Small Caliber Needle Research Articles

Percutaneous Image-Guided Biopsy for a Comprehensive Hybridization Capture-Based Next-Generation Sequencing in Primary Lung Cancer: Safety, Efficacy, and Predictors of Outcome

IntroductionTo evaluate factors associated with successful comprehensive genomic sequencing of image-guided percutaneous needle biopsies in patients with lung cancer using a broad hybrid capture-based next-generation sequencing assay (CHCA). MethodsWe conducted a single-institution retrospective review of image-guided percutaneous transthoracic needle biopsies from January 2018 to December 2019. Samples with confirmed diagnosis of primary lung cancer and for which CHCA had been attempted were identified. Pathologic, clinical data and results of the CHCA were reviewed. Covariates associated with CHCA success were tested for using Fisher’s exact test or Wilcoxon ranked sum test. Logistic regression was used to identify factors independently associated with likelihood of CHCA success. ResultsCHCA was requested for 479 samples and was successful for 433 (91%), with a median coverage depth of 659X. Factors independently associated with lower likelihood of CHCA success included small tumor size (OR = 0.26 [95% confidence interval (CI): 0.11–0.62, p = 0.002]), intraoperative inadequacy on cytologic assessment (OR = 0.18 [95% CI: 0.06–0.63, p = 0.005]), small caliber needles (≥20-gauge) (OR = 0.22 [95% CI: 0.10–0.45, p < 0.001]), and presence of lung parenchymal abnormalities (OR = 0.12 [95% CI: 0.05–0.25, p < 0.001]). Pneumothorax requiring chest tube insertion occurred in 6% of the procedures. No grade IV complications or procedure-related deaths were reported. ConclusionsPercutaneous image-guided transthoracic needle biopsy is safe and has 91% success rate for CHCA in primary lung cancer. Intraoperative inadequacy, small caliber needle, presence of parenchymal abnormalities, and small tumor size (≤1 cm) are independently associated with likelihood of failure.

In Situ Cross-linking Hydrogel as a Vehicle for Retinal Progenitor Cell Transplantation

One of the current limitations of retinal transplantation of stem cells as well as other cell types is the dispersion of cells from the injection site (including loss of cells into the vitreous chamber) and low survival after transplantation. Gelatin-hydroxyphenyl propionic acid (Gtn-HPA) conjugate is a biodegradable polymer that can undergo covalent cross-linking in situ, allowing for injection of incorporated cells through a small caliber needle followed by gel formation in vivo. We tested the hypothesis that Gtn-HPA hydrogel supports survival and integration of retinal progenitor cells (RPCs) post-transplantation. In vitro compatibility and in vivo graft survival were assessed by mixing an equal volume of Gtn-HPA conjugate and RPC suspension and triggering enzyme-mediated gelation, using minute amounts of horseradish peroxidase and peroxide. Immunocytochemistry showed >80% survival of cells and minimal apoptosis for cells incorporated into Gtn-HPA, equivalent to controls grown on fibronectin-coated flasks. RPCs undergoing mitosis were seen within the three-dimensional Gtn-HPA hydrogel, but the percentage of Ki-67-positive cells was lower compared with the monolayer controls. For in vivo studies, gel–cell mixture or cell suspension in saline was trans-sclerally injected into the left eye of female Long Evans rats immunosuppressed with cyclosporine A. Grafts survived at the 1 week time point of the study, with Gtn-HPA-delivered grafts showing less inflammatory response demonstrated by anti-leukocyte staining. More eyes in the gel–cell mixture group showed surviving cells in the subretinal space compared with saline-delivered controls, while the number of cells surviving per graft was not significantly different between the two groups. This work demonstrates an injectable in situ cross-linking hydrogel as a potential vehicle for stem cell delivery in the retina.

Selective transperitoneal aspiration of a distended bowel with a small-caliber needle during laparoscopic Nissen fundoplication: a prospective randomized controlled trial.

Anecdotal reports have demonstrated the feasibility of needle aspiration to deflate a distended bowel, but we do not know of any prospective study that has evaluated this technique. We designed a controlled study to evaluate the use of the selective transperitoneal needle aspiration of a bowel loop (STAB) in infants. Candidates were patients of less than 6 months of age, scheduled for laparoscopic Nissen fundoplication, in whom severe colonic distension was observed. We randomized the patients to the study drug or placebo in a 1:1 mode. The treatment group received STAB, whereas the control group was subject to conventional maneuvers. We performed 403 Nissen procedures laparoscopically: 102 were in infants ≤ 6 months old, but only 44 presented severe transverse colonic distension. STAB facilitated the surgical procedure and drastically reduced surgical time. Thus, we calculated our sample size with use of the following inputs: 90% power, a critical P value of .05, and 50% reduction in surgical time. This resulted in a necessary sample size of 21 subjects per group, for a total required sample size of 42 subjects. STAB procedures were done in 23 patients, and conventional measures were used in 21. STAB was attempted a total of 45 times. Mean operative time was shorter in the STAB group. We propose the use of STAB as alternative therapy to decompress a dilated large-bowel loop during laparoscopic surgery. This maneuver is simple and efficient and has no clinical complications. Future studies are required to evaluate its role in the subset of other patients or procedures.

Reducing risk of transjugular intrahepatic portosystemic shunt using ultrasound guided single needle pass

Delayed liver laceration following transjugular intrahepatic portosystemic shunt (TIPS) is a serious and likely underdiagnosed complication. It is however an important complication following TIPS, which remains one of the most technically challenging interventional procedures performed. In addition to laceration, a number of complications regarding bleeding and perforation are well described following TIPS procedures. We feel the adoption of techniques such as ours and that of other authors described in the literature using an ultrasound-guided percutaneous transhepatic approach with a small caliber needle provides a safer and less traumatic procedure and should reduce complications of bleeding and almost completely eliminate the risk of liver laceration. Our procedure was successfully performed under conscious sedation rather than general anaesthesia further reducing the overall procedural risk to the patient.

Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series

Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.

Transcatheter Injection-Induced Changes in Human Bone Marrow-Derived Mesenchymal Stem Cells

Human mesenchymal stem cells (hMSC) are being administered by direct intramyocardial (IM) injection into patients with myocardial dysfunction with an objective to improve clinical status. However, surprisingly little attention has been directed to qualifying hMSC functionality beyond simple viability. In particular, the transit of hMSCs through a small-caliber needle lumen, the final fluidic pathway for all IM injection devices, may be especially prone to inducing unwarranted effects on cell function. This study evaluated the changes in clonogenicity, gene expression, and cytokine secretion that may be induced in hMSC (20 million/ml) by injection through a 26-gauge Nitinol needle at two different flow rates compared to noninjected control samples. Results indicated that hMSC viability and colony forming unit (CFU) formation was not altered by changes in injection rate, although a trend toward lower titers was noted at the higher flow rate, for the specific batch of hMSCs studied. The gene expression and cytokine analysis data suggest that delivering a suspension of MSCs through narrow lumen needles may marginally alter certain gene expression programs, but that such in vitro effects are transient and not translated into measurable differences in protein production. Gene expression levels of four cytokines (bFGF, SDF-1, SCF, VEGF) were significantly different at 400 microl/min, and that of all cytokines were significantly different at 1600 microl/min when compared to controls (p < 0.05). These changes were less pronounced (statistically insignificant for most cases, p > 0.05) and, in certain instances directionally opposite, at 72 h. However, no differences in the amounts of secreted bFGF, VEGF, or TGF-beta were detectable at either of the two time points or flow rates. We infer that intramyocardial administration by transcatheter techniques is unlikely to interfere with the machinery required for cell replication or secretion of regulatory and other growth factors, which are the mainstays of MSC contribution to cardiac tissue repair and regeneration.

The Role of EUS-Assisted Biliary Drainage after Failed ERCP

Purpose: To evaluate technical success and outcomes of EUS-assisted biliary drainage after ERCP attempts at a tertiary center have failed. Methods: Patients included all those with failed ERCP for distal biliary obstruction at a tertiary center over 9 years, in whom repeat ERCP was felt unlikely to succeed. EUS-assisted biliary drainage was performed under general anesthesia with fluoroscopy, and categorized into 2 methods: 1) EUS rendezvous for transpapillary access followed by ERCP and 2) direct EUS guided transmural biliary drainage. If ampulla was accessible at initial ERCP, EUS rendezvous was attempted first. In cases of inaccessible ampulla and inoperable malignancy, direct EUS guided transmural drainage was performed. 1) For rendezvous, EUS-assisted transduodenal (N = 12) or transhepatic (N = 1) bile duct puncture was performed via a diagnostic linear EUS scope with a 19 or 22 gauge needle; a guidewire was advanced through papilla by fluoroscopy; the guidewire left in place, and ERCP performed immediately afterwards with stent insertion ± sphincterotomy. 2) Direct EUS-guided biliary drainage was performed through a transduodenal approach, the fistula tract dilated, and metallic stents placed. If bile duct access failed by all methods, patients were immediately converted to PTC. Results: EUS-BD was attempted in 15 patients (mean age 68, malignant 12/benign 3, CBD diameter 4–20 mm). EUS rendezvous was attempted in 13 cases, and direct EUS guided transmural biliary drainage in 2. Reasons for initial ERCP failure included tumor distorting papilla (N = 8), duodenal stents (N = 2), intradiverticular papilla (N = 1), or other anatomic anomalies (N = 4). EUS-assisted biliary drainage was performed at the same session as initial ERCP attempt in 12/15 patients. EUS-guided bile duct puncture was achieved in all 15 (100%) patients, with drainage successfully completed in 12/15 (80%). Failures occurred in 3 attempted rendezvous cases because of inability to traverse biliary stricture (N = 2) or dissecting a choledochocele with guidewire (N = 1); all were successfully drained via PTC. Stents placed were metallic in 9 and plastic in 3. Complications occurred in 2/15 patients (13%); 1 moderate pancreatitis after difficult ERCP attempt in papillary stenosis, and 1 bacteremia after PTC, with no perforations. Mean hospital stay was 5.4 (0–33) days, mostly for preexisting medical problems. Conclusion: EUS-assisted biliary drainage using a preferentially transduodenal and rendezvous approach demonstated a high success rate without any complications attributable to the EUS access. Advantages over PTC include performance under the same anesthesia as initial ERCP attempt, and internal drainage with access achieved by a very small caliber needle puncture similar to EUS/FNA.Table: Overtube Assisted Endoscopic Retrograde Cholangiography in Roux-en-Y Anatomy

Percutaneous Decompression of the Bowel with a Small-Caliber Needle: A Method to Facilitate Percutaneous Abdominal Access

In our pediatric interventional practice, we have found that occasionally a loop of bowel is interposed between the stomach and the anterior wall of the abdomen, preventing safe needle access for procedures such as placement of a gastrostomy tube. The use of a small-caliber needle to aspirate air from the colon or small bowel, for bowel decompression, may be a safe way to aid in establishing a safe access route for the subsequent percutaneous introduction of larger needles or tubes. Our retrospective review of patients who have undergone bowel-gas aspiration during an interventional procedure shows that the aspiration of air from the colon with a small-caliber needle is technically easy and may permit completion of an abdominal procedure.

CO 2 Splenoportography for Evaluating the Splenic and Portal Veins before or after Liver Transplantation

The authors report their experience with CO(2) splenoportography in a retrospective review of 15 studies performed in 13 patients before or after liver transplantation. The studies were performed by injecting CO(2) through a small caliber needle introduced into the splenic parenchyma with ultrasound guidance and imaging with conventional digital subtraction techniques. The findings were compared with clinical follow-up and other imaging studies when available. Eight of the 15 studies were normal, of which two were confirmed by additional studies. Six of the 15 studies were abnormal, all of which were compared with additional studies. There was one nondiagnostic study and two false positives. There were no reported complications. The authors' experience suggests that CO(2) splenoportography is a minimally invasive method for safely and accurately evaluating the splenic and portal veins.

中耳しん出液排出用電動式マイクロポンプの開発

For the treatment of otitis media with effusion, aspiration of fluid through a suction tube is conventionally performed after puncture or myringotomy. However, hypertrophy scars and sclerosis of the tympanic membrane can occur when the radial fiber bundles are cut by myringotomy. It is also very difficult to aspirate the hyperviscous fluid. We thus developed a micropump for use with a small caliber needle to avoid unnecessary injuries to the tympanic membrane. It is also equipped to mechanically transport viscous fluid.The micropump is composed of a motor and needle to puncture the tympanic membrane. Two spiral helical wires inside the needle which are connected to the airspindle (first model) or electric (second model) rotation machine rotate to remove even highly viscous fluid. We used standard viscosity oil to test the relationship between the viscosity of fluid and removal speed. We found that the faster the rotation, the quicker the removal of fluid, independent of viscosity. We confirmed the clinical usefulness of the new micropump and needle system for otitis media with effusion because the puncture needle is fine enough to perform a minimally invasive puncture of the tympanic membrane.We treated 16 patients (19 ears) with otitis media with effusion using this electric micropump between October 2000 and April 2001. In 15 ears, effusion was removed successfully, in 2 ears, we almost totally removed the effusion with very little residual fluid, and in 2 ears we could not remove the effusion due to the extremely high viscosity.

Percutaneous Computed Tomography-guided Fine Needle Brachytherapy of Pulmonary Malignancies

Small caliber needle aspiration of lung lesions has been successfully and safely used for diagnostic purposes. We report our initial experience using computed tomography-guided fine needle percutaneous implantation for direct intralesional high-dose rate brachytherapy for malignant pulmonary lesions. Twenty patients with primary lung cancer or metastatic cancer which involved the lung or chest wall were treated with a high-dose rate remote afterloader. Eighteen of the 20 patients also received external beam radiation in conjunction with intralesional radiation therapy. Fourteen patients had primary lung cancer. A complete response was obtained in 5 of the 14 patients. Ten of the 14 patients with primary non-small-cell carcinoma of the lung showed a significant response to treatment (greater than 50 percent reduction in tumor measurement). Six patients with metastatic lesions also were treated. Five of the six showed a significant tumor response measured as either 50 percent reduction in tumor measurement or complete pain relief. The only significant complication was pneumothorax (6 of the 20), which did not prevent completion of any treatment plan.

An Improvement in Catheter Technic for Continuous Caudal Anesthesia

Recently Adams and Lundy 1 described the catheter technic for continuous caudal anesthesia. The method they described involved the use of a 13 gage Love-Barker spinal needle and a number 5 ureteral catheter. We 2 have used this method in over 250 obstetric cases without any serious complications. There are, however, some objections: 1. The caliber of the needle is such that it is difficult to insert it into the caudal canal. 2. If there is difficulty in locating the caudal foramen and it becomes necessary to reinsert the needle, considerable trauma ensues. As a result, patients complain of soreness at the site of insertion during the first few days post partum. Recently we have overcome this difficulty and simplified the technic considerably by employing a 15 gage needle with obturator and a number 4 ureteral catheter. It is much easier to insert a small caliber needle into the caudal

Variations in Monocytic Response to Peroxydase Test.

Naegeli states that almost all, if not all, of the human monocytes are peroxydase reacting. The author found no peroxydase-reacting monocytes in the blood of a rabbit. In a normal adult man there were present 3.4% peroxydase mononuclear phagocytes and 1.1% phagocytes that did not react to the peroxydase test. The conclusion was that the peroxydase cells of human blood are of myeloid origin, which is the view held by Naegeli. The negative phagocytes were thought to be the true monocytes derived from the reticular portion of lymphoid tissue. Recently some unpublished observations have brought me to a consideration of the alternative view, namely, that the peroxydase-positive phagocyte gets its granulation secondarily in a more or less accidental manner. The conclusions arrived at in this paper are based on tissue cultures of blood leukocytes. Methods and Results: Numerous cultures of human blood were made by the coverglass method and examined by the peroxydase test daily from one day to 4 weeks. This was done on the assumption that the peroxydase granulation of the monocytes would disappear, provided the granulation was acquired secondarily and was not an essential part of the cell cytoplasm. After one month in the incubator large peroxydase reacting phagocytes were present in the cultures. Never was the number of phagocytes great and no conclusion was possible in regard to the proportion of positive and negative cells. Rhoads and Parker found at the end of 2 weeks of incubation both positive and negative mononuclear phagocytes in normal human blood. The next procedure was to culture rabbit leukocytes in contact with variable amounts of human blood: Rabbit blood was cultured on sterile cover-glasses covered with smears of human blood made with aseptic precautions. The smears were kept dry in the air for 2 hours. The rabbit blood was obtained from the heart and drops of blood placed directly on the covers from the small caliber needle. The covers which had previously been rimmed with sterile vaseline were inverted over the well and placed in the incubator within 5 minutes after withdrawal of the blood from the heart. After about one hour the covers were sealed permanently with paraffin. At the end of 2 weeks as many as 500 large mononucleated cells were present in some of the cultures while in the human blood cultures mentioned above the cells at the most numbered a few dozen.

Mediastinal Cyst

The patient, a married woman, aged 35, had influenzal pneumonia in November, 1918, from which she felt she had never fully recovered. A thyroidectomy in April, 1920, was followed by pneumonia, the patient being confined to bed for seven weeks. Since then there has been continuous cough and copious expectoration of thick, foul sputum. Some morning temperature. Marked loss of weight and energy. X-ray examination, September 7, 1920, showed globular, non-pulsating mass (Fig. 1) 4½ inches in diameter attached to the upper mediastinal shadow and closely related to the left main bronchus, through which it probably drained. It lay behind the bifurcation of the trachea (Fig. 3) and displaced the esophagus 1½ inches to the right and backwards (Fig. 3) . The posterior wall of the shadow was about 1¼ inch from the posterior thoracic wall. An outline of the mass was transposed to an anatomical cross-section of the region. The relation of the shadow to the mediastinum, its partial drainage through the bronchus, and its even, globular, non-pulsating outline suggested cyst. Several attempts at aspiration were made, but without success. Finally, with the assistance of an improvised arrangement of two fluoroscopes at right angles, a small caliber needle 3½ inches long was inserted safely through the posterior wall. The needle point being found to be well within the mass, aspiration was attempted, but, owing to the thickness of the contents, met with only partial success. A small amount of air was injected which proved by its change of position when the patient assumed various postures that the contents of the mass was fluid or semi-fluid (Fig. 2). The surgeon followed up the needle, still in place, establishing partial drainage. Following this procedure there was complete cessation of cough and expectoration, and a rapid gain in weight and strength followed, with an improvement in general physical condition. The laboratory test, March 7, 1921, showed saprophytic organisms: no fetal parts. Subsequent Course Until October 13, 1925, when the patient was last seen, examinations were made from time to time. The empty cyst as shown in Figures 3 and 4 was readily visible and of only slightly diminished size. The distortion of the esophagus during these five years has remained practically unchanged (Fig. 3). The patient, who refuses further operation, remains in excellent health and has gained about fifty pounds in weight. There is no cough and no expectoration, but the tube is retained in position. Drainage is practically nil, the dressing applied once or twice daily showing only a stain and the odor is scarcely noticeable. An attempt to remove the tube about two years ago demonstrated its impracticability at that time by a return of the symptoms.

A SMALL NEEDLE FOR AVOIDING LUMBAR PUNCTURE HEADACHE

The accompanying illustration shows a 3 inch No. 24 gage Luer needle used for making spinal punctures. The sliding sleeve serves as a holder and prevents the bending and wobbling that would otherwise occur in performing lumbar puncture with a small caliber needle. The obturator is made of No. 0 cast steel music wire. The small needle is employed to reduce the size of the puncture-hole in the dura, and thus diminish the subsequent escape of spinal fluid into the tissues. Marked decrease in the incidence of postpuncture headache results. Before the lumbar puncture is performed, the obturator wire is withdrawn a short distance into the needle. When the spinal canal has been penetrated, the obturator can be pushed forward through the point of the needle. The obturator is then withdrawn, and the spinal fluid normally flows at a rate of from 16 to 24 drops a minute with the