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Ginesu GC, Feo CF, Cossu ML, Ruiu F, Addis F, Fancellu A, Fois AG, Paliogiannis P, Porcu A. Thoracoscopic treatment of a broncho-esophageal fistula: A case report. Int J Surg Case Rep 2016; 28:74-77. [PMID: 27689523 PMCID: PMC5043393 DOI: 10.1016/j.ijscr.2016.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/16/2016] [Accepted: 09/17/2016] [Indexed: 02/05/2023] Open
Abstract
Broncho-Esophageal Fistula (BEF) in adults is rare. If left untreated, BEF may lead to fatal complications despite its benign nature. The most frequent approach is thoracotomy. Video Assisted Thoracoscopic Surgery (VATS) may be a minimally invasive approach.
Introduction Broncho-esophageal fistula is a rare clinical condition which can be manifested with non-specific signs and symptoms. Presentation of a case Here, we report an adult case of a broncho-esophageal fistula in a 43-year-old man referred for chronic cough after fluid food intake and weight loss. Barium swallow, esophagogastroduodenoscopy, bronchoscopy and Computed Tomography of the chest demonstrated a broncho-esophageal fistula between the apical segmental bronchus of the lower right lobe and the middle section of the esophagus. The patient underwent video-assisted thoracoscopic surgery for resection of the fistula. No post-operative complications occurred. Discussion Broncho-esophageal fistula in adults is rare and its diagnosis is often delayed due to the frequent lack of specific symptoms. Although there is no standard protocol, the most widely used treatment is thoracotomy with identification and dissection of the fistula tract followed by repair of bronchial and esophageal defects. Conclusions Video-assisted thoracoscopic surgery appears to be an effective and minimally invasive approach for the treatment of broncho-esophageal fistulas, especially in young, healthy subjects.
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Affiliation(s)
- Giorgio C Ginesu
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Claudio F Feo
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Maria L Cossu
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Francesca Ruiu
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Francesca Addis
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Alessandro Fancellu
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Alessandro G Fois
- Respiratory Disease Institute, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Panagiotis Paliogiannis
- Surgical Pathology Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Alberto Porcu
- Unit of General Surgery, Department of Clinical and Experimental Medicine, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
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Moon E, Gillespie CT, Vachani A. Pulmonary complications of inflammatory bowel disease: focus on management issues. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2009. [DOI: 10.1016/j.tgie.2009.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Paúl L, Pinto I, Gómez H, Fernández-Lobato R, Moyano E. Metallic stents in the treatment of benign diseases of the colon: preliminary experience in 10 cases. Radiology 2002; 223:715-22. [PMID: 12034940 DOI: 10.1148/radiol.2233010866] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To assess the effectiveness of and complications associated with metallic stent placement for treatment of benign diseases of the colon. MATERIALS AND METHODS With radiologic guidance, the authors placed metallic stents in 10 patients with benign diseases of the colon: Nine stents were placed in the rectosigmoid colon, and one was placed in the descending colon. The stents were placed in two cases of diverticulitis complicated by pelvic abscess, four cases of colonic fistula following surgery, and four cases of postsurgical anastomotic stricture. Coated stents were placed in the cases involving fistulas and diverticulitis. RESULTS In the two cases of diverticulitis complicated by pelvic abscess, the coated stents helped to resolve the abscesses, but both patients subsequently developed complications: fistula and perforation. Of the four cases of colonic fistula, two were resolved with stent placement. In the four cases of postsurgical stenosis, the stents temporarily relieved the symptoms of obstruction, but additional treatments were required before the patients became entirely asymptomatic. CONCLUSION Metallic stents may represent an effective temporary treatment for certain benign colonic conditions in the absence of other therapeutic alternatives.
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Affiliation(s)
- Laura Paúl
- Department of Radiology, University Getafe Hospital, Carretera de Toledo Km 12,5, 28905 Getafe, Madrid, Spain.
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Riccioni ME, Shah SK, Tringali A, Ciletti S, Mutignani M, Perri V, Zuccalà G, Coppola R, Costamagna G. Endoscopic palliation of unresectable malignant oesophageal strictures with self-expanding metal stents: comparing Ultraflex and Esophacoil stents. Dig Liver Dis 2002; 34:356-63. [PMID: 12118954 DOI: 10.1016/s1590-8658(02)80130-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two types of self-expanding metal stents to palliate dysphagia in patients with unresectable malignant oesophageal strictures have been compared. METHODS From February 1996 to October 2000, 50 metal stents (23 covered Ultraflex and 27 Esophacoil) were placed in 50 patients (40 males, mean age: 67+/-12 years, range: 33-100, mean dysphagia score: 3.18+/-0.66) with unresectable malignant oesophageal strictures. Patients were followed until death. A retrospective review has been made of a prospectively collected database. RESULTS The two groups were comparable as far as concerns degree of dysphagia, location and stricture length. Stent placement was successful in all cases. Covered Ultraflex stent was placed in 2 patients with oesophagobronchial fistula. No procedure-related deaths were seen. Early severe complications occurred in 2 patients (perforation in 1 and tumour bleeding in 1, in the Esophacoil group). Nine patients and 1 patient complained of pain following Esophacoil and Ultraflex stent placement, respectively. Late complications were asymptomatic rupture of distal Esophacoil rings in 2 patients, symptomatic Ultraflex stent migration in 2 and tumour overgrowth in 3 (Esophacoil 1, Ultraflex 2). Mean dysphagia score at 4 weeks after stent placement was 1.9+/-0.77. Mean survival was 177+/-109 days (range: 35-603 days). There were no significant differences in technical success, dysphagia palliation, complications (except chest pain) and survival using the two types of stent. CONCLUSIONS Self-expanding metal stents are safe with high technical success and achieve satisfactory long-term palliation for dysphagia. The covered Ultraflex and Esophacoil stents are equally effective.
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Affiliation(s)
- M E Riccioni
- Department of Surgery, Catholic University Sacro Cuore, Rome, Italy
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Abstract
Self-expanding metal esophageal stents (SMES) are highly effective in relieving dysphagia in patients with esophageal carcinoma. As the incidence of cancer at the lower esophagus/cardia continues to increase, SMES also are being deployed across the gastroesophageal junction (GEJ). However, use of SMES in this location makes the stomach and the esophagus, in effect, a common cavity, which predisposes patients to gastroesophageal reflux (GER) and aspiration. Reflux may result from an increase in intra-abdominal pressure or it may occur passively when the patient is recumbent. Acid-suppression medications do not protect against regurgitation and aspiration. We developed a modified antireflux SMES and evaluated its efficacy in vitro, in dogs, and in 11 patients with distal esophageal/GEJ carcinoma. The modification involved extending the polyurethane coating of the stent to 8 cm below the lower edge. In dogs, significantly more reflux episodes occurred with the regular stent (mean, 197 episodes) than with the modified stent (mean, 16 episodes; P = 0.03). In patients who received the modified stent, dysphagia scores were significantly reduced (mean baseline score, 3.4; mean end point score, 1.1; P <0.001). The modified stent prevented GER while allowing belching and vomiting.
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Affiliation(s)
- K S Dua
- Division of Gastroenterology and Hepatology, Froedtert Memorial Lutheran Hospital, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
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Siersema PD, Schrauwen SL, van Blankenstein M, Steyerberg EW, van der Gaast A, Tilanus HW, Dees J. Self-expanding metal stents for complicated and recurrent esophagogastric cancer. Gastrointest Endosc 2001; 54:579-86. [PMID: 11677473 DOI: 10.1067/mge.2001.118716] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Fewer complications are encountered with the use of self-expanding metal stents compared with semirigid prostheses in the palliation of patients with malignant esophagogastric obstructions. Metal stents can also be used to treat patients with complicated and/or recurrent esophagogastric carcinoma. METHODS Covered metal stents were placed in 57 patients for the following reasons: esophagorespiratory fistula (n = 16), recurrent carcinoma in a gastric tube interposition (n = 21), recurrent carcinoma after partial (n = 4) or total (n = 6) gastrectomy, or a carcinoma near the upper esophageal sphincter (n = 10). RESULTS The procedure was technically successful in 55 of 57 (96%) patients. Dysphagia score improved from a mean of 3.6 to 1.6 (p < 0.001). Major complications occurred in 13 (23%) patients. In all cases, esophagorespiratory fistulas were occluded. Tumor recurred in 5 of 16 patients with a fistula, 8 of 21 patients after gastric tube interposition, 3 of 10 patients after gastrectomy, and 2 of 10 patients with a tumor immediately distal to the upper esophageal sphincter. Median survival was 61 days. Prior radiation, chemotherapy, or both increased the risk of specific stent-related complications in relation to the (neo)esophagus (6 of 16 [38%] versus 4 of 41 [10%]: odds ratio, 5.5: 95% CI [1.3, 24], p = 0.018). CONCLUSIONS Self-expanding metal stents are effective and relatively safe for palliation of patients with malignancy and dysphagia caused by fistula formation, postoperative recurrence, and tumors near the upper esophageal sphincter. Placement should be considered at an early stage in these conditions.
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Affiliation(s)
- P D Siersema
- Department of Gastroenterology and Hepatology, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands
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Dua KS, Kozarek R, Kim J, Evans J, Medda BK, Lang I, Hogan WJ, Shaker R. Self-expanding metal esophageal stent with anti-reflux mechanism. Gastrointest Endosc 2001; 53:603-13. [PMID: 11323586 DOI: 10.1067/mge.2001.114054] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND When deployed across the gastroesophageal junction, self-expanding metal esophageal stents can predispose to gastroesophageal reflux. Our aim was to evaluate the efficacy of a self-expanding metal esophageal stent that was modified to prevent gastroesophageal reflux. METHODS The polyurethane coating of a metal Z-stent was extended beyond its lower end to form windsock-type valve. The anti-reflux property of this stent was studied in vitro by submerging the stent under water and measuring the pressure required to invert the valve. Esophageal acid exposure time was measured in 5 dogs with a standard and the modified stent placed across the gastroesophageal junction. The modified stent was also placed in 11 patients with cancer of the gastroesophageal junction who were prospectively followed. RESULTS The pressure required to invert the valve was directly proportional to the thickness of the valve membrane (48 +/- 0.4 cm water for a 0.0067-inch thick membrane). Esophageal acid exposure time was significantly less with the modified stent as compared with a standard stent (1% +/- 0.3%, 49% +/- 11%, respectively, p = 0.03). Dysphagia score in patients improved from 3.4 +/- 0.1 to 1.1 +/- 0.2 (p < 0.001). Daytime heartburn and regurgitation scores were less than 1 (score 10 = severe). No patient complained of nocturnal reflux symptoms. Karnofsky performance status scale did not improve significantly. CONCLUSIONS The efficacy of the modified stent in relieving dysphagia is comparable with a standard stent. It also effectively prevents gastroesophageal reflux.
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Affiliation(s)
- K S Dua
- M.C.W. Dysphagia Institute, Medical College of Wisconsin and V.A. Medical Center, Milwaukee, USA
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Raijman I. Expandable metal stents for malignant esophageal obstruction. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2001. [DOI: 10.1053/tgie.2001.22153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lee JG, Hsu R, Leung JW. Are self-expanding metal mesh stents useful in the treatment of benign esophageal stenoses and fistulas? An experience of four cases. Am J Gastroenterol 2000; 95:1920-5. [PMID: 10950036 DOI: 10.1111/j.1572-0241.2000.02246.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to review the long-term results of treating benign esophageal fistula and stenosis using self-expanding metal stents. METHODS We treated four patients using covered mesh or coiled stents. We removed the stents electively in two patients (one endoscopically and one during planned partial esophagectomy) and unexpectedly in one patient who developed bleeding. One stent migrated and required laparotomy for removal. RESULTS Placement of self-expanding metal stents successfully sealed the benign fistula in two patients and reestablished swallowing in two other patients with complicated achalasia. Two patients were swallowing normally on long-term follow-up, one died of the underlying disease, and one required gastrostomy. CONCLUSION Temporary use of self-expanding metal stents as a feasible option for treating benign esophageal stenosis and fistula in patients who have failed other conventional treatments.
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Affiliation(s)
- J G Lee
- Division of Gastroenterology, UC Davis Medical Center, Sacramento, California 95817, USA
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Repici A, Reggio D, Saracco G, Marchesa P, De Angelis C, Barletti C, Musso A, Falco M, Rizzetto M. Self-expanding covered esophageal ultraflex stent for palliation of malignant colorectal anastomotic obstruction complicated by multiple fistulas. Gastrointest Endosc 2000; 51:346-8. [PMID: 10699787 DOI: 10.1016/s0016-5107(00)70367-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- A Repici
- Department of Gastroenterology, Molinette Hospital, Torino, Italy
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May A, Ell C. Palliative treatment of malignant esophagorespiratory fistulas with Gianturco-Z stents. A prospective clinical trial and review of the literature on covered metal stents. Am J Gastroenterol 1998; 93:532-5. [PMID: 9576443 DOI: 10.1111/j.1572-0241.1998.160_b.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Esophagorespiratory fistulas, especially in the upper third of the esophagus, are a complication of malignant esophageal tumors, which are difficult to manage. The efficacy of polyurethane-covered, self-expanding metal stents for palliation of malignant esophagorespiratory fistulas was investigated prospectively. METHODS Eleven patients with malignant esophagorespiratory fistulas resp. perforations were treated with Gianturco-Z stents. In five patients the lesion was located in the proximal part of the esophagus. Because of the fistula all patients suffered from dysphagia even for liquids. RESULTS No technical problems during the implantation procedure of the stents occurred. In the control radiography with water-soluble contrast media, the fistulas were completely sealed in 10 of 11 patients. Therefore the dysphagia score improved from 3.0 to 0.6. Nearly all Gianturco-Z stents (10/11) showed a sufficient expansion within 24 h after placement. Severe early or late complications were not encountered, with the exception of tumor overgrowth in one patient about 9 months after stent placement. In five patients, short term (3-6 days) retrosternal pain was observed, and one patient complained of slight foreign body sensation. By August 1997 all 11 patients had died of advanced disease, with a median survival time of 121 days (range, 22-300 days). CONCLUSIONS Gianturco-Z stents are highly effective for palliative treatment of esophagorespiratory fistula resp. perforations and have a low complication rate. Due to the fact that this stent shows no retraction during the release, a precise positioning is possible, especially in the case of tumors and fistulas in the upper third of the esophagus. It seems that use of the Gianturco-Z stent can be considered a good therapeutic method for palliative endoscopic treatment of this high risk patient group.
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Affiliation(s)
- A May
- Department of Medicine II, Horst-Schmidt-Kliniken Wiesbaden, Germany
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Nevitt AW, Vida F, Kozarek RA, Traverso LW, Raltz SL. Expandable metallic prostheses for malignant obstructions of gastric outlet and proximal small bowel. Gastrointest Endosc 1998; 47:271-6. [PMID: 9540882 DOI: 10.1016/s0016-5107(98)70326-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data are limited on use of expandable metal stents for treatment of malignant gastric outlet obstruction. Accordingly, we report our experience using these stents to palliate malignant obstructions of the gastric outlet, duodenum, and proximal jejunum. METHODS Eight patients with malignant strictures causing gastric obstruction underwent endoscopy with fluoroscopic guidance to delineate tumor borders and length followed by expandable metallic prosthesis placement (Wallstent, Z-Stent, Ultraflex, and Endocoil). RESULTS Symptoms were relieved in seven patients, five of whom had previous surgeries (Whipple, Billroth II, esophagojejunostomy, and gastrojejunostomy) for malignancy. One patient underwent surgical resection of a presumed malignant stricture containing a previously placed Wallstent after a 45-pound weight gain. CONCLUSIONS Expandable metallic prostheses placed in patients with malignant obstruction of the gastric outlet, duodenum, or proximal jejunum, before or after surgery, effectively palliate obstructive symptoms and may also serve to improve nutrition.
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Affiliation(s)
- A W Nevitt
- Department of Radiology, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Kozarek RA, Raltz S, Marcon N, Kortan P, Haber G, Lightdale C, Stevens P, Lehman G, Rex D, Benjamin S, Fleischer D, Bashir R, Fry S, Waxman I, Benson J, Polio J. Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial. Gastrointest Endosc 1997; 46:156-60. [PMID: 9283867 DOI: 10.1016/s0016-5107(97)70065-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems. METHODS Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia. RESULTS Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula. CONCLUSIONS Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.
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Affiliation(s)
- R A Kozarek
- Virginia Mason Medical Center, Seattle, Washington 98101, USA
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Abstract
In conclusion, the explosion of interventional radiology and its impact on the pediatric patient have resulted in a completely new approach to the subspecialty of interventional pediatric radiology. The interventional radiologist has become an integral part of the management of patients and has become directly involved in the day-to-day care of patients. The use of interventional MR imaging recently has been described in clinical trial. Open-configuration magnets that allow full access to the patient and are equipped with instrument tracking systems provide an interactive environment in which biopsies, endoscopic procedures, and minimally invasive interventions or surgeries are performed. In addition, thermal ablation and image-based control of energy deposition also can be performed. Among these procedures, noninvasive MR-guided focused ultrasound ablation has the most promising future and may replace some conventional surgery. The merging of new and exciting technologies including MR, ultrasound, CT, and fluoroscopy into an environment in which both surgical and interventional radiologic procedures can be performed with image guidance is the basis of the operating room of the future. The role of the interventional radiologist as both the imager and interventionalist is central to this procedural environment; however, the interventional radiologist must accept all the responsibilities of imaging, therapy, patient care, and associated complications.
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Affiliation(s)
- P Chait
- Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Ontario, Canada
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