P-BN59 Danger is there, do we want to know about it? Routine intra operative cholangiography highlights dangerous biliary anatomy for safer cholecystectomy

Background Normal biliary anatomy is uncommon. Different classification for biliary anatomy has been described, with Huang Types A4 & A5 of great interest for laparoscopic cholecystectomy (LC) due to the proximity of aberrant bile duct to Cystic duct (CD). These types of dangerous anatomy might contribute to bile duct injury. This study aims to analyse the prevalence of dangerous biliary anatomy. Methods Prospectively collected data for all patients who underwent laparoscopic cholecystectomy was analysed. All LC were performed by single surgeon or under his direct supervision, between 01/07/2020 and 20/08/2021. Index admission and single session management of cholelithiasis disease with routine Laparoscopic cholecystectomy + intra operative cholangiography (IOC) +/- LCBD exploration were standard practice. Results Laparoscopic cholecystectomy was performed in 137 patients. Mean age was 56y (17-84). 62% were females. 66% of Laparoscopic cholecystectomies were emergency. IOC was performed in 92% of cases. Abnormal biliary anatomy was found in 54% : Huang A1 - 48%, A2 - 29%, A3 - 12%, A4 - 9.7% and A5 - 0.7%. Dangerous anatomy (A4 and A5) was found in 10.5%, 78 % were females. Female with dangerous anatomy were younger than males 49 y, 60y respectively. Nassar difficulty grading for dangerous anatomy was as follows: G2 28%, G3 42% and G3 28% Abnormal cholangiogram was found in 48%, due to filling defect in 58%, no contrast flow into duodenum in 4%, Cystic duct stone in 4%, and short CD in 8%. CBD stones were treated using transcystic approach in 92% of cases. No intra-operative or post operative complications were recorded for patients with dangerous anatomy. Conclusions This study demonstrates that dangerous biliary anatomy, that could lead to bile duct injury is relatively common, occurring in 10.7% of LCs. Routine intra-operative cholangiography highlights these high-risk variations in biliary anatomy and may prevent inadvertent bile duct injury in such cases.

Modification of the Cervical Transforaminal Epidural Steroid Injection Technique Based Upon the Anatomic Angle of the Superior Articular Process on MRI

Objective A modification of the conventional technique for cervical transforaminal epidural steroid injection (CTFESI) has been developed. This technique may, theoretically, decrease the likelihood of the needle encountering the vertebral artery and spinal nerve. The approach uses angle measurements of the superior articular process ventral surface from the patient’s axial MRI as a guide for fluoroscopic set-up and needle trajectory. This report aims to compare contrast flow patterns of the modified approach with those of the conventional technique. Design Retrospective chart review and prospective blinded analysis of contrast flow patterns. Setting. Outpatient interventional physiatry practice. Methods A retrospective blinded qualitative review of fluoroscopic images was performed to compare contrast flow patterns of CTFESIs performed using the modified approach with those using the conventional technique. A detailed description of the modified approach is provided in this report. Results Ninety-seven CTFESI procedures were used for flow analysis. The modified approach resulted in a statistically significant greater percentage of injections with epidural flow: 69% [95% CI = 57–82%] modified approach vs. 42% [95% CI = 28–56%] conventional approach. The modified technique also showed a statistically significant higher percent of injections categorized as having an ideal flow pattern, that of predominate epidural and/or intraforaminal flow: 65% [95% CI = 52–78%] vs. 27% [95% CI = 14–40%]. Conclusions A modification of the conventional CTFESI technique, developed for the purpose of improved safety, may provide superior contrast flow patterns when compared to the conventional approach.

Incidence of Extravascular Perivertebral Artery Contrast Flow During Cervical Transforaminal Epidural Injections

Background During a cervical transforaminal epidural injection, injectate flows along the path of least resistance. Given the proximity of the vertebral artery to the intervertebral foramen, injected contrast may flow along the external wall of the artery. The incidence of this contrast flow pattern during cervical transforaminal epidural injections is unknown. Purpose To determine the incidence of extravascular perivertebral artery contrast flow patterns during cervical transforaminal epidural injections. Study Design/Setting Retrospective, observational, in vivo study. Patient Sample Patients receiving cervical transforaminal epidural injections at a single outpatient spine clinic. Outcome Measures The presence or absence of extravascular perivertebral artery contrast flow. Methods The saved images from 100 consecutive patients were reviewed by two independent observers and classified with or without extravascular perivertebral artery contrast flow. The incidence was determined and kappa was used to examine inter-rater reliability. All disagreements were reviewed, and the final classification was determined by consensus. Results The inter-rater reliability was moderate, with a kappa value of 0.69. The incidence of extravascular perivertebral artery contrast flow patterns was 49% by consensus. No statistically significant differences in incidence were present when comparing three different final needle tip positions. Conclusions During a cervical transforaminal epidural injection, an extravascular perivertebral artery contrast flow pattern is frequently encountered. This includes flow along the exiting nerve and then around the vertebral artery, as suggested by this study. Although this contrast pattern does not represent an intravascular injection into the vertebral artery, practitioners should remain cautious to exclude intravascular needle placement before injecting medication.