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ABSTRACT: BACKGROUND: Analysis of small pulmonary nodules in children poses an important diagnostic and therapeutic challenge for clinicians. OBJECTIVE: To review our experience of lung tattooing with immediate video-assisted thoracoscopic resection (IVATR) performed as a single procedure in a hybrid room for technical difficulties, complications and diagnostic yield of the procedure. MATERIAL AND METHODS: Retrospective analysis of 31 children (16 boys, 15 girls) who underwent lung tattooing of various lesions from January 2001 to July 2011. Data were collected from the Interventional Radiology database, Electronic Patient Chart (EPC) and PACS. RESULTS: A total of 34 lesions were treated in 31 children. Tattooing was performed on lung lesions with median size 3 mm and median depth 2 mm from pleura. Technical success was 91.1% and diagnostic yield was 100%. In seven children, it was combined with other interventional radiologic procedures. The median procedure time for lung tattooing and IVATR was 197 min. CONCLUSION: Lung tattooing with IVATR as a single procedure in a hybrid room is safe and effective in children with several inherent advantages, including avoiding the need to move the child from the interventional radiology suite to the operating room.
Pediatric Radiology 03/2013; · 1.67 Impact Factor
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ABSTRACT: Postoperative bile leaks are difficult to diagnose because signs and symptoms are nonspecific, and definitive diagnosis requires a drainage catheter to be placed that drains frank bile or fluid that turns out bile on laboratory analysis. Hepatobiliary scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) have been traditionally used to diagnose bile leak. Scintigraphy has poor spatial resolution and cannot localize the site of leak, ERCP may not be possible with altered postoperative anatomy and PTC is invasive and difficult to perform in the absence of dilated ducts. Recently, contrast-enhanced MR cholangiography using hepatobiliary-specific contrast media has been shown to be a noninvasive, safe way to diagnose and localize the site of bile leak in adults. We report a case of postoperative bile leak after choledochal cyst resection in a child in whom diagnosis was confirmed and the site of leak was accurately localized using gadobenate-enhanced MR cholangiography. This case demonstrates the potential of hepatobiliary-specific contrast media to diagnose postoperative bile leak and accurately localize the site of the leak in children noninvasively.
Pediatric Radiology 11/2012; · 1.67 Impact Factor
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ABSTRACT: BackgroundInterventional radiology (IR) procedures in very low birth-weight (VLBW) infants (<1.5kg) are challenging due to size, immaturity,
comorbidities and lack of devices of suitable size. Infants are moved from the neonatal intensive care unit to the IR suite,
further exposing them to risk. Our purpose was to review our experience of interventional procedures in VLBW infants, specifically
complications and potential risks.
Materials and methodsVLBW infants referred for image-guided therapy between 1998 and 2005 were identified and medical records reviewed. “Complications”
were divided into: major or minor, periprocedural or postprocedural, and intervention-/device-related, patient-related or
equipment-related. Transport risk index of physiological stability (TRIPS) scores were calculated.
ResultsA total of 116 infants (68 male, 48 female) underwent 176 procedures (159 vascular access-related and 17 nonvascular). Of
158 complications identified, 116 were major and 42 were minor. Major complications included hypothermia (n=33), line manipulations/removals (n=25), bleeding (n=12), thrombosis (n=4), cardiac arrest (n=3), tamponade (n=2), and multiorgan failure (n=1). Of the complications, 119 were categorized as intervention-/device-related, 32 patient-related and 7 equipment-related.
There were no significant differences between pre- and postprocedural TRIPS scores.
ConclusionSuccessful completion of IR procedures in the VLBW infant is possible, but complications still occur in these fragile infants.
Pediatric Radiology 04/2012; 39(8):781-790. · 1.67 Impact Factor
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ABSTRACT: To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children.
Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis.
PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001).
Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.
Journal of vascular and interventional radiology: JVIR 03/2012; 23(3):351-7. · 1.81 Impact Factor
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ABSTRACT: Children with Pierre Robin sequence (PRS) have significant oropharyngeal abnormalities, with respiratory and feeding difficulties. Gastrostomy tubes (G-tube) provide a means for nutrition.
To evaluate the safety and efficacy of percutaneous G-tube insertion in children with PRS.
Of 120 children with PRS (1996-2009), 40 were referred for G-tube insertion; clinical details were reviewed in 37/40 children (18M, 19F) at three time periods: (1) pre-G-tube insertion, (2) at G-tube insertion, (3) at G-tube removal.
Pre-G-tube: 32/37 were term infants; 5 were preterm; 16/37 children were ≤ 10th weight percentile. At G-tube insertion, mean age was 66 days, mean weight 4.4 kg (1.1-7.0 kg); 19 dropped ≥10 weight percentiles; 12 tolerated nil by mouth; 2/37 were intubated for the procedure. All G-tubes were successfully placed, with five minor technical issues. Early postprocedure, there were eight minor complications and two dislodgements (classified as major). At G-tube removal mean G-tube dwell time was 2 years, with an average of 3.6 maintenance procedures per child, approximately 3 tube changes/1,000 tube days. At G-tube removal, 76% had maintained or increased weight centiles.
G-tubes in PRS provide a safe method for nutrition until children feed adequately by mouth.
Pediatric Radiology 12/2011; 42(5):566-73. · 1.67 Impact Factor
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ABSTRACT: Anterior mediastinal masses in children are clinically challenging, requiring prompt histological diagnosis.
The purpose of this study was to review the experience with US-guided percutaneous core needle biopsy (PCNB) of anterior mediastinal masses in children, particularly with respect to safety and diagnostic accuracy.
We retrospectively reviewed the clinical presentation, imaging, sedation approach, procedural details and pathology results of US-guided PCNB of mediastinal masses that occurred during an 8-year period (2001-2008). Complications were graded and pathology was categorized into four groups based on adequacy and diagnostic yield.
32 US-guided PCNBs were performed on 32 children, mean age 12 years (range 18 months to 17 years), mean weight 48 kg (range 11.5 to 109 kg, median 49 kg). A coaxial US-guided technique was used, with a mean of 8.2 passes and a mean 7.6 cores obtained (range 2-15). There were no major complications. The biopsies were adequate in volume and quality of specimens in 29/32, and 25/32 were diagnostic. PCNB was diagnostic in all cases of non-Hodgkin disease.
Experience with anterior mediastinal masses suggests that US-guided PCNB can be considered a viable, safe and accurate method of reaching a diagnosis in the pediatric population.
Pediatric Radiology 08/2011; 42(1):40-9. · 1.67 Impact Factor
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Waqas Ullah Khan,
Paolo Campisi,
Sanjeevan Nadarajah,
Yaseer Abdul Shakur,
Nasir Khan,
Dan Semenuk,
Cathy McCann,
Lisa Roske,
Sharon McConney-Ellis,
Melissa Joseph,
Dimitri Parra,
Joao Amaral,
Philip John, Michael Temple,
Bairbre Connolly
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ABSTRACT: To report (1) our experience with botulinum toxin A injections into the salivary glands of pediatric patients with sialorrhea, (2) the clinical outcomes of these interventions, and (3) the associated complication rates.
Retrospective cohort study.
Urban pediatric hospital and pediatric rehabilitation center.
Forty-five neurologically impaired children.
Patients received botulinum toxin A intrasalivary injections between January 2004 and May 2008 at the Hospital for Sick Children in Toronto, Ontario, Canada. All patients received sedation or general anesthesia for their botulinum toxin A injections, which were performed using ultrasonographic guidance.
Posttreatment assessments included the duration of effect, patient complications, saliva consistency, caregiver willingness to repeat the treatment, caregiver satisfaction with the treatment, and caregiver overall assessment of the child's posttreatment quality of life.
Forty-five subjects received a total of 91 botulinum toxin A treatments. The mean (SD) duration of effect was 4.6 (5.2) months. Duration of effect (log transformed) was significantly negatively associated with saliva quantity (P = .02), and there was a positive association with both increasing age and female sex, although neither reached statistical significance (P = .08 for each). Seven of the 24 documented complications were major, according to the Society of Interventional Radiology Classification System for Complications by Outcome scale. Thirty-six of the caregivers reported that this treatment improved the child's quality of life (80%).
Ultrasonographically guided botulinum toxin A injections into the salivary glands are safe and efficacious in the management of sialorrhea in children with neurologic disorders.
Archives of otolaryngology--head & neck surgery 01/2011; 137(4):339-44. · 1.92 Impact Factor
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ABSTRACT: Percutaneous biopsies of soft-tissue organs are frequently performed using US guidance. US permits visualization of blood flow on color Doppler imaging.
To report the presence of color Doppler signal (positive color Doppler sign) along the biopsy tract after percutaneous needle biopsy of the liver and kidney as an indication of bleeding and to describe US-guided hemostasis.
A case-control study of US-guided liver and kidney biopsies performed between January 2005 and September 2009 was undertaken. All pediatric patients with a positive color Doppler sign along the biopsy tract were included. Controls consisted of patients in whom no color Doppler sign was identified.
Fifty-three cases with positive color Doppler sign were identified. One hundred and six matched controls were selected. The average compression time was 9.2 min in kidney and 8.4 min in liver cases. US-guided compression achieved cessation of the positive color Doppler sign in all cases. There was no significant difference between the mean pre- and post-procedure hemoglobin and platelet levels between kidney cases and controls (P=0.68 and P=0.63, respectively) and between liver cases and controls (P=0.45 and P=0.80).
Color Doppler US can detect bleeding post percutaneous liver and kidney biopsies. US-guided compression is effective in obliterating the color Doppler signal and achieving appropriate hemostasis.
Pediatric Radiology 10/2010; 41(3):362-8. · 1.67 Impact Factor
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Manraj K S Heran,
Francis Marshalleck, Michael Temple,
Clement J Grassi,
Bairbre Connolly,
Richard B Towbin,
Kevin M Baskin,
Josee Dubois,
Mark J Hogan,
Sanjoy Kundu,
Donald L Miller,
Derek J Roebuck,
Steven C Rose,
David Sacks,
Manrita Sidhu,
Michael J Wallace,
Darryl A Zuckerman,
John F Cardella
Pediatric Radiology 02/2010; 40(2):237-50. · 1.67 Impact Factor
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ABSTRACT: Esophageal strictures refractory to conservative treatment (balloon dilation, bouginage) are difficult to manage. Recently, some investigators reported great success using endoscopy-guided topical application of mitomycin-C to prevent scar formation and restenosis in children with benign esophageal strictures unresponsive to balloon dilation. Herein, the authors report a fluoroscopic approach for topical application of mitomycin-C in a case of refractory esophageal stricture after surgical repair in a child with congenital esophageal atresia. This technique is a feasible alternative to endoscopic techniques.
Journal of vascular and interventional radiology: JVIR 11/2009; 21(1):152-5. · 1.81 Impact Factor
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ABSTRACT: Interventional radiology (IR) procedures in very low birth-weight (VLBW) infants (<1.5 kg) are challenging due to size, immaturity, comorbidities and lack of devices of suitable size. Infants are moved from the neonatal intensive care unit to the IR suite, further exposing them to risk. Our purpose was to review our experience of interventional procedures in VLBW infants, specifically complications and potential risks.
VLBW infants referred for image-guided therapy between 1998 and 2005 were identified and medical records reviewed. "Complications" were divided into: major or minor, periprocedural or postprocedural, and intervention-/device-related, patient-related or equipment-related. Transport risk index of physiological stability (TRIPS) scores were calculated.
A total of 116 infants (68 male, 48 female) underwent 176 procedures (159 vascular access-related and 17 nonvascular). Of 158 complications identified, 116 were major and 42 were minor. Major complications included hypothermia (n=33), line manipulations/removals (n=25), bleeding (n=12), thrombosis (n=4), cardiac arrest (n=3), tamponade (n=2), and multiorgan failure (n=1). Of the complications, 119 were categorized as intervention-/device-related, 32 patient-related and 7 equipment-related. There were no significant differences between pre- and postprocedural TRIPS scores.
Successful completion of IR procedures in the VLBW infant is possible, but complications still occur in these fragile infants.
Pediatric Radiology 05/2009; 39(8):781-90. · 1.67 Impact Factor
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ABSTRACT: The purpose of our study was to evaluate the safety and effectiveness of radiologic percutaneous gastrostomy and gastrojejunostomy for providing nutritional support in children with cardiac disease.
Retrospective chart review of 58 children with cardiac disease who underwent radiologic percutaneous gastrostomy from November 2001 to June 2005 was conducted. Patient data were collected until January 2007. The patients' weights were collected at the time of insertion and 6, 12, 18, and 24 months after insertion, and weight-for-age z-scores were calculated.
The mean weight-for-age z-score increased from -2.79 at the time of radiologic percutaneous gastrostomy insertion to -2.33 (p = 0.05) at 6 months after insertion, -1.89 (p = 0.001) at 12 months, -1.65 (p = 0.0002) at 18 months, and -1.40 (p = 0.0004) at 24 months. Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase in weight-for-age z-score of 0.055 per month. No mortality was associated with the insertion or usage of radiologic percutaneous gastrostomy. Major complications included intestinal perforation (3.4%) and aspiration pneumonia (12.1%).
Radiologic percutaneous gastrostomy is a safe method for providing long-term nutritional support in children with cardiac disease and is effective for improving growth and nutrition in this group of patients.
American Journal of Roentgenology 10/2008; 191(4):1169-74. · 2.78 Impact Factor
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Betty Tuong,
Ziv Shnitzer,
Carolyne Pehora,
Perry Choi,
Mark Levine,
Ganesh Krishnamurthy,
Peter Chait, Michael Temple,
Philip John,
Joao Amaral,
Bairbre Connolly
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ABSTRACT: To review the experience and impact of conducting multidisciplinary Morbidity and Mortality (M&M) reviews in pediatric interventional radiology (IR) and describe issues, lessons, and recommendations.
A dedicated functionality of an existing database was developed to retrospectively analyze pediatric IR M&M issues. Patient demographics, sedation/anesthesia, and procedure type were recorded. M&M issues were assigned to at least one of 10 categories and graded as major or minor per Society of Interventional Radiology (SIR) guidelines. Issues could result in recommendations, which were divided into six categories; each was classified as implemented or not implemented.
Of 31,983 patient encounters over a period of 10 years, 516 patient events (1.6%) were discussed at M&M reviews. A total of 772 categories were assigned; they related to the procedure (34%), patient comorbidity (20%), processes (15%), device (10%), management (8%), sedation/anesthesia (4%), medication (2%), ethical issues (1%), "near-misses" (1%), and other (5%). A total of 292 issues (57%) were graded as minor (SIR class A, n = 202; class B, n = 90) and 224 (43%) as major (SIR class C, n = 42; class D, n = 151; class E, n = 6; class F, n = 27). Twenty-seven deaths were reviewed. Of 397 recommendations made, 80% were fully implemented, 11% partially implemented, and 9% not implemented. Recommendations made related to process improvements (49%), technical changes (20%), interdisciplinary discussions (15%), educational endeavors (9%), contacting manufacturers (6%), and other issues (1%).
As a result of regular multidisciplinary M&M reviews being conducted, a large number of practical recommendations were made for improvements in quality of care, and implemented over a 10-year period. M&M reviews provide a useful forum for team discussions and are a vehicle for change and potential improvement in the delivery of care in a pediatric IR service.
Journal of vascular and interventional radiology: JVIR 10/2008; 20(1):77-86. · 1.81 Impact Factor
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ABSTRACT: Appendicitis is the most common cause of an acute abdomen in children. With perforation, multiple intraperitoneal collections can be seen at presentation. In this situation, surgical treatment alone is rarely effective.
To determine the role of image-guided drainage in treating patients with acute appendicitis complicated by multiple intraabdominal collections.
A retrospective review of patient charts and interventional radiology records was performed to identify all patients with acute complicated appendicitis treated by multiple image-guided drainage procedures. Data reviewed included the number of drainages and aspirations performed, drain dwell time, the clinical course and temperature profile, and the length of inpatient hospital stay and any complications experienced.
The study population comprised 42 children with a mean age of 107.6 months. A total of 100 drainage catheters were inserted and 56 aspirations were performed. Of the 42 children, 24 were successfully treated at a single sitting, while 18 returned for further intervention. The mean drain dwell time was 8.18 days. The mean inpatient stay was 15.02 days. Treatment of the acute presentation with image-guided intervention was successful in 92.3% of children.
Successful management of acute perforated appendicitis with multiple intraabdominal abscesses can be achieved with multiple minimally invasive image-guided drainage procedures.
Pediatric Radiology 07/2008; 38(6):661-8. · 1.67 Impact Factor
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ABSTRACT: Enteral feeding is ideal for children with low caloric intake. It can be provided through different methods, including nasogastric, nasojejunal, gastrostomy, or gastrojejunostomy tubes.
To assess growth outcomes of pediatric patients following retrograde percutaneous gastrostomy (RPG) and compare complications with those following other gastrostomy methods.
We retrospectively reviewed 120 random RPG patients from 2002 to 2003 (mean follow-up, 2.7 years). Patient weights and growth percentiles were recorded at insertion, and at 0-5 months, 6-12 months, and 18-24 months after insertion, and then compared using a Student's t-test. Complications and tube maintenance issues (TMIs) were recorded.
Gastrostomy tube insertion was successful in all 120 patients (59 boys, 61 girls; mean age 4.3 years). The most common underlying diagnosis was neurologic disease (29%, 35/120) and the main indication was inadequate caloric intake (24%, 29/120). Significant increases in growth percentile for the entire population were demonstrated between insertion and 0-5 months (18.7-25.3; P<0.001) and between insertion and 18-24 months (18.7-25.8; P<0.001). In boys and girls significant growth increases occurred between insertion and 0-5 months (boys P=0.004; girls P=0.01). There were 11 major postprocedural complications, 100 minor complications and 169 TMIs.
RPG provides long-term enteral nutrition in the pediatric population and increases growth significantly 6 and 24 months after insertion. Minor complications and TMIs are frequent.
Pediatric Radiology 07/2008; 38(9):963-70. · 1.67 Impact Factor
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ABSTRACT: The purpose of our study was to review the clinical aspects and long-term outcomes of imaging-guided percutaneous aspiration or drainage of liver abscesses in neonates.
We retrospectively reviewed the clinical and imaging records of eight neonates with liver abscesses referred for imaging-guided percutaneous aspiration or drainage, including one autopsy-proven case in whom the percutaneous aspiration or drainage was not performed. Clinical and imaging features, complications, and long-term follow-up results were assessed.
Eight neonates with liver abscesses were referred for imaging-guided percutaneous aspiration or drainage (five males, three females; age range, 7-100 days; weight, 610-3,400 g). Six were born prematurely (24-29 weeks of gestation). Six had a history of umbilical catheterization. All were clinically septic. All neonates received long-term i.v. antibiotics. Five neonates had solitary multiloculated abscesses (right lobe [n = 3], straddling both lobes [n = 2]), and three had solitary uniloculated abscesses (right lobe [n = 1] and left lobe [n = 2]). Imaging-guided drainage catheter insertion (n = 4), aspiration (n = 2), and aspiration followed by drainage catheter insertion (n = 1) were performed in seven neonates within 1 day after referral. Coagulase-negative Staphylococcus (4/8) was the most common organism isolated from blood and pus. There were no procedure-related complications. Catheter repositioning was required in one. Serial sonography (mean, 12.5 months) and clinical follow-up (mean, 20.7 months) showed complete clinical remission in seven cases. Three healed with calcification in the previous abscess site. Long-standing left portal vein thrombosis was seen in two cases.
Neonatal liver abscess is associated with good long-term outcome and minimal complications when imaging-guided percutaneous aspiration or drainage is performed in conjunction with long-term antibiotic coverage.
American Journal of Roentgenology 04/2008; 190(3):616-22. · 2.78 Impact Factor
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ABSTRACT: Portal hypertensive biliopathy (PHB) is defined as abnormal biliary changes that take place most likely secondary to extrahepatic portal vein obstruction (EHPVO) with portal hypertension. This condition may be asymptomatic or could lead to a cholestatic state, which is not well-described in children. We report a child who developed a cholestatic nature with portal hypertension some time after having neonatal surgery for duodenal atresia. We discuss the differential diagnosis and management of this rare condition. Symptomatic PHB has been only rarely reported in children. It should be suspected in patients with portal hypertension and having features of biliary obstruction. Hepaticojejunostomy may have a therapeutic role in selected patients in whom endoscopic or percutaneous manipulation of the biliary tree is unsuccessful and who have not responded to a surgical portal-systemic shunt procedure.
European Journal of Pediatrics 03/2008; 167(11):1339-42. · 1.88 Impact Factor
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ABSTRACT: To examine the results of the multimodal management of patients with endangering hepatic hemangioma associated with systemic compromise.
Retrospective descriptive case series of children with endangering hepatic hemangioma managed at our institution between January 1996 and June 2006.
Six children (5 females) presented with endangering hepatic hemangioma with systemic effects during the index time period. Mean age at presentation was 1.9 months (range, 2 days to 4 months). All patients received medical treatment, and all patients also underwent hepatic embolization, with a median number of procedures of 2 (range, 1-6). Two patients died, one of sepsis and one of progressive liver failure in a child presenting with advanced liver disease owing to neonatal hemochromatosis that was unrecognized at the time. The remaining 4 patients all recovered and were discharged. With mean postprocedure follow-up of 2.11 years (range, 0-6.2 years), all remain well.
Multimodal management of endangering hepatic hemangioma is a strategy that deserves consideration in the management of these patients. Although the strategy requires further evaluation as to its safety and efficacy, the procedure has the potential to decrease the need for liver transplantation because of treatment failures in this population.
Journal of Pediatric Surgery 02/2008; 43(1):120-5; discussion 126. · 1.45 Impact Factor
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American Journal of Roentgenology - AMER J ROENTGENOL. 01/2008; 190(3):616-622.
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ABSTRACT: The technique of enterostomy access frequently uses a needle preloaded with a suture anchor to appose the bowel wall to the abdominal wall. Two of the intrinsic disadvantages of this method are the possible dislodgment of the suture anchor out of the needle hub during the process of guide-wire insertion and the escape of air with subsequent deflation of the viscus, which may necessitate a second puncture. The use of a Check-Flo performer assembly with a valve mechanism provides a leakproof system. It avoids possible dislodgment of the suture anchor during deployment, maintains viscus distension, and may be useful for trainees to do the procedure in a controlled manner.
Journal of Vascular and Interventional Radiology 07/2007; 18(6):797-9. · 2.08 Impact Factor
