Placement Of Drainage Catheter Research Articles

Endoscopic biliary drainage using a 4-Fr catheter for biliary obstruction: a pilot study

Introduction Stent or endoscopic nasobiliary drainage (ENBD) catheter placement for a tight, complicated biliary stricture is still technically challenging. A thin, 4-Fr ENBD catheter (4-Fr catheter) has been developed to overcome this difficulty. The study aimed to evaluate the feasibility of the 4-Fr catheter for endoscopic biliary drainage (EBD). Material and methods We performed a retrospective review of 51 patients who underwent EBD with the 4-Fr catheter because placement of a conventional drainage catheter (CDC) had failed. Results The success rate of 4-Fr catheter placement was 96.1% (49/51). The median patency period of the catheter was 114 days (95% CI, 53–200). Among the 49 patients with successful placement of the catheter, adverse events occurred in five (10.2%) patients: post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), two patients; catheter dislocation, one patient; and kinking of the 4-Fr catheter, two patients. Both cases of PEP improved with conservative treatment, but all cases of catheter dislocation and kinking required reintervention with a 4-Fr catheter. Forty-three (87.8%) patients achieved clinical remission after EBD with a 4-Fr catheter. Conclusions The newly developed 4-Fr catheter is safe and feasible for EBD in patients in whom CDC placement is difficult due to a tight, complicated biliary stricture.

Abstract No. 241 Safety and efficacy of fluoroscopically guided cerebrospinal fluid drainage for thoracoabdominal aortic aneurysm repair

To review the safety and efficacy of perioperative cerebrospinal fluid (CSF) drainage catheter placement using fluoroscopic guidance in patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair

The Guidewire-assisted Drainage Catheter Placement in Chronic Subdural Hematoma.

BackgroundChronic subdural hematoma (cSDH) is a common neurosurgical pathology associated with older age. The burr hole drainage is a predominant technique with a lower incidence of recurrence and morbidity. The blind placement of the subdural drain could result in intracerebral hemorrhage. This paper describes a simple and reliable technique for drainage catheter placement in cSDH to reduce intracerebral hemorrhage.MethodsForty-nine consecutive patients with cSDH were treated with The Guidewire-assisted Drainage Catheter Placement Technique between July 2019 and June 2021. Epidemiological, clinical and radiographical data were collected and reviewed. The operative technique consists of an angular guidewire tip and catheter. Under the navigation of the guidewire, the catheter is inserted into the subdural space and the length of catheter remaining in the subdural space was 4–5 cm. The catheter was tunneled subcutaneously and fixed at the point where it emerged from the scalp.ResultsForty-nine consecutive patients underwent 55 The Guidewire-assisted Drainage Catheter Placement. The gender distribution was 37 men and 12 women. The mean age was 69.3 years. The patients presented with headache (31 patients), weakness of limbs (28 patients), speech disturbances (7 patients), and Altered behavior (6 patients). Neither intracerebral hemorrhages nor post-operative seizure occurred. Forty-seven patients were improved after the operation. The recurrence occurred in one patient.ConclusionsThe Guidewire-assisted Drainage Catheter Placement Technique is a reliable method for the insertion of a subdural catheter to evacuate of the Chronic Subdural Hematoma, and is associated with an extremely low risk to cortical structures and cerebral veins.

Intrapleural fibrinolysis and DNase versus video-assisted thoracic surgery (VATS) for the treatment of pleural empyema (FIVERVATS): protocol for a randomised, controlled trial – surgery as first-line treatment

IntroductionPleural empyema is a frequent disease with a high morbidity and mortality. Current standard treatment includes antibiotics and thoracic ultrasound (TUS)-guided pigtail drainage. Simultaneously with drainage, an intrapleural fibrinolyticum can...

The Effect of Palliative Invasive Interventions on Overall Survival in the Last 3 Months of Life in Metastatic Gastric Cancer.

Gastric cancer is one of the biologically aggressive and highly mortal cancers. In addition to limited treatment options, especially in advanced stages, palliative treatment methods are applied to increase patients' quality of life with gastric cancer. This study aims to discuss the effects of paracentesis, thoracentesis, tube thoracostomy, double J catheter nephrostomy, percutaneous transhepatic cholangiography (PTC), and abscess drainage catheter placement procedures applied in the last 3 months for problems requiring palliation, in the light of literature. The patient characteristics of the patients and, in addition, the history of any invasive intervention for palliative treatment in the last 3 months were questioned and recorded with the electronic medical record system. The effect of an invasive intervention on survival was examined. The data of patients with metastatic gastric cancer followed in the medical oncology clinic between February 2012 and May 2020 were reviewed retrospectively. In this study, in which the effect of palliative invasive intervention (PIG) stories on survival in the last 3 months of life of patients diagnosed with metastatic gastric cancer was examined, no significant difference was found between those who underwent PIG and those who did not, in terms of overall survival. However, since PIG was not included in the design of our study, the effect of PIG in terms of quality of life, mood, motivation of patient relatives, and the cost is unknown. In the final analysis, it was noted that 143 (94.1%) of the 152 patients included in the study died and 9 (5.9%) were still alive. Overall survival of all patients was reported as 12.9 months (95% CI, 10.9-14.9). The mean overall survival of 36 patients who underwent palliative invasive intervention (PIG) in the last 3 months was 13.0 months (95% CI, 9.1-17.0), and a similar 13.0 months (95% CI, 10.6-15.3) of 116 patients who did not undergo PIG no significant difference was found (p: 0.887).

Percutaneous Balloon Retrieval Technique for Fractured Biliary Drainage Catheter in a Paediatric Patient: Can a Major Surgery be Averted?

Percutaneous Transhepatic Biliary Drainage (PTBD) involves temporary placement of an external drainage catheter into an obstructed bile duct prior to internal biliary stenting or surgery. Chronic indwelling PTBD catheters can develop surrounding adhesions and are prone to fractures and retention during their removal. Retained segments can cause impaired biliary drainage, inflammation and recurrent cholangitis. Retrieval of retained catheters can be done by endoscopic/surgical/percutaneous techniques. In patients who have undergone Hepatico-Jejunostomy (HJ), endoscopic removal is not possible and percutaneous/surgical removal are the only options. The authors present a case of a five-year-old child who came for removal of a fractured, retained PTBD catheter, nine months after undergoing HJ. The catheter was removed by a percutaneous balloon retrieval technique. The objective here is to highlight the technical challenges encountered and present a modification of the usual balloon retrieval technique used to successfully remove the catheter and thus avert a major surgery.

Metallic stent placement versus catheter drainage for malignant bilioenteric anastomotic stricture.

The purpose of the study was to compare self-expandable metallic stent placement with catheter drainage for malignant bilioenteric anastomotic stricture in terms of efficacy and safety. This study included 54 patients with malignant bilioenteric anastomotic stricture treated from March 2016 to February 2021. Twenty-seven patients underwent insertion of self-expandable metallic stent (Stent group); the remaining twenty-seven patients underwent internal-external catheter drainage (Catheter group). Technical success was defined as successful placement of stent or drainage catheter in the appropriate position; clinical success was defined as a 20% reduction in serum bilirubin within 1week after the procedure, compared with baseline. Complications, duration to stent/catheter malfunction, and overall survival were evaluated. Technical success was achieved in all patients in both groups. In the Stent group, 21 patients received one stent and the other 6 patients required two stents. Clinical success rates were similar between the groups [Stent group, 92.6% (25/27); Catheter group, 88.9% (24/27)]. There were no major complications. The median duration to stent/catheter malfunction was significantly longer in the Stent group (130days) than in the Catheter group (82days; P = 0.010). The median overall survival was also significantly longer in the Stent group (187days) than in the Catheter group (118days; P = 0.038). Self-expandable metallic stent placement might be better than internal-external catheter drainage for malignant bilioenteric anastomotic stricture in terms of the duration before stent/catheter malfunction and patient survival.

Value of spectral detector computed tomography to differentiate infected from noninfected thoracoabominal fluid collections

PurposeTo investigate the diagnostic value of spectral detector CT (SDCT)-derived virtual non-contrast (VNC), virtual monoenergetic images (VMI) and iodine overlays (IO) for distinguishing infected from noninfected fluid collections (FC) in the chest or abdomen. MethodThis retrospective study included 58 patients with venous phase SDCT with 77 FC. For all included FC, microbiological analysis of aspirated fluid served as reference. For quantitative analysis, wall thickness was measured, and (ROI)-based analysis performed within the fluid, the FC’s wall (if any) and the aorta. Two radiologists qualitatively evaluated visibility of wall enhancement, diagnostic confidence regarding infection of fluid collection, confidence of CT-guided drainage catheter placement and visibility of anatomical landmarks in conventional images (CI) and VNC, VMI40keV, IO. ResultsWall thickness significantly differed between infected (n = 46) and noninfected (n = 31) FC (3.5 ± 1.8 mm vs. 1.4 ± 1.8 mm, AUC = 0.81; p < 0.05). Fluid attenuation and wall enhancement was significantly higher in infected as compared to noninfected FC in all reconstructions (p < 0.05, respectively). Highest AUC regarding A) attenuation in fluid was yielded in CI and VMI70,80keV (0.75); B) wall enhancement in CI (0.88) followed by iodine concentration (0.86). Contrast-to-noise ratio of wall vs. fluid was highest in VMI40keV (p < 0.05). All assessed qualitative parameters received significantly higher ratings when using spectral reconstructions vs. CI (p for all <0.05), except for visibility of wall enhancement. ConclusionSpectral reconstructions improve the assessment of infected from noninfected thoracoabdominal fluid collections and depiction of wall enhancement. Diagnostic performance of the quantitative measurements in spectral reconstructions were comparable with measurements in conventional images.

S2610 Perihepatic Biloma: A Rare Complication After Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure and an effective therapeutic option for managing portal hypertension complications. Biliary complications after TIPS are uncommon. Here we present a case of recurrent perihepatic biloma in a woman who underwent TIPS. Case Description/Methods: A 40-year-old woman was admitted for epigastric abdominal pain for five days. She reported taking oral contraceptive pills (OCPs) for one month before presentation. She had epigastric tenderness on examination and normocytic anemia (Hgb 10 g/L) on admission labs. CT scan of the abdomen showed a large thrombus in the main portal vein extending into the right and left portal venous branches. The patient was started on heparin drip and underwent TIPS with thrombectomy. Hypercoagulability workup was unremarkable. The post-procedure course was complicated by elevation of alkaline phosphatase (552 U/L), AST (293 U/L), and ALT (324 U/L). Abdomen MRI showed patent TIPS and persistent complete thrombosis of all intrahepatic portal venous branches. She underwent repeat thrombolysis. However, liver enzymes continued to rise, and a repeat MRI showed intrahepatic biloma at the mid aspect of TIPS (Figure 1A, B). IR-guided drainage of the biloma was performed. The hospital course was complicated by fever and leukocytosis. A follow-up CT scan showed a 13 cm complex fluid collection at the dome of the liver (Figure 2A). She underwent drainage of the new collection and received IV Cefoxotin with an interval decrease in the collection size (Figure 2B). Fever resolved, and liver enzymes normalized. Discussion: Bilomas are either intra- or extrahepatic collections of bile that can occur spontaneously, or as a result of trauma to the biliary tree, including iatrogenic injury. Bilomas are usually asymptomatic but may present with abdominal pain due to symptomatic bile peritonitis or secondary bacterial infection leading to abscess formation and sepsis. A biloma may wall off or may continue to have active bile leakage. CT intravenous cholangiography, MRI with gadolinium, and Tc99 scintigraphy can identify bile leak. Differential diagnoses include hepatic cyst and hematoma, liver abscess, loculated ascites, and postoperative fluid collections, including seroma and lymphocele. Treatment options include endoscopic drainage, IR guided, or surgical drainage with bile leak repair.Figure 1.: 1A, and 1B: MRI coronal T2W, MRI axial T2W and MRI coronal post contrast, respectively, showing intrahepatic biloma (white arrow) abutting a portion of the TIPS (yellow arrow) with upstream intrahepatic biliary ductal dilatation (blue arrow). 2A and 2B: CT coronal image demonstrates a new peri-hepatic collection surrounding the hepatic dome (black arrow) and interval placement of a percutaneous drainage catheter and decrease in size of the peri-hepatic collection (black arrow).

INTRAPLEURAL AMPHOTERICIN B INSTILLATION: A NOVEL APPROACH TO THE TREATMENT OF CHRONIC PULMONARY COCCIDIOIDOMYCOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coccidioidomycosis is transmitted by inhalation of fungal spores commonly found in southwestern border of United States and South America. Most primary coccidioidomycosis cases are asymptomatic and do not require treatment. Symptomatic progressive coccidioidomycosis affect people with certain risk factors: ethnic origin, advanced age, pregnancy, and immunosuppressive state. Most cases are effectively treated with oral triazoles. Intravenous (IV) amphotericin B (AMB) is reserved for severe cases. Although intrapleural instillation of AMB has been reported in cases for aspergillus empyema, it has not been reported for other diseases (1). We are reporting the first known case of successful novel use of intrapleural instillation of amphotericin B in the treatment of chronic progressive pulmonary coccidioidomycosis. CASE PRESENTATION: A 48-year-old Hawaiian man with diabetes mellitus type 2 presented with 10 days of epigastric pain, anorexia, constipation, chills, progressive shortness of breath, and low-grade fever. He had a 9-month nonproductive cough after returning from Las Vegas. He was admitted to another facility where he was diagnosed with cryptogenic organizing pneumonia and treated with moderate dose prednisone for over 6 months. Initial chest x-ray here revealed a large left pneumothorax. Chest tube insertion did not provide significant improvement. Subsequent chest computerized tomography (CT) revealed a large hydropneumothorax with lingular and left lung base consolidation. Transbronchial biopsy showed coccidioides. After 7 days of hospitalization, patient was discharged home with fluconazole. He was readmitted 2 weeks later due to recurrence of same set of symptoms. Chest CT scan now revealed progression of multifocal necrotizing pneumonia. Based on continued deterioration despite IV AMB, there was a high suspicion of persisting intrapleural infection with coccidioides. A left pneumonectomy with placement of a special drainage catheter for intrapleural instillation was performed, in addition to continued IV AMB. He tolerated 7 days of intrapleural AMB well and discharged home 9 days afterward with continued fluconazole. One year later he was able to resume all normal activities. DISCUSSION: Our patient developed progressive coccidioidomycosis due to uncontrolled diabetes mellitus from prednisone prolonged use. He has progressive pneumonia, pulmonary nodules and cavities, fever, cough, chills, hemoptysis, abdominal pain, anorexia, weight loss, and weakness. Due to the many adverse reactions of AMB, it is generally reserved for severe cases; in our case, the addition of intrapleural instillation was successful in conjunction with his pneumonectomy and IV antifungal therapy. CONCLUSIONS: This is the first known reported case of intrapleural amphotericin B instillation, in combination with conventional therapy, in the successful treatment of chronic progressive coccidioidomycosis. REFERENCE #1: Almuhareb, A., & Habib, Z. (2018). Management of Aspergillus Pleural Empyema with Combined Systemic and Intrapleural Antifungal Therapy in a Pediatric Patient: Case Report. Journal of Infection and Public Health, 11(2), 280-282. DISCLOSURES: No relevant relationships by Angelica Guzman Paz, source=Web Response No relevant relationships by Takkin Lo, source=Web Response

S2896 Encysted Empyema: An Uncommon Complication of Pyogenic Liver Abscess

Introduction: Pyogenic liver abscess (PLA) is uncommon in the U.S. with an estimated incidence of 8-15 cases per 100,000 persons and has a mortality rate between 15% and 20%. Despite being a rare complication, PLA has been found to increase 18 times the risk of pleural empyema. Case Description/Methods: A 36-year-old woman with presented to the emergency department with intractable right hypochondrial and shoulder pain. HPI: 2 weeks before the presentation the patient developed right hypochondrium and epigastric pain, radiating to the right shoulder, dull aching, gradually worsening, associated with nausea, vomiting. PMH: Hypertension, Asthma, and Lactose intolerance. Physical Exam : The patient was found to be afebrile, Elevated blood pressure, mildly distressed due to severe abdominal pain. Abdomen: Normoactive bowel sounds. soft, non distended, tender to palpation in RUQ, No rebound tenderness, No gardening. Clinical Course: • CT of the abdomen demonstrated right hepatic lobe abscess. • The patient was started on empiric antibiotic coverage with cefepime and metronidazole. • CT-guided liver abscess drainage and pig tail catheter placement resulted in drainage of 200 cc of foul-smelling, thick, maroon-brown fluid. • Fluid culture was positive for K. pneumoniae sensitive to ceftriaxone. • Despite drainage of the abscess and appropriate antibiotic coverage the patient’s condition deteriorated as she developed signs of sepsis with worsening right sided chest pain and leukocytosis. • Repeat CT of the chest showed a newly formed right-sided large multiloculated pleural effusion concerning for empyema. • Patient underwent video-assisted thoracoscopic surgery decortication and laparoscopic liver abscess drainage and marsupialization. • The patient improved after these interventions and was discharged one week after the procedure with a plan to continue oral ciprofloxacin for 10 days. Discussion: PLA of the right hepatic lobe with exophytic extension to the posterior thoracic wall is a risk factor for the development of an encysted pleural effusion complicated by empyema. Image guided percutaneous drainage is the most reliable method for both diagnosis and treatment of a single, unilocular liver abscess. However, this procedure may increase the risk of developing a pleural effusion and subsequent empyema suggesting that these cases may benefit from early surgical intervention rather than image guided drainage.Figure 1.: Triphasic CT abdomen and pelvis; Liver: There is a 7.0 x 6.8 x 8.0 cm peripherally enhancing lesion in the posterior RIGHT hepatic lobe., with exophytic extension to involve the posterior wall of the lower thorax and adjacent retroperitoneum.

The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.

Limited Clinical Utility of Chest Radiography in Asymptomatic Patients after Interventional Radiology-Performed Ultrasound-Guided Thoracentesis: Analysis of 3,022 Consecutive Patients

Abstract Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis. Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations &lt; 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules. Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.

A Retrospective Analysis of the Effectiveness of Extrapleural Autologous Blood Patch Injection on Pneumothorax and Intervention Need in CT-guided Lung Biopsy.

To assess the effect of extrapleural autologous blood injection (EPABI) technique on pneumothorax development before and after coaxial needle withdrawal (CNW) and intervention rate for pneumothorax. To analyze the risk factors of pneumothorax and parenchymal hemorrhage. The records of 288 patients who had lung biopsies were analyzed. Of these patients, 188 received EPABI (group-A) before penetrating the parietal pleura, and the remaining did not (group-B). Intraparenchymal autologous blood patch injection was applied at the end of the procedure. The pneumothorax rates before/after CNW and intervention requirement for pneumothorax were compared between groups. The risk factors of pneumothorax before/after CNW and parenchymal hemorrhage were assessed with stepwise logistic regression. The pneumothorax rate before CNW was significantly lower in group-A (5.92%) than in group-B (19.10%) (p = 0.029). Pneumothorax risk before CNW was reduced if EPABI was applied and skin-to-pleura distance increased. The pneumothorax rate after CNW was similar between two groups (group-A: 6.94%, group-B: 8%), while emphysema grade along the needle path and procedure duration was the significant risk factor. The intervention requirement for pneumothorax was significantly lower in group-A (6.38%) than in group-B (16%) (p = 0.012). Needle aspiration requirement was significantly reduced in group-A. The rate of external drainage catheter and chest tube placement was similar in both groups. The risk factors of parenchymal hemorrhage were overall emphysema grade of the lung, target-to-pleura distance, and target size. Use of EPABI along with IAPBI significantly decreased the pneumothorax rate during biopsy procedure and the intervention rate compared to IAPBI-alone.

Abstract No. 580 Lower risk of major arterial hemorrhage after percutaneous biliary drainage with primary stent versus primary catheter placement

To compare the incidence of arterial hemorrhage requiring embolization after percutaneous biliary drainage with a primary biliary stent (PBS) vs. a primary biliary drainage catheter (PBDC) placement. This IRB-approved retrospective study included 524 consecutive cancer patients who underwent 548 percutaneous biliary drainage procedures with a PBDC or a PBS between January 2016 and November 2019. Demographic, laboratory, and procedure data were collected after chart and PACS review. Biliary drainage was performed with 278 PBDC in 260 (50%) patients and 270 PBS in 264 (50%) patients. In 65/270 (24%) PBS, a covering catheter was left to ensure decompression. There was no statistically significant difference between the groups in the number of left-sided biliary interventions, INR, and platelet count. Major arterial bleeding requiring embolization occurred after 20/278 (7%) PBDC placements (8/20 in the left side) in 18 patients after a median of 9 days (range, 1–18 days). Only 1/270 (0.4%) PBS, with a covering catheter present, was followed by arterial bleeding requiring embolization after 10 days. There were no patients with PBS only (no covering catheter) that required embolization. The difference in major bleeding episodes after biliary drainage with PBDC vs. PBS was statistically significant (P < .001). Percutaneous biliary drainage with PBS is associated with a lower incidence of major arterial bleeding compared with PBDC. A covering catheter may increase the risk of bleeding after PBS placement.

Extraluminal Recanalization for Biliary Duct-to-Duct Anastomotic Obstruction After Living Donor Liver Transplantation: Experience in Eight Patients.

To investigate clinical outcomes and safety of extraluminal recanalization for duct-to-duct anastomotic obstruction after living donor liver transplantation (LDLT). Extraluminal recanalization was performed as a salvage procedure after failure of intraluminal cannulation in eight patients who underwent percutaneous transhepatic treatment of duct-to-duct anastomotic obstruction 11.0 ± 5.27months after LDLT between October 2012 and April 2019. Technical details, safety, and outcomes of extraluminal recanalization were investigated. Total ten sessions of extraluminal recanalization were performed in the eight patients with the stiff backend of a 0.035inch hydrophilic guide wire, 22-gauge Chiba needle, or Colapinto needle. Percutaneous common bile duct access was performed in three sessions to obtain a straight course for the puncture. There was one instance of subcapsular and intraparenchymal hematoma requiring placement of an additional drainage catheter and conservative treatment. During a follow-up period ranging from 18.4 to 100.7months, the drainage catheter was removed in seven of the eight patients, including three patients who had recurrent stricture requiring repeat percutaneous treatment and one who underwent a routine change of an endoscopic retrograde biliary drainage catheter. Extraluminal recanalization can be an effective and safe salvage procedure after failed intraluminal cannulation of duct-to-duct anastomotic obstruction in LDLT.

Biliary involvement in liver metastases: long-term experience with biliary biopsy from a single center.

ObjectiveTo investigate long-term results of biliary biopsy performed with transluminal forceps in the setting of metastatic biliary involvement.Materials and MethodsBetween September 2014 and June 2019, 25 patients-18 males (72%)-with a mean age of 65 ± 15 years, underwent 26 biliary biopsy procedures with a dedicated forceps system. All patients presented with obstructive jaundice that was suspected of being malignant and underwent pre-procedural magnetic resonance cholangiopancreatography. The biopsies were performed during percutaneous placement of an internal-external biliary drainage catheter, under fluoroscopic guidance.ResultsThe technical success rate was 96% (corresponding to 25 of the 26 procedures). The histological diagnosis was inflammatory biliary stricture in five cases, pancreatic adenocarcinoma in six, liver metastases from colorectal cancer in eight, and hepatocellular carcinoma in three, the biliary mucosa being categorized as normal in three cases. In one case, the sample was considered insufficient and the procedure was successfully repeated, after which a diagnosis of pancreatic adenocarcinoma was made. Over a follow-up period of 6-48 months, there were five false-negative results: two findings of inflammatory biliary stricture were later identified as liver metastases from breast and gastric cancer, respectively; and all three patients in which the biliary mucosa was categorized as normal were subsequently diagnosed with metastatic hilar lymph nodes. The procedure was found to have a sensitivity of 77%, a specificity of 100%, and an overall accuracy of 80%. The complication rate was 11.5% (mild, transient hemobilia occurring in three cases).ConclusionPercutaneous transluminal forceps biopsy is a safe, effective, minimally invasive procedure for histological characterization in patients presenting with obstructive jaundice due to a non-primary biliary tumor.

Ultra-sonography guided pigtail placement for drainage of liver abscess in 40 patients: A retrospective study

Aim and Objective: 1. To evaluate the advantages of USG guided pigtail catheter placement for drainage of liver abscess. 2. To assess the morbidity and complications of percutaneous pigtail catheter drainage in treatment of liver abscess. Methods: The study was conducted at Zydus Medical College and Hospital, Dahod, Gujarat, January 2018 to January 2020. It included 40 USG confirm cases of liver abscess. The liver Abscess ≥5x5 cm underwent percutaneous drainage was determined by doing serial USG scans.Results: Age group varied from 20 to 60 years. Out of 40 patients 36 were men and 4 were women. The male to female ratio 10:1. 28 patients had solitary abscess, while 12 had multiple abscess. Pigtail catheter of various sizes (10 F or 12 F) were introduced in these patients using the Seldinger technique. The volume of pus drained ranged from 150 to 400 ml, complications were minor and included catheter blockage in 8 patients and tract pain in 35 patients. There was no mortality associated with this procedure. This study shows a success rate of 96%. One patient required repeat pigtail placement after 6 months for recurrent liver abscesses. Conclusion: This study concludes that drainage of liquefied moderate to large sized liver abscess by USG guided pigtail placement as a minimally invasive procedure with low morbidity and mortality and should be first line of management of liver abscesses.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

S1390 Caroli Disease With Choledochoduodenal Fistula and SUMP Syndrome

INTRODUCTION: Choledochoduodenostomy (CDDS) is a common procedure performed in patients with recurrent, impacted bile duct stones. We present a unique case of a patient with Caroli disease and repeat choledocholithiasis with CDDS presenting with a distal choledochoduodenal fistula (DCDF) and SUMP syndrome. CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of Caroli disease, multiple abdominal surgeries including CDDS, cholecystectomy secondary to recurrent choledocholithiasis presented to the clinic with abdominal pain. Further evaluation with an MRCP revealed filling defects in the distal common bile duct suggestive of choledocholithiasis. She underwent ERCP which revealed DCDF. Multiple small stones were extracted with purulent drainage with failed cannulation of the primary system. She developed severe right upper quadrant pain and nausea shortly after ERCP and presented to the emergency department. Her vitals and labs were unremarkable. Intravenous (IV) antibiotics were started due to concerns of cholangitis. Interventional radiology (IR) placed a percutaneous biliary drainage catheter. A repeat ERCP revealed old choledocho-duodenostomy and internal and external biliary drain within the bile duct, and without cannulation of the intrahepatic duct. Fluid cultures grew Enterococcus faecium and antibiotics were added and discharged home. A biliary catheter was removed two weeks later after gadolinium spillage of contrast into the bowel was seen, showing patency. DISCUSSION: Caroli disease is a congenital disorder presenting with large intrahepatic ductal dilation with an increased risk of hepatic fibrosis. There is bile stagnation leading to recurrent cholelithiasis. CDDS is a procedure performed in recurrent choledocholithiasis leading to gallstone pancreatitis and acute cholangitis despite cholecystectomy. CDDS creates a connection between the proximal common bile duct (CBD) and the 1st portion of the duodenum. The bile no longer drains via the distal CBD, creating a reservoir called a “sump”. Lithogenic bile, debris, or calculi accumulate causes recurrent cholangitis or choledocholithiasis. DCDF occurs at the entrance of the distal CBD into the 2nd part of the duodenum and caused by impacted stones in 90% of the cases. DCDF is a rare complication from CDDS leading to SUMP syndrome. The impacted stone erodes the CBD wall leading fistulation into the duodenum. The diagnosis of DCDF is made with ERCP. Treatment requires fistulotomy, sphincterotomy, stone removal, and biliary drainage.Figure 1.: MR reconstruction of the biliary tree (A) showing a dilated proximal common bile duct (CBD) measuring 11 mm and dilated main pancreatic duct (PD) measuring 4.5 mm. MRCP (B) showing ill-defined intraluminal filling defects are seen in the distal portion of the common duct suggestive of choledocholithiasis.Figure 2.: IR guided percutaneous biliary drainage catheter placement. A: Cholangiogram with gadolinium-based contrast showed mild central biliary dilatation with abnormal anatomy and possible two outflow tracts the bowel (SB). B: An 8.5 Fr. Internal and external catheter (C) was placed.Figure 3.: IR guided percutaneous biliary drainage catheter removal. Prior to the removal of the catheter, a small amount of gadolinium was injected through the existing tube to demonstrate patency. Free spillage of contrast into the bowel (SB) is noted.