Nicholas Fidelman

Purpose To evaluate the radiation exposure of pediatric patients during exchange of percutaneous gastrojejunostomy tubes. Materials and Methods Retrospective review of consecutive pediatric patients undergoing percutaneous gastrojejunostomy tube exchanges from January 1, 2010 to August 8, 2016 was performed. Procedural records were evaluated for total fluoroscopy time, cumulative air kerma, and cumulative dose area product (DAP). The total number of procedures, indications, and interval time for repeat procedures were also recorded. Patients were subcategorized into an increased cumulative procedure group if three or more procedures were performed and an increased frequency group if the interval between any two consecutive procedures occurred within a 6-month period. Results In the 77-month study period, a total of 175 gastrojejunostomy tube exchanges were performed on 62 patients, median age 62 months (range: 1 month–206 months). The mean fluoroscopy time was 7.36 minutes (range: 0.20–40 minutes), mean cumulative air kerma was 41.13 mGy (range: 0.40–507 mGy), and mean cumulative DAP was 3,717.19 mGy-cm² (range: 102–72,479 mGy-cm²). Twenty-six patients were subcategorized into an “increased cumulative procedure” group with an average of five procedures during the study period. The mean fluoroscopy time, cumulative air kerma, and cumulative DAP for the individual procedures of this group was 8.13 minutes, 49.07 mGy, and 4250.73 mGy-cm², respectively. Thirty-three patients were subcategorized into an “increased frequency” group with average 2 months interval between procedures. The mean fluoroscopy time, cumulative air kerma, and cumulative DAP for the individual procedures of this group was 7.87 minutes, 46.77 mGy, and 4147.52 mGy-cm², respectively. Twenty-three patients underwent single procedures during the study period. The mean fluoroscopy time, cumulative air kerma, and cumulative DAP for the individual procedures of this group was 3.02 minutes, 6.11 mGy, and 1232.13 mGy-cm², respectively. A statistically significant difference in means (p < 0.05) exists in all radiation metrics for a given procedure while comparing either the “increased cumulative procedure” group or the “increased frequency group” to the single procedure group. Conclusion Chronically ill pediatric patients may require serial percutaneous gastrojejunostomy tube exchanges, subjecting them to high doses of radiation exposure, particularly if repeat procedures are required. Such patients may benefit from alternative methods of enteral feeding, such as through surgical interventions.

E15689 Background: Carcinoid crisis is a life-threatening event caused by release of vasoactive substances from neuroendocrine tumors (NETs). Octreotide is often used in the periprocedural setting as prophylaxis against carcinoid crisis; however, there is no standardized protocol for its use. We aimed to describe the periprocedural management of patients with metastatic NETs who underwent liver-directed procedures at UCSF. Methods: We identified 54 patients with NETs with hepatic metastases who underwent either liver resection/ablation (n = 30) or liver-directed embolization (n = 24) between 2012 and 2016. Anesthesia records and clinical data were abstracted. Carcinoid crisis was defined by physician documentation. Hemodynamic instability was defined as ≥10 minutes of systolic blood pressure < 80 mmHg or > 180 mmHg or heart rate > 120. Pearson chi-squared tests were used to test associations with three outcomes: crisis, instability, or none. Results: Three (6%) patients were documented to have developed carcinoid crisis. Another 14 (26%) patients developed hemodynamic instability. Of 16 patients who received preprocedural octreotide, 1 (6%) had a carcinoid crisis and 5 (31%) developed hemodynamic instability. History of carcinoid syndrome, degree of hepatic involvement, and use of pre or intraprocedural octreotide were not associated with carcinoid crisis or at least hemodynamic instability. Patients undergoing embolization were less likely to develop hemodynamic instability versus those undergoing liver resection (17% vs 43%, Pearson chi-squared p = 0.04). Conclusions: Occurrence of documented carcinoid crisis was low in this high-risk population. However, a significant proportion of patients developed hemodynamic instability, suggesting that carcinoid crisis is a spectrum diagnosis and may be clinically under-recognized. Use of octreotide was not associated with risk of carcinoid crisis or hemodynamic instability; however, this analysis was limited by our modest sample size at a single institution. There remains a need to establish an objective definition of carcinoid crisis and to inform standardization of periprocedural use of octreotide for at-risk patients.

Objective: To compare the visibility of hepatocellular carcinoma (HCC) at angiography during transarterial chemoembolization (TACE) in patients with and without transjugular intrahepatic portosystemic shunt (TIPS). Materials and Methods: A retrospective review of patients with HCC and TIPS who underwent TACE between January 2004 and June 2014 was performed resulting in 26 patients. A group of 23 patients with HCC treated with TACE but without TIPS were used as comparison that encompassed the same time period. Both groups had comparable model for end-stage liver disease (MELD) scores. The angiographic tumor blush of the HCC at TACE was graded as poorly visualized, easily visualized, or hyperenhancing by two independent board-certified interventional radiologists. Results: Twenty-six patients with TIPS and 23 patients without TIPS who underwent TACE for HCC were included resulting in a total of 98 grades by the two reviewers. The tumor blush of the HCC was more visible in patients without TIPS than those with TIPS during TACE for both reviewers, (p = 0.0003). In the TIPS group, only 5 of 26 patients (19%) had a hyperenhancing blush at TACE for both reviewers. Hyperenhancing or easily visualized tumor blush was present in 22 of 23 patients (96%) for reviewer 1 and in 17 of 23 patients (74%) for reviewer 2 without TIPS. Of the HCC’s with a poorly visualized tumor blush, 12 of 13 patients (92%) and 14 of 20 patients (70%) had TIPS for reviewer 1 and reviewer 2, respectively. Conclusion: The tumor stain of HCC at TACE may be more difficult to see in patients with TIPS compared with patients without TIPS in place. Patients with TIPS with poor vascular blush may benefit from nonvascular interventions such as radiofrequency or alcohol ablation.

Objective: To determine prevalence of hepatobiliary infections following Yttrium-90 (⁹⁰Y) radioembolization in patients with history of biliary instrumentation. Materials and Methods: Records of 126 patients (median: 64 years, 84 men) with primary (n = 40) or metastatic (n = 86) cancer of the liver and a history of biliary-enteric anastomosis (n = 65), sphincterotomy (n = 17), or indwelling biliary stent (n = 36) or drain (n = 5) across the ampulla of Vater, who underwent 180 ⁹⁰Y radioembolization procedures with resin or glass microspheres at 14 high-volume centers between 2005 and 2016 were retrospectively reviewed. The primary outcome was development of hepatobiliary infection. Univariate and multivariate analyses were performed using generalized estimating equation method. Results: Hepatobiliary infections (abscesses in 8 patients, cholangitis in 4 patients) developed following 12 (6.7%) radioembolization procedures in 11 (8.7%) patients. Ten patients required at least one hospitalization (range: 1–7), spent a median of 12 days (range 2–113) in a hospital for treatment of the infection, and required invasive treatments including percutaneous abscess drainage (n = 10), endoscopic retrograde cholangiography with stenting and removal of stones (n = 3), or insertion of percutaneous biliary drains (n = 1). Infections resolved in six patients, two patients died secondary to infection, and three patients continue to receive antibiotics. Glass microspheres (p = 0.02), prior liver resection (p = 0.019), and younger age (p = 0.003), were independently predictive of a higher risk of infection based on multivariate models. Antibiotic prophylaxis and bowel preparation were not protective against infection. Conclusion: Hepatobiliary infections are uncommon but morbid and difficult to manage complications of ⁹⁰Y radioembolization in patients with a history of biliary instrumentation.

Purpose Radiosurgery requires precise lesion localization. Fiducial markers enable lesion tracking, but complications from insertion may occur. The purpose of this study was to describe complications of fiducial marker insertion into pulmonary lesions. Materials and Methods Clinical and imaging records of 28 consecutive patients with 32 lung nodules or masses who underwent insertion of a total of 59 fiducial markers before radiosurgery were retrospectively reviewed. Results Eighteen patients (67%) developed a pneumothorax, and six patients (22%) required a chest tube. The rates of pneumothorax were 82% and 40%, respectively, when 18-gauge and 19-gauge needles were used for marker insertion (P = 0.01). Increased rate of pneumothorax was also associated with targeting smaller lesions (P = 0.03) and tumors not in contact with the pleural surface (P = 0.04). A total of 11 fiducials (19%) migrated after insertion into the pleural space (10 markers) or into the airway (1 marker). Migration was associated with shorter distances from pleura to the marker deposition site (P = 0.04) and with fiducial placement outside of the target lesion (P = 0.03). Conclusion Fiducial marker placement into lung lesions is associated with a high risk of pneumothorax and a risk of fiducial migration.