Jinoo Kim

Evaluation of portal hypertension by real-time shear wave elastography in cirrhotic patients.

To assess the correlation between liver stiffness measurement (LSM) by real‐time shear wave elastography (SWE) and hepatic venous pressure gradient (HVPG) and to investigate the diagnostic performance of SWE for predicting clinically significant and severe portal hypertension (CSPH and SPH).

Severe Portal Hypertension in Cirrhosis: Evaluation of Perfusion Parameters with Contrast-Enhanced Ultrasonography

Objective To investigate the role of contrast-enhanced ultrasonography (CEUS) and Doppler ultrasonography (DUS) in the diagnosis of severe portal hypertension (PH) in patients with liver cirrhosis (LC). Methods Patients with PH scheduled to receive hepatic venous pressure gradient (HVPG) measurement were recruited for this study. Hepatic DUS and CEUS were performed successively. Several Doppler and CEUS parameters were explored for correlation with HVPG values and their association with severe PH (≥ 12 mmHg of HVPG). Comparison of the parameters between the severe and non-severe PH groups and their correlation with HVPG values was evaluated. A receiver operating characteristic (ROC) curve analysis was also performed to investigate the performance in order to diagnose severe PH. Results Fifty-three consecutive patients were enrolled in this study. Among them, 43 patients did not have significant ascites. Compared with the non-severe PH group, portal venous velocity and intrahepatic transit time (ITT) were significantly reduced in the severe PH group (all p<0.05). Difference between inspiratory and expiratory hepatic venous damping indices (ΔHVDI), hepatic venous arrival time (HVAT) and ITT moderately correlated with HVPG (r = -0.358, -0.338, and -0.613, respectively). Areas under the curves for severe PH were 0.94 of ITT and 0.72 of HVAT, respectively (all p<0.05). ITT under 6 seconds indicated severe PH with a sensitivity of 92% and a specificity of 89%. Conclusions Hepatic CEUS may be more useful in estimating the HVPG value and determining the presence of severe PH compared to DUS, and ITT was the most accurate parameter to diagnose severe PH.

Lymphatic Embolization for the Treatment of Pelvic Lymphoceles: Preliminary Experience in Five Patients

PURPOSE To retrospectively assess the outcome of lymphatic embolization in the treatment of pelvic lymphoceles. MATERIALS AND METHODS From July 2014 to December 2015, a retrospective analysis was performed in 5 consecutive female patients (mean age, 54.6 y; range, 45-65 y) who underwent lymphangiography for the management of symptomatic pelvic lymphoceles that developed after gynecologic surgery. Sclerotherapy had failed in 4 patients. Lymphangiography was performed through an inguinal lymph node to reveal disrupted lymphatic vessels draining into the lymphocele. This inflow vessel was targeted with a fine needle, and N-butyl cyanoacrylate (NBCA) was injected. Outcomes and complications were assessed by reviewing electronic medical records and computed tomography (CT). RESULTS Lymphangiography revealed disrupted lymphatic vessels draining into the lymphocele in all patients. A single inflow vessel was seen in 3 patients and was subsequently embolized. Catheters were successfully removed upon decrease of drainage. Multiple inflow vessels were seen in the remaining 2 patients. Therapeutic effect was anticipated in 1 patient after lymphangiography alone, whereas only the dominant feeding vessel was embolized in the other. The initial procedures failed in both patients, prompting repeat embolization with adjunctive sclerotherapy. Both patients showed improvement and had their catheters removed. Follow-up CT was available in 3 patients. Two patients showed complete regression of lymphoceles, and 1 showed an asymptomatic lymphocele. No procedure-related complications occurred during a mean follow-up period of 35 weeks (range, 2-73 wk). CONCLUSIONS Lymphatic intervention was technically feasible in treating lymphoceles. However, those with multiple inflow vessels were relatively difficult to treat.

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate

OBJECTIVE To evaluate the safety and feasibility of N-butyl cyanoacrylate (N-BCA) embolization of percutaneous transhepatic portal venous access tract and to establish an appropriate technique. METHODS 40 consecutive patients underwent percutaneous transhepatic portal venous intervention for various reasons. Embolization of percutaneous transhepatic portal venous access tract was performed after the procedure in all of the patients using N-BCA and Lipiodol® (Lipiodol Ultra Fluide; Laboratoire Guerbet, Aulnay-sous-Bois, France) mixture. Immediate ultrasonography and fluoroscopy were performed to evaluate perihepatic haematoma formation and unintended embolization of more than one segmental portal vein. Follow-up CT was performed, and haemoglobin and haematocrit levels were checked to evaluate the presence of bleeding. RESULTS Immediate haemostasis was achieved in all of the patients, without development of perihepatic haematoma or unintended embolization of more than one segmental portal vein. Complete embolization of percutaneous access tract was confirmed in 39 out of 40 patients by CT. Seven patients showed decreased haemoglobin and haematocrit levels. Other complications included mild pain at the site of embolization and mild fever, which resolved after conservative management. 16 patients died during the follow-up period owing to progression of the underlying disease. CONCLUSION Embolization of percutaneous transhepatic portal vein access tract with N-BCA is feasible and technically safe. With the appropriate technique, N-BCA can be safely used as an alternate embolic material since it is easy to use and inexpensive compared with other embolic materials. ADVANCES IN KNOWLEDGE This is the first study to investigate the efficacy of N-BCA for percutaneous transhepatic portal venous access tract embolization.

Percutaneous Treatment of Chylous Ascites

Chylous ascites occurs as a result of lymphatic leakage, which contains high concentration of triglycerides. The leakage is caused by various benign or malignant etiologies ranging from congenital lymphatic abnormality to trauma. Lymphangiography has been shown to be effective in the diagnosis of lymphatic leakage and has also been reported to have therapeutic outcome. The development of intranodal technique for lymphangiography has recently made the procedure more widespread. As an adjunctive procedure, percutaneous embolization may be performed which involves use of embolic agents such as N-butyl cyanoacrylate and coil to occlude the leak. Embolization in the lymphatic system was first made popular by the introduction of thoracic duct embolization by Cope et al and has recently led to the development of various techniques for percutaneous embolization. This article reviews the options and techniques for percutaneous treatment of lymphatic leaks in patients presenting with chylous ascites.

Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization

Objective To evaluate risk factors for massive lymphatic ascites after laparoscopic retroperitoneal lymphadenectomy in gynecologic cancer and the feasibility of treatments using intranodal lymphangiography (INLAG) with glue embolization. Methods A retrospective analysis of 234 patients with gynecologic cancer who received laparoscopic retroperitonal lymphadenectomy between April 2006 and November 2015 was done. In June 2014, INLAG with glue embolization was initiated to manage massive lymphatic ascites. All possible clinicopathologic factors related to massive lymphatic ascites were determined in the pre-INLAG group (n=163). Clinical courses between pre-INLAG group and post-INLAG group (n=71) were compared. Results In the pre-INLAG group (n=163), four patients (2.5%) developed massive lymphatic ascites postoperatively. Postoperative lymphatic ascites was associated with liver cirrhosis (three cirrhotic patients, p<0.001). In the post-INLAG group, one patient with massive lymphatic ascites had a congestive heart failure and first received INLAG with glue embolization. She had pelvic drain removed within 7 days after INLAG. The mean duration of pelvic drain and hospital stay decreased after the introduction of INLAG (13.2 days vs. 10.9 days, p=0.001; 15.2 days vs. 12.6 days, p=0.001). There was no evidence of recurrence after this procedure. Conclusion Underlying medical conditions related to the reduced effective circulating volume, such as liver cirrhosis and heart failure, may be associated with massive lymphatic ascites after retroperitoneal lymphadenectomy. INLAG with glue embolization can be an alternative treatment options to treat leaking lymphatic channels in patients with massive lymphatic leakage.

A QoS Provisioning Technique in a Residential Gateway using Heterogeneous Network Access Technology

We propose a packet scheduling algorithm for an efficient transmission in a residential gateway used in the home network. The packet scheduling algorithm is modeled by the hybrid method that is a QoS technique based on the parameterized QoS method and the prioritized QoS method. We applied the prioritized QoS technique to earliest deadline first scheme. We proposed a QoS parameter mapping scheme that can be used in the home network using the heterogeneous access technology. We also proposed the fairness scheme for IEEE 1394. The access technologies such as IEEE 802.11 WLAN, IEEE 1394, and Ethernet are considered for the QoS algorithm mapping scheme. Finally, we evaluate the performance of the proposed QoS provisioning technique by using the simulation. The simulation results show that the proposed schemes are a good candidate for the home network.

Hepatic Venous Pressure Gradient Predicts Long-Term Mortality in Patients with Decompensated Cirrhosis.

Purpose The present study aimed to investigate the role of hepatic venous pressure gradient (HVPG) for prediction of long-term mortality in patients with decompensated cirrhosis. Materials and Methods Clinical data from 97 non-critically-ill cirrhotic patients with HVPG measurements were retrospectively and consecutively collected between 2009 and 2012. Patients were classified according to clinical stages and presence of ascites. The prognostic accuracy of HVPG for death, survival curves, and hazard ratios were analyzed. Results During a median follow-up of 24 (interquartile range, 13-36) months, 22 patients (22.7%) died. The area under the receiver operating characteristics curves of HVPG for predicting 1-year, 2-year, and overall mortality were 0.801, 0.737, and 0.687, respectively (all p<0.01). The best cut-off value of HVPG for predicting long-term overall mortality in all patients was 17 mm Hg. The mortality rates at 1 and 2 years were 8.9% and 19.2%, respectively: 1.9% and 11.9% with HVPG ≤17 mm Hg and 16.2% and 29.4% with HVPG >17 mm Hg, respectively (p=0.015). In the ascites group, the mortality rates at 1 and 2 years were 3.9% and 17.6% with HVPG ≤17 mm Hg and 17.5% and 35.2% with HVPG >17 mm Hg, respectively (p=0.044). Regarding the risk factors for mortality, both HVPG and model for end-stage liver disease were positively related with long-term mortality in all patients. Particularly, for the patients with ascites, both prothrombin time and HVPG were independent risk factors for predicting poor outcomes. Conclusion HVPG is useful for predicting the long-term mortality in patients with decompensated cirrhosis, especially in the presence of ascites.

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam–based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up

OBJECTIVE To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)-based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). METHODS A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan- Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child-Pugh classification) were analysed by univariate logistic regression. RESULTS HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21-21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83-66.29) during 10 sessions and 68.0% (95% CI, 67.62-88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors. CONCLUSION In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE. ADVANCES IN KNOWLEDGE In patients who underwent three or more sessions of cisplatin and Gelfoam-based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.

Plasma MicroRNA-21, 26a, and 29a-3p as Predictive Markers for Treatment Response Following Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma

Background We investigated an association between the levels of plasma microRNA (miRNA)-21, -26a, and -29a-3p and treatment outcomes following transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). Methods A total of 198 patients with TACE-treated HCC were followed up for TACE refractoriness and liver transplantation (LT)-free survival. Pretreatment plasma miRNA-21, -26a, and -29a-3p levels were measured using quantitative real-time polymerase chain reaction. Results During the mean follow-up of 22.3 (range, 0.7–79) months, 118 (59.6%) patients exhibited TACE refractoriness. Multivariate analyses showed that expression of a specific combination of miRNAs (miRNA-21 ≥ 2.5, miRNA-26a ≥ 1.5, and miRNA-29a-3p < 0.4) was associated with early TACE refractoriness (within 1 year; hazard ratio [HR], 2.32; 95% confidence interval [CI], 1.08–4.99; P = 0.031) together with tumor size (HR, 4.62; 95% CI, 1.50–14.21; P = 0.008), and macrovascular invasion (HR, 3.80; 95% CI, 1.19–12.20; P = 0.025). However, miRNA-21, -26a, and -29a-3p levels were not significantly associated with overall TACE refractoriness or LT-free survival. Additionally, large tumor size and macrovascular invasion were common predictive factor of overall TACE refractoriness and survival. Conclusion Combination of plasma miRNA-21, -26a, and -29a-3p expression could predict early TACE refractoriness in patients with TACE-treated HCC.