Difficult Anatomic Locations Research Articles

2148 A Mediastinal Abscess Due to Actinomcyes Odontolyticus Diagnosed by Endoscopic Ultrasound-Guided FNA

INTRODUCTION: Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury. CASE DESCRIPTION/METHODS: A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort & fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5 × 2 × 2 cm posterior mediastinum collection (Figure 1) abutting the esophagus with mid and distal esophagitis. An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31 cm with a mucosal fistula at 27 cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative. On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 × 2 cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed >100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus. DISCUSSION: Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.

1471 Normal Polypoid Tissue After Endoscopic Full Thickness Resection of Colonic Lesions

INTRODUCTION: Endoscopic full thickness resection (EFTR) is a novel endoscopic procedure for management of challenging colorectal lesions. Resection site growths after EFTR are usually concerning for incomplete resection or recurrence of the initial lesion. Here we report two patients who underwent EFTR and had polypoid growth of normal tissue at the site of EFTR on surveillance colonoscopy. CASE DESCRIPTION/METHODS: Case 1 A 51-year-old Caucasian male was referred for evaluation of residual sigmoid colon tubulovillous adenoma with focal high grade dysplasia. He has a family history of late onset colorectal cancer in his mother and grandmother. He had no abdominal symptoms and examination was unremarkable. Colonoscopy revealed residual polypoid tissue at the site of a prior attempted polypectomy for which he underwent EFTR. Surveillance colonoscopy 6 months later showed a 15-mm polyp-like growth at the site of prior EFTR that was lifted and resected with a hot snare (Figure 1). Pathology showed benign mesenchymal proliferation. Case 2 A 70 year-old Caucasian female was referred to our clinic for evaluation of an incompletely resected 20-mm transverse colon tubular adenoma. Her father developed colon cancer after the age of 60. She had no abdominal symptoms and examination was unremarkable. Colonoscopy showed a 20-mm transverse colon polyp with overlying scarring. She underwent EFTR and pathology showed tubular adenoma with clear margins. Repeat colonoscopy 6 months later showed a 10-mm polyp-like lesion at the site of previous EFTR that was lifted and resected with a hot snare (Figure 2). Pathology showed normal colonic mucosa. DISCUSSION: EFTR is a novel procedure for management of lesions that are not amenable to conventional endoscopic resection methods such as non-lifting lesions, lesions with high probability of malignancy, and lesions located in difficult anatomic locations. It is an attractive alternative to surgical resection or endoscopic submucosal dissection for management of such lesions. Resection site growths after EFTR are usually concerning for recurrence. However, polyp-like growths of normal tissue after EFTR were noted in 2 out of 8 patients who underwent EFTR at our institution. Therefore, EFTR site growths may not always represent recurrence of the initial lesion. Awareness of this possibility can alleviate patient anxiety and reduce cost associated with further investigations and resections.

Stereotactic image-guided microwave ablation of hepatocellular carcinoma using a computer-assisted navigation system.

Ablation plays an important role in the treatment of hepatocellular carcinoma. Because image-guided navigation technology has recently entered the clinical setting, we aimed to analyse its safety, therapeutic and procedural efficiency. Retrospective analysis of patients treated with stereotactic image-guided microwave ablation (SMWA) between January 2015 and December 2017. Interventions were performed using computertomography-guidance with needle trajectory, ablation planning and automatic single-marker patient registration. Needle placement and ablation coverage was controlled by image fusion under general anaesthesia with jet-ventilation. In total 174 ablations were performed in 88 patients during 119 interventions. Mean age was 66 (46-84) years, 74 (84.1%) were men and 74% were Child Pugh Class A. Median tumour size was 16 (4-45) mm, 62.2% were BCLC A. Median lateral and longitudinal error of needle placement were 3.2 (0.2-14.1) and 1.6 (0-15.8) mm. Median one tumour (1-4) was ablated per session. One patient developed a Dindo IIIb (0.8%) complication, six minor complications. After re-ablation of 12 lesions, an efficacy rate of 96.3% was achieved. Local tumour progression was 6.3% (11/174). Close proximity to major vessels was significantly correlated with local tumour progression (P<.05). Median overall follow-up was 17.5months after intervention and 24months after initial diagnosis. BCLC stage, child class and previous treatment were significantly correlated with overall survival (P<.05). Stereotactic image-guided microwave ablation is a safe and efficient treatment for HCC offering a curative treatment approach in general and in particular for lesions not detectable on conventional imaging or untreatable because of difficult anatomic locations.

Use of the Magellan Robotic System for Conventional Transarterial Chemoembolization (cTACE): A 6-Patient Case Series Showing Safety and Technical Success

AbstractRobotic endovascular technology is an emerging concept, and is being developed to allow more precise navigation of anatomy in challenging endovascular cases. The Magellan Endovascular System allows either direct or remote steerability of a 2-point articulating robotic platform with the ability to place a conventional microcatheter through the catheter tip. Such flexibility may help to reach an otherwise difficult anatomic location, especially in variant anatomy. To date, this platform has been shown to be technically successful in a small number of different settings. This case series shows another potential platform for such technology and explores the technical use and overall safety in conventional transarterial chemoembolization (cTACE). The study retrospectively assessed 6 patients undergoing selective cTACE. Treatments were performed in a single center by two experienced interventional radiologists. Fluoroscopy time, radiation dose, anatomic target, and adverse events were logged. In spite of a longer than expected average fluoroscopy time, which can be expected for a first-generation technology, the average radiation dose was comparable to literature and technical success was able to be shown in all 6 patients with no adverse events. This technology has wide scope for future use and once overcoming a learning curve, may allow us to avoid repeat procedure attempts thus reducing fluoroscopy time and leading to earlier successful treatment. Providing a platform of interest and usability in the interventional radiology world may also lead to further development of smaller, cheaper, and more widely-accessible devices.

Petroclival meningiomas: radiological features essential for surgeons.

Petroclival meningiomas (PCMs) have always been a challenge for surgeons because of their difficult anatomical location. The role of radiology in providing precise indications regarding the tumour site and aggressiveness plays a major part in guiding the subsequent therapeutic process. The purpose of this review is to provide a set of the main radiological features helpful in the management of PCMs towards the most correct therapeutic approach.We aim to offer a radiological overview to allow the patient to be directed to surgery with the least possible risk of complications.

Screening mammography for second breast cancers in women with history of early-stage breast cancer: factors and causes associated with non-detection

BackgroundThe aim of our study was to identify the factors and causes associated with non-detection for second breast cancers on screening mammography in women with a personal history of early-stage breast cancer.MethodsBetween January 2000 and December 2008, 7976 women with early-stage breast cancer underwent breast surgery in our institution. The inclusion criteria of our study were patients who had: (a) subsequent in-breast recurrence, (b) surveillance mammography within 1 year before recurrence. Retrospective analysis of mammography was performed. Non-detection was defined as second breast cancers that were not visible on screening mammography. Imaging features, demographics, primary breast cancer (PBC) characteristics, and clinical features were evaluated to determine its association with non-detection. Univariate and multivariate logistic regression analyses were also performed to identify the factors related to non-detection.ResultsWe identified 188 patients that met the criteria. Among them, 39% of patients showed non-detection (n = 74). Of the 74 patients with non-detection, 53 (72%) were classified as having no detectable mammographic abnormality (i.e., true negative) due to overlapping dense breast tissue (n = 32), obscured by postoperative scar (n = 12) or difficult anatomic location / poor positioning (n = 9). The remaining 21 patients were categorized as having subtle findings (n = 11) or missed cancer (n = 10). Non-detection for second breast cancers were significantly associated with mammographic breast density (p = 0.001, OR = 2.959) and detectability of PBC on mammography (p = 0.011, OR = 3.013).ConclusionNon-detection of second breast cancer in women with a personal history of early-stage breast cancer were associated with mammographic dense breast and lower detectability of PBC on mammography.

Giant cell tumor of bone: Unusual features of a rare tumor.

Giant cell tumor of bone is a benign tumor with an aggressive behavior. Its typical subarticular location and high recurrence risk can be associated with significant morbidity. Although benign, it can rarely metastasize especially to the lungs. Also, it can be multicentric in less than 1% of patients. Late malignant transformation, although rare, can occur with a very poor prognosis. This series reports on these unusual and challenging features and management considerations of giant cell tumor of bone.This retrospective study included review of the medical records of patients with a confirmed histopathological diagnosis of giant cell tumor of bone.A total of 25 patients (16 females and 9 males) with a mean age of 34.5 years were included; 22 had primary tumors, while 3 were referred with recurrent tumors. Pain was the most common presenting symptom. Most patients had grade III tumors. Tumors around the knee were the most common. Multicentric tumors were detected in three patients. Twenty-three patients (20 primary giant cell tumor of bone and 3 with recurrence) received treatment. Most patients (15/23) were treated with intralesional curettage with or without adjuvants. Seven patients had wide excision. Recurrence was seen in 45% (9/20) of primary giant cell tumor of bone especially with difficult anatomical locations. Most recurrences occurred more than 4 years after treatment. Pulmonary nodules were detected in four patients; two of them showed resolution during follow-up. One patient developed secondary sarcoma transformation with a fatal outcome.Giant cell tumor of bone was more common in females. Long bones were more affected, especially around the knee. Intralesional curettage was the most frequently used treatment. Recurrence was associated with inadequate tumor resection (especially in difficult anatomical location), younger age, male gender, and advanced local tumor grade. Denosumab can be used in the treatment of pulmonary metastasis, multicentric and recurrent giant cell tumor of bone. Due to late recurrence and malignant transformation, a prolonged follow-up is warranted.

Antigravity ESD – double-balloon-assisted underwater with traction hybrid technique

Background and study aims Complex colorectal polyps or those positioned in difficult anatomic locations are an endoscopic therapeutic challenge. Underwater endoscopic submucosal dissection (UESD) is a potential technical solution to facilitate efficient polyp removal. In addition, endoscopic tissue retraction has been confined to limited methods of varying efficacy and complexity. The aim of this study was to evaluate the efficiency of a unique UESD technique for removing complex polyps using double-balloon-assisted retraction (R). Materials and methods Using fresh ex-vivo porcine rectum, 4-cm polyps were created using electrosurgery and positioned at “6 o’clock” within an established ESD model. Six resections were performed in each group. Underwater techniques were facilitated using a novel double-balloon platform (Dilumen, Lumendi, Westport, Connecticut, United States). Results UESD-R had a significantly shorter total procedural time than cap-assisted ESD and UESD alone (24 vs. 58 vs. 56 mins). UESD-R produced a dissection time on average of 5 minutes, attributed to the retraction provided. There was also a subjective significant reduction in electrosurgical smoke with the underwater techniques contributing to improved visualization. Conclusions Here we report the first ex-vivo experience of a unique double-balloon endoscopic platform optimized for UESD with tissue traction capability. UESD-R removed complex lesions in significantly shorter time than conventional means. The combined benefits of UESD and retraction appeared to be additive when tackling complex polyps and should be studied further.

Secondary coiling after incomplete surgical clipping of cerebral aneurysms: a rescue strategy or a treatment option for complex cases? Institutional series and systematic review.

Residual and recurrent intracranial aneurysms after surgical clipping present a persistent risk of bleeding. Secondary coiling after incomplete clipping represents a strategy to occlude the residual sac: feasibility, bleeding risk and outcome were evaluated through a systematic review of literature along with the series of two tertiary referral neurovascular centres. Demographics, ruptured status, aneurysm morphology, topography, exclusion at surgery, timing of secondary coiling, complications, occlusion rate and outcome were analysed. Percentage of incidence and 95% CI were calculated for all variables. T test was used for continue variables, whereas Fisher's test (two-sided) is for categorical ones. Overall, 102 patients (92 cases from literature and 10 cases from institutional series) were included. Mean age at diagnosis was 52.94 ± 12.17years, and male/female ratio 0.5; 3/4 of aneurysms involved the anterior circulation, whereas ¼ the posterior circulation. An aneurysmal neck remnant was described in 58.43% of cases, an aneurysmal sac remnant in 29.21% and a regrowth in 12.36%. Residual aneurysm rupture was reported in 22% of cases. Complete/near-complete occlusion after secondary coiling was observed in 70% of cases, a partial in 25.56% and a failure in 4.44%. Only one case of perforation was reported. Complications were comparable to standard endovascular procedures. Aneurysms remnants after clipping are often observed in cases difficult anatomical locations. Their bleeding risk is not negligible. Secondary coiling is a rescue strategy to effectively and safely secure the aneurysm remnant. Only in a minority of cases, it is a staged treatment after 'remodelling' of the aneurysm neck.

Long-term outcomes after percutaneous renal cryoablation performed with adjunctive techniques

ObjectiveTo review the technical success of image-guided percutaneous cryoablation of renal masses in difficult anatomic locations using adjunctive techniques to displace critical structures away from the ablation zone, while also reporting longer-term outcomes within this patient population. MethodsAn IRB approved, retrospective analysis of 92 renal masses treated with percutaneous cryoablation revealed 15 cases utilizing adjunctive techniques. Tumor size and distance to adjacent organ before and after adjunctive technique and long-term outcomes were evaluated. ResultsThe adjunctive techniques used were hydrodissection (n=15) and angioplasty balloon interposition (n=1). Before and after adjunctive technique, median tumor proximity to closest organ was 4mm and 26mm, respectively. All cases had appropriate ablation zones and protection of adjacent critical structures. There is no evidence of recurrence or complication on follow-up (median 51months). ConclusionsAdjunctive techniques to ablate renal masses in difficult locations provide technical success, safety, and favorable long-term outcomes.

Retroperitoneoscopic Excision of Recurrent Paraganglioma

Abstract Introduction: Paragangliomas are rare tumors that can be sporadic or familial. They are located along the sympathetic or parasympathetic chain with an incidence from 0.005% to 0.1% in the general population.1 About 85% of paragangliomas are below the diaphragm in difficult anatomic locations. Majority are functional.2 The retroperitoneoscopic approach has been used to resect these tumors with certain advantages over the transperitoneal method, including a shorter operative time, reduced pain, a shorter recovery, and subsequently earlier hospital discharge.3 Materials and Methods: The aim of this video is to present a resection of a recurrent paraganglioma in a difficult anatomic location. Results: A 45-year-old lady was investigated for hypertension and palpitations in 2010. She was found to have a 4.1 cm left extra-adrenal pheochromocytoma/paraganglioma distorting the left renal vessels with markedly raised normetanephrine excretion. The patient underwent an open left excision histology, which c...

Bilious pleuritis following transpulmonary radiofrequency ablation of liver metastases

A 55-year-old man with pancreatic cancer metastatic to the liver underwent percutaneous radiofrequency ablation (RFA) of the liver deposits. The liver harboured four metastatic foci, the largest of which was...

Complex Double Balloon-Assisted Colonic ESD: First Human Experience

Complex colorectal polyps (defined as >2cm) or those positioned in difficult anatomic locations may be major endoscopic challenges. Double-balloon systems have been predominantly confined for use in small bowel enteroscopy, however recently its utility has been explored in the lower intestine. Despite clear benefits of ESD (R0 resection and low recurrence rate), it remains a technically challenging procedure with higher perforation rates compared to EMR. In these 2 cases, we employed a unique ESD approach facilitated by a novel endoscopic double balloon system which permitted polyp tissue retraction, increased stability and improved visualization. Clinical case details: 1 - 74 year old male, 3 polyps located in the ascending colon and hepatic flexure. PMH: CHF; CAD s/p Stents; AICD; DM 2- 68 year old male, large complex polyp located in the ascending colon. PMH: OSA, PVC, HLD, HTN ESD technique (briefly): The balloons were deployed behind and in front of the lesion. After the balloons were inflated, a sealed ‘therapeutic zone' was created. A mucosal incision was made at the proximal lesion margin and developed. The incision leading edge was developed further. At the appropriate point the mucosal edge was clipped to the base of the fore balloon. Using variable tension on the fore balloon, tissue dissection continued until resection. After the procedure, the specimen was removed using the fore-balloon as a specimen retrieval bag. The technique was feasible (see Table 1), safe and effective. The double balloon system enabled complex ESD. This led to an enhanced sense of scope stability in a difficult anatomical locations. The additional benefits of retraction and specimen retrieval appeared to be additive and should be studied further.Table: Table. Case data and clinical observationsFigure: Patient 1 - polyps removed.Figure: Patient 2 - polyps removed.

Studying the thermal performance of a bipolar radiofrequency ablation with an improved electrode matrix system: In vitro experiments and modelling

Radiofrequency ablation (RFA) is becoming an effective treatment method for both primary tumors and tumors that have metastasized. Large tumors in difficult anatomic locations can be treated by RFA technologies. However, constant size and regular shape of damage zones cannot be obtained by recent RFA technologies. The aim of this study is to optimize the stability of RFA treatment by employing a newly proposed bipolar electrode system. A hepatic RFA mathematical model is developed by the finite element method approach. The model is validated with the experimental data. This model is then used to verify the reliability and stability of the proposed electrode system. Simulated results showed the cross section of the ablation zone utilizing designed electrode system approximates a square. In addition, the fraction of the necrosed tissue with this electrode pattern turned out to be larger than the fraction with single-probe RFA techniques. This system demonstrated higher ablation stability even for tissue regions that are close to blood vessels. The proposed electrode system is better suited for matrix-type RFA.

Safety and impact of endoscopic ultrasound-guided fine needle aspiration of the lymph nodes in cirrhotics with hepatocellular carcinoma or pyrexia of unknown origin

Background and Objectives:Fine needle aspiration (FNA) of the enlarged lymph nodes or adrenal is advisable in patients with cirrhosis who have hepatocellular carcinoma (HCC) or pyrexia of unknown origin (PUO), before choosing optimal management strategy. It is difficult to perform percutaneous FNA due to the presence of collaterals and difficult anatomic location. The influence of endoscopic ultrasound (EUS)-guided FNA in patients with cirrhosis has been seldom reported.Patients and Methods:Patients with HCC (n = 97, no extrahepatic disease on positron emission tomography-computed tomography), and PUO (n = 20) or >1 cm lymph nodes on imaging during liver transplantation workup (n = 3) underwent EUS-guided FNA. The data are represented as mean (standard deviation) or median (interquartile range).Results:One hundred and twenty (100 males) patients, with the mean age 56 ± 8 years, had EUS-guided FNA from 129 sites (95 abdominal nodes, 32 mediastinal nodes, and 2 left adrenals). The platelet counts were 1.4 (1–1.7) ×105/cumm and international normalized ratio was 1.2 (1.07–1.43); lymph nodes measured 1.5 (1–1.8) cm and 0.9 (0.7–1.3) cm at long and short axis, respectively. The Child’s score and Model for End-Stage Liver Disease scores were 7 (6–9) and 11 (8–15), respectively. The cytopathological diagnoses were metastatic disease in 28 (21.7%; two mediastinal nodes, one left adrenal, rest abdominal nodes), granulomatous change in 14 (10.9%), histoplasmosis in 2 (1.6% including one left adrenal), and reactive lymphadenopathy in 73 (56.6%) specimens. Twelve (9.3%) specimens were inadequate for opinion. Two patients had transient sedation-related encephalopathy (both Child’s C), and one had mild ooze from the FNA site that ceased spontaneously.Conclusion:EUS-guided FNA of the lymph nodes/adrenal is safe and significantly impacts management in patients with cirrhosis.

A novel fusion imaging system for endoscopic ultrasound.

Background and Objective:Navigation of a flexible endoscopic ultrasound (EUS) probe inside the gastrointestinal (GI) tract is problematic due to the small window size and complex anatomy. The goal of the present study was to test the feasibility of a novel fusion imaging (FI) system which uses electromagnetic (EM) sensors to co-register the live EUS images with the pre-procedure computed tomography (CT) data with a novel navigation algorithm and catheter.Methods:An experienced gastroenterologist and a novice EUS operator tested the FI system on a GI tract bench top model. Also, the experienced gastroenterologist performed a case series of 20 patients during routine EUS examinations.Results:On the bench top model, the experienced and novice doctors reached the targets in 67 ± 18 s and 150 ± 24 s with a registration error of 6 ± 3 mm and 11 ± 4 mm, respectively. In the case series, the total procedure time was 24.6 ± 6.6 min, while the time to reach the clinical target was 8.7 ± 4.2 min.Conclusions:The FI system is feasible for clinical use, and can reduce the learning curve for EUS procedures and improve navigation and targeting in difficult anatomic locations.

Facilitating retroflexed endoscopic full-thickness resection through loop-mediated or rope-mediated countertraction (with videos)

Endoscopic full-thickness resection (EFTR) is difficult to perform in a retroflexed fashion in the gastric fundus and lesser curvature. Here we describe two simple methods to provide countertraction and thereby facilitate dissection. In this retrospective cohort study, 62 patients diagnosed as having gastric submucosal tumors in the fundus or in the lesser curvature received EFTR with or without countertraction methods. For the clip-with-thread method, a clip tied with surgical suture was anchored on the distal edge of the tumor to provide countertraction; for the loop-assisted method, a snare placed on the transparent cap beforehand was adopted to grasp the tumor to provide countertraction. Mean operative time was significantly reduced in the thread-with-clip group and loop-assisted group (45 minutes, 40 minutes, respectively) compared with the time needed in the traditional EFTR group (85 minutes). Intraoperative pneumoperitoneum occurred regularly among the 3 groups because of iatrogenic perforation, but fewer patients in the thread-with-clip group and loop-assisted group (23%, 18%, respectively) needed abdominal puncture to relieve free air and stabilize life signs compared with patients in the traditional EFTR group (63%). A reduced occurrence of high fever after surgery may contribute as another advantage from accelerated dissection. Both techniques did not jeopardize oncologic safety during short-term follow-up. Both the thread-with-clip method and loop-assisted method provide effective countertraction and offer faster and safer gastric EFTR in difficult anatomic locations.

Abstract No. 411 - Surviving the interventional radiology ice-bucket challenge: percutaneous cryoablation of renal masses in difficult anatomic locations

Renal masses in difficult anatomic locations can often be safely and appropriately treated with percutaneous image-guided cryoablation. The purpose of this exhibit is to describe and demonstrate adjunctive techniques that improve safety and technical success rates of percutaneous cryoablation of renal masses in difficult anatomic locations. Management strategies for the treatment of small renal masses include active surveillance, percutaneous ablation, or nephron-sparing surgery. The decision is made based on age of patient, medical history, surgical comorbidities, mass size and location, rate of growth, and patient preference. Percutaneous image-guided cryoablation is a well-accepted, minimally invasive therapy to treat small renal masses, particularly in patients who are poor surgical candidates due to multiple comorbidities, multiple tumors, or renal failure. Lesions typically considered more difficult to ablate include central lesions, size larger than 3 centimeters, upper pole location, endophytic, and adjacent to ureter, colon, or other organs. Some renal lesion locations have been classically described as more difficult to treat with percutaneous cryoablation due to risk of damaging adjacent critical structures, such as the ureter, renal pelvis, or adjacent bowel. Retrograde pyeloperfusion, hydrodissection, and angioplasty balloon interposition are three techniques that can be used to safely perform cryoablation in these difficult anatomic locations. In addition, choosing a patient position on the procedure table to create the safest treatment window is critical. These techniques can be used individually or in combination to improve safety when ablating renal masses in challenging anatomic locations. Maximizing patient positioning, retrograde pyeloperfusion, hydrodissection, and angioplasty balloon interposition are critical adjunctive techniques that can be used to improve safety when performing percutaneous image-guided cryoablation of small renal masses in difficult anatomic locations.

Use of Radioactive Seed to Localize Axillary Lymph Node in Breast Cancers

Introduction: Axillary lymph node biopsy in an irradiated or previously operated axilla can be technically challenging. Radio-labeled seed localized (RSL) biopsy is an emerging modality for localizing tissue of interest that is not amenable to wire localization. Case Report: A 60 year old female with history of breast cancer presented ten months after her initial resection with a new chest wall mass and an enlarged right axillary lymph node situated posterior and superior to the axillary vein. Given its location, wire localization was not possible and on the other hand operating without localization was too risky. We elected to place a 125I labeled titanium seed in the lymph node which greatly facilitated this otherwise difficult dissection and safely delivered the specimen needed for diagnostic purposes. Discussion: With the advancement of imaging technology, surgeons are able to safely and accurately recover diagnostic tissue specimen from extremely challenging anatomic spaces. Radio-labeled seed localization is another step in furthering surgical capabilities in this regard. RSL provides several advantages over wire localization: placement in lesions located deep in body cavities, seed placement can be scheduled a day prior to surgery thus making it more easier on patients, and no risk of cutting or dislodging the wire. Clinical practice points: The use of radio-labeled seed localized (RSL) breast biopsy is growing in popularity and is replacing wire localized breast biopsy. We present a case of a radioactive seed localized axillary lymph node resection that was not amenable to wire localization. Radioactive seed allowed precise localization of the node in a difficult anatomic location, thus facilitating successful resection of the node. Seed localization is a versatile approach for localizing lesions of interest and holds promise for not only breast surgery, but also for marking nodes or lesions of interest that are located deep in the abdominal or thoracic cavity.

Hybrid push-pull endoscopic and laparoscopic full thickness resection for the minimally invasive management of gastrointestinal stromal tumors: a pilot clinical study.

Background. Gastric gastrointestinal stromal tumors (GISTs) that are predominantly endophytic or in anatomically complex locations pose a challenge for laparoscopic wedge resection; however, endoscopic resection can be associated with a positive deep margin given the fourth-layer origin of the tumors. Methods. Patients at two tertiary care academic medical centers with gastric GISTs in difficult anatomic locations or with a predominant endophytic component were considered for enrollment. Preoperative esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA), and cross-sectional imaging were performed. Eligible patients were offered and consented for hybrid and standard management. Results. Over ten months, four patients in two institutions with anatomically complex or endophytic GISTs underwent successful, uncomplicated push-pull hybrid procedures. GIST was confirmed in all resection specimens. Conclusion. In a highly selected population, the hybrid push-pull approach was safe and effective in the removal of complex gastric GISTs. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique manages with a laparoscopic, full thickness, R0 resection. This novel, minimally invasive, hybrid laparoscopic and endoscopic push-pull technique is a safe and feasible alternative in the management of select GISTs that are not amenable to standard laparoscopic resection.