Abstract:

Aim: was to evaluate the feasibility and effectiveness of using transperineal access for sanitation of «deep» exudative pelvic lesions in patients after gynecological operations.

Materials and methods: results of percutaneous drainage with perineal access of «deep» – perirectal postoperative exudative pelvic lesions in 18 patients after extirpation of the uterus in oncological pathology were subjected to retrospective analysis. Exudative formations in the pelvis were detected during continuous postoperative ultrasound screening of operated patients starting from 3rd day of the postoperative period, taking into account clinical data.

Perineal access was used in patients with verification of the nature of the pathological contents and subsequent drainage of the pathological exudation zone by 8fr drains with form memory using Seldinger method.

Results: manipulation was successful in all 18 patients. In 5 cases, a lyzed pelvic hematoma was drained, and in 13 cases, an abscess was drained. In three cases, the connection of the abscess cavity with the lumen of the rectum was revealed. There were no complications due to manipulation. The drainage period was 6-7 days for hematoma and 10-16 days for abscess without internal fistula. If there is a connection with the lumen of the rectum, the drainage period was 21 days, the drainage was removed with x-ray confirmed closure of the internal fistula.

Conclusion: our first positive experience of using transperineal access for the rehabilitation of intrapelvic exudative complications of the postoperative period in oncogynecological patients inspires cautious optimism, expands the arsenal of mini-invasive methods of treatment of intra-pelvic postoperative exudative complications, but undoubtedly requires further research for optimal integration of the technique into the practice of oncogynecology and x-ray surgery departments.

References

1.     Lorenz JM, Al-Refaie WB, Cash BD, et al. ACR appropriateness criteria radiologic management of infected fluid collections. J Am Coll Radiol 2015; 12: 791–799.

2.     Hynes D, Aghajafari P, Janne d'Othee B. Role of Interventional Radiology in the Management of Infection. Semin Ultrasound CT MR. 2020 Feb; 41(1):20-32.

3.     Kadrev AV. Punctures under the control of echography in the diagnosis and treatment of pelvic fluid in women. Cand. of med. sci. diss. Мoscow. 2007: 159 [In Russ].

4.     Albuquerque A, Pereira E. Current applications of transperineal ultrasound in gastroenterology. World J Radiol. 2016; 8(4): 370-377.

5.     Sperling DC, Needleman L, Eschelman DJ, Hovsepian DM, Lev-Toaff AS. Deep pelvic abscesses: transperineal US-guided drainage. Radiology. 1998; 208(1):111-5.

6.     Golferi R, Cappelli A. Computed tomography-guided percutaneous abscess drainage in coloproctology: review of the literature. Tech Coloproctol. 2007; 11: 197–208.

7.     Khurrum Baig M, Hua Zhao R, Batista O, et al. Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery. Tech Coloproctol. 2002; 6: 159–164.

8.     De Kok BM, Marinelli A.W.K.S., Puylaert J.B.C.M., et. al. Image-guided posterior transperineal drainage for presacral abscess: An analysis of 21 patients. Diagn Interv Imaging. 2019; 100(2): 77-83.

Abstract:

Aim: was to assess the possibility of x-ray surgical recovering of the integrity of the upper urinary tract in the absence of dilatation of kidney collecting system.

Material and methods: for the period of 2018-2020, under our supervision there were 9 patients with an unexpanded kidney collecting system against the background of the existing external or internal urinary fistula. In 6 patients after cystoprostatectomy and ureteroenterocutaneostomy (Bricker surgery), a migration of urethral drainage occurred. In 3 cases, after gynecological operations, patients were diagnosed with iatrogenic complete transverse ureter damage with the formation of retroperitoneal (intrapelvic) uroma. At the first stage in all 9 patients we performed percutaneous nephrostomy on unexpanded kidneys’ collecting system under ultrasound guidance using special techniques.

To restore patency of the damaged ureter, a combined ante-retrograde approach was used. The antegrade flexible guidewire was moved through damaged (cut off) ureter, and retrograde through the entrance of damaged ureter or enterostomy with a capturing device, under x-ray control, the guidewire was brought out. Then, pyeloureteral drainage was placed in an adequate position of the enterocutaneostomy retrograde or antegrade, splinting the ureter damage zone.

Results: in 6 patients, after Bricker surgery, the lost ureteral drainage was adequately restored. In patients with a cut off ureter, it was possible to restore the course of the damaged ureter on the external-internal pyelo-urethral drainage by closing the internal urinary fistula and eliminating retroperitoneal urine by percutaneous drainage under radiation control. There were no complications associated with the technique of x-ray surgery.

Conclusion: percutaneous nephrostomy on an unexpanded kidney collecting system using special techniques for the verification of kidney collecting system is a potentially replicable safe technique that allows to perform in stages adequate external derivation of urine. Percutaneous nephrostomy can be used as a «bridge» technique for subsequent x-ray surgical interventions on the ureter, including with its complete iatrogenic damage.

References

1.     Patel U, Hussain FF. Percutaneous nephrostomy of non-dilated renal collecting systems with fluoroscopic guidance: technique and results. Radiology. 2004 Oct; 233(1 ):226-233.

https://doi.org/10.1148/radiol. 2331031342

2.     Liu BX, Huang GL, Xie XH et al. Contrast-enhanced US-assisted Percutaneous Nephrostomy: A Technique to Increase Success Rate for Patients with Nondilated Renal Collecting System. Radiology. 2017 Oct; 285(1):293-301.

https://doi.org/10.1148/radiol.2017161604

3.     Usawachintachit M, Tzou DT, Mongan J et al. Feasibility of Retrograde Ureteral Contrast Injection to Guide Ultrasonographic Percutaneous Renal Access in the Nondilated Collecting System. J Endourol. 2017 Feb; 31 (2): 129-134.

https://doi.org/10.1089/end.2016.0693

4.     Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011 Dec; 28(4):424-37.

https://doi.org/10.1055/S-0031-1296085

5.     Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidencebased analysis. BJU Int. 2004 Aug; 94(3):277-89.

https://doi.org/10.1111 /j.1464-410X.2004.04978.X

6.     Ray CE Jr, Brown AC, Smith MT, Rochon PJ. Percutaneous access of nondilated renal collecting systems. Semin Intervent Radiol. 2014 Mar; 31 (1):98-100.

https://doi.org/10.1055/S-0033-1363849

7.     American College of Radiology (ACR) and the Standarts of Practice Committee of the Society of Interventional Radiology (SIR) and the Society for Pediatric Radiology (SPR) practice guideline for the performance of percutaneous nephrostomy. Revised 2011 (resolution 42). Accessed March 9, 2013.

http://www.arc.org/~/media/ACR/Documents/PGTS/guidelines/Percutaneous_Nephrostomv.pdf

8.     Clark TW, Abraham RJ, Flemming BK. Is routine micropuncture access necessary for percutaneous nephrostomy? A randomized trial. Can Assoc Radiol J. 2002 Apr; 53(2):87-91.

Abstract

Aim: was to assess feasibility and effectiveness of using special methods for preventing of port-biliary fistula formation, at all stages of percutaneous transhepatic cholangiostomy (PTC).

Material and methods: we analyzed results of 3786 cholangiostomies with Seldinger technique, performed during the period from 1995 to 2019. Primary puncture of target bile duct was performed with a 17,5-18G needle for Amplaz guidewire 0,035’’ with a safe J-tip. With benign lesion of the biliary tree, 2066 cholangiostomies (54.6%) were performed, with tumor – 1720 (45,4%).

Results: significant hemobilia was registered in 21 patients (0.55%) from the analyzed group (3786 PTC), while in 3 cases arteriobiliary fistula was diagnosed, in 16-portbiliary fistula, 2 - biliary-venous fistula. The frequency of portоbiliary fistulas was 0,42%. The presence of blood impurities during aspiration from bile ducts was considered as obvious sign of portоbiliary fistula. Prevention of the formation of port-biliary fistula was realized by using well-guided puncture needles of large diameter (17,5-18G), including use of the «open needle» technique and timely changing the puncture trajectory during puncture of the vessel before penetration of the bile duct. Discredited access was used only for cholangiography with simultaneous puncture of bile ducts with a second needle along a different path and control of the severity of hemobilia according to the established second conflict-free cholangiostoma. All portоbiliary fistulas were closed conservatively.

Conclusion: the use of special methods of prophylaxis, determined a low frequency of portоbiliary fistulas - 4.2 port-biliary fistulas per 1000 percutaneous transhepatic cholangiostomy (0,42%), as well as their relatively benign nature (marginal wound of lateral portal vein branches), which did not require the use of embolization techniques.

References

1.     Shiau EL, Liang HL, Lin YH. (et al.). The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute. J Vasc Interv Radiol. 2017 Jul;28(7):1025-1032. doi: 10.1016/j.jvir. 2017.03.016.

2.     Dolgushin BI, Virshke ER, Cherkasov VA, Kukushkin VA, Mkrtchjan GS. Selective Embolization of Hepatic Arteries in Bleeding Complications of Percutaneous Transhepatic Biliary Dranage. Annaly khirurgicheskoy gepatologii. Annals of HPB surgery. 2007; 12(4): 63-68 [In Russ].

3.     Aung TH, Too CW, Kumar N (et al.). Severe Bleeding after Percutaneous Transhepatic Drainage of the Biliary System. Radiology. 2016 Mar; 278(3):957-8. doi: 10.1148/ radiol.2016151954.

4.     Saad WE, Wallace MJ, Wojak JC (et al.). Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol. 2010 Jun; 21(6): 789-95. doi: 10.1016/j.jvir.2010.01.012.

5.     Dietrich CF, Lorentzen T, Appelbaum L (et al.). EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III-abdominal treatment procedures (Long Version). Ultraschall Med. 2016 Feb;37(1):E1-E32. doi: 10.1055/s-0035-1553917.

6.     Mortimer AM, Wallis A, Planner A. Multiphase multidetector CT in the diagnosis of haemobilia: a potentially catastrophic ruptured hepatic artery aneurysm complicating the treatment of a patient with locally advanced rectal cancer. Br J Radiol. 2011, May; 84(1001):e95-8. doi: 10.1259/bjr/20779582.

7.     Quencer KB, Tadros AS, Marashi KB (et al.). Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments. J Clin Med. 2018 May 1;7(5). pii: E94. Doi 10.3390/jcm7050094.

8.     Chanyaputhipong J, Lo RH, Tan BS, Chow PK Portobiliary fistula: successful transcatheter treatment with embolisation coils. Singapore Med J. 2014 Mar; 55(3):e34-6.

9.     Madhusudhan KS, Dash NR, Afsan A (et al.). Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement. J Clin Exp Hepatol. 2016 Sep; 6(3):241-243.

Abstract:

Aim: was to estimate the expediency of one-time sanation of the gallbladder, performed under ultrasound control in patients with acute cholecystitis as a preoperative preparation.

Material and methods. For the period 2007-2016, 1365 sanations of the gallbladder were performed in 1289 patients with acute cholecystitis. In 1284 cases (94.1%), the manipulation was single-staged, performed under local anesthesia by echo-puncture needles, caliber of 17.5 G under ultrasound control by the "free hand" method or using a program of biopsy cursor, percutaneously transhepatic. Access was made through the hepatic parenchyma with a thickness of at least 10 mm. Results. Sanation of the gallbladder was effective in all 1365 cases. Repeated sanitation in a day was necessary in 76 patients. Cholecystectomy within the current hospitalization was performed ir 1132 of (87.8%) 1289 patients, in terms from 1 to 4 days after initial manipulation. The dislocation of the blocking gall-stone from the cervical region of the gallbladder into its lumen was made with a rigid 0.035" gidewire in order to restore cystic duct flow was effective in 122 cases (35.2%). Complications: subcapsular hematomas of the liver in the puncture zone - 4 (0.3%), bilomus of the gallbladder bed - 1 (0.07%), bleeding to the gallbladder lumen - 11 (0.8%) were treated conservatively. There were no lethal outcomes.

Conclusion: one-time sanation of gallbladder allows to decompress safely the gallbladder, to stop pain syndrome, to conduct a full pre-examination and preoperative preparation of patient and perform cholecystectomy in the most comfortable and safe conditions in a delayed or planned order. 

References

1.     Buyanov V.M., Ishutinov V.D., Zinyakova M.V., Titkova I.M. Ultrazvukovaya klassifikatsia ostrogo holetsistita. [Ultrasound classification of acute cholecystitis.] Vserossijskaja konferencija hirurgov: Tezisy dokladov. [Proc. Conf. Surgeons: All-Russian conference of surgeons: Tez. dokl]. Yessentuki. 1994; 51-52 [In Russ].

2.     Takada T., Strasberg S.M., Solomkin J.S., Pitt H.A., Gomi H., Yoshida M., Mayumi T., Miura F., Gouma D.J., Garden O.J., Bьchler M.W., Kiriyama S., Yokoe M., Kimura Y, Tsuyuguchi T., Itoi T., Gabata T., Higuchi R., Okamoto K., Hata J., Murata A., Kusachi S., Windsor J.A., Supe A.N., Lee S., Chen X.P., Yamashita Y, Hirata K., Inui K., Sumiyama Y Tokyo Guidelines Revision Committee. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013; 20(1): 1 -7. doi: 10.1007/s00534-012-0566-y. PMID: 23307006.

3.     Yokoe M., Takada T., Strasberg S.M., Solomkin J.S., Mayumi T., Gomi H., Pitt H.A., Garden O.J., Kiriyama S., Hata J., Gabata T., Yoshida M., Miura F., Okamoto K., Tsuyuguchi T., Itoi T., Yamashita Y, Dervenis C., Chan A.C., Lau W.Y, Supe A.N., Belli G., Hilvano S.C., Liau K.H., Kim M.H., Kim S.W., Ker C.G. Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2013; 20(1):35-46. doi: 10.1007/s00534-012-0568-9. PMID: 23340953.

4.     Kimura Y, Takada T., Strasberg S.M., Pitt H.A., Gouma D.J., Garden O.J., Bьchler M.W., Windsor J.A., Mayumi T., Yoshida M., Miura F., Higuchi R., Gabata T., Hata J., Gomi H., Dervenis C., Lau W.Y, Belli G., Kim M.H., Hilvano S.C., Yamashita Y TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013; 20( 1 ):8-23. doi: 10.1007/s00534-012-0564-0. PMID: 23307004.

5.     Mayumi T., Someya K., Ootubo H., Takama T., Kido T., Kamezaki F., Yoshida M., Takada T. Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. J UOEH. 2013; 35(4):249-57. PMID: 24334691.

6.     Briskin B.S., Minasyan A.M., Vasilieva М.А., Barsukov M.G. Chreskozhnaja chrespechenochnaja mikroholecistostomija v lechenii ostrogo holecistita. [Percutaneous transhepatic microcholecystostomy in acute cholecystitis treatment]. Annaly khirurgicheskoy gepatologii. 1996; 1(1):98-107 [In Russ].

7.     Ivanov S. V., Okhotnikov O.

Abstract:

Aim: was to improve the efficiency of external drainage in patients with biliary tree obstruction by tumor process in the porta hepatis zone.

Materials and methods: percutaneous transhepatic cholangiostomy under the combined sonofluoroscopic control with using on the first phase of the treatment of self-locking drainages pig tail №8Fr followed by external-internal drainage or endobiliary stenting were performed in 147 patients with «high» tumor block of the biliary tree.

Results: depending on the extent of biliary occlusion there were from 1 to 6 drainages. «Big» post-manipulating complication encountered in one patient (0.7%) - migration of cholangiostomic drainage with the development of biliary peritonitis.

«Small» complications (short-period haemobilia, migration of cholangiostomy amilazemiya at transpapillary insertion of an external-internal drainage) occurred in 20 patients (13.6%). Mortality rate was 6.1%. Death causes: common bile peritonitis (1 case), and the progression of hepatorenal insufficiency on the background of biliary decompression (8 cases).

Conclusion: antegrade cholangiostomy at «high» tumor obstruction of the biliary tree is a necessary manipulation as in palliative biliary decompression, and in the preparation of the patient for radical surgery for Klatskin tumors. Satisfactory performance of postmanipulating complications and in-hospital mortality involve the use of special techniques for effective external and external-internal drainage of bile ducts.  

References 

1.    Witzigmann H., Lang H., Lauer H. Guidelines for palliative surgery of cholangiocarcinoma HPB (Oxford). Jun 1, 2008; 10(3): 154-160. doi: 10.1080/13651820801992567 PMCID: PMC2504365.

2.    Rerknimitr R., Kullavanijaya P. Operable malignant jaundice: To stent or not to stent before the operation? World J. Gastrointest. Endosc. 2010 Jan 16;2(1):10-4. doi: 10.4253/wjge.v2.i1.10.

3.    Paik W.H., Loganathan N., Hwang J.H. Preoperative biliary drainage in hilar cholangiocarcinoma: When and how? World J. Gastrointest. Endosc. 2014 Mar 16;6(3):68-73. doi: 10.4253/wjge.v6.i3.68. Review.

4.    Liu F., Li Y, Wei Y, Li B. Preoperative biliary drainage before resection for hilar cholangiocarcinoma: whether or not? A systematic review. Dig. Dis. Sci. 2011 Mar; 56(3):663-72. doi: 10.1007/s10620-010-1338-7. Epub 2010 Jul 16.

5.    Kawakami H., Kondo S., Kuwatani M., Yamato H., Ehira N., Kudo T., Eto K., Haba S., Matsumoto J., Kato K., Tsuchikawa T., Tanaka E., Hirano S., Asaka M. Preoperative biliary drainage for hilar cholangiocarcinoma: which stent should be selected? J. Hepatobiliary Pancreat Sci. 2011 Sep; 18 (5):630-5. doi: 10.1007/s00534-011- 0404-7.

6.    Ustunda Y, Boyvat F. Debate continues over which method we should prefer for the preoperative biliary decompression in cases with hilar cholangiocarcinoma. J. Gastroenterol. 2012 Jan; 47(1):88-9; author reply 90-1. doi: 10.1007/s00535-011-0496-5. Epub 2011 Nov 15.

7.    Nuzzo G., Giuliante F., Ardito F., Giovannini I., Aldrighetti L., Belli G., Bresadola F., Calise F., Dalla Valle R., D’Amico D. F., Gennari L., Giulini S. M., Guglielmi A., Jovine E., Pellicci R., Pernthaler H., Pinna A.D., Puleo S., Torzilli G., Capussotti L., Improvement in perioperative and longterm outcome after surgical treatment of hilar cholangiocarcinoma: results of an Italian

Experience of 100 successful antegrade transhepatic contact choledocholithothripsy as treatment in patients with difficulties of endoscopy method