Endoscopic ultrasound-guided versus percutaneous drainage for the management of post-operative fluid collections after distal pancreatectomy

BACKGROUND

Post-operative pancreatic fluid collections (POPFCs) can be drained using percutaneous or endoscopic approaches. The primary aim of this study was to compare rates of clinical success between endoscopic ultrasound-guided drainage (EUSD) with percutaneous drainage (PTD) in the management of symptomatic POPFCs after distal pancreatectomy. Secondary outcomes included technical success, total number of interventions, time to resolution, rates of adverse events (AEs), and POPFC recurrence.

METHODS

Adults who underwent distal pancreatectomy from January 2012 to August 2021 and developed symptomatic POPFC in the resection bed were retrospectively identified from a single academic center database. Demographic data, procedural data, and clinical outcomes were abstracted. Clinical success was defined as symptomatic improvement and radiographic resolution without requiring an alternate drainage modality. Quantitative variables were compared using a two-tailed t-test and categorical data were compared using Chi-squared or Fisher's exact tests.

RESULTS

Of 1046 patients that underwent distal pancreatectomy, 217 met study inclusion criteria (median age 60 years, 51.2% female), of whom 106 underwent EUSD and 111 PTD. There were no significant differences in baseline pathology and POPFC size. PTD was generally performed earlier after surgery (10 vs. 27 days; p < 0.001) and more commonly in the inpatient setting (82.9% vs. 49.1%; p < 0.001). EUSD was associated with a significantly higher rate of clinical success (92.5% vs. 76.6%; p = 0.001), fewer median number of interventions (2 vs. 4; p < 0.001), and lower rate of POPFC recurrence (7.6% vs. 20.7%; p = 0.007). AEs were similar between EUSD (10.4%) and PTD (6.3%, p = 0.28), with approximately one-third of EUSD AEs due to stent migration.

CONCLUSION

In patients with POPFCs after distal pancreatectomy, delayed drainage with EUSD was associated with higher rates of clinical success, fewer interventions, and lower rates of recurrence than earlier drainage with PTD.

Adrenal venous sampling for lateralization of cortisol hypersecretion in patients with bilateral adrenal masses

OBJECTIVE

The objective of this study was to evaluate the role of adrenal venous sampling (AVS) in guiding the management of patients with corticotropin (ACTH)-independent glucocorticoid secretory autonomy and bilateral adrenal masses.

DESIGN AND PATIENTS

A cohort with 25 patients underwent AVS and surgical management.

MEASUREMENTS

Cortisol was measured from the adrenal veins (AVs) and inferior vena cava (IVC). AV/IVC cortisol ratio and cortisol lateralization ratio (CLR) (dominant AV cortisol concentration divided by the nondominant AV cortisol concentration) were calculated. Posthoc receiver-operating characteristic curves were generated to determine the specificity of revised AV/IVC cortisol ratio and CLR in differentiating unilateral from bilateral disease.

RESULTS

Patients underwent unilateral (n = 21) or bilateral (n = 4) adrenalectomy. The mean AV/IVC cortisol ratio for unilateral adrenalectomy was 12.1 ± 9.6 (dominant) and 4.7 ± 3.8 (contralateral) with a mean CLR of 3.6 ± 3.5. The mean AV/IVC cortisol ratio for bilateral adrenalectomy was 7.5 ± 2.1, with a mean CLR of 1.1 ± 0.6. At a mean follow-up of 22 months, one patient who underwent unilateral adrenalectomy for the predicted bilateral disease developed recurrent mild autonomous cortisol secretion. Posthoc analyses demonstrated a specificity of 95%-100% for unilateral disease with AV/IVC cortisol ratio >9 for one side, <2.0 for the opposite side and a CLR > 2.3. The specificity was 80%-90% for bilateral disease with AV/IVC cortisol ratio >5.1 bilaterally and a CLR < 1.1.

CONCLUSIONS

Among patients with bilateral adrenal masses and ACTH-independent autonomous cortisol secretion, AVS can distinguish between unilateral and bilateral disease with high specificity and may guide surgical management.

Patency rates of hepatic arterial resection and revascularization in locally advanced pancreatic cancer

BACKGROUND

Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization.

METHODS

We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed.

RESULTS

HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p = 0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158.

CONCLUSION

CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.

PSMA as a Theranostic Target in Hepatocellular Carcinoma: Immunohistochemistry and 68 Ga-PSMA-11 PET Using Cyclotron-Produced 68 Ga

Prostate-specific membrane antigen (PSMA) is a validated target for molecular diagnostics and targeted radionuclide therapy. Our purpose was to evaluate PSMA expression in hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and hepatic adenoma (HCA); investigate the genetic pathways in HCC associated with PSMA expression; and evaluate HCC detection rate with 68 Ga-PSMA-11 positron emission tomography (PET). In phase 1, PSMA immunohistochemistry (IHC) on HCC (n = 148), CCA (n = 111), and HCA (n = 78) was scored. In a subset (n = 30), messenger RNA (mRNA) data from the Cancer Genome Atlas HCC RNA sequencing were correlated with PSMA expression. In phase 2, 68 Ga-PSMA-11 PET was prospectively performed in patients with treatment-naïve HCC on a digital PET scanner using cyclotron-produced 68 Ga. Uptake was graded qualitatively and semi-quantitatively using standard metrics. On IHC, PSMA expression was significantly higher in HCC compared with CCA and HCA (P < 0.0001); 91% of HCCs (n = 134) expressed PSMA, which principally localized to tumor-associated neovasculature. Higher tumor grade was associated with PSMA expression (P = 0.012) but there was no association with tumor size (P = 0.14), fibrosis (P = 0.35), cirrhosis (P = 0.74), hepatitis B virus (P = 0.31), or hepatitis C virus (P = 0.15). Overall survival tended to be longer in patients without versus with PSMA expression (median overall survival: 4.2 vs. 1.9 years; P = 0.273). FGF14 (fibroblast growth factor 14) mRNA expression correlated positively (rho = 0.70; P = 1.70 × 10-5 ) and MAD1L1 (Mitotic spindle assembly checkpoint protein MAD1) correlated negatively with PSMA expression (rho = -0.753; P = 1.58 × 10-6 ). Of the 190 patients who met the eligibility criteria, 31 patients with 39 HCC lesions completed PET; 64% (n = 25) lesions had pronounced 68 Ga-PSMA-11 standardized uptake value: SUVmax (median [range] 9.2 [4.9-28.4]), SUVmean 4.7 (2.4-12.7), and tumor-to-liver background ratio 2 (1.1-11). Conclusion: Ex vivo expression of PSMA in neovasculature of HCC translates to marked tumor avidity on 68 Ga-PSMA-11 PET, which suggests that PSMA has the potential as a theranostic target in patients with HCC.

Long-term renal function outcomes after renal cryoablation complicated by major hemorrhage requiring selective transarterial embolization

PURPOSE

To determine long-term renal function outcomes after renal cryoablation complicated by major hemorrhage requiring transarterial embolization compared to patients who underwent uncomplicated renal cryoablation without major hemorrhage.

METHODS

Utilizing a matched cohort study design, retrospective review identified 23 patients who underwent percutaneous image-guided renal cryoablation complicated by major hemorrhage requiring ipsilateral transarterial embolization (TAE group) and a control group of 23 patients who underwent uncomplicated renal cryoablation matched 1:1 by age, gender and RENAL Nephrometry score at a single institution from 1/1/2005 to 12/31/2019. Primary outcome parameters included change in creatinine (mg/dl) and estimated glomerular filtration rate (ml/min/1.73 m²; eGFR) from baseline and were compared between TAE and control group using a paired t-test.

RESULTS

There was a significantly higher proportion of patients on pre-ablation anticoagulation in the TAE v. control group (30% v. 4%; p = 0.047), but all patients were off anticoagulation and with normal coagulation parameters at the time of cryoablation. Otherwise there were no significant differences in clinical, renal tumor, Charlson co-morbidity index, baseline renal function or cryoablation parameters between the TAE and control group. In the post-ablation period, there was trend toward greater increase in creatinine from baseline to worst post-ablation creatinine in the TAE v. the control group (+ 0.5 ± 0.7 mg/dl v. 0.2 ± 0.1 mg/dl; p = 0.056). However, at a mean follow-up of 42.7 ± 35.7 months, there was no significant difference between the TAE and control group in creatinine (p = 0.68), eGFR (p = 0.60) or change from baseline in creatinine (p = 0.28), eGFR (p = 0.80) or CKD stage (p = 0.74). No patient required initiation of hemodialysis.

CONCLUSION

Selective transarterial embolization for post-renal cryoablation hemorrhage does not significantly affect long-term renal function compared to cryoablation alone. Pre-ablation anticoagulation despite normal coagulation at time of ablation may be a risk factor for post-ablation hemorrhage, and warrants further evaluation when considering pre-ablation embolization.

Transjugular Renal Biopsy Bleeding Risk and Diagnostic Yield: A Systematic Review

This study aimed to better define the safety and efficacy of transjugular renal biopsy (TJRB) based on published studies. Seventeen published articles were included (1,321 biopsies). Complications were classified as major if they resulted in blood transfusion or additional invasive procedures. All other bleeding complications were considered minor. Diagnostic tissue was obtained in 1,193 procedures (90.3%). The total incidence of bleeding complications among 15 articles with complete data was 202 of 892 procedures (22.6%): 162 (18.2%) minor and 40 (4.5 %) major. These results show that TJRB is a feasible procedure for obtaining renal tissue for diagnosis and that most complications are self-limiting.

The efficacy, safety, and predictors of outcomes of transarterial radioembolization for hepatocellular carcinoma: a retrospective study

OBJECTIVES

Yttrium-90 transarterial radioembolization (TARE) is a safe, effective modality of locoregional therapy for intermediate and advanced-stage hepatocellular carcinoma (HCC). We aim to identify novel predictors of important outcomes of TARE therapy.

METHODS

A single-center retrospective study of 166 patients treated with TARE for HCC at Mayo Clinic Rochester between 2005-2015 and followed until December 2017. Multivariate logistic and stepwise regression analysis models were used to identify variables associated with overall survival (OS) and progression-free survival (PFS).

RESULTS

The median OS and the median PFS were12.9  (95% CI: 11.0-17.3), and 8 months (95% CI: 6-11), respectively. Macrovascular invasion (HR: 1.9 [1.3-2.8]), Child-Pugh score (CPS) B or C vs. A (HR: 1.8 [1.2-2.7]), Eastern Cooperative Oncology Group Performance status (ECOG-PS) 2 or 1 vs. 0 (HR: 1.6 [1.1-2.4]) and activity (A) of administered radiation dose (HR: 1.005[1.00-1.010), independently correlated with poorer OS. Infiltrative HCC (HR: 2.4 [1.3-4.5), macrovascular invasion (HR: 1.6 [1.1-2.7]), and high activity of administered radiation dose (HR: 1.005 [1.00-1.010) were associated with worse PFS.

CONCLUSION

In HCC patients treated with TARE; macrovascular invasion, the activity of radiation dose, CPS, ECOG-PS, and infiltrative HCC predict OS and PFS.

Portomesenteric Venous Complications after Pancreatic Surgery with Venous Reconstruction: Imaging and Intervention

Pancreatic surgery with en bloc venous resection and reconstruction is becoming increasingly common in the current era of expanding neoadjuvant oncologic therapies and advanced surgical techniques for patients with more anatomically complex tumors. However, patients who have alterations in their venous outflow are at increased risk for postoperative portomesenteric venous stenosis and/or thrombosis. Cross-sectional imaging for postoperative surveillance, including multiphase CT or MRI, is critical for recognizing portomesenteric venous complications and thus implementing early intervention and preventing complications related to portomesenteric venous hypertension. Hypertension-related complications include ascites, variceal or gastrointestinal bleeding, postprandial abdominal pain, intestinal edema, protein-losing enteropathy, malabsorptive diarrhea, and splenomegaly. Percutaneous transhepatic, transsplenic, and transjugular portomesenteric interventions, including venoplasty, stent placement, and thrombectomy or thrombolysis, are safe and effective options for restoring patency to the portomesenteric venous system. Preintervention CT or MRI and diagnostic catheter venography are important for procedural planning, while postintervention CT or MRI surveillance is critical for detecting recurrent stenosis or thrombosis, or de novo portomesenteric venous disease. Online supplemental material is available for this article. ^©RSNA, 2020.

Evaluation of Technical Success, Efficacy, and Safety of Portomesenteric Venous Intervention following Nontransplant Hepatobiliary or Pancreatic Surgery

PURPOSE

To evaluate technical success, efficacy and safety of portomesenteric venous (PMV) intervention for PMV stenosis or occlusion following nontransplant hepatobiliary or pancreatic (HPB) surgery.

MATERIALS AND METHODS

A retrospective review identified 42 patients (mean age 60 y) with PMV stenosis (n = 33; 79%) or occlusion (n = 9; 21%) who underwent attempted PMV intervention following HPB surgery between June 1, 2011, and April 1, 2018. Main outcomes were technical success, primary patency rates, and complications. Technical success was compared by venous pathology and primary PMV patency based on anticoagulation status after the procedure using Fisher exact test. Rates of primary patency by stent group were estimated using Kaplan-Meier method.

RESULTS

Technical success was 91% (n = 38/42) and significantly higher in patients with stenosis (n = 33/33; 100%) vs occlusion (n = 5/9; 56%) (P = .001). Primary presenting symptom resolved in 28 (87%) patients, including 6 (100%) patients with gastrointestinal bleeding. At mean imaging follow-up of 8.6 months ± 8.8, primary stent patency was 76%. There was no significant difference in primary stent patency based on anticoagulation status after the procedure (P = .48). There were 2 (4.8%) periprocedural complications.

CONCLUSIONS

Portomesenteric venoplasty and stent placement following nontransplant HPB surgery is safe with a high rate of technical success if performed before chronic occlusion.

Future Liver Remnant Hypertrophy after Portal Vein Embolization Is Inversely Correlated with Intrahepatic Tumor Burden

PURPOSE

To determine if there is a correlation between intrahepatic tumor volume and future liver remnant (FLR) hypertrophy after portal vein embolization (PVE).

MATERIALS AND METHODS

Forty-four consecutive patients with hepatocellular carcinoma or metastatic colorectal cancer who underwent PVE from 2009 to 2017 and who had complete imaging follow-up were retrospectively reviewed. To maximize the accuracy of tumor volume measurements, 11 patients were excluded for having more than 5 intrahepatic tumors. Volumetric analyses of the patient livers before and after PVE, as well as pre-embolization intrahepatic tumor burden, were performed.

RESULTS

A significant inverse correlation was observed between tumor volume and FLR hypertrophy after PVE (Spearman ρ = -0.53, P = .002). Initial FLR volume was also inversely correlated with subsequent hypertrophy (P = .01). Fourteen patients received neoadjuvant chemotherapy 1 month prior to intervention. The number of chemotherapy cycles did not affect hypertrophy (P = .57). Patients with cirrhosis experienced less FLR hypertrophy than patients without cirrhosis (P = .02).

CONCLUSIONS

Patients with large intrahepatic tumor burden may experience limited FLR hypertrophy.

Small Bowel Imaging: Computed Tomography Enterography, Magnetic Resonance Enterography, Angiography, and Nuclear Medicine

Radiology examinations play a major role in the diagnosis, management, and surveillance of small bowel diseases and are complementary to endoscopic techniques. Computed tomography enterography and magnetic resonance enterography are the cross-sectional imaging studies of choice for many small bowel diseases. Angiography still plays an important role for catheter-directed therapies. With the emergence of hybrid imaging techniques, radionuclide imaging has shown promise for the evaluation of small bowel bleeding and Crohn disease and may play a larger role in the future. This article reviews recent advances in technology, diagnosis, and therapeutic options for selected small bowel disorders.

Percutaneous radiologic gastrostomy catheter placement without gastropexy: a co-axial balloon technique and evaluation of safety and efficacy

PURPOSE

The purpose of this study is to evaluate the short-term safety and efficacy of a co-axial angioplasty balloon technique for percutaneous radiologic gastrostomy catheter placement (PRG).

METHODS

A total of 65 percutaneous radiologic gastrostomy tube placements were performed with the co-axial angioplasty balloon technique from 10/1999 to 1/2014. This included 19 females and 46 males between the ages of 20-83. Without the use of T-fasteners for gastropexy, the gastrostomy tube was placed over a catheter-shaft angioplasty balloon as a co-axial system. The angioplasty balloon was used to sequentially approximate the stomach wall to the abdominal wall, dilate the tract, and was then used as a dilator to aid gastrostomy tube advancement into the gastric lumen. Technical success, complications, and dislodgements were evaluated by means of retrospective review of patient medical records and imaging.

RESULTS

There was no procedural failure in any of the 65 placements. 30-day follow-up was available for 56 patients. 7 patients died within 30 days; none of the deaths were recorded as procedure-related. There was 1 major complication (1.5%) consisting of a colocutaneous fistula. There were 4 minor complications (6.2%). There was no occurrence of bleeding or skin infection while using this technique.

CONCLUSIONS

PRG with the co-axial angioplasty-balloon technique is a safe and effective technique for gastrostomy placement.

Severe Acute Cardiopulmonary Failure Related to Gadobutrol Magnetic Resonance Imaging Contrast Reaction: Successful Resuscitation With Extracorporeal Membrane Oxygenation

Nonanaphylactic noncardiogenic pulmonary edema leading to cardiorespiratory arrest related to the magnetic resonance imaging contrast agent gadobutrol has rarely been reported in the literature. Rarer is the association of hypokalemia with acidosis. We report 2 patients who had severe pulmonary edema associated with the use of gadobutrol contrast in the absence of other inciting agents or events. These cases were unique not only for their rare and severe presentations but also because they exemplified the increasing role of extracorporeal membrane oxygenation in resuscitation. Emergency extracorporeal membrane oxygenation resuscitation can be rapidly initiated and successful in the setting of a well-organized workflow, and it is a viable alternative and helps improve patient outcome in cases refractory to conventional resuscitative measures.

Intravenous contrast material-induced nephropathy: causal or coincident phenomenon?

PURPOSE

To determine the causal association and effect of intravenous iodinated contrast material exposure on the incidence of acute kidney injury (AKI), also known as contrast material-induced nephropathy (CIN).

MATERIALS AND METHODS

This retrospective study was approved by an institutional review board and was HIPAA compliant. Informed consent was waived. All contrast material-enhanced (contrast group) and unenhanced (noncontrast group) abdominal, pelvic, and thoracic CT scans from 2000 to 2010 were identified at a single facility. Scan recipients were sorted into low- (<1.5 mg/dL), medium- (1.5-2.0 mg/dL), and high-risk (>2.0 mg/dL) subgroups of presumed risk for CIN by using baseline serum creatinine (SCr) level. The incidence of AKI (SCr ≥ 0.5 mg/dL above baseline) was compared between contrast and noncontrast groups after propensity score adjustment by stratification, 1:1 matching, inverse weighting, and weighting by the odds methods to reduce intergroup selection bias. Counterfactual analysis was used to evaluate the causal relation between contrast material exposure and AKI by evaluating patients who underwent contrast-enhanced and unenhanced CT scans during the study period with the McNemar test.

RESULTS

A total of 157,140 scans among 53,439 unique patients associated with 1,510,001 SCr values were identified. AKI risk was not significantly different between contrast and noncontrast groups in any risk subgroup after propensity score adjustment by using reported risk factors of CIN (low risk: odds ratio [OR], 0.93; 95% confidence interval [CI]: 0.76, 1.13; P = .47; medium risk: odds ratio, 0.97; 95% CI: 0.81, 1.16; P = .76; high risk: OR, 0.91; 95% CI: 0.66, 1.24; P = .58). Counterfactual analysis revealed no significant difference in AKI incidence between enhanced and unenhanced CT scans in the same patient (McNemar test: χ(2) = 0.63, P = .43) (OR = 0.92; 95% CI: 0.75, 1.13; P = .46).

CONCLUSION

Following adjustment for presumed risk factors, the incidence of CIN was not significantly different from contrast material-independent AKI. These two phenomena were clinically indistinguishable with established SCr-defined criteria, suggesting that intravenous iodinated contrast media may not be the causative agent in diminished renal function after contrast material administration.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12121823/-/DC1.

Efficacy and safety of transarterial radioembolization versus chemoembolization in patients with hepatocellular carcinoma

PURPOSE

Intermediate-stage hepatocellular carcinoma (HCC) is usually treated with locoregional therapy using transarterial chemoembolization (TACE). Transarterial radioembolization (TARE) using β-emitting yttrium-90 integral to the glass matrix of the microspheres is an alternative to TACE. This retrospective case-control study compared the outcomes and safety of TARE versus TACE in patients with unresectable HCC.

MATERIALS AND METHODS

Patients with unresectable HCC without portal vein thrombosis treated with TARE between 2005 and 2008 (n = 61) were retrospectively frequency-matched by age, sex, and liver dysfunction with TACE-treated patients (n = 55) in the Mayo Clinic Hepatobiliary Neoplasia Registry. Imaging studies were reviewed, and clinical and safety outcomes were abstracted from the medical records.

RESULTS

Complete tumor response was more common after TARE (12 %) than after TACE (4 %) (p = 0.17). When complete response was combined with partial response and stable disease, there was no difference between TARE and TACE. Median survival did not differ between the two groups (15.0 months for TARE and 14.4 months for TACE; p = 0.47). Two-year survival rates were 30 % for TARE and 24 % for TACE. TARE patients received fewer treatments (p < 0.001). Fifty-nine (97 %) TARE patients received outpatient treatment. In contrast, 53 (98 %) TACE patients were hospitalized for ≥1 day (p < 0.001). Compared with TACE, TARE was more likely to induce fatigue (p = 0.003) but less likely to cause fever (p = 0.02).

CONCLUSION

There was no significant difference in efficacy between TARE and TACE. TARE patients reported more fatigue but had less fever than TACE patients. Treatment with TARE required less hospitalization than treatment with TACE. These findings require confirmation in randomized trials.

Tube thoracostomy: a review for the interventional radiologist

Small-caliber tube thoracostomy is a valuable treatment for various pathologic conditions of the pleural space. Smaller caliber tubes placed under image guidance are becoming increasingly useful in numerous situations, are less painful than larger surgical tubes, and provide more accurate positioning when compared with tubes placed without image guidance. Basic anatomy and physiology of the pleural space, indications, and contraindications of small caliber tube thoracostomy, techniques for image-guided placement, complications and management of tube thoracostomy, and fundamental principles of pleurodesis are discussed in this review.

Outcomes of endoscopic and percutaneous drainage of pancreatic fluid collections arising after pancreatic tail resection

BACKGROUND

Up to 15% to 30% of patients develop pancreatic fluid collections (PFCs) after pancreatic tail resection. Percutaneous and endoscopic methods have been used to drain these collections, though few data are available that compare outcomes of these modalities.

STUDY DESIGN

From December 1998 to April 2011, we identified all patients who underwent pancreatic tail resection and developed PFCs requiring intervention. The primary aim was to compare overall success rates in resolution of PFCs using endoscopic and percutaneous modalities. Success rates, hospital length of stay, number of CT scans, sinograms and endoscopies performed, and days with drain(s) in place were compared.

RESULTS

Forty-eight patients were identified. Percutaneous drainage was performed a median of 25 days postoperatively, compared with 85 days for endoscopic drainage (p < 0.001). Endoscopic and percutaneous methods had similar rates of technical success (100% vs 97%, p = 0.50) and treatment success (80% vs 81%, p = 0.92), respectively. Recurrence rates were 16.6% for the endoscopic group and 23% for the percutaneous group (p = 0.65), and adverse events occurred in 9.4% of those treated endoscopically vs 13.3% of those treated percutaneously (p = 0.68). Location and characteristics of PFCs did not influence success rates. Recurrences were often treated by "salvage" drainage via the other modality. Median hospital stay was longer after primary percutaneous drainage compared with primary endoscopic drainage (5.5 days vs 2 days, p = 0.046). Primary percutaneous drainage patients also had more CT scans (median 3 vs 2, p = 0.03).

CONCLUSIONS

Endoscopic drainage and percutaneous drainage appear to be equally effective and complementary interventions for PFCs occurring after pancreatic tail resection. Primary endoscopic drainage may be associated with shorter hospital stay and fewer CT scans.

Hepatic artery embolization for neuroendocrine tumors: postprocedural management and complications

BACKGROUND

There is scant evidence to guide the management of patients after hepatic artery embolization (HAE). We examined length of stay (LOS), laboratory patterns, medication usage, morbidity, and mortality of patients hospitalized after HAE for metastatic neuroendocrine tumors.

METHODS

Data were abstracted retrospectively from electronic medical records on LOS, liver function tests (LFTs), i.v. antibiotics, analgesia, peak temperature, bacteremia, hepatic abscess formation, carcinoid crisis, and metastatic burden on cross-sectional imaging.

RESULTS

In 2005-2009, 72 patients underwent 174 HAEs for carcinoid and islet cell tumors. The median LOS was 4 days (range, 1-8 days). There was no correlation between peak LFTs and tumor burden. Declines in LFTs were not uniform before hospital discharge; 25%, 37%, 30%, 53%, and 67% of patients were discharged before their respective aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total and direct bilirubin levels began to decline, with no readmissions for acute hepatic failure. The median i.v. analgesia dose was 60 mg oral morphine equivalents (range, 3-1,961 mg). Pre-HAE i.v. antibiotics were administered in 99% of cases; post-HAE fever occurred in 37% of patients, with no documented bacteremia. One patient developed a hepatic abscess after HAE. There were two carcinoid crises. The single in-hospital death was associated with air in the portal veins.

CONCLUSIONS

The duration and intensity of in-hospital care following HAE should be managed on an individual basis. A downward trend in LFTs is not required before discharge. Modest use of i.v. analgesia suggests that many patients could exclusively receive oral analgesics. Given the rarity of serious complications, hospital stays could be shortened, thereby reducing costs and nosocomial risks.

Current trends and controversies in cutaneous melanoma

Cutaneous melanoma is an emerging and complex health problem. Management may require the expertise of multiple specialties. Although the outlook for advanced disease remains very poor, there are major advances in the understanding of melanoma. The heterogeneous nature of melanoma is more apparent and as such it is becoming evident that in the future we will probably utilise multiple approaches to treat disease and treatments may be tailored to individual needs. We can anticipate that as technology improves and information continues to accrue, our increased understanding of melanoma will lead to improved treatment of advanced disease.

A pilot study of treatment of lentigo maligna with 5% imiquimod cream

BACKGROUND

Lentigo maligna (LM) is an in situ form of malignant melanoma, and surgical excision is often unsatisfactory. Imiquimod cream is an immune response modifier and induces a predominantly T-helper 1 type response.

OBJECTIVES

Assessment of histological and clinical response of surgically resectable LM after treatment with 5% imiquimod cream.

METHODS

Six patients with LM were treated with 5% imiquimod cream daily for 6 weeks. The whole site of the original lesion was then excised. Clinical and histological and appearances were measured using clinical response and histological grading scores.

RESULTS

Complete or almost complete clearance of pigmentation with minimal residual histological evidence of LM was observed in four patients, one patient showed no clinical or histological improvement, and the remaining patient had almost no residual pigmentation clinically after treatment yet histopathological changes remained as severe as before treatment.

CONCLUSIONS

Topical imiquimod cream merits further investigation as a new therapy for LM.

DNA sequence and analysis of human chromosome 9

Chromosome 9 is highly structurally polymorphic. It contains the largest autosomal block of heterochromatin, which is heteromorphic in 6-8% of humans, whereas pericentric inversions occur in more than 1% of the population. The finished euchromatic sequence of chromosome 9 comprises 109,044,351 base pairs and represents >99.6% of the region. Analysis of the sequence reveals many intra- and interchromosomal duplications, including segmental duplications adjacent to both the centromere and the large heterochromatic block. We have annotated 1,149 genes, including genes implicated in male-to-female sex reversal, cancer and neurodegenerative disease, and 426 pseudogenes. The chromosome contains the largest interferon gene cluster in the human genome. There is also a region of exceptionally high gene and G + C content including genes paralogous to those in the major histocompatibility complex. We have also detected recently duplicated genes that exhibit different rates of sequence divergence, presumably reflecting natural selection.

Cosmetic camouflage advice improves quality of life

BACKGROUND

The subjective benefit of attendance at cosmetic clinics has not previously been reported.

OBJECTIVES

To assess the effect on perceived quality of life (QoL) of cosmetic camouflage advice.

METHODS

In a three-centre study, 135 individuals were invited to complete a dermatology-specific QoL measure, the Dermatology Life Quality Index (DLQI), before and 1 month after their first visit to a cosmetic camouflage clinic.

RESULTS

Eighty-two completed DLQI questionnaires were returned before the camouflage clinic appointment, and 56 corresponding questionnaires were returned 1 month after. The mean age of responders was 50 years, and the mean duration of their skin conditions was 15 years. The main conditions seen were pigmentary disorders (29%), scars (22%) and vascular disorders (13%). There was a significant difference in mean DLQI scores before and after the clinic visit (9.1 vs. 5.8, P = 0.0001).

CONCLUSIONS

When assessed at 1 month, attendance at a cosmetic camouflage clinic appears to improve QoL significantly.

Accuracy of questions related to allergic contact dermatitis

BACKGROUND

The ability of a physician to select individuals likely to benefit from patch testing depends on his or her ability to interpret responses to enquiries related to contact allergy. The significance of such responses to questions of nickel, fragrance and colophon allergy is unclear.

OBJECTIVE

The specificity, sensitivity and predictive value of questions relating to nickel, fragrance and colophony allergy were determined.

METHOD

A total of 258 patients attending for routine patch testing were questioned about skin reactions to nickel, fragrances and Elastoplast (Smith and Nephew Healthcare, Hull, England). All subjects were then patch tested to nickel, fragrance mix, and colophony. Responses to questions were compared with patch test results.

RESULTS

The sensitivity of questions relating to nickel, fragrance, and colophony was 82%, 49%, and 71%, respectively. The specificity of the same questions was 77%, 79%, and 90%; the positive predictive value was 54%, 46% and 29%, respectively. After adjustment to include clinical relevance, the sensitivity of nickel questions rose to 100%.

CONCLUSION

These data permit greater understanding of the role of patient history in selection of patients for patch testing.

Survey of patch testing in Scotland

We have surveyed Scottish dermatologists to establish the extent of patch testing, to assess the reasons for referral and to document resources and methods used by dermatologists. 104 questionnaires were sent to members of the Scottish Dermatological Society. 82 questionnaires (79%) were returned. 50% of respondents were consultants, 27% were trainees and 23% held staff grade or clinical assistant positions. The mean waiting time for a patch test appointment was 4.5 months. The most frequent reasons for patch testing were localized eczema, eczema not responding to conventional treatment, occupational eczema, history of contact sensitivity and eczema of uncertain cause. 17 of 82 respondents (21%) were the principal clinicians supervising patch testing in their hospitals. 11 of 17 read reactions at 2 and 4 days. Mean time spent on advising patients was 13 min per patients. 7 of 17 were dissatisfied with resources available for patient education and 16 of 17 felt they would benefit from a central source for patient information. Only 4 of 17 centres recorded patch test results on a database and 3 centres regularly reviewed their patch test results. In conclusion, we have identified areas of patch testing that require further improvement.

The genetics of allergic contact hypersensitivity to nickel

We have examined evidence for familial disposition to nickel allergic contact dermatitis (Ni ACD). 258 patients attending for routine patch testing were recruited prospectively. 39 patients were diagnosed with Ni ACD. 31 of 209 1st-degree relatives (15%) of probands had a history of nickel hypersensitivity. 84 patients with no history of nickel hypersensitivity and negative patch tests to nickel were used as controls. 24 of 458 1st degree relatives of controls (5.2%) had a history of Ni ACD. The risk ratio for 1st degree relatives of a patient with Ni ACD is 2.83 (95% confidence intervals are 2.45, 3.27). This is the 1st study to present a statistic to represent risk to relatives of developing ACD. Relatives of patients with Ni ACD have an increased risk of developing the condition, but the genetic basis for this is not yet known. With currently available techniques, this value of relative risk makes a positional cloning approach to gene identification impractical.

Contact sensitivity to cigarettes and matches

The results of patch testing with a series containing components of cigarettes and matches were reviewed. 2 years were reviewed, 1987 and 1997. 314 patients were patch tested to this series, 203 in 1987 and 111 in 1997. 31 patients had clinically relevant positive reactions to the series, 25 in 1987 and 6 in 1997. 26 patients had relevant positive tests to cigarette components in the series. There were 14 relevant positive reactions to phosphorus sesquisulfide in 1987 and one in 1997. All patients with relevant positive reactions to red match tips also had reactions to phosphorus sesquisulfide. There was a significant association between cigarette and fragrance hypersensitivity. The eczema in 3 of 4 patients who stopped smoking improved. A series containing match heads, smoked cigarette filters and remnants of tobacco from smoked cigarettes may be useful in smokers with eczema of the face, neck or hands.

Systemic complement activation in psoriasis vulgaris

Nineteen patients with psoriasis vulgaris and no other cause for systemic complement activation were studied for evidence of such activation. There was a marked elevation in serum C5b-9 complexes with no other significant complement abnormalities, and no correlation between C5b-9 levels and disease activity. This is the most detailed study of complement in psoriasis yet attempted and confirms that complement activation is a feature of psoriasis vulgaris.

Minocycline-induced hyperpigmentation in leprosy

A 36-year-old man was treated with dapsone, rifampicin and clofazimine for borderline lepromatous leprosy. After 9 months, his leprosy plaques became progressively more red and after 23 months, the clofazimine was stopped and he was given minocycline instead. Six weeks later, he developed blue-black pigmentation in his leprosy lesions. The histology was consistent with minocycline-induced hyperpigmentation. This is the first report of minocycline-induced pigmentation in leprosy. We suggest it is important to consider this side-effect before the administration of minocycline in leprosy, particularly if it is prescribed in place of clofazimine.

Chrysiasis after low-dose gold and UV light exposure

We describe a case of chrysiasis in a 54-year-old woman. The diagnosis was confirmed by light microscopy, transmission electron microscopy, and radiographic microanalysis. The condition developed after a relatively low dose of gold. We propose that chrysiasis developed because of the patient's exposure to the intense UV light in Australia.