Kichang Han

Metachronous colorectal cancer.

Objective  Although the diagnosis of metachronous colorectal cancer have increased, due primarily to improvements in diagnostic modalities, the potential risk factors for these tumours are not well known. We compared the characteristics of patients with metachronous and sporadic primary colorectal cancer to determine risk factors for its occurrence.

Radiofrequency Ablation in the Treatment of Unresectable Intrahepatic Cholangiocarcinoma: Systematic Review and Meta-Analysis

The purpose of this study was to perform a meta-analysis and systematic review of the clinical efficacy and safety of radiofrequency (RF) ablation in the treatment of intrahepatic cholangiocarcinoma (ICC). A comprehensive literature search of Ovid MEDLINE and EMBASE identified studies describing the use of RF ablation in the treatment of ICC. Data describing overall survival, local tumor progression, and complications were collected. Seven observational studies that comprised 84 patients were reviewed. The pooled 1-year, 3-year, and 5-year survival rates were 82% (95% confidence interval [CI], 72%-90%), 47% (95% CI, 28%-65%), and 24% (95% CI, 11%-40%). One or 2 major complications occurred in 4 studies, and 1 patient died of liver abscess and subsequent sepsis despite treatment with percutaneous drainage and antibiotics. RF ablation is a locoregional treatment option that prolongs survival rates in patients with ICC who are ineligible for surgery.

Subprosthetic Pannus after Aortic Valve Replacement Surgery: Cardiac CT Findings and Clinical Features

PURPOSE To investigate the cardiac computed tomographic (CT) findings and clinical implications of subprosthetic pannus in patients who have undergone aortic valve replacement. MATERIALS AND METHODS The institutional review board approved this retrospective study, and the need to obtain written informed consent was waived. From April 2011 to March 2012, 88 patients (mean age, 63 years; 45 men) with a prosthetic aortic valve who underwent cardiac CT were retrospectively selected. Dynamic cardiac CT images were analyzed by using a multiplanar reformatted technique. The presence or absence of subprosthetic pannus and its extent were evaluated at cardiac CT. The geometric orifice area and the effective orifice area of each prosthetic valve were measured to enable analysis of the pannus encroachment ratio in the systolic phase. Hemodynamic parameters at echocardiography, including mean transprosthetic pressure gradient (MTPG), were compared between patients with and those without pannus. The encroachment ratio and the MTPG were correlated by using the Spearman test to evaluate the relationship between the two variables. RESULTS Seventeen patients (19%) had subprosthetic pannus at cardiac CT. In patients with subprosthetic pannus, MTPG, peak pressure gradient, transvalvular peak velocity, and left ventricular ejection fraction (LVEF) were significantly higher than in patients without pannus (MTPG: 28.1 mm Hg ± 19.8 [standard deviation] vs 14.0 mm Hg ± 6.5, P = .004; peak pressure gradient: 53.1 mm Hg ± 38.4 vs 26.1 mm Hg ± 11.4, P = .004; transvalvular peak velocity: 3.3 m/sec ± 1.3 vs 2.5 m/sec ± 0.5; and LVEF: 64.7% ± 7.4 vs 56.8% ± 10.5, P = .004). A high MTPG (≥40 mm Hg) was observed in four patients at echocardiography, and subprosthetic panni were identified at CT in all four patients. In patients with increased MTPGs, the encroachment ratio by subprosthetic pannus at CT was significantly higher than that in patients with MTPGs of less than 40 mm Hg (42.7 ± 13.3 vs 7.6 ± 3, P = .012). CONCLUSION Cardiac CT revealed subprosthetic pannus to be a cause of the hemodynamic changes in patients who had undergone aortic valve replacement. By helping quantify the encroachment ratio by pannus, cardiac CT may help differentiate which subprosthetic panni might lead to substantial flow limitation over the prosthetic aortic valve.

Afferent Loop Syndrome: Treatment by Means of the Placement of Dual Stents

OBJECTIVE The purpose of this article is to assess the technical feasibility and clinical effectiveness of the placement of partially covered self-expandable dual stents in patients with afferent loop syndrome. MATERIALS AND METHODS Data from 13 consecutive patients who had undergone partially covered dual stent placement for afferent loop syndrome after various types of surgery were retrospectively analyzed. Nine patients underwent stent placement via the percutaneous transhepatic biliary drainage tract, and four patients underwent placement via the peroral route. A total of 16 stents were used in this study (i.e., 15 dual stents and one fully covered esophageal stent). RESULTS The route of stent insertion was determined on the basis of each patients general condition, the site of obstruction, anatomic variations, and associated symptoms. Stent placement was technically successful in all patients. After stent placement, 12 of 13 patients experienced normalization of their abnormal biliary laboratory findings and decompression of the dilated bowel loop, whereas the remaining patient showed no change. This patient had to undergo the additional treatment of surgical jejunojejunostomy. No procedure-related complications occurred in any patients enrolled in this study. CONCLUSION Placement of partially covered dual stents appears to be a promising technique that may offer successful palliation for patients who develop afferent loop syndrome after various types of surgery.

Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review.

The natural history of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal (approximately 2-4 mo), and PVTT is reportedly found in 10%-40% of HCC patients at diagnosis. According to the Barcelona Clinic Liver Cancer (BCLC) Staging System (which is the most widely adopted HCC management guideline), sorafenib is the standard of care for advanced HCC (i.e., BCLC stage C) and the presence of PVTT is included in this category. However, sorafenib treatment only marginally prolongs patient survival and, notably, its therapeutic efficacy is reduced in patients with PVTT. In this context, there have been diverse efforts to develop alternatives to current standard systemic chemotherapies or combination treatment options. To date, many studies on transarterial chemoembolization, 3-dimensional conformal radiotherapy, hepatic arterial chemotherapy, and transarterial radioembolization report better overall survival than sorafenib therapy alone, but their outcomes need to be verified in future prospective, randomized controlled studies in order to be incorporated into current treatment guidelines. Additionally, combination strategies have been applied to treat HCC patients with PVTT, with the hope that the possible synergistic actions among different treatment modalities would provide promising results. This narrative review describes the current status of the management options for HCC with PVTT, with a focus on overall survival.

Transcatheter Arterial Chemoembolization for Infiltrative Hepatocellular Carcinoma: Clinical Safety and Efficacy and Factors Influencing Patient Survival

Objective To evaluate the safety and efficacy of transcatheter arterial chemoembolization (TACE) in patients with infiltrative hepatocellular carcinoma (HCC) and to identify the prognostic factors associated with patient survival. Materials and Methods Fifty two patients who underwent TACE for infiltrative HCC were evaluated between 2007 and 2010. The maximum diameter of the tumors ranged from 7 cm to 22 cm (median 15 cm). Of 46 infiltrative HCC patients with portal vein tumor thrombosis, 32 patients received adjuvant radiation therapy for portal vein tumor thrombosis after TACE. Results The tumor response by European Association for the Study of the Liver criteria was partial in 18%, stable in 47%, and progressive in 35% of the patients. The median survival time was 5.7 months (Kaplan-Meier analysis). The survival rates were 48% at six months, 25% at one year, and 12% at two years. In the multivariable Cox regression analysis, Child-Pugh class (p = 0.02), adjuvant radiotherapy (p = 0.003) and tumor response after TACE (p = 0.004) were significant factors associated with patient survival. Major complications occurred in nine patients. The major complication rate was significantly higher in patients with Child-Pugh B than in patients with Child-Pugh A (p = 0.049, χ2 test). Conclusion Transcatheter arterial chemoembolization can be a safe treatment option in infiltrative HCC patients with Child Pugh class A. Child Pugh class A, radiotherapy for portal vein tumor thrombosis after TACE and tumor response are good prognostic factors for an increased survival after TACE in patients with infiltrative HCCs.

Demonstration of Prosthetic Aortic Valve Dehiscence in a Patient With Noninfectious Aortitis by Multimodality Imaging Findings of Echocardiography and Computed Tomography

A 43-year-old man who had undergone aortic valve replacement (St. Jude Medical) for aortic regurgitation 9 years ago, presented to the emergency department with a sudden onset of chest pain. He began to have intermittent squeezing chest pain when he tried to lift a heavy object 2 weeks ago. When he arrived at our hospital, he reported chest pain persisting for >30 minutes. Electrocardiography and laboratory evaluation showed no evidence of myocardial ischemia (Figure 1). On physical examination, body temperature of 36.0°C, blood pressure of 167/77 mm Hg, and a holodiastolic murmur were noted. Peripheral stigmata of endocarditis were not found. He had no history of night sweats and weight loss. C-reactive protein was 0.14 mg/dL (normal range, <0.6 mg/dL), and the white blood cell count was 6100/μL. Blood culture was negative. Transthoracic echocardiography revealed the rocking motion (Movie I in the online-only Data Supplement) of the prosthetic aortic valve and severe paravalvular leakage (Figure 2; Movies II and III in the online-only Data Supplement). The pressure half-time of paravalvular regurgitation was 193 ms. Holodiastolic flow reversal in the descending thoracic aorta suggesting severe regurgitation was also found. On transesophageal echocardiography, the location of the paravalvular leakage was the …

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature

Cirrhosis-related chylothorax and chylous ascites are rare conditions. The pathophysiologic mechanism of cirrhosis-related chylous fluid collections is believed to be excessive lymph flow resulting from portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established method for reducing portal hypertension. The case of a 61-year-old man with cirrhosis-related chylothorax treated successfully with a TIPS is described. A systematic review of the literature revealed nine additional cases of chylothorax or chylous ascites treated successfully with a TIPS. These cases showed that TIPS creation may be effective and safe for the treatment of chylous fluid collections in patients with cirrhosis.

Prostatic Arterial Embolization for Control of Hematuria in Patients with Advanced Prostate Cancer

Nine patients with advanced prostate cancer (stage T4) underwent prostatic arterial embolization (PAE) for refractory prostatic hematuria. Angiograms showed prostatic neovascularity in all cases, and complete PAE was achieved in 8 cases (89% technical success rate). Gross hematuria ceased after PAE in 6 cases, translating to a 67% clinical success rate. There were no PAE-related complications. At 3-month follow-up, 2 cases showed recurrent hematuria, 4 patients had died from PAE-unrelated etiologies, and only 3 patients survived and were without gross hematuria. PAE could represent an alternative option for patients with advanced prostate cancer to control hematuria.

Transcatheter Arterial Embolization of Angiographically Visible and Occult Renal Capsular Artery Hemorrhage in 28 Patients

PURPOSE To evaluate the effectiveness and safety of transcatheter arterial embolization to control bleeding from the renal capsular artery (RCA). MATERIALS AND METHODS Embolization was performed in 28 patients (14 men; mean age, 49.7 y). Presence and type of previous invasive procedures, initial presentation, and coagulation profile were reviewed. Any preceding abdominal computed tomography (CT) findings were analyzed. Angiographic findings were categorized as active bleeding, suspicious for bleeding, or no bleeding. Technical and clinical success and clinical outcomes were evaluated. Changes in hemoglobin level and transfusion volume of packed red blood cells (pBRCs) before and after embolization were evaluated with the paired t test and Wilcoxon signed-rank test, respectively. RESULTS Technical and clinical success rates of therapeutic embolization for active bleeding (n = 11) were 90.9% and 80%, respectively. One case of technical failure (5.9%) and 3 cases of postembolization bleeding (18.7%) were noted in the prophylactic embolization group in patients with suspicion of bleeding (n = 13) or no bleeding (n = 4). Transient renal insufficiency occurred in 4 patients (14.3%). The average hemoglobin level and volume of transfused pBRCs changed from 8.1 g/dL to 9.9 g/dL and from 871 mL to 543 mL, respectively (P < .05). Extravasation of contrast media or acute hematoma in the right subhepatic or perirenal space on CT was noted in 21 patients (78%). CONCLUSIONS Embolization can provide an effective and safe method to control RCA bleeding. Perirenal invasive procedures and signs of active or recent right subhepatic or perirenal hemorrhage should raise the suspicion of an RCA source.