Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis

Objectives

Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency.

Methods

This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected.

Results

Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications.

Conclusions

CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

A prospective observational trial of fusion imaging in infrarenal aneurysms

OBJECTIVE

Use of three-dimensional fusion has been shown to significantly reduce radiation exposure and contrast material use in complex (fenestrated and branched) endovascular aneurysm repair (EVAR). Cydar software (CYDAR Medical, Cambridge, United Kingdom) is a cloud-based technology that can provide imaging guidance by overlaying preoperative three-dimensional vessel anatomy from computed tomography scans onto live fluoroscopy images both in hybrid operating rooms and on mobile C-arms. The aim of this study was to determine whether radiation dose reduction would occur with the addition of fusion imaging to infrarenal repair in all imaging environments.

METHODS

All patients who consented to involvement in the trial and who were treated with EVAR in our center from March 2016 until April 2017 were included. A teaching session about radiation protection and Cydar fusion software use was provided to all operators before the start of the fusion group enrollment. This group was compared with a retrospective cohort of patients treated in the same center from March 2015 to March 2016, after a dedicated program of radiation awareness and reduction was introduced. Ruptured aneurysms and complex EVAR were excluded. Preoperative and perioperative characteristics were recorded, including parameters of radiation dose, such as air kerma and dose-area product. Results were expressed in median and interquartile range.

RESULTS

Forty-four patients were prospectively enrolled and compared with 21 retrospective control patients. No significant differences were found in comparing sex, body mass index, and age at repair. The median operation time (wire to wire) and fluoroscopy time were 90 (75-105) minutes and 30 (22-34) minutes, respectively, without significant differences between groups (P = .56 and P = .36). Dose-area product was nonsignificantly higher in the control group, 21.7 (8.9-85.9) Gy cm², compared with the fusion group, 12.4 (7.5-23.4) Gy cm² (P = .10). Air kerma product was significantly higher in the control group, 142 (61-541) mGy, compared with 82 (51-115) mGy in the fusion group (P = .03). The number of digital subtraction angiography runs was significantly lower in the fusion group (8 [6-11]) compared with the control group (10 [9-14]); (P = .03). There were no significant differences in the frequency of adverse events, endoleaks, or additional procedures required.

CONCLUSIONS

When it is used in simple procedures such as infrarenal aneurysm repair, image-based fusion technology is feasible both in hybrid operating rooms and on mobile systems and leads to an overall 50% reduction in radiation dose. Fusion technology should become standard of care for centers attempting to maximize radiation dose reduction, even if capital investment of a hybrid operating room is not feasible.