladder bile.

DNA integrity in plasma and serum of patients with malignant and benign diseases.

This study aimed to test the diagnostic utility of the DNA integrity index for detection of cancer. Matched serum and plasma samples of 42 patients with various forms of cancer and 17 patients with corresponding benign diseases were analyzed. DNA was isolated from 1 mL serum and plasma using the MagNA Pure LC system. Cell-free DNA was quantified by real-time PCR using the reference gene of the LightCycler t(14;18) kit. Subsequently, the DNA integrity index was calculated as the ratio in relative abundance of 347-bp versus 137-bp PCR products. We found that DNA concentrations were not different in plasma (median: 4.5 ng/mL) and serum (67.1 ng/mL) of patients with benign diseases when compared with values in plasma (5.1 ng/mL) and serum (65.4 ng/mL) of cancer patients. Similarly, the DNA integrity index in plasma (0.38), and serum of patients with benign diseases (0.29) was comparable to values in plasma (0.33) and serum (0.37) of cancer patients. Diagnostic sensitivity of DNA (AUC 0.53) and DNA integrity (AUC 0.45) was poor in plasma, and was increased only slightly by the combination of both (AUC 0.57). In serum, sensitivity of DNA (AUC 0.52) and DNA integrity (AUC 0.64) was higher and was further improved by the combination of both (AUC 0.72) reaching a sensitivity of 30% at 100% specificity. In conclusion, we could not confirm a high diagnostic utility of the DNA integrity index. However, a combination with other markers such as DNA may enhance sensitivity for cancer detection.

Relation of gallbladder function and Helicobacter pylori infection to gastric mucosa inflammation in patients with symptomatic cholecystolithiasis.

BACKGROUND: Inflammatory alterations of the gastric mucosa are commonly caused by Helicobacter pylori (Hp) infection in patients with symptomatic gallstone disease. However, the additional pathogenetic role of an impaired gallbladder function leading to an increased alkaline duodenogastric reflux is controversially discussed. AIM: To investigate the relation of gallbladder function and Hp infection to gastric mucosa inflammation in patients with symptomatic gallstones prior to cholecystectomy. PATIENTS: Seventy-three patients with symptomatic gallstones were studied by endoscopy and Hp testing. METHODS: Gastritis classification was performed according to the updated Sydney System and gallbladder function was determined by total lipid concentration of gallbladder bile collected during mainly laparoscopic cholecystectomy. RESULTS: Fifteen patients revealed no, 39 patients mild, and 19 moderate to marked gastritis. No significant differences for bile salts, phospholipids, cholesterol, or total lipids in gallbladder bile were found between these three groups of patients. However, while only 1 out of 54 (<2%) patients with mild or no gastritis was found histologically positive for Hp, this infection could be detected in 14 (74%) out of 19 patients with moderate to marked gastritis. CONCLUSION: Moderate to marked gastric mucosa inflammation in gallstone patients is mainly caused by Hp infection, whereas gallbladder function is not related to the degree of gastritis. Thus, an increased alkaline duodenogastric reflux in gallstone patients seems to be of limited pathophysiological relevance.