Duk Sik Kang

Transcaval TIPS in Patients with Failed Revision of Occluded Previous TIPS

Objective To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) in patients with occluded previous TIPS. Materials and Methods Between February 1996 and December 2000 we performed five transcaval TIPS procedures in four patients with recurrent gastric cardiac variceal bleeding. All four had occluded TIPS, which was between the hepatic and portal vein. The interval between initial TIPS placement and revisional procedures with transcaval TIPS varied between three and 31 months; one patient underwent transcaval TIPS twice, with a 31-month interval. After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted. Results Transcaval TIPS placement was technically successful in all cases. In three, tractography revealed slight leakage of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space. There was no evidence of propagation of extravasated contrast materials through the retroperitoneal space or spillage into the peritoneal space. After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred. After successful shunt creation, variceal bleeding ceased in all patients. Conclusion Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.

Preoperative Staging in Non-Small Cell Lung Cancer without Lymphadenopathy on Computed Tomogram

Objectives: Careful evaluation about mediastinal involvement is important in the management of patients with non-small cell lung cancer. Invasive staging procedure such as mediastinoscopy is advocated because of the unreliability of noninvasive staging methods such as CT, MRI. We compared differences between pre- and postoperative staging in non-small cell lung cancer without lymphadenopathy on CT scan and investigated the methods for more accurate preoperative staging. Methods & Results: 1) Records of a total of 41 patients with preoperative non-small cell lung cancer were reviewed and the histologic types of tumors were squamous cell carcinoma in 32 cases, adenocarcinoma in 6 cases and large cell carcinoma in 3 cases. Twenty-four cases were central lesions and seventeen cases were peripheral lesions. 2) Among the 32 cases with preoperative , 2 cases were identified postoperatively as with invasion of chest wall and among 6 cases with preoperative , 1 case was identified postoperatively as with invasion of aorta and pulmonary arteries. 3) After the operation of 35 cases with , 5 cases were and 3 cases were postoperatively. After the operation of 6 cases with , 2 cases were and 3 cases were postoperatively. Preoperative showed more intrathoracic lymph node metastases and higher involvement ratio than preoperative . 4) Complete surgical resections were done in 34 out of 41 cases. Incomplete resection were done in all postoperative tumors. Conclusion: Invasive staging procedures such as mediastinoscopy should be considered in the case of preoperative non-small cell lung cancer even though mediastinal lymphadenopathy is not recognized on the CT scan of the chest.