Chien-Fu Hung

Endovascular repair of spontaneous isolated dissection of the superior mesenteric artery

AIM To present our experience of the clinical management of spontaneous isolated dissection of superior mesenteric artery (SIDSMA) and analyse the clinical features, imaging findings, and treatment outcomes. MATERIALS AND METHODS In this retrospective study, eight consecutive patients with symptomatic SIDSMA were treated in Chang Gung Memorial Hospital between April 2007 and April 2010; among these patients, six underwent endovascular stent placement. The clinical manifestations, imaging findings, endovascular stent placement outcome, and follow-up results of the patients were retrospectively analysed. RESULTS Eight patients were diagnosed with SIDSMA by contrast-enhanced computer tomography. One patient died due to comorbidity before angiography. Six patients underwent percutaneous endovascular stent placement in the superior mesenteric artery (SMA): four patients with bare stents and two with stent grafts. Because it was not appropriate to perform stent implantation in the remaining patient, he received only conservative treatment. All seven patients had an uneventful recovery and the follow-up period was 16 month, ranging from 1 to 35 months. CONCLUSION For patients with symptomatic SIDSMA, endovascular repair is a feasible treatment choice with a high success rate and good clinical outcome.

Diagnosis and staging of gallbladder carcinoma:Evaluation with dynamic MR imaging

The purpose of this study is to determine the ability of dynamic magnetic resonance imaging (MRI) in the diagnosis and staging of gallbladder cancer (GBC). Images of dynamic MRI of hepatobiliary system combined with MR cholangiography (MRC) of 18 patients with pathologically proved gallbladder cancer were correlated with pathological and operative findings. Focal or diffuse wall thickening was present in 10 patients. In five patients, the tumor appeared as a fungating or intramural mass. A tumor replacing the gallbladder was found in two patients and a small cancer in cystic duct in one patient. The tumor featured early and irregular enhancement, which persisted throughout the dynamic study. Metastatic nodes were found by surgicopathology in 13 patients and were depicted by the dynamic MRI in 11 patients. Local invasion to liver was found by surgery in 12 patients and correctly detected by MRI in 11 patients. MRI detected duodenum invasion in three out of six patients and none of the three cases with omental metastasis. In conclusion, dynamic MRI is useful and reliable in staging of advanced gallbladder cancer. MRI combined with MRC is sensitive in detection of obstructive jaundice, liver invasion as well as liver and lymph nodes metastasis. It is more difficult to delineate the invasion to duodenum and omental metastasis by MRI.

Uterine Artery Embolization for Symptomatic Uterine Leiomyoma and Adenomyosis

BACKGROUND AND PURPOSE Uterine artery embolization (UAE) is increasingly accepted as an alternative treatment for symptomatic uterine leiomyoma and adenomyosis. The purpose of this study was to compare the outcomes of UAE in 3 diagnostic categories--submucosal leiomyoma, intramural leiomyoma, and adenomyosis--to assist in patient selection for this relative new form of therapy. METHODS The medical records of 43 patients (aged 22 to 54 years) who underwent UAE for symptomatic uterine leiomyoma or adenomyosis were retrospectively reviewed. Magnetic resonance imaging (MRI) was used for categorization of the patients into the 3 diagnostic categories, and also for objective measurement of the uterine and leiomyoma size, and subsequent imaging follow-up. UAE was performed using polyvinyl alcohol particles. Symptom improvement and complications after treatment were evaluated at gynecologist clinics using monthly questionnaires. The group differences in complete symptom resolution, uterine and leiomyoma size reduction, incidence of complications, and subsequent surgeries were analyzed. RESULTS The mean duration of follow-up was 10.9 months. Complete resolution of symptoms was achieved in 13 out of 16 patients with submucosal leiomyoma (81%), 3 out of 15 patients (20%) with intramural leiomyoma (p = 0.002) and 3 out of 12 patients (25%) with adenomyosis (p = 0.01). The average reduction of leiomyoma size in the submucosal and intramural groups was 56% and 29%, respectively (p = 0.02). None of the patients died. Severe complications occurred in 3 of 43 patients (7%), including permanent amenorrhea in 2 and pelvic actinomycosis in 1 patient. The incidence of complications (p = 0.17) and subsequent surgery (p = 0.67) did not differ significantly among the 3 groups. CONCLUSIONS UAE is an effective treatment for patients with symptomatic leiomyoma or adenomyosis. In this study, patients with submucosal leiomyoma had the best treatment outcome.

Antral web--a rare cause of vomiting in children.

Abstract Antral web is a rare cause of gastric-outlet obstruction. We report a case of gastric antral web with intermittent vomiting in a 10-year-old girl who received medical treatment for 6 months. The literature on this anomaly is reviewed with respect to differential diagnosis on the basis of upper gastrointestinal radiographic series, gastroscopy, and treatment planning.

Triphasic dynamic CT findings of 63 hepatic focal nodular hyperplasia in 46 patients: correlation with size and pathological findings

BackgroundTo correlate the dynamic computed tomography (CT) of hepatic focal nodular hyperplasia (FNH) with its size and pathology.MethodsThe clinical data, pathological and dynamic CT findings of 36 FNHs in 24 males and 27 lesions in 22 females were reviewed. The pathological and CT findings of the 32 small FNHs (diameter < 3 cm) and 31 large FNHs (diameter ≥ 3 cm) were compared and analyzed.ResultsAll FNHs were hypervascular at arterial phase except for central scarring. The mean diameter of FNHs with hypoattenuating, isoattenuating, hyperattenuating on delayed scans were 5.05 cm, 3.06 cm, and 2.70 cm, respectively (p = 0.026). As compared with small FNHs, large ones were significantly more likely to reveal central scarring (p = 0.005), vascular displacement (p < 0.001), and abnormal vessels around lesions (p < 0001). Coexistent bile ductile proliferation and bridging septa were more commonly observed in small FNHs (p = 0.028 for both). FNHs without aberrant vessels tended to feature hyperattenuating during the portal venous phase (p = 0.041).ConclusionsFNHs with different tumor sizes may manifest various dynamic CT findings that are more or less related to the different pathological findings.

Impact of spontaneous tumor rupture on prognosis of patients with T4 hepatocellular carcinoma.

Compare the outcomes of three groups of patients with T4 hepatocellular carcinoma (HCC): tumor rupture with shock (RS group), tumor rupture without shock (R group), and no tumor rupture (NR group).

CT-guided percutaneous core-needle biopsy of pancreatic masses: comparison of the standard mesenteric/retroperitoneal versus the trans-organ approaches

AIM To compare the safety and efficacy of percutaneous computed tomography (CT)-guided core-needle biopsy (CNB) of pancreatic masses traversing the gastrointestinal tract or solid viscera versus trans-mesenteric and retroperitoneal approaches. MATERIALS AND METHODS CT-guided CNB of pancreatic lesions performed between May 2004 and December 2014 were retrospectively analysed at a single centre. Biopsies were performed using 18- or 20-G needles with a coaxial system. CT images, histopathology reports, medical records, and procedural details for all patients were reviewed to evaluate the biopsy route, complications, and diagnostic accuracy. According to the routes, biopsies were divided into trans-mesenteric, retroperitoneal and trans-organ approaches for comparison. RESULTS A total of 85 patients, who had undergone 89 CNBs for pancreatic masses were reviewed. The overall sensitivity, specificity, and accuracy of CNB for detecting malignancy via various routes were 88.8%, 100%, and 89.9%, respectively, with a complication rate of 20.2%. Trans-organ biopsies of pancreatic masses (n=22) were performed safely via a direct pathway traversing the stomach (n=14), colon (n=3), small bowel (n=2), liver (n=2), and spleen (n=1). The sensitivity, specificity, and accuracy were 90.5%, 100%, and 90.9%, respectively. In the trans-organ biopsy group, three biopsies (13.6%) resulted in minor haematomas, but no major complications occurred. There were no statistically significant differences in the diagnostic efficacy or complication rate among the different biopsy routes. CONCLUSION Percutaneous CT-guided CNB using a trans-organ approach is a feasible technique for diagnosing pancreatic malignancy; however, as this series was small, more data is required.

Safety and efficacy of image-guided percutaneous biopsies in the diagnosis of gastrointestinal stromal tumors

BACKGROUND After the invention of effective target agent therapy for gastrointestinal stromal tumors (GISTs), percutaneous biopsies may be indicated for unresectable diseases or before neoadjuvant chemotherapy. The purpose of this study was to evaluate the safety and efficacy of percutaneous biopsies for GISTs. MATERIAL AND METHODS Fifty-eight procedures of transluminal biopsies or image-guided percutaneous biopsies in 49 patients at our Institution from 1999 to 2010 were retrospectively reviewed. RESULT Twenty-three transluminal biopsies, 20 ultrasonography-guided biopsies, and 15 CT-guided biopsies were performed. Failure rate was higher in the group of transluminal biopsies (17%). There is no major procedure-related complication in patients who underwent percutaneous biopsy. However, life-threatening bleeding after transluminal biopsies happened in two patients. CONCLUSION Image-guided percutaneous biopsy is a safe and efficient alternative tool for the diagnosis of patients with GISTs.

Trans-organ versus trans-mesenteric computed tomography-guided percutaneous fine-needle aspiration biopsy of pancreatic masses: Feasibility and safety

AIM To evaluate the safety and efficacy of computed tomography (CT)-guided percutaneous fine-needle aspiration biopsy (FNAB) of pancreatic masses that traverses the gastrointestinal tract or solid viscera. MATERIALS AND METHODS From January 2002 to December 2012, 144 patients underwent 165 CT-guided biopsies of pancreatic masses. Biopsies were performed using a 21 or 22 G needle. Cytology reports, medical records, and procedure details for all patients were retrospectively reviewed to evaluate the biopsy route, complications, and diagnostic accuracy. RESULTS Trans-organ biopsies of pancreatic masses were safely performed via a direct pathway traversing the stomach (n = 45), colon (n = 14), jejunum (n = 4), or liver (n = 5). There were five self-limiting mesenteric haematomas along the biopsy route on immediate post-procedure CT and all patients remained asymptomatic. All haematomas occurred after a trans-mesenteric approach rather than passage through abdominal organs. Three patients had acute pancreatitis. There was no significant difference in complications and diagnostic yields between the groups. The sensitivity, specificity, positive predictive value, and negative predictive value of final FNAB cytology for malignancy were 98.3%, 100%, 100% and 71.4%, respectively. The overall accuracy was 98.4%. CONCLUSION Percutaneous FNAB using the trans-organ approach is a safe and effective technique to diagnose pancreatic malignancy.

Predictive Factors for Additional ProGlide Deployment in Percutaneous Endovascular Aortic Repair

PURPOSE To evaluate outcomes and predictive factors for additional ProGlide device deployment in percutaneous endovascular aortic repair (PEVAR) with the preclose technique. MATERIALS AND METHODS Clinical data of patients who underwent PEVAR with the preclose technique from February 2012 to January 2015 were retrospectively reviewed. A total of 268 patients (229 men, 39 women) who underwent PEVAR (thoracic endovascular aortic repair [TEVAR], n = 113; endovascular abdominal aortic repair [EVAR], n = 152; simultaneous TEVAR and EVAR, n = 3) with 418 femoral access sites were enrolled. The mean age of the patients was 69 years ± 14. Univariate and multivariate analyses were performed to identify predictive factors associated with additional ProGlide device deployment. RESULTS Primary technical success with adequate hemostasis and two ProGlide devices was 87.6%, and 48 femoral arterial access sites (11.5%) required additional ProGlide device deployment. The secondary technical success rate was 99.0%. Four femoral access sites (1.0%) needed surgical repair. Anterior wall calcification near the arteriotomy increased the risk of additional ProGlide device deployment (adjusted odds ratio, 6.19; 95% confidence interval, 2.81-13.64; P < .001), whereas larger sheath size, common femoral artery (CFA) diameter, and depth from the skin to the arteriotomy did not. CONCLUSIONS Additional ProGlide device deployment reduces the rate of surgical repair after primary hemostasis failure in PEVAR. Anterior CFA wall calcification is a significant predictor for additional ProGlide device deployment.