Biliary complications after orthotopic liver transplant (OLT) remain one of the primary causes of morbidity and mortality in liver transplant recipients with an approximate incidence between 5% and 32%. Given the limited supply of hepatic grafts, one of the most feared outcomes as a result of biliary complications is acute and or chronic graft failure. Biliary complications include leaks, biliary stasis, and stone formation, sphincter of Oddi dysfunction, recurrence of biliary disease (primary sclerosing cholangitis and primary biliary cirrhosis), and biliary strictures/obstruction. Overwhelmingly, the most common complication in hepatic transplantation is biliary stricture formation accounting for more than 50%. Currently, the mainstay of therapy as it pertains to biliary strictures/obstruction includes endoscopic retrograde cholangiography–guided therapy, percutaneous transhepatic cholangiography–guided therapy, or surgical revision/retransplantation. We present a case of biliary obstruction in a patient with a second liver transplant complicated by Cocoon Syndrome managed via sharp recanalization of CBD occlusion and placement of an endoscopic biliary Viabil stent.

Duodenal webs in neonates and infants have been traditionally managed with open or laparoscopic surgery. Surgical management has been associated with high morbidity and mortality and prolonged length of stay. Other treatments include endoscopic resection of the web with cautery or laser energy. This modality carries a high risk of perforation. Endoscopic balloon dilatation has been recently reported with good clinical outcome. Most of the patients reported in the literature required serial balloon dilatations to achieve resolution of the symptoms. We report a 10-month-old infant with duodenal obstruction secondary to a congenital duodenal web. He was successfully managed with a single high-pressure balloon dilatation using an interventional radiology technique. He tolerated liquid diet on day 2 post procedure and was discharged home on day 3. He has remained asymptomatic after 4 years of follow-up.

Contrast-enhanced ultrasound (CEUS) is a low cost and effective imaging modality that is accessible immediately post procedure which allows the clinician to instantly perform additional ablation of the tumor if a residual tumor is detected. CEUS can be an alternative to contrast enhanced CT in patients with underlying renal disease or iodine allergy. The purpose of this abstract is to share our experience with use of contrast enhanced ultrasound after microwave ablation for HCC with MRI correlation and posttransplant pathology. This is a retrospective analysis of 13 patients in an IRB-approved study conducted at our institution from 2017-2019. The patients were identified during liver tumor board with diagnosis of hepatocellular carcinoma (HCC) amenable to microwave ablation. These patients underwent CT-guided microwave ablation of HCC. Immediately post procedure patients underwent CEUS to evaluate for residual tumor, which was reported by an expert ultrasound radiologist providing us with instant feedback regarding residual tumor. Patients underwent MRI one month post procedure to evaluate for residual tumor within the treatment bed. Pathology reports were obtained for the patients that received liver transplants and radiologic and pathologic correlation was made to the treatment site. 7 postablation CEUS examinations demonstrated complete response to therapy with concordant results on follow-up MRI. 3 went on to have a liver transplant with complete or near complete response. Four post ablation CEUS examinations were read as suboptimal. Follow-up MRI for 3 showed complete response and 1 showed viable tumor in the treatment cavity. 1 patient had transplant before MRI. Transplant pathology showed complete response. Out of 13 patients 1 study was discordant with no enhancement seen on CEUS at the time of ablation with viable tumor on MRI. See Table 1. Preliminary data demonstrates congruence between post ablation CEUS and follow-up MRI or CEUS with no residual tumor in the treatment bed in 7 of 13 of our patients. Artifact and operator dependence can limit evaluation however CEUS is still an inexpensive and useful tool post ablation.Table 1Summary of Patients with Postablation CEUS and MRI13 Patients7 patients: concordant CEUS and MRI complete response3 patients transplanted2 pathology reports with complete response; 1 with partial response4 patients: postablation CEUS suboptimal because of artifact3 compete response; 1 viable tumor1 transplant with complete response1 patient: CEUS no MRI because of transplantPathology report shows complete response1 patient: discordant CEUS and MRI Open table in a new tab

Massive splenomegaly can be defined as one of the following: a spleen that reaches the iliac crest, crosses the midline, is longer than 18 cm, and weighs more than 1500 g.1, 2 Causes of massive splenomegaly include lymphoma, myelofibrosis, chronic myeloid leukemia, beta thalassemia, and acquired immunodeficiency syndrome, among others. In the elderly, hematologic disorders, metabolic disorders, and malignant tumors are extremely rare causes of splenomegaly, whereas leukemia and lymphoma are more common.1 Management of splenomegaly primarily consists of treating the underlying disease. It is only in select conditions, refractory to medical therapies, that splenectomy and/or splenic artery embolization (SAE) is considered. Although splenic embolization with hematologic disorders in children is common, there are limited data on embolization in the elderly population ($65 years). Our patient is a 78-year-old farmer with a past medical history of stage IV metastatic melanoma on second-line chemotherapy. He was also diagnosed with myelofibrosis causing severe abdominal fullness for the past 14 years and progressive anemia that required frequent blood transfusions. In recent years, the frequency of blood transfusions increased from 1 to 2 units of packed red blood cells every other week. He was referred to our surgery clinic where he reported two months of increased abdominal discomfort and shortness of breath, particularly when his hemoglobin fell below 7 g/dL. A CT scan revealed massive splenomegaly (Fig. 1 A), which on physical examination was palpable and visible on the left abdomen. In preparation for the operation, the patient received the following vaccines: polyvalent pneumococcal vaccine (Pneumovax 23), meningococcal polysaccharide vaccine (Menomune-A/C/Y/W-135), and Haemophilus influenzae B vaccine (HibTITER, Wyeth Pharmaceuticals Inc., Philadelphia, PA) two weeks before splenectomy. However, two days before his scheduled surgery, the patient was admitted emergently for reported symptoms of dyspnea and excessive dizziness. At the time, the patient’s hemoglobin was 6.7 g/dL. To minimize potential bleeding immediately before surgery, the patient underwent SAE using 400 microns of Embozine microspheres through a 5-French angiographic sheath. Splenectomy was performed through a large midline incision with left transverse/subcostal extension of the incision. Three and half liters of ascites was immediately drained and replaced with 5 per cent albumin. Substantial omental adhesions to the spleen were noted and divided using electrocautery and LigaSure device. The splenic hilum and vessels were isolated and suture ligated with large clips and 2-0 Prolene. The spleen weighed 3478 g and measured 45 · 18 · 10 cm (Fig. 1 B). Pathologic analysis of the spleen revealed extramedullary trilineage hematopoiesis and extensive myeloid proliferation, confirmed by immunohistochemical staining. The patient’s postoperative course was complicated by accumulations of hemorrhagic ascites requiring percutaneous drainage (Clavien-Dindo Class 3)3 including a nonocclusive portal venous thrombosis requiring oral anticoagulation as an outpatient (Clavian-Dindo Class 2).3 The overall comprehensive complication index score was 33.5.3 Historically, open FIG. 1. (A) Enlarged spleen (*) seen on CT scan and (B) resected spleen.

To ascertain calibers and numbers of arteries within Hepatocellular Carcinoma (HCC). A retrospective review of 29 formalin-fixed specimens of HCC obtained from 29 randomly selected patients was conducted. Nine largely necrotic tumors were excluded. A representative section from each of the other 20 tumors was embedded in paraffin, sliced into 4-μm-thick serial sections, stained with hematoxylin and eosin, and examined by light microscopy. From each section, a single slide with the least amount of non-tumorous or necrotic tissue was double stained using the immunostains (SMA and CD34) for smooth muscles and endothelium. The digital images of the slides were examined with high power electronic magnification using the scanner’s software. On each image three standardized 4.5 mm2 regions of interest (ROI) were outlined avoiding necrotic areas. All arteries within the three ROIs were counted and measured electronically in μm up to the second decimal place. For each artery, its diameter was determined as a straight line drawn perpendicular to the artery’s major axis between the most separated points of opposing layers of endothelium. Considering that the fixation technique shrinks the examined tissue by 19-25% (22% average), each obtained measurement was multiplied by 1.28. The resultant data were analyzed. Overall, 1639 arteries were identified and measured. Although the arterial calibers vary between 6.4 and 281.86 μm, 60.7% were smaller than 20 μm, 80.29% were smaller than 30 μm, and 88.95% were smaller than 40 μm. The vascular densities vary from 13 to 222 arteries per 13.5-mm2 region of in interest on a 4-μm-thick section. Within the given sample, 88.95% of HCC arteries have calibers of less than 40 μm. There was up to a 17-fold difference in arterial densities among the HCCs. The obtained data may present interest for a selection of particle sizes used for treatment of HCC by transarterial embolization.

To characterize the incidence of vascular complications in patients receiving orthotopic liver transplants (OLT) at a single regional liver transplant center between 2005 and 2017, and review the frequency of endovascular techniques as primary treatment. All OLTs performed at our institution between 2005 and 2017 on patients aged 18-89 were reviewed. Cases with vascular complications were included in the study. From 2005 to 2017, 523 OLTs were performed at our institution. During this period, there were 45 (8.6%) vascular complications after transplant. These involved the hepatic artery (HA) in 37 (82.2%) patients, portal vein (PV) in 11 (24.4%) patients, and inferior vena cava (IVC) in 3 (6.7%) patients; 9 patients had multiple vascular complications. HA stenosis (HAS) was the most common, occurring in 28 patients. Of these, the initial intervention was endovascular in 20 patients: successful by balloon angioplasty alone (2/20, 10%) or angioplasty and stent (10/20, 50%). 25% (5/20) of patients needed surgical intervention after a failure or complication of primary endovascular treatment. The rest of the patients were primarily treated with either surgical intervention (5) or no treatment (3). HA thrombosis occurred in 9 patients. 4 patients were treated initially by endovascular approach: subsequently successful in (1), re-transplanted (1), surgically revised (1), and failed with conservative management (1). The remaining 5 patients required primary surgical intervention by either re-transplant (3) or revision (2). PV thrombosis occurred in 8 patients. No endovascular interventions were performed. 2 patients were managed primarily with surgical thrombectomy, and the remaining 6 treated conservatively. PV stenosis occurred in 3 patients: treated primarily with a stent via trans-ileocolic venous access (1), surgically revised (1), and required no intervention (1). Lastly, IVC stenosis occurred in 3 patients: 1 patient was treated successfully with stent and the remaining 2 patients required no intervention. Endovascular techniques provide effective minimally invasive options for the management of vascular complications after orthotopic liver transplant.

This chapter describes the use of an elongated radiopaque gelatin sponge plug for tract occlusion after percutaneous biliary, portal venous, or hepatic venous access or intervention. Often, embolization coils or a gelatin sponge “slurry” is sufficient for hemostasis following liver intervention. This technique offers an inexpensive, temporary, and readily available option for achieving hemostasis following liver interventions. A contrast-soaked Gelfoam plug is loaded into a delivery cylinder that is advanced into the access sheath and positioned and deployed under fluoroscopic guidance. This technique is an alternative option to the use of embolization coils or a gelatin sponge slurry when seeking hepatic parenchymal tract hemostasis following intervention.

This chapter describes construction of a temporary large-bore biliary endoprosthesis from a standard pigtail drainage catheter. Management of benign common duct biliary strictures often requires multiple interventions and leaves the patient with an indwelling biliary catheter for a prolonged time course. Commercially available plastic, bare-metal, and covered metal biliary stents are not ideally suited for the management of benign strictures. The endoprosthesis is cut to length and then positioned, deployed, and tethered to the abdominal wall with an absorbable suture. After the suture dissolves in several months, the catheter is propelled into the intestine by peristalsis and expelled without the need for an additional procedure.

Transmesenteric portal access via mini-laparotomy may be used as a salvage technique when standard transjugular intrahepatic portosystemic shunt (TIPS) is unsuccessful due to difficult anatomy or portal vein thrombosis. This technique allows for precise determination of both the portal and the hepatic vein branch involved in the TIPS. This method usually involves the cooperation of a surgeon, who performs a mini-laparotomy and exposes a small bowel loop in the interventional suite. A mesenteric venous branch is then cannulated, providing direct access to the portal venous system. In distinction to standard technique, the hepatic parenchymal tract is created by a puncture from the portal vein into the hepatic vein. A guidewire advanced through the puncture needle is then snared from the hepatic vein, providing through-and-through access. The TIPS can be completed using standard techniques. Upon completion, the mini-laparotomy is closed by the surgeon.

© 2017. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

To refresh interventional radiologists, residents, and medical students about the principal physics behind angiography in order to optimize imaging and reduce dose to the patient and themselves. It is important for an Interventional radiologist to have a working knowledge of the essentials of radiation physics. The IR is responsible for the radiation exposure to the patient, staff, and his/herself. Achieving the lowest dose possible requires a background in physics. Additionally, having a sound physics background can also help produce better imaging leading to improved diagnostic and therapeutic results. Physics is often taught during radiology residency and principles memorized for board examinations, which are then quickly forgotten. We will discuss key physics principles which relate to interventional radiology. Principles will cover appropriate distances between the x-ray tube and patient as well as receptor and patient, the need to minimize the air gap, factors which increase the entry skin dose such as magnification and obliquity, as well as methods to reduce dose to the staff in the angiography suite. We will discuss what characterizes a "sentinel event," what should be done when such an event occurs, and methods to avoid the event all together. Additionally, we will discuss the principle of air KERMA and how it relates to dose. Interventional radiologists need to have a sound understanding of physics principles in order to safely perform angiographic procedures as well as to optimize their images. These principles often have not been reviewed since radiology residency. We discuss key principles an IR should be familiar with in order to serve as a quick refresher on often forgotten principles.

This chapter describes the use of a standard mushroom-retained gastrostomy (MRG) tube for stenting benign esophageal strictures. For effective long-term management, an esophageal stent should be easily placed, repositioned, and retrieved and also resistant to migration. An MRG tube can be used as a replaceable stent to allow oral feeding in the setting of benign esophageal stricture. The tube is readily available, easily adjustable, and an easily removable option. Using standard interventional techniques, the strictured segment is first dilated with a balloon catheter. The gastrostomy tube is then deployed over a guidewire. The tube spans the stricture, allowing for oral feeding.

Purpose: A 76-year-old male with no history of liver disease was evaluated for multiple episodes of confusion and altered mental status for two years. Patient was repeatedly found to have elevated ammonia levels during prior hospitalizations for altered mental status. He was on medical management of hyperammonemia with rifaximin and lactulose with little benefit. There was no history of alcohol abuse or recreational drug use. Vital signs and physical exam on presentation were normal, with no signs of chronic liver disease or asterixis. He was admitted with evidence of mild confusion. Labs on admission were notable for Ammonia: 83 and 112 μg/dl (two consecutive days); AST 110, ALT 110, Alkaline Phosphatase 151 (U/L). Total Bilirubin 0.7 mg/dl, INR 1.30. There was no evidence of HBV or HCV infection, iron overload or autoimmune liver disease. Head CT revealed age related cerebral atrophy. Abdomen CT showed no radiologic evidence for cirrhosis. Abdominal portography demonstrated multiple intrahepatic portosystemic shunts. An attempt at shunt embolization via a transjugular approach was unsuccessful. A transmesenteric approach was then used. The patient underwent minilaparotomy and placement of a blunt directional canula in the superior mesenteric vein. The major portal branch supplying the upper shunt was occluded with two vascular plugs and several embolization coils. The portal branch supplying the lower shunt was embolized with an IVC filter, followed by deployment of a vascular plug and several embolization coils within the filter. Smaller portal vein branches supplying the shunt were also selectively embolized. The patient's ammonia levels normalized after the procedure and he was asymptomatic during the rest of his hospital stay. Spontaneous large intra hepatic portosystemic shunts in the absence of chronic liver disease are extremely rare and are associated with persistent embryonic venous anastomoses. It is hypothesized that blood flow in the shunt increases with age. Progressive decreased tolerance to toxins like ammonia in the aging brain may explain the late presentation of these cases. Only the symptomatic cases need medical or surgical intervention. This is a rather unusual case of spontaneous, perhaps congenital extensive shunting that presented late in life with severe episodic hyperammonemia and confusion. Symptoms responded briskly to successful angiographic closure of the shunt.

Babesiosis is an infection of red blood cells by the parasite Babesia microti, with a clinical presentation similar to malaria. The organism is endemic to the northeastern United States and is specifically found on Long Island and the barrier islands of Martha's Vineyard and Nantucket ( 1 Vannier E. Krause P. Update on babesiosis. Interdiscip Perspect Infect Dis. 2009; 2009: 984568 PubMed Google Scholar ). B. microti is a parasite spread by the same deer tick that spreads Borrelia burgdorferi, the parasite responsible for Lyme disease. The parasite is spread by the nymph stage of the tick, which is found in warm summer months. Babesiosis infection has also been transmitted via blood transfusion ( 2 Zhao Y. Love K.R. Hall S.W. Beardell F.V. A fatal case of transfusion-transmitted babesiosis in the state of Delaware. Transfusion. 2009; 49: 2583-2587 Crossref PubMed Scopus (14) Google Scholar , 3 Asad S. Sweeny J. Mernel L.A. Transfusion-transmitted babesiosis in Rhode Island. Transfusion. 2009; 49: 2564-2573 Crossref PubMed Scopus (38) Google Scholar ).

BACKGROUND:The optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution. OBJECTIVE:The objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis. METHODS:During 1997-2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child-Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT). RESULTS:The median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3 cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3 cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis. CONCLUSIONS:Survival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3 cm.

Mesenteric vascular disease has been diagnosed increasingly over the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population, an increasing number of critically ill patients and a greater clinical recognition of the condition. Although surgical revascularization and resection has long been the standard of treatment, medical management can also play an important adjunctive role. Early diagnosis before irreversible bowel damage, which may occur within 6-8 hours after the insult, is necessary to improve survival and reduce morbidity. Even in the presence of irreversible bowel ischemia, perioperative medical treatment may reduce disease progression, enabling more limited bowel resection. This article outlines the appropriate pharmacologic management of ischemic disorders of the intestine, with an emphasis on the pharmacologic treatments presently being used in clinical practice and those being studied in the laboratory.

Background There is no clear consensus regarding the best treatment strategy for patients with advanced hepatocellular carcinoma (HCC). Methods Patients with cirrhosis and HCC beyond Milan who had undergone liver resection (LR) or primary orthotopic liver transplantation (OLT) between November 1995 and December 2005 were included in this study. Pathological tumor staging was based on the American Liver Tumor Study Group modified Tumor-Node-Metastasis classification. Results A total of 23 HCC patients were primarily treated by means of LR, 5 of whom eventually underwent salvage OLT. An additional 32 patients underwent primary OLT. The overall actuarial survival rates at 3 and 5 years were 35% after LR, and 69% and 60%, respectively, after primary OLT. Recurrence-free survival at 5 years was significantly higher after OLT (65%) than after LR (26%). Of the patients who underwent LR, 11 (48%) experienced HCC recurrence only in the liver; 6 of these 11 presented with advanced HCC recurrence, poor medical status, or short disease-free intervals and were not considered for transplantation. Salvage OLT was performed in 5 patients with early stage recurrence (45% of patients with hepatic recurrence after LR and 22% of all patients who underwent LR). At a median of 18 months after salvage OLT, all 5 patients are alive, 4 are free of disease, and 1 developed HCC recurrence 16 months after salvage OLT. Conclusion For patients with HCC beyond Milan criteria, multimodality treatment—including LR, salvage OLT, and primary OLT—results in long-term survival in half of the patients. When indicated, LR can optimize the use of scarce donor organs by leaving OLT as a reserve option for early stage HCC recurrence.

Objective To evaluate the predictive abihty of three severity scoring systems: the acute physiology and chronic health evaluation (APACHE I1), the model for end stage liver disease (MELD) and the Child-Turcotte-Pngh (CTP) in patients w~th cirrhosis and acute upper gastrointestinal bleeding Design: Retrospective cohort study Setting: Medical [Cls at 2 University a{ldiated hospitals Patients: We identffmd 48 patients w~th a history of cirrhosis on adimssion, trom 192 patients admitted to the medical ICU between Janua~ T 1999 to June 2002 for acute UG[ bleeding.Patients who developed in-hospital bleedmg were excluded.Methods: l'he perfnrmance of MELD, CTP and APACHE lI scores in predicting in-hospital mortality rates was assessed using the receiver operating characteristic (ROC) curves The prediction accuracy was quantified using the concordance index (c-index).Measuretnents and results: The actual mortality observed was 29.0% (95% C1, 158% to 425%) The mean length of stay in medical ICU was 4.2 d (95% CI, 30 d to 6.1 d) and the mean length of stay in the hospital was 100 d (95% CI, 71 d to 130 d) The area under the ROC curve for MEID, CPP and APACHE i[ scores were 083 (95% CI, 068 to 097), 081(95% C1,066 to 095) and 061 (95% CI, 043 to 077) respectively There was significant difference between the c-index tor APACHE-II vs MELD (p=0.03).There was no difference among the MELD and (TP scores (p = 078) and between APACHE-II vs CTP scores (p=O 08) Conclusions: MELD score was hmnd to be equivalent to the CTP score m Fvdictmg inhospital patient mortality, adding to its roIe in determining prognosis tor cirrhotic patients 1 09 08 .