Efficacy of intra-arterial contrast-enhanced ultrasonography during transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma

AIM To assess the usefulness of intra-arterial contrastenhanced ultrasonography(IAUS) during transarterial chemoembolization(TACE) with drug-eluting beads(DEB) for hepatocellular carcinoma(HCC).METHODS Thirty two patients with 39 HCC underwent DEB-TACE guided with IAUS, and examined by contrast-enhanced ultrasonography(CEUS) or dynamic CT after DEB-TACE were enrolled in this study. CEUS findings before DEBTACE and IAUS findings were compared. Treatments judged to be complete and incomplete for lesions were appropriate and insufficient, respectively. Findings on CEUS and/or dynamic CT performed 1, 3 and 6 mo after DEB-TACE were evaluated using m RECIST(CR/PR/SD/PD).RESULTS The treatments were complete and incomplete in 26 and 13 lesions, respectively. On imaging evaluation using CEUS and/or dynamic CT one month after treatment, 25 and 1 lesions were judged to be CR and PR, respectively, and at 6 mo after treatment, the results were CR, PR, SD and PD for 24, 1, 0 and 1 of these lesions, respectively, in the 26 completely treated lesions. Of the 13 lesions in which treatment was incomplete, the results on imaging at one month after treatment were CR, PR, SD and PD for 0, 6, 4 and 3 lesions, respectively. The overall CR rate at 6 mo after treatment was 61.5%(24/39).CONCLUSION A combination of DEB-TACE with IAUS can improve the therapeutic effects in patients with HCC.     

Is endoscopic papillary large balloon dilatation without endoscopic sphincterotomy effective?

AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation(EPLBD) without endoscopic sphincterotomy in a prospective study.METHODS: From July 2011 to August 2013, we performed EPLBD on 41 patients with nae papillae prospectively. For sphincteroplasty of EPLBD,endoscopic sphincterotomy(EST) was not performed,and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter(ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome.RESULTS: The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4mm, and the mean number of stones was 3.0 ± 2.4.Complete stone removal was achieved in 97.5%(40/41)of cases, and ML was used in 12.2%(5/41) of cases.The mean number of sessions required was 1.2 ± 0.62.Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was73.1%(30/41). No significant differences were noted in procedure time, rate of complete stone removal(100% vs 100%), number of sessions(1.1 vs 1.3, P= 0.22), application of ML(13% vs 9%, P = 0.71),or occurrence of pancreatitis(3.3% vs 9.1%, P =0.45) between cases with and without balloon waist disappearance.CONCLUSION: EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.     

High spatial resolution 3D MR cholangiography with high sampling efficiency technique (SPACE): comparison of 3T vs. 1.5T

Purpose

The aim of this study was to evaluate image quality of 3D MR cholangiography (MRC) using high sampling efficiency technique (SPACE) at 3 T compared with 1.5 T.

Methods and materials

An IRB approved prospective study was performed with 17 healthy volunteers using both 3 and 1.5 T MR scanners. MRC images were obtained with free-breathing navigator-triggered 3D T2-weighted turbo spin-echo sequence with SPACE (TR, >2700 ms; TE, 780 ms at 3 T and 801 ms at 1.5 T; echo-train length, 121; voxel size, 1.1 mm × 1.0 mm × 0.84 mm). The common bile duct (CBD) to liver contrast-to-noise ratios (CNRs) were compared between 3 and 1.5 T. A five-point scale was used to compare overall image quality and visualization of the third branches of bile duct (B2, B6, and B8). The depiction of cystic duct insertion and the highest order of bile duct visible were also compared. The results were compared using the Wilcoxon signed-ranks test.

Results

CNR between the CBD and liver was significantly higher at 3 T than 1.5 T (p = 0.0006). MRC at 3 T showed a significantly higher overall image quality (p = 0.0215) and clearer visualization of B2 (p = 0.0183) and B6 (p = 0.0106) than at 1.5 T. In all analyses of duct visibility, 3 T showed higher scores than 1.5 T.

Conclusion

3 T MRC using SPACE offered better image quality than 1.5 T. SPACE technique facilitated high-resolution 3D MRC with excellent image quality at 3 T.     

Diagnostic and therapeutic single-operator cholangiopancreatoscopy in biliopancreatic diseases: Prospective multicenter study in Japan

AIM: To assess the utility and safety of single-operator cholangiopancreatoscopy(SOCPS) using the Spy Glass system in widespread clinical application for biliary and pancreatic diseases.METHODS: This study was a prospective case series conducted in 20 referral centers in Japan. There were 148 patients who underwent SOCPS; 124 for biliary diseases and 24 for pancreatic diseases. The attempted interventions were SOCPS examination, SOCPS-directed tissue sampling, and therapy for stone removal, among others. The main outcomes were related to the procedure success rate in terms of visualizing the target lesions, SOCPS-directed adequate tissue sampling, and complete stone removal. RESULTS: A total of 148 patients were enrolled for the diagnosis of indeterminate biliary and pancreatic lesions or treatment of biliary and pancreatic disease. The overall procedure success rate of visualizing the target lesions was 91.2%(135/148). The overall procedural success rates of visualizing the target lesions of diagnostic SOCPS in the bile duct and pancreatic duct were 95.5%(84/89) and 88.2%(15/17), respectively. Diagnosis: the overall adequate tissue for histologic examination was secured in 81.4% of the 86 patients who underwent biopsy under SOCPS(bile duct, 60/75, 80.0%; pancreatic duct, 10/11, 90.9%). The accuracy of histologic diagnosis using SOCPS-directed biopsies in indeterminate bile duct lesions was 70.7%(53/75). In the pancreatic duct, the accuracy of SOCPS visual impression of intraductal papillary mucinous neoplasm was 87.5%(14/16). Stone therapy: complete biliary and pancreatic stone clearance combined with SOCPS-directed stone therapy using electrohydraulic lithotripsy or laser lithotripsy was achieved in 74.2%(23/31) and 42.9%(3/7) of the patients, respectively. Others: SOCPS using the Spy Glass system was used in cannulation of the cystic duct in two patients and for passing across the obstructed self-expandable metallic stent for a malignant biliary stricture in two patients. All procedures were successful in both SOCPS-guided therapies. The incidence of procedure-related adverse events was 5.4%(8/148). CONCLUSION: SOCPS with direct visualization and biopsy for diagnosis and SOCPS-directed therapy for biliary and pancreatic diseases can be safely performed with a high success rate.     

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent(PS) or nasobiliary catheter(NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedurerelated adverse events, stent/catheter dysfunction(occlusion or migration of PS/NBC, developmentof cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution(bilirubin level 3.0 mg/d L) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study(PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients(46%), bile duct cancer in 172(41%), gallbladder cancer in three(1%), and ampullary cancer in 50(12%). The median serum total bilirubin was 7.8 mg/d L and 324 patients(77%) had ≥ 3.0 mg/d L. During the median time to surgery of 29 d [interquartile range(IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio(SHR) = 4.76; 95%CI: 2.44-10.0, P 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method(PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.     

Plaque accumulation on Teflon-coated metal

This study demonstrated that plaque accumulation was reduced and plaque removal facilitated by the TFE coating. These findings suggest that the TFE coating has a practical application for pontics and the proximal and cervical surfaces of crowns. These inaccessible surfaces are not easily cleaned by brushing.     

Transthoracic percutaneous radiofrequency ablation for liver tumors in the hepatic dome

Computed tomography (CT)-guided transthoracic radiofrequency ablation was performed for nine liver tumors of eight patients, which were located in the hepatic dome and undetectable by ultrasound (US). A total 11 sessions of ablation were performed. Complications were noted in five sessions (45%) and no complications were noted in six sessions (55%). Pneumothorax was noted in five sessions (45%), including two sessions (18%) with major pneumothorax requiring a chest tube. Major complications were seen in two sessions (18%), major pneumothorax and both major pneumothorax and moderate pleural effusion, respectively. CT-guided transthoracic radiofrequency ablation may be an alternative for treatments of liver tumor in the hepatic dome.     

Evaluation of motion correction effect and image quality with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) (BLADE) and parallel imaging acquisition technique in the upper abdomen

PURPOSE: To evaluate motion correction effect and image quality in the upper abdomen with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) (BLADE) and parallel imaging acquisition technique. MATERIALS AND METHODS: A total of 50 consecutive patients underwent abdominal MR imaging. Fat-saturated T2-weighted turbo spin-echo sequences were obtained by respiratory triggering. The subjects were examined with three different conditions of echo train length (ETL), blade width, and percent k-space coverage in the same scanning time: 19/30/100%, 30/30/100%, and 30/52/175%, which were designated as L/C(1), L/C(2), and L/C(3), respectively. The parallel imaging acquisition technique was used to either reduce ETL from 30 to 19 in L/C(1) or increase k-space coverage from 100% to 175% in L/C(3) compared with L/C(2). Motion and streak artifacts, and overall image quality were evaluated visually by two radiologists, independently. RESULTS: Motion and streak artifacts were mostly reduced in L/C(3) condition. The L/C(3) image also gave the best overall image quality compared with other conditions (P < 0.001). The inter-rater reliability for each evaluation agreed well. CONCLUSION: In upper abdominal BLADE MRI, it was possible to reduce image artifacts and obtain better image quality by increasing the k-space coverage with parallel imaging in the same scanning time.