• Biodegradable oesophageal stents: a potentially useful adjunct in the treatment of dysphagia in patients undergoing radiotherapy for oesophageal carcinoma

      White, K; Thampy, S; Sheikh, H; Bhatt, Lubna; Mullan, Damian; Laasch, Hans-Ulrich; Manchester NHS Foundation Trust (2019)
      Aim Dysphagia is common in patients presenting with oesophageal malignancy. This study aimed to determine the clinical effectiveness of biodegradable stents to help with malignant dysphagia due to radiotherapy for oesophageal cancer and furthermore to establish the complication and re-intervention rates associated with their use. Methods This was a retrospective, observational study of 22 patients between 2008 and 2013. Complications within 2 weeks and episodes of re-intervention required within 4 months of stent insertion prior to radiotherapy were recorded. Results Pre-stent insertion, the mean O�Rourke dysphagia score was 3�5 (median 3, range 2�5). This improved to a mean score of 2�8 (median 3, range 1�4) 1�3 weeks following stent insertion. Complications occurred in seven patients (32%) in an immediate 2-week period, including: pain (2), dysphagia requiring dilatation (1), food obstruction not requiring intervention (1), food obstruction requiring intervention (2) and upper gastrointestinal bleed not requiring intervention (1). Re-intervention was required in 18% within a 4-month period. Findings We propose that biodegradable oesophageal stents are safe and may have benefit over self-expanding metal stents. We recommend they are placed alongside a radiologically inserted gastrostomy in a combined procedure prior to radiotherapy planning.
    • Clinical performance status and technical factors affecting outcomes from percutaneous transhepatic biliary interventions; a multicentre, prospective, observational cohort study.

      Makris, G. C.; Macdonald, A. C.; Allouni, K.; Corrigall, H.; Tapping, C. R.; Hughes, J. P.; Anthony, S.; Boardman, P.; Patel, R.; Wigham, A.; et al. (2021)
      Purpose: The purpose of this study was to evaluate the predictive value of a 'Modified Karnofsky Scoring System' on outcomes and provide real-world data regarding the UK practice of biliary interventions. Materials and methods: A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure. Results: A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky 'high risk' group the 7 day mortality was 9.7% versus 0% for the 'low risk' group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001) CONCLUSION: Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions.
    • Developing a nurse led day care abdominal paracentesis service.

      Hill, Steve; Smalley, Joanna R; Laasch, Hans-Ulrich; The Christie NHS Foundation Trust, Wilmslow Road, Withington, Manchester, M20 9BX, UK (2013)
      Abdominal ascites can be a debilitating condition resulting in physical and psychological distress for patients. The authors identified that patients who required large volume abdominal paracentesis were experiencing a suboptimal service, such as delays in accessing the service, which led to some patients becoming grossly ascitic. Once admitted, they experienced fragmented care. This article examines the development of a nurse-led, day-case, abdominal paracentesis service, to improve the patient experience and quality of life by reducing length of stay. Pilot studies assessed the feasibility of day-case drainage and whether nurse specialists could undertake the procedure safely. In the first year of the service’s operation, bed occupancy was reduced by 1,300 and a financial saving of £250,000 was made.
    • Disc-retained tubes for radiologically inserted gastrostomy (RIG): Not up to the job?

      Kibriya, N; Wilbraham, Lynne; Mullan, Damian; Puro, Paula; Vasileuskaya, Sviatlana; Edwards, Derek W; Laasch, Hans-Ulrich; Department of Radiology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK. Electronic address: nabskib@yahoo.co.uk. (2013-08-10)
      To assess the insertion procedure and performance of disc-retained gastrostomy tubes, recording complications and accidental displacements by prospective audit, and to determine whether primary placement of the tube off-licence was feasible.
    • Draining malignant ascites at home with tunnelled catheters: complications and costs

      Mullan, Damian; Kibriya, Nabil; Jacob, Arun; Laasch, Hans-Ulrich; Hassan, H; Dept of Clinical and Interventional radiology, The Christie NHS FT, Manchester (2015-12)
    • Emphysematous cholecystitis in a patient with metastatic pancreatic neuroendocrine tumour.

      Khan, Muhammad; Little, Martin; Campbell, Geraldine; Laasch, Hans-Ulrich; Cooksley, Timothy J; Department of Acute Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK (2017-01-05)
    • Gastrostomy insertion: comparing the options--PEG, RIG or PIG?

      Laasch, Hans-Ulrich; Wilbraham, L; Bullen, K; Marriott, Andrew S; Lawrance, Jeremy A L; Johnson, Richard J; Lee, S H; England, R E; Gamble, G E; Martin, D F; et al. (2003-05)
      AIM: To compare percutaneous endoscopic gastrostomy (PEG) with radiologically inserted gastrostomy (RIG) and assess a hybrid gastrostomy technique (per-oral image-guided gastrostomy, PIG). MATERIALS AND METHODS: Fifty PEGs and 50 RIGs performed in three centres were prospectively compared and the endoscopic findings of 200 PEGs reviewed. A fluoroscopy-guided technique was modified to place 20 F over-the-wire PEG-tubes in 60 consecutive patients. RESULTS: Technical success was 98%, 100% and 100% for PEG, RIG and PIG, respectively. Antibiotic prophylaxis significantly reduced stoma infection for orally placed tubes (p=0.02). Ten out of 50 (20%) small-bore RIG tubes blocked. Replacement tubes were required in six out of 50 PEGs (12%), 10 out of 50 RIGs (20%), but no PIGs (p<0.001). No procedure-related complications occurred. The function of radiologically placed tubes was significantly improved with the larger PIG (p<0.001), with similar wound infection rates. PIG was successful in 24 patients where endoscopic insertion could not be performed. Significant endoscopic abnormalities were found in 42 out of 200 PEG patients (21%), all related to peptic disease. Insignificant pathology was found in 8.5%. CONCLUSION: PIG combines advantages of both traditional methods with a higher success and lower re-intervention rate. Endoscopy is unlikely to detect clinically relevant pathology other than peptic disease. PIG is a very effective gastrostomy method; it has better long-term results than RIG and is successful where conventional PEG has failed.
    • Inaugural meeting of the Society of Gastrointestinal Intervention.

      Laasch, Hans-Ulrich; Department of Radiology, Christie Hospital NHS Foundation Trust, Manchester, M20 4BX, UK. hul@christie.nhs.uk (2008-02)
      The Society of Gastrointestinal Intervention was founded to provide a multidisciplinary forum for medical staff, scientists and allied health professionals involved in minimally invasive gastrointestinal intervention. Besides providing an international meeting, the society aims to establish a clinical, as well as an academic network among the three main disciplines of gastroenterology, surgery and interventional radiology. A further aim is to promote collaboration between healthcare professionals and industry.
    • Management of benign intrahepatic bile duct strictures: initial experience with polydioxanone biodegradable stents.

      Petrtýl, J; Brůha, R; Horák, L; Zádorová, Z; Dosedel, J; Laasch, Hans-Ulrich; 1st Faculty of Medicine, Charles University Prague, 4th Department of Internal Medicine, General Teaching Hospital, Prague, Czech Republic. (2010)
    • New "knitted" EGIS esophageal stent allows atraumatic inside-out removal by inversion.

      Suntharanathan, J; Edwards, D W; Mullan, Damian; Martin, D; Laasch, Hans-Ulrich; Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK. (2013)
    • Oesophageal stenting: status quo and future challenges.

      Kaltsidis, H; Mansoor, Was; Park, J; Song, H; Edwards, Derek W; Laasch, Hans-Ulrich; Department of Gastroenterology, Manchester University Hospitals NHS Foundation Trust , Manchester , UK (2018-06-27)
      Oesophageal stents are widely used for palliating dysphagia from malignant obstruction. They are also used with increasing frequency in the treatment of oesophageal perforation, as well as benign strictures from a variety of causes. Improved oncological treatments have led to prolonged survival of patients treated with palliative intent; as a consequence, stents need to function and last longer in order to avoid repeat procedures. There is also increasing need for meticulous procedure planning, careful selection of the device most appropriate for the individual patient and planned follow-up. Furthermore, as more patients are cured, there will be more issues with resultant long-term side-effects, such as recalcitrant strictures due to radiotherapy or anastomotic scarring, which will have to be addressed. Stent design needs to keep up with the progress of cancer treatment, in order to offer patients the best possible long-term result. This review article attempts to illustrate the changing realities in oesophageal stenting, differences in current stent designs and behaviour, as well as the pressing need to refine and modify devices in order to meet the new challenges.
    • Patterns, incidence and predictive factors for pain after interventional radiology.

      England, A; Tam, C L; Thacker, D E; Walker, Anne; Parkinson, A S; Demello, W; Bradley, A J; Tuck, J S; Laasch, Hans-Ulrich; Butterfield, J S; et al. (2005-11)
      AIM: To evaluate prospectively the pattern, severity and predictive factors of pain after interventional radiological procedures. MATERIALS AND METHODS: All patients undergoing non-arterial radiological interventional procedures were assessed using a visual-analogue scale (VAS) for pain before and at regular intervals for 24 h after their procedure. RESULTS: One hundred and fifty patients (87 men, mean age 62 years, range 18-92 years) were entered into the study. Significant increases in VAS score occurred 8 h after percutaneous biliary procedures (+47.7 mm, SD 14.9 mm; p=0.001), 6 h after central venous access and gastrostomy insertion (+23.7 mm, SD 19.5 mm; p=0.001 and +28.4 mm, SD 9.7 mm; p=0.007, respectively) and 4h after oesophageal stenting (+27.8 mm, SD 20.2 mm, p=0.001). Non-significant increases in VAS pain score were observed after duodenal and colonic stenting (duodenal: +5.13 mm, SD 7.47 mm; p=0.055, colonic: +23.3 mm, SD 13.10 mm, p=0.250) at a mean of 5h (range 4-6h). Patients reported a significant reduction in pain score for nephrostomy insertion (-28.4mm, SD 7.11 mm, p=0.001). Post-procedural analgesia was required in 99 patients (69.2%), 40 (28.0%) requiring opiates. Maximum post-procedural VAS pain score was significantly higher in patients who had no pre-procedural analgesia (p=0.003). CONCLUSION: Post-procedural pain is common and the pattern and severity of pain between procedures is variable. Pain control after interventional procedures is often inadequate, and improvements in pain management are required.
    • Pneumoperitoneum following percutaneous biliary intervention: not necessarily a cause for alarm.

      Amonkar, Suraj J; Laasch, Hans-Ulrich; Valle, Juan W; Manchester Radiology Training Scheme, University of Manchester, Manchester, M13 9PL, UK. surajamonkar@hotmail.com (2009-04-21)
      Percutaneous transhepatic cholangiography (PTC) is a well-established technique for assessing and treating obstructive jaundice. Plastic and self-expanding metal stents can be deployed as an alternative when ERCP is not feasible or hilar strictures require an antegrade approach. Complication rates of percutaneous procedures are low, and are usually related to bile leakage or hemorrhage; pneumoperitoneum following PTC is rare and is usually taken to indicate bowel perforation. We describe two cases of pneumoperitoneum without peritonitis following PTC and stenting, both of which resolved spontaneously with conservative management. The literature is reviewed and possible causes discussed.
    • Radiologic gastrostomy.

      Laasch, Hans-Ulrich; Martin, D F; Department of Radiology, Christie Hospital, Manchester, UK. hans-ulrich.laasch@christie-tr.nwest.nhs.uk (2007-03)
      Radiologic gastrostomy has a higher success rate and a lower complication rate and offers a greater choice of tubes than percutaneous endoscopic gastrostomy (PEG). The position and configuration of the stomach and colon are clearly seen under fluoroscopy, and ultrasound can be used to locate the liver. Radiologic gastrostomy procedures can be performed when there are oropharyngeal tumors, or esophageal strictures and stents, and can be performed under local anesthesia alone. Peroral push-gastrostomies are preferable for palliative care and for patients with neurogenic dysphagia, but percutaneously inserted tubes should be used in patients with upper gastrointestinal cancers in order to avoid tumor seeding. Unfortunately, awareness of and access to radiologic techniques are still limited and this has led to the development of "adventurous" techniques for placing endoscopes in stomachs rather than applying simple fluoroscopic alternatives.
    • Radiological balloon dilatation of post-treatment benign pharyngeal strictures.

      Williams, L R; Kasir, D; Penny, S; Homer, Jarrod J; Laasch, Hans-Ulrich; Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK. luke.williams@srft.nhs.uk (2009-11)
      AIMS: To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer. MATERIALS AND METHODS: Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire. RESULTS: Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula. CONCLUSION: Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.
    • Retrograde radiological gastrostomy technique and retrograde stent placement in a completely occluded cervical esophagus

      Bi, Yixi; Edwards, Derek W; Mullan, Damian; Laasch, Hans-Ulrich; Radiology, The Christie Hospital, Manchester (2021)
      Malignant obstruction of the cervical esophagus presents some anatomical and technical challenges when considering radiologic or endoscopic intervention. This case report describes the failure of antegrade access to place a gastrostomy tube and stent due to complete luminal occlusion from an esophageal tumor. The ultrasound-guided percutaneous gastric puncture was performed to achieve retrograde pneumodistension to allow radiologic gastrostomy insertion. Subsequently, the cervical esophagus was retrogradely cannulated via insertion of a guidewire from the gastrostomy site. A distal release esophageal stent was then inserted over the wire and deployed from the mouth in an antegrade manner. However, due to the unpredictable proximal shortening of distal release stents, this stent was eventually shortened and displaced so that it no longer covered the top of the tumor stricture, and further antegrade access failed. Once more, a retrograde access approach was adopted via the gastrostomy stoma, a guidewire and catheter were passed retrogradely through the original stent and out through the mouth. A distal release stent system was then inserted in a retrograde manner via the gastrostomy stoma, effectively making it a proximal release stent which enabled more precise positioning of the stent above the tumor. Palliation was achieved until death, and beyond expected mean survival.
    • A retrospective analysis of selective internal radiation therapy (SIRT) with yttrium-90 microspheres in patients with unresectable hepatic malignancies.

      Omed, A; Lawrance, Jeremy A L; Murphy, G; Laasch, Hans-Ulrich; Wilson, G; Illidge, Timothy M; Tipping, Jill; Zivanovic, M; Jeans, S; Manchester Medical School, University of Manchester, Stopford Building, Manchester, UK. aliomed0101@doctors.org.uk (2010-09)
      AIM: To evaluate the efficacy and safety of selective internal radiation therapy (SIRT). MATERIALS AND METHODS: A retrospective analysis was undertaken of all patients who underwent SIRT at a single institution. Diagnostic and therapeutic angiograms, computed tomography (CT) images, positron-emission tomography (PET) images, and planar isotope images were analysed. The response to SIRT was analysed using radiological data and tumour markers. Overall survival, complications, and side effects of SIRT were also analysed. RESULTS: The initial 12 patients were included on an intention-to-treat basis, between 21/09/2005 and 07/05/2008. All patients had advanced disease and multiple prior courses of chemotherapy. One patient did not receive yttrium-90 due to complex vascular anatomy; the remaining 11 patients underwent 13 SIRT treatment episodes following work-up angiography. A response was seen using PET in 80% of patients. Using CT, the response of the tumour to therapy in the treated hepatic segments demonstrated a 20% partial response, stable disease in 50%, and progressive disease in 30%. Estimated median survival was 229 days, with 64% of patients still alive at the time of writing. No major complications were observed, although 82% of patients experienced side-effects following SIRT, mainly nausea, vomiting, and abdominal pain. CONCLUSIONS: There have been no complications in the 12 SIRT patients. Tumour response was seen in four out of five patients who underwent PET. Objective CT response rates were mixed and are perhaps partially explained by advanced disease and limitations of using measurements to assess response. This complex and potentially hazardous service has been successfully and safely established.
    • Safety and efficacy of venting gastrostomy in malignant bowel obstruction: a systematic review

      Thampy, S; Mullan, Damian; Najran, Pavan; Laasch, Hans-Ulrich; Department of Interventional Radiology, Christie NHS Foundation Trust, Manchester (2019)
      Malignant bowel obstruction (MBO) is a common manifestation in patients with advanced intra-abdominal malignancy. It is especially common with bowel or gynecological cancers and produces distressing symptoms, including nausea, vomiting, and pain. Medical management options are less effective than decompressive strategies for symptom control. Surgery is the gold-standard treatment but is unsuitable for most patients with high complication rates. Consensus guidelines recommend nonsurgical management with a venting gastrostomy in those unsuitable for surgery or for whom medical management is ineffective. The aim of this systematic review is to establish the safety and efficacy of percutaneous venting gastrostomy in relieving symptoms of MBO. Twenty-five studies were included in this review comprising 1194 patients. Gastrostomy insertion was successful at first attempt in 91% of cases and reduction in symptoms of nausea and vomiting was reported in 92% of cases. Mean survival following the procedure ranged from 35 to 147 days. Major complications were rare, with most complications classed as minor wound infections or leakage of fluid around the tube. Studies suggest that the presence of ascites is not an absolute contraindication to the insertion of percutaneous venting gastrostomy in patients with MBO; however, these studies lack longitudinal outcomes and complication rates related to this. However, it is reasonable to suggest that ascitic drainage is performed to reduce potential complications. There is a relative lack of good quality robust data on the utilization of percutaneous venting gastrostomy in MBO, but overall, the combination of being a safe and efficacious procedure alongside the known complication profile suggests that it should be considered a suitable management option.
    • Selective internal radiation therapy (SIRT) with yttrium-90 microspheres and peri-procedural FOLFIRI/irinotecan in pre-treated colorectal liver metastases patients: an analysis of outcomes from a UK cancer centre between 2009 and 2017.

      Wilson, Gregory; Bentley, D; Mullamitha, Saifee A; Braun, Michael S; Nasralla, Magdy; Bell, Jon; Mullan, David; Hasan, Jurjees; Saunders, Mark P; Marti-Marti, Francisca; et al. (2018-06)
    • Technical feasibility and safety of a new, implantable reflux control system to prevent gastroesophageal reflux in patients with stents placed through the lower esophageal sphincter (with video).

      Hirdes, M; Vleggaar, P; Laasch, Hans-Ulrich; Siersema, P; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands. M.M.C.Hirdes@umcutrecht.nl (2012-01)
      When an esophageal stent is placed through the lower esophageal sphincter (LES), gastroesophageal reflux symptoms may persist despite high-dose proton pump inhibitor therapy. A recently developed, short segment, uncovered nitinol stent with a tricuspid-like valve can be placed inside a previously placed esophageal stent.