Richard Maher

Four‐dimensional computed tomography for parathyroid localization: a new imaging modality

Four‐dimensional computed tomography (4DCT) is a new parathyroid localization technique not previously reported in Australia. It provides both functional and anatomical imaging in a single test, with superior sensitivity compared with sestamibi scintigraphy (SeS). This study examines the utility of 4DCT in defined clinical situations.

The Role of Minimally Invasive Percutaneous Embolisation Technique in the Management of Bleeding Stomal Varices

IntroductionStomal varices can develop in patients with ostomy in the setting of portal hypertension. Bleeding from the stomal varices is uncommon, but the consequences can be disastrous. Haemorrhage control measures that have been described in the literature include pressure dressings, stomal revision, mucocutaneous disconnection, variceal suture ligation and sclerotherapy. These methods may only serve to temporise the stomal bleeding and have a high risk of recurrent bleed. While transjugular intrahepatic porto-systemic shunting has been advocated as the treatment of choice in patients with underlying liver cirrhosis, histoacryl glue or coil embolisation has been successfully employed in patients who are not suitable candidates for TIPS.Methods and ResultsDirect percutaneous embolisation of the dominant varices was performed successfully under ultrasound and fluoroscopic guidance in two patients using a combination of coils and histoacryl glue.ResultsWhile transjugular intrahepatic porto-systemic shunting has been advocated as the treatment of choice in patients with underlying liver cirrhosis, histoacryl glue or coil embolisation has been successfully employed in patients who are not suitable candidates for TIPS.ConclusionDirect percutaneous embolisation is a safe and effective treatment for stomal varices in selected patients.

Cocaine-induced myocardial injury seen as multiple mid-wall foci of late enhancement by contrast-enhanced cardiac magnetic resonance imaging

A previously well 26-year-old man presented with severe retrosternal chest pain. There were no associated symptoms, and no relationship of the pain to inspiration, exertion, or posture. He was a frequent user of cocaine, most recently 48 h prior to presentation. Initial cardiac enzymes were substantially elevated [creatine kinase level 710 U/L (normal range 40–300 U/L) and troponin I 10.3 µg/L (normal value <0.14 µg/L)] but rapidly returned to normal values. Twelve-lead electrocardiogram showed biphasic T-waves in the inferolateral leads. Computed tomography of the coronary and pulmonary arteries was normal. Cardiac magnetic resonance …

Intra-arterial infusion and chemo-embolization for melanoma liver metastases.

This article will review the rationale for hepatic arterial administration of agents to treat melanoma liver metastases, the techniques and practical considerations pertinent to hepatic arterial therapy, the variety of agents that have been used and the reported outcomes. Recent and emerging developments will be highlighted and the potential role of liver-directed therapies in the context of molecular advances and improved systemic therapy will be discussed. J. Surg. Oncol. 2014 109:376–382.

Syringomyelia: A rare extracardiac contributor to syncope detected incidentally by CMR

We describe an extracardiac finding of syringomyelia in CMR study of a patient who was being investigated to exclude an infiltrative cause for presumptive cardiogenic syncope. Extension of a syrinx to involve the sympathetic structures in the intermediolateral column of the spinal cord can lead to well-recognised autonomic disturbances including Horners syndrome. Autonomic control of the heart has also been shown to be impaired in patients with syringomyelia. We investigated a 20 year old man presented with a history of recurrent syncope triggered by pain, micturition and defaecation. The cardiac MRI findings were normal, however close inspection of the scout images was suggestive of a lower thoracic spinal cord syrinx - a finding later confirmed by dedicated spinal MRI. Subsequent neurological investigations were essentially normal. We suggest that syringomyelia-induced disruption of sympathetic fibres in the thoracic spinal cord is a plausible, but rare mechanism of syncope.

Endovascular stenting of mesenterico-portal vein stenosis to reduce blood flow through venous collaterals prior to pancreatoduodenectomy

BackgroundWhen the mesenterico-portal vein is stenosed due to tumor related compression, venous collaterals develop and flow occurs antegrade towards the portal vein through the collateral tributaries. Undertaking pancreatoduodenectomy for pancreatic cancer in this setting may result in significant blood loss during the process of ligation of these tributaries.Description of techniqueWe describe the technique of endovascular stenting of the mesenterico-portal vein to reduce flow within these collateral tributaries and hence blood loss, to facilitate extended pancreatoduodenectomy and vein resection.ConclusionPercutaneous transhepatic placement of endovascular stent into a stenotic mesentero-portal vein facilitates pancreatoduodenectomy by reducing operative time, which would otherwise be required in dealing with the extensive venous collaterals and hence also reducing blood loss.

Portal vein embolization prior to major liver resection

Portal vein embolization (PVE) induces compensatory hypertrophy of the future liver remnant volume (FLRV) to improve the safety of major liver surgery by reducing the risk of post‐operative liver failure. The aim was to describe our experience of PVE for patients with large or multifocal malignant liver tumours who initially were deemed unresectable.

A multireferral centre retrospective cohort analysis on the experience in treatment of metastatic uveal melanoma and utilization of sequential liver-directed treatment and immunotherapy

Metastatic uveal melanoma is a rare malignancy with a poor prognosis. To date, systemic therapy has been ineffective; however, there are few data on the benefits of anti-CTLA4 or anti-PD-1 antibodies in sequence with liver-directed therapy. A retrospective cohort analysis was carried out on 37 consecutive patients managed in a tertiary referral centre examining the safety and efficacy of treatment; patterns of care; and impact on survival. The sequential treatment with transarterial chemotherapy (TAC), systemic immunotherapy (IT) and systemic chemotherapy was reviewed. In all, 18 patients in the series received sequential therapy. The median overall survival (OS) was 17 months (n=37), which compared favourably with previously reported series. Patients treated with TAC first or second line had an overall progression-free survival (PFS) of 9 months (n=29) and IT PFS 7 months (n=26). The overall response rate (ORR) for TAC first line was 26% and the disease control rate (DCR) was 65% (n=23). ORR for IT first line was 7%, DCR 77% (n=14). Second-line (cross-over) IT ORR was 16%, DCR 58% (n=12). For second-line (cross-over) TAC, ORR was 50% and DCR was 66% (n=6). Toxicity was manageable. There were no cases of autoimmune hepatitis. In this retrospective small series analysis in uveal melanoma, liver-directed therapy and IT in sequence have shown to be active and reasonably well tolerated. Further prospective clinical trials should clarify the role of these treatments and their potential survival benefit.

Incremental Diagnostic Value of Magnetic Resonance Imaging in the Characterization of a Cardiac Mass

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] Metastasis of melanoma to the heart bears a poor prognosis but is often asymptomatic. A 73-year-old man with a history of malignant melanoma and pulmonary metastasis was referred for the assessment of a

Management of recurrent bleeding after pancreatoduodenectomy.

Re‐bleeding after management of a first haemorrhage following pancreatic surgery is an ever‐present danger and often presents diagnostic and management dilemmas.