Kiyoshi Matsueda

Radiologic placement of side-hole catheter with tip fixation for hepatic arterial infusion chemotherapy.

PURPOSE To investigate the technical outcome of radiologic catheter placement with use of a side-hole catheter with distal fixation for hepatic arterial infusion chemotherapy. MATERIALS AND METHODS Between January 1993 and September 1999, 426 patients were referred to our department to undergo intraarterial infusion chemotherapy for unresectable malignant liver tumors. A subclavian artery was exposed under local anesthesia and a catheter was inserted. After inserting the tip of the side-hole catheter into the gastroduodenal artery, splenic artery, or peripheral branch of the hepatic artery, the catheter tip was fixed to the vessel with use of coils and a mixture of n-butyl cyanoacrylate (NBCA) and iodized oil. The proximal end of the catheter was connected to an implanted port, and the port system was embedded subcutaneously. RESULTS Placement was successful in 425 of 426 patients (99.8%) in a mean time of 76 minutes. Catheter dislodgement was noted in 12 patients (2.8%). Cumulative patency rates of the hepatic artery calculated according to the Kaplan-Meier method for the entire group were 91.0%, 81.4%, and 58.1% at 6 months and 1 and 2 years, respectively. Complications related to catheter placement were observed in nine cases and included dysfunction of the implanted system (n = 3), significant bleeding around the implanted port (n = 2), improper infusion of NBCA and iodized oil (n = 2), and cerebral infarction (n = 2). CONCLUSION Radiologic catheter placement via a subclavian artery with side-hole catheter placement with distal fixation for hepatic arterial infusion chemotherapy is a highly successful procedure with a reduced risk of catheter dislodgment and arterial occlusion.

Right Gastric Artery Embolization to Prevent Acute Gastric Mucosal Lesions in Patients Undergoing Repeat Hepatic Arterial Infusion Chemotherapy

PURPOSE The purpose of the study was to investigate the technical outcome and clinical effect of right gastric artery (RGA) embolization to prevent acute gastric mucosal lesions caused by influx of anticancer agents into the RGA in patients undergoing repeat hepatic arterial infusion chemotherapy (HAIC). MATERIALS AND METHODS In 217 patients with malignant hepatic tumors, we attempted RGA embolization with use of metallic coils and/or a mixture of n-butyl cyanoacrylate (n-BCA) and iodized oil, along with the embolization of the gastroduodenal artery. After this procedure, an infusion catheter was placed radiologically and HAIC was performed. We then evaluated the technical outcome and clinical effect of RGA embolization. RESULTS RGA embolization was technically successful in 201 of 217 patients (93%). Major complications--nausea, epigastric pain, and fever--were noted in 12%, 4%, and 2% of successful cases, respectively, and were treated conservatively. Recanalization occurred in 4% (nine of 201) of the patients. Eventually, sufficient RGA embolization was achieved in 192 patients. The incidence of acute gastric mucosal lesions confirmed endoscopically was only 3% (five of 192) in patients with sufficient RGA embolization, whereas it was 36% (nine of 25) in patients without sufficient RGA embolization, with a significant difference (P <.01). CONCLUSION RGA embolization is a highly feasible procedure that can reduce the incidence of acute gastric mucosal lesions associated with HAIC.

Post-TIPS hepatic encephalopathy treated by occlusion balloon-assisted retrograde embolization of a coexisting spontaneous splenorenal shunt

A 51-year-old man with posthepatitis cirrhosis underwent a transjugular intrahepatic portosystemic shunt (TIPS) for bleeding of recurrent esophageal varices. The patient had a coexisting, spontaneous, splenorenal shunt. He subsequently developed hepatic encephalopathy, presumably due to excessive portosystemic shunting. Since medical management resulted in no significant improvement, the splenorenal shunt was embolized from the jugular vein approach via renal vein access during temporary balloon occlusion. Within a few days, the patients hepatic encephalopathy resolved. Twelve months later the patient showed no recurrence of encephalopathy and had maintained a patent TIPS.

Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation.

Splenic vein ligation may result in sinistral (left‐sided) portal hypertension and gastrointestinal haemorrhage. The aim of this study was to analyse the pathogenesis of sinistral portal hypertension following splenic vein ligation in pancreaticoduodenectomy.

Routine Preoperative Liver-specific Magnetic Resonance Imaging Does Not Exclude the Necessity of Contrast-enhanced Intraoperative Ultrasound in Hepatic Resection for Colorectal Liver Metastasis.

Objectives: To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) during surgery for colorectal liver metastases (CRLM) when gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid–enhanced magnetic resonance imaging (EOB-MRI) is performed as a part of preoperative imaging work-up. Background: EOB-MRI is expected to supersede CE-IOUS, which is reportedly indispensable in surgery for CRLM. Methods: One hundred consecutive patients underwent EOB-MRI, contrast-enhanced computed tomography (CE-CT), and contrast-enhanced ultrasound within 1 month before surgery for CRLM. Conventional IOUS and subsequent CE-IOUS using perflubutane were performed after the laparotomy. All the nodules identified in any of the preoperative or intraoperative examinations were resected and were submitted for histological examination, in principle. Results: Preoperative imaging examinations identified 242 nodules; 25 additional nodules were newly identified using IOUS, 22 additional nodules were newly identified during CE-IOUS, and a histological examination further identified 4 nodules. Among the 25 nodules newly identified using IOUS, all 21 histologically proven CRLMs and 3 of the 4 benign nodules were correctly diagnosed using CE-IOUS. Among the 22 nodules newly identified using CE-IOUS, 17 nodules in 16 patients were histologically diagnosed as CRLMs. The planned surgical procedure was modified on the basis of IOUS and CE-IOUS findings in 12 and 14 patients, respectively. The sensitivity, positive-predictive value, and accuracy of CE-IOUS were 99%, 98%, and 97%, respectively. Those values of EOB-MRI (82%, 99%, 83%, respectively) were similar to CE-CT (81%, 99%, 81%, respectively). Conclusions: CE-IOUS is useful in hepatic resection for CRLM, even if EOB-MRI and CE-CT are performed.

CT fluoroscopy for lung nodule biopsy: a new device for needle placement and a phantom study.

Abbreviation: CTF computed tomography fluoroscopy A computed tomography fluoroscopy (CTF) system provides real-time reconstruction and display of CT images, and is used to monitor nonvascular interventional procedures (1–4). There are several merits of a CTF system compared with a conventional CT system. One is realtime monitoring of a target and a needle, and another is that CTF unit can be controlled by a physician in the CT room. These merits potentially enable more precise placement a needle and shorter procedure time. A disadvantage of this system is direct irradiation to the physician’s hand. To avoid this, surgical forceps are used to manipulate a needle (5); also, a special needle holder (Kato device, Fig 1) was developed by Kato et al (6). Both devices hold the needle perpendicular to their axis. However, with use of these devices, precise needle placement is sometimes difficult and/or tactile feedback from the resistance of the needle cannot be perceived. We developed a device for the assistance of needle placement under CTF, and the purpose of this article is to clarify how to best use CTF and to examine and compare our device with the Kato device using a phantom of the human thoracic cage. We also studied whether it was possible to complete all portions of lung nodule biopsy within a single breath holding.

Pancreatogram findings for carcinoma in situ (CIS) of the pancreas seen on endoscopic retrograde cholangiopancreatography and postoperative pancreatography of resected specimens: can CIS be diagnosed preoperatively?

Background/Aims: From 1992 to 2003, 7 carcinomata in situ (CIS) were incidentally discovered during microscopical observation of resected materials for advanced carcinomas of peripancreatic organs, of which 4 had undergone endoscopic retrograde cholangiopancreatography (ERCP) or postoperative pancreatography of the resected specimen (POP). In addition, 7 of 79 invasive ductal carcinomata (IDC) of the pancreas were accompanied by CIS ≧2 cm long. A total of 11 patients were reviewed here for pancreatographic findings for CIS of the pancreas. Methods: All resected pancreatobiliary materials were sliced serially at 5- to 8-mm intervals in a plane at right angles to the main pancreatic duct, referring to POP images. Results: Irregularity (I), non-continuous narrowing (N), granular defects (G), and dilatation (D) were seen in 78, 67, 33 and 22% on ERCP, respectively, and in 90, 70, 60 and 40% on POP, respectively. Conclusions: I, N, G, and D are most important pancreatographic findings in ERCP and highly suggestive of CIS of the pancreas, so that whenever they are encountered, cytological and/or pathological examination of the pancreatic duct should be actively performed.

Malignant mucosal melanoma of the eustachian tube

Malignant mucosal melanoma is a rare condition. Although the head and neck region is the most common site for mucosal melanoma, a melanoma arising in the eustachian tube is rare. Here we present a case of mucosal melanoma arising in the right eustachian tube.

Transcatheter arterial embolization for external iliac artery hemorrhage associated with infection in postoperative pelvic malignancy

Transcatheter arterial embolization was attempted for external iliac artery (EIA) hemorrhage in five patients with wound infection after pelvic malignant tumor surgery. To prevent distal migration of coils and to preserve distal branches of the EIA, the entire weakened artery was occluded with use of coils via a bilateral femoral artery approach with balloon occlusion of the distal side. The success rate was 100%. No limb loss was observed immediately after embolization. This method can prevent distal migration of coils and preserve branches that can be collaterals to the femoral artery, and as such it can be used to embolize an adequate portion of the affected artery.

Clinical Outcome of Biliary Drainage for Obstructive Jaundice Caused by Colorectal and Gastric Cancers

OBJECTIVE To clarify the prognostic factors for patients with obstructive jaundice due to advanced colorectal and gastric cancers who had undergone percutaneous transhepatic biliary drainage. METHODS Baseline variables and clinical outcomes were evaluated for 92 consecutive patients treated with percutaneous transhepatic biliary drainage. RESULTS Of the 92 patients, 32 (35%) had colorectal cancer and the remaining 60 (65%) had gastric cancer. Percutaneous transhepatic biliary drainage was successfully achieved in 74 (80%) patients, and 39 of them could receive subsequent chemotherapy. The median survival after percutaneous transhepatic biliary drainage was 273 days in the 39 patients who had undergone successful percutaneous transhepatic biliary drainage and subsequent chemotherapy, 65 days in 35 patients who had undergone successful percutaneous transhepatic biliary drainage but who had not received subsequent chemotherapy and 34 days in the remaining 18 patients who had undergone unsuccessful percutaneous transhepatic biliary drainage (P < 0.001). Multiple liver metastases and hepatic hilar bile duct stricture were independently associated with unsuccessful percutaneous transhepatic biliary drainage. Poor performance status, multiple liver metastases, presence of ascites, multiple prior chemotherapy administrations, undifferentiated type histology and high serum CA19-9 level were independently associated with a poor prognosis. A prognostic index calculated based on the number of these six factors was used to classify the patients into a good-risk group (index ≤2) (n = 56) and a poor-risk group (index ≥3) (n = 36). The median survival time and 2-month survival rate for the two groups were 163 and 44 days, respectively, and 85.7 and 33.3%, respectively (P < 0.001). CONCLUSIONS As regards the introduction of percutaneous transhepatic biliary drainage in patients with obstructive jaundice due to colorectal and gastric cancers, careful patient selection might be necessary. A prognostic model seems to be useful for making decisions as to whether percutaneous transhepatic biliary drainage is indicated for particular patients.