J.H. Shin

Intraoperative stent placement in the portal vein during or after liver transplantation

The purpose of this research was to evaluate the intermediate effectiveness of intraoperative portal vein stent placement for portal venous stenosis in liver transplantation. We attempted intraoperative portal vein stent placement in 44 portal venous anastomotic stenoses in 36 patients. All patients underwent stent placement via either the inferior or superior mesenteric vein. A total of 22 patients underwent portal vein stent placement simultaneously with liver transplantation, and 14 patients underwent stent placement 1‐25 days (mean 5.93 days) after liver transplantation. Of the 22 patients, there was portal vein occlusion in 3 patients and small portal vein (<6 mm) in 10 patients (2.5‐5.7 mm; mean size 3.9 mm). Patient follow‐up included clinical and laboratory data collection, Doppler ultrasonography (US), and computed tomography (CT). Intraoperative portal vein stent placement was technically successful in all of our study patients, even in 6 patients with total occlusion of the portal vein. A total of 10 study patients underwent thrombectomy of the portal vein, 1 underwent patient portosystemic shunt ligation, and 7 patients had both procedures simultaneously. Portal venous patency has been maintained for 0‐56 months (mean 16 months) in 42 (95%) of the 44 stent placements. In conclusion, intraoperative portal vein stent placement is an effective and long lasting treatment modality for treat portal venous stenosis, especially in patients with portal vein occlusion or small sized portal vein. Liver Transpl 13:1145–1152, 2007.

Oesophageal strictures caused by the ingestion of corrosive agents : effectiveness of balloon dilatation in children

AIMnTo evaluate the safety and clinical effectiveness of balloon dilatation in children for oesophageal strictures caused by the ingestion of corrosive agents.nnnMATERIALS AND METHODSnThe study comprised 11 children (median age 6 years; range 1-14 years) with oesophageal strictures caused by corrosive agents, who underwent a total of 36 balloon dilatation sessions. The technical and clinical success, recurrence of dysphagia, complications, and primary and secondary patency rates were retrospectively evaluated.nnnRESULTSnTechnical success was achieved in 91% of patients and in 97% of balloon dilatation sessions. Clinical success (defined as improved food intake and reduced dysphagia within 1 month of the first balloon dilatation session) was achieved in 64% of patients (7/11). During the mean 35-month follow-up period (range 1-89 months), 10 (91%) patients experienced recurrence. Oesophageal rupture (types 1 or 2) occurred in 45% of patients and in 31% of balloon dilatation sessions. Primary patency rates at 6 months and 1, 2, 3, 4, and 5 years were 36, 27, 14, 14, 14, and 14%, respectively. Secondary patency rates at 6 months and 1, 2, 3, 4, and 5 years were 82, 82, 82, 56, 42, and 42%, respectively. The secondary patency rate was higher than the primary patency rate (p<0.05).nnnCONCLUSIONnThe present study examined oesophageal balloon dilatation for paediatric oesophageal strictures caused by the ingestion of corrosive agents. Although the technical success rate was high and there were no deaths, the clinical success rate was low owing to a high recurrence rate. However, repeated balloon dilatations resulted in an acceptable secondary patency rate.

Persistent or recurrent varicocoele after failed varicocoelectomy: Outcome in patients treated using percutaneous transcatheter embolization

AIMnTo determine the efficacy of percutaneous transcatheter embolization in the management of patients with spermatic varicocoeles persisting or recurring after surgery.nnnMATERIALS AND METHODSnOver a period of 10 years, 28 patients (age range 13-55 years) were referred for percutaneous transcatheter embolization of postsurgical, recurrent varicocoeles. Medical documents were retrospectively reviewed to evaluate past surgical history, subjective symptoms, and results of scrotal examination, ultrasound, and semen parameters. Pre-embolization venograms were analysed to assess the anatomy of the testicular vein. The technical and clinical outcomes of embolization were then determined.nnnRESULTSnThe 28 patients included in the study had undergone laparoscopic varicocoelectomy (39.3%), high retroperitoneal ligation (25%), or inguinal ligation (25%). Subjective symptoms were scrotal pain (60.7%) and a palpable scrotal mass (50%) exclusively on the left side. Venograms revealed abnormalities of the left testicular vein in all cases. Embolization was technically successful in all but two cases, thus yielding an occlusion rate of 93%; a single case of suspected thrombophlebitis was the only complication. After excluding two, technically unsuccessful cases and one patient who was lost to follow-up, 25 patients underwent scrotal examination after embolization, which revealed complete resolution in 20 cases (80%), partial improvement in four cases (16%), and no improvement in a single case (4%). Among the follow-up group of patients, of the 12 who initially presented with scrotal pain, six (50%) were symptom-free and four (33.3%) had partial improvement.nnnCONCLUSIONnPercutaneous transcatheter embolization of the testicular vein is technically feasible and effective for managing postsurgical recurrent varicocoeles.

Management of airway involvement of oesophageal cancer using covered retrievable nitinol stents

AIMnTo assess the efficacy and safety of covered retrievable nitinol stents in oesophageal cancer patients with airway involvement.nnnMATERIALS AND METHODSnUnder fluoroscopic guidance, covered retrievable nitinol airway stents were placed in 23 oesophageal cancer patients with airway stricture and/or oesophagorespiratory fistula (ERF) over a long period of 12 years. Six patients only had aspiration by ERF and three patients had both airway stricture and asymptomatic ERF. Technical aspects, dyspnoea improvement, and/or resolution of ERF symptoms, complications, reinterventions, and survival data were evaluated.nnnRESULTSnA total of 27 airway stents (14 tracheal, 11 bronchial, and two hinged) were placed successfully in 23 patients with airway stricture or ERF. Dyspnoea score decreased significantly after stent placement (p<0.001). ERF were sealed off in all nine patients. Complications included stent migration or expectoration (n=4), haemoptysis (n=2), sputum retention (n=7), and tumour overgrowth (n=1). All three migrated stents were easily removed. Twenty-one patients died, with the median survival period of 76 days (range 2-197 days).nnnCONCLUSIONnPlacement of covered retrievable expandable nitinol stents was safe and effective for the palliative treatment of airway strictures and/or ERF, with a reasonable range of complications, in patients with advanced oesophageal cancer.

Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up

AIMnTo evaluate the efficacy and safety of renal artery embolisation (RAE) for renal arteriovenous malformation (AVM) as well as its outcomes.nnnMATERIALS AND METHODSnThe technical and clinical success rates, radiological and laboratory findings, and complications of RAE for 31 renal AVMs in 24 patients (M:F=9:15, mean age 46 years) at two separate medical institutions were retrospectively evaluated. Technical success was defined as complete occlusion of feeding arteries with no residual nidus seen on post-treatment angiography. Clinical failure was defined as recurrence of haematuria, presence of AVM on follow-up ultrasound or computed tomography, repeated RAE or surgery for the control of haematuria. Overall clinical success was defined as resolution haematuria or disappearance of AVM on follow-up imaging after single or multiple sessions of RAE.nnnRESULTSnTypes of renal AVM were AVM, arterio-venous fistula (AVF) with intranidal aneurysm, and acquired AVF in 19, 1, and 4 patients, respectively. 18 patients (75%) underwent a single session of RAE, while 6 patients (25%) had two or more sessions of RAE. The level of embolisation was feeder, segmental artery, and main renal artery in 28 (90%), 2 (6%), and 1 (4%) procedures, respectively. Coil, n-butyl 2-cyanoacrylate, and polyvinyl alcohol were the most frequently chosen embolic materials and were used in 19, 14, and 8 procedures, respectively. The clinical success rate after initial RAE was 67% (16/24). Overall clinical success rate, including multisession RAE, was 88% (21/24). The technical success rate of 31 procedures was 65% (20/31). Among 11 technical failures in 10 patients, 4 achieved clinical success without additional RAE, 3 underwent second session RAE to achieve clinical success, and 3 patients underwent nephrectomy due to recurrence.nnnCONCLUSIONnRAE is a safe and effective treatment for renal AVM. Technical failure of RAE does not always lead to clinical failure and multiple embolisation sessions may be effective for recurrent renal AVM.

Volumetric analysis of the liver after right portal vein embolization: mid-term follow-up based on embolization score

AIMnTo evaluate liver volume alterations and liver function after right portal vein embolization (PVE) during mid-term follow-up based on embolization score.nnnMATERIALS AND METHODSnComputed tomography (CT) images and liver function profiles were obtained before PVE, and at short-term (7-45 days), and mid-term follow-up (106-380 days) after PVE in all 30 patients. The patients were divided into group A (PVE score >or=3, n=20) and group B (PVE score <3, n=10). High score indicates more complete embolization.nnnRESULTSnLeft liver volume (LLV) and percentage future liver remnant (%FLR) increased significantly between pre-PVE and short-term follow-up and between short-term and mid-term follow-up in group A. Increase in FLR volume was significantly higher at the mid-term follow-up than at the short-term follow-up in group A. The ratio of embolized to total liver volume (RETLV) on short-term follow-up was significantly higher in group A than in group B. Aspartate transaminase (AST) and alanine transaminase (ALT) were elevated on short-term follow-up, whereas at mid-term follow-up in group A, they had significantly returned to the baselines.nnnCONCLUSIONnPVE resulted in continued compensatory hypertrophy of the unembolized liver during the 6-month follow-up. Compensatory hypertrophy in the unembolized liver was proportional to the ratio of embolization and to the embolized liver volume.

Percutaneous nephrostomy placement in infants and young children

PURPOSEnThe purpose of this study was to evaluate the feasibility, safety, and clinical effectiveness of ultrasound and fluoroscopy-guided percutaneous nephrostomy (PCN) placement in infants and young children.nnnMATERIALS AND METHODSnBetween January 2000 and December 2015, 57 patients had a total of 66 fluoroscopically guided PCN placement procedures. There were 37 boys and 20 girls with a mean age 8.6±15.3 (SD) months (range: 1 day-75.5months). The most common underlying disease was upper-urinary-tract obstruction, including ureteropelvic-junction stenosis (27/66, 40.9%) and ureterovesical-junction stenosis (16/66, 24.2%). Technical success, complications, clinical effectiveness, and radiation exposure were retrospectively analyzed. Technical success was defined as completion of PCN catheter in the renal calyx or proximal ureter. Complications were graded in severity using the Common Terminology Criteria for Adverse Event (version 4.03). Clinical effectiveness was evaluated with presence of decompression of the hydronephrosis on follow-up ultrasonography.nnnRESULTSnAll PCN placement procedures were technically successful. A total of 37 complications were identified in 33/37 procedures (89.2%), with transient gross hematuria (n=28) being most common (mean hematuria duration 2.2±1.4 [range: 1-6] days), which were grade 1 Postprocedural fever occurred after eight procedures; four and three patients were graded 1 and 2, respectively. Complete hydronephrosis decompression was achieved in 35/53 kidneys (66%), incomplete hydronephrosis decompression in 17/55 kidneys (32.1%), and progression of hydronephrosis was noted in 1/55 kidney (1.9%). Dose-area-product (DAP) was 44.86±89 (SD) (range: 3.7-464) μGycm2 and cumulative dose was 10.3±20.4 (SD) (range: 0.3-97.9) mGy.nnnCONCLUSIONnPCN is a feasible and effective treatment option to relieve urinary obstruction, and can serve as a bridging procedure until definitive corrective surgery in pediatric patients.

Bleeding after dilatation and curettage: the efficacy of transcatheter uterine artery embolisation.

AIMnTo evaluate safety and clinical outcomes of uterine artery embolisation (UAE) for bleeding after dilatation and curettage (D&C) performed for abortion or termination.nnnMATERIALS AND METHODSnThe outcomes were analysed in 11 patients who underwent UAE for bleeding after D&C for missed abortions (n=8), caesarean scar pregnancies (n=2), or planned termination (n=1) between October 2001 and December 2013. Angiograms and medical records were retrospectively reviewed in order to obtain the patients baseline characteristics, technical/clinical success rate, complications, and follow-up data regarding menstruation.nnnRESULTSnTechnical success, defined as successful catheterisation of both uterine arteries with embolisation to haemostasis, was 100%, whereas clinical success, defined as cessation of bleeding after the initial session of UAE and without the need for additional UAE or surgery for the purpose of haemostasis, was 81.8% (nine of 11). In the two patients with clinical failure due to recurrent vaginal bleeding after UAE, one patient underwent repeat UAE and showed a successful outcome, whilst the other patient required hysterectomy with pathological results of placenta increta. Two other patients underwent hysterectomy for placenta percreta or hydatidiform mole-mimicking remnant placenta. None of the patients included in the present series had procedure-related complications. Menstruation resumed in all eight patients with an intact uterus during the mean follow-up period.nnnCONCLUSIONnUAE may be a safe and effective treatment for bleeding after D&C, especially for women who wish to preserve their fertility; however, hysterectomy may be indicated for patients with a placental abnormality.

Covered airway stent placement for malignant tracheobronchial strictures in patients with an endotracheal tube

AIMnTo evaluate the technical feasibility and safety of covered airway stent placement for malignant tracheobronchial strictures in patients with an endotracheal tube.nnnMATERIALS AND METHODSnData regarding retrievable, expandable, metal stent placement under fluoroscopic guidance in 20 patients with an endotracheal tube inserted for malignant tracheobronchial strictures were retrospectively analysed. The clinical effectiveness was assessed using the following variables: technical and clinical success; procedure and stent-related complications; and duration of intubation following stent placement.nnnRESULTSnStent placement was technically successful in all 20 patients (100%), and with 19 of the 20 patients (95%) showing symptomatic improvement within 5 days. The endotracheal tube could be removed during (n=7) or after (n=12) stent placement, and the mean duration of intubation following stent placement was 1.4 days (range 0-3 days). One patient could not have his endotracheal tube removed and he died 9 days following stent placement in an intubated state. There were no procedure-related complications. Stent-related complications in three patients included partial (n=2) and complete (n=1) stent migration, all of which were managed with placement of a second stent (n=2) or stent removal and placement of a second stent (n=1).nnnCONCLUSIONnCovered airway stent placement under fluoroscopic guidance in patients with an endotracheal tube inserted for malignant tracheobronchial strictures, is both technically feasible and safe.