Introduction: The management of gastrobronchial fistula (GBF) is not well defined in the literature. First line management is non-operative, allowing time for the fistula to close naturally. Surgical intervention is implemented when non-operative management fails. In medically complex patients, who often fail non-operative management, surgical procedures for closure remain high risk for complications. Case: We present a 2 year-old female with congenital esophageal atresia, duodenal atresia and annular pancreas. Beginning October 2015, she underwent multiple surgical procedures resulting in a multitude of complications. In August 2017, she transferred to our institution for management. Additional immediate operative intervention was pursued given the presence of the GBF. Despite two attempts at operative repair, the fistula recurred. Interventional radiology, consulted March 2018, developed a plan to place a percutaneous pigtail catheter in the esophagus through the dehiscent stomach wall from an external chest tube entry site, creating an iatrogenic enterocutaneous fistula (ECF). Diversion of flow from the GBF to the ECF was hypothesized to allow a conservative alternative for closure and tissue healing to occur. Initially, a 12 French (F) pigtail catheter was placed through the gastric wall into the esophageal pouch allowing the formation of the ECF tract. The patient returned for catheter downsizing to 8F three weeks later. A third intervention was performed to reposition the catheter to ensure that the tissues remained as dehydrated as possible. In May 2018, a 7 mm Cook Biodesign SIS fistula plug was placed. The 8F catheter was used to place a guide wire through the tract, then removed. The AFP bioplug, soaked in contrast to facilitate use of fluoroscopy, was placed through the mouth to seal the gastric wall. Placement was confirmed with a rigid esophagoscope and fluoroscopy. One week later, esophogram confirmed no leak. At 1 month follow-up the patient had no evidence of right pleural fluid and remains without evidence of fistula at five months. The skin site is well-healed. Discussion: In this case, an ECF was closed with a Cook Biodesign SIS fistula plug allowing for a successful non-operative strategy after multiple failed operative revisions. The plug has FDA approval for the treatment of anal fistula, but given the positive outcome in this case, its use in esophagocutaneous fistulas may be a viable off-label option for other patients. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Johnson Brittany, Desai Sudhen, Minifee Paul

Keywords: Gastrobronchial Fistula, SIS Fistula Plug

1) Reviewing the pathology and outcomes of children with spinal muscular atrophy (SMA) 2) Learning the procedures available for intrathecal access 3) Understanding the indications for choosing more advanced techniques to deliver nusinersen Spinal muscular atrophy is an autosomal recessive disease affecting motor neurons and is the most common genetic cause of death in infants. Nuinersen (Spinraza) was recently approved by FDA for intrathecal administration in SMA patients. Commonly administered by lumbar puncture in the clinic or with imaging guidance, this is the initial method of administering nusinersen. Deformities and spinal instrumentation from orthopedic surgeries are common in SMA patients, preventing traditional intrathecal access by lumbar puncture for nusinersen delivery. Transforaminal lumbar sac access, ultrasound or fluoroscopy guided cervical spine access, or subcutaneous catheter placement can be the alternative approaches with failed/difficult lumbar access. Given the potential benefit of nusinersen, understanding all methods to obtain intrathecal access is essential for a pediatric interventional radiology (IR) practice. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Ortiz Carlos, Chau Alex, Desai Sudhen, Kukreja Kamlesh

Keywords: nusinersen, spinal muscular atrophy, intrathecal administration

Bone biopsy for histopathology and tissue culture remains the gold standard for diagnosis of osteomyelitis. However, MRI often results in a radiologic diagnosis of osteomyelitis preceding biopsy. The purpose of this study is to examine the diagnostic yield of percutaneous bone biopsies and the effect of biopsy results on clinical management in children with suspected osteomyelitis and positive MRI findings. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Yen Christopher, Hernandez Alberto, Gardner Gregory, Nazario Maricarmen, Kukreja Kamlesh, Desai Sudhen

Keywords: Biopsy, Osteomyelitis, MRI