Endoscopic ultrasound-guided coeliac plexus block

The landmark paper discussed in this chapter is ‘Endosonography-guided celiac plexus neurolysis’, published by Wiersema and Wiersema in 1996. Pain is one of its most distressing complaints of pancreatic cancer, affecting more than 80% of patients with advanced disease. However, the use of opioids and other drugs is often limited by undesirable side effects, which include somnolence, confusion, lethargy, and decreased cognitive function. Intrathecal drug delivery systems, although effective, are often deemed impractical in pancreatic cancer, due to its poor prognosis and the fact that it is often diagnosed late. Tumour infiltration of the coeliac plexus results in pain in the abdomen and back; thus, this area has often been targeted for analgesia via a neurolytic coeliac plexus block. The paper by Wiersema and Wiersema examines the efficacy of an approach that uses ultrasound to guide needle placement in celiac plexus neurolysis, in a study of 30 patients.

Prospective study of percutaneous tracheostomy: Role of bronchoscopy and surgical technique

Objective: Percutaneous tracheostomy is a common procedure but varies considerably in approach. The aim of our study was to evaluate the need for intraoperative bronchoscopy and to compare various surgical techniques. Methods: During 1 year all percutaneous tracheostomies in three intensive care units were prospectively documented according to a unified protocol. In one unit, bronchoscopy was used routinely and in others only during the study. Results: A total of 111 subjects (77 males) with median age 64 (range, 18–86) years and body mass index 25.4 (range, 15.9–50.7) were included. In unit A, tracheal wall was directly exposed; in unit B, limited dissection to enable tracheal palpation was made. In both units, bronchoscopy was used to check the location of an already inserted guiding needle; needle position required correction in 8% and 12% of cases, respectively. In unit C, in tracheostomies without pretracheal tissue dissection, bronchoscopy was used to guide needle insertion; needle position required correction in 66% of cases. Median duration of operations performed by thoracic surgeons and residents was 10 (range, 3–37) min and by intensive care doctors and residents was 16.5 (range, 3–63) min (p < 0.001). Time from the beginning of preparations for tracheostomy until the end of the whole procedure was median 32 min for bedside tracheostomies and 64 min for operations in the operating theatre (p < 0.001). Conclusion: Limited pretracheal tissue dissection enabled proper guiding needle insertion and bronchoscopy was rarely needed. Percutaneous tracheostomies performed by thoracic surgeons took less time, and duration of the whole procedure was remarkably shorter when performed at bedside.

Vertebral Stenting and Vertebroplasty Guided by an Angiographic 3D Rotational Unit

Introduction. Use of interventional imaging systems in minimally invasion procedures such as kyphoplasty and vertebroplasty gives the advantage of high-resolution images, various zoom levels, different working angles, and intraprocedure image processing such as three-dimensional reconstructions to minimize complication rate. Due to the recent technological improvement of rotational angiographic units (RAU) with flat-panel detectors, the useful interventional features of CT have been combined with high-quality fluoroscopy into one single machine. Intraprocedural 3D images offer an alternative way to guide needle insertion and the safe injection of cement to avoid leakages.Case Report. We present the case of a 72-year-old female patient with insidious lumbar pain. Computed tomography revealed a wedge-shaped osteoporotic compression fracture of T10 vertebrae, which was treated successfully with the installation of vertebral stenting system and vertebroplasty with methacrylate guided with a rotational interventional imaging system.Conclusion. Rotational angiographic technology may provide a suitable place for the realization of high-quality minimally invasive spinal procedures, such as kyphoplasty, vertebroplasty, and vertebral stenting. New software programs available nowadays offer the option to make three-dimensional reconstructions with no need of CT scans with the same degree of specificity.