Sundeep Punamiya

Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma.

Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia–Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio‐frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia–Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.

Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy.

Percutaneous cholecystostomy (PC) is an established treatment for high surgical risk patients with acute cholecystitis. This paper studies factors predictive of mortality and eventual cholecystectomy.

Role of TIPS in Improving Survival of Patients with Decompensated Liver Disease

Liver cirrhosis is associated with higher morbidity and reduced survival with appearance of portal hypertension and resultant decompensation. Portal decompression plays a key role in improving survival in these patients. Transjugular intrahepatic portosystemic shunts are known to be efficacious in reducing portal venous pressure and control of complications such as variceal bleeding and ascites. However, they have been associated with significant problems such as poor shunt durability, increased encephalopathy, and unchanged survival when compared with conservative treatment options. The last decade has seen a significant improvement in these complications, with introduction of covered stents, better selection of patients, and clearer understanding of procedural end-points. Use of TIPS early in the period of decompensation also appears promising in further improvement of survival of cirrhotic patients.

Aortoenteric Fistula Treated With Endovascular Aortic Stent-Graft and Bilateral Chimney Stent-Grafts to Renal Arteries

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.

Endoscopic ultrasound forum summary from the asian pacific digestive week 2012

Pradermchai Kongkam, Benedict M. Devereaux, Ryan Ponnudurai, Thawee Ratanachu-ek, Anand V. Sahai, Takuji Gotoda, Suthep Udomsawaengsup, Jacques Van Dam, Nonthalee Pausawasdi, Somchai Limsrichemrern, Dong-Wan Seo, Shomei Ryozawa, Yoshiki Hirooka, Yongyut Sirivatanauksorn, Siyu Sun, Sundeep Punamiya, Takao Itoi, Bancha Ovartlanporn, Ichiro Yasuda, Tiing Leong Ang, Hsiu-Po Wang, Khek Yu Ho, Heng Boon Yim, Kenjiro Yasuda, Christopher J.L. Khor

Management of Blunt Traumatic Thoracic Aorta Injuries With Endovascular Stent-Grafts in a Tertiary Hospital in an Urban Asian City

BACKGROUND Thoracic aortic injury from blunt trauma is a life-threatening condition with significant mortality and morbidity with open surgical repair. Endovascular means of treatment is emerging as an attractive and less invasive option. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. METHODS Between January 2003 and August 2009, six patients underwent endovascular repair of blunt traumatic thoracic aorta injury. Data from the medical records of these patients were analyzed. RESULTS All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at the aortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who had been involved in road-traffic accidents and two had fallen from a height. The mean Injury Severity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours of admission and technical success was 100%. Five patients (83.3%) had the left subclavian artery intentionally covered by the stent-graft to achieve adequate proximal landing zone. None of them had any left upper limb ischemic complications or cerebrovascular events after the procedure. One patient had preservation of the left subclavian artery because intraoperative vertebral angiogram showed a hypoplastic right vertebral artery. No other procedural complications, paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months). CONCLUSIONS Our early experience of endovascular stent-grafting for blunt traumatic thoracic aorta injury suggests that this emerging technique is safe for treatment of such pathology in our inherently Asian population. Left subclavian artery may be sacrificed if adequate proximal landing zone is required for the stent-graft; and when vertebral angiogram was performed which did not show a dominant left vertebral artery.

Critical limb ischaemia in a diabetic population from an Asian Centre: angiographic pattern of disease and 3-year limb salvage rate with percutaneous angioplasty as first line of treatment.

Purpose: Lower extremity amputation prevention (LEAP) is an ongoing program in our institution aimed at salvaging limbs in patients with critical limb ischemia (CLI). Patients in the LEAP program with reconstructible anatomy on initial Doppler imaging received either bypass surgery or percutaneous transluminal balloon angioplasty (PTA). We present the 3 year limb salvage rate and angiographic disease patterns in 42 consecutive diabetic patients with CLI who received PTA in 2005. Methods and Material: 26 women and 16 men with diabetes between the ages of 45 and 91 years old (mean age, 70.8 years) received PTA in 2005. Presenting symptoms were rest pain (n = 22), pre-existing gangrene (n = 17), non-healing ulcer (n = 16) and cellulitis (n = 2). The aim of the PTA was to achieve straight-line flow from the abdominal aorta down to the patent dorsalis pedis or plantar arch, with limb salvage as the ultimate outcome. Failure of treatment was defined as any amputation above the level of a Syme’s amputation or the need for further surgical bypass. Technical success was achieved in 90% (38 out of 42 patients). Results: Limb salvage rates were 93% at 1 month, 87% at 3 months, 82% at 6 months, 78% at 1 year, 69% at 2 years and 66% at 3 years. Mortality was 17% (n = 7) at 3 years. Of the 13 patients with failed therapy, 3 underwent bypass, 9 had amputations and 1 had bypass followed by amputation. Four of the cases required further intervention due to worsening gangrene and infection, while the remaining was due to persistent rest pain. The rest of the 32 patients had no lower limb related issues at the end of 3 years, with improvement of the presenting symptoms. Patterns of treated segments were aortoiliac occlusions (n = 3), pure infrapopliteal disease (n = 3), femoropopliteal with at least 1 good infrapopliteal run-off vessel (n = 14) and combined femoropopliteal and infrapopliteal disease (n = 25). Conclusion: Involvement of infrapopliteal vessels that needs to be treated is common in Asian diabetics. While early limb salvage rates up to 1 year are similar, the 3 year limb salvage rates in Asian diabetics are lower than the western population.

Interventional radiology in the management of portal hypertension

From being a mere (though important) diagnostic tool, radiology has evolved to become an integral part of therapy in portal hypertension today. Various procedures are currently available, the choice depending on the etiology and location of disease, the pathoanatomy, and the symptomatology. The main aim of any procedure is to reduce the portal pressure by either direct or indirect methods. This can be achieved with transjugular intrahepatic portosystemic shunt (TIPS), recanalization of the hepatic vein outflow, recanalization of the portal vein and its tributaries, recanalization of dysfunctional portosystemic shunts, partial splenic embolization, and embolization of arterioportal shunts. When any of these procedures cannot be performed due to anatomical or physiological reasons, the symptoms can often be controlled effectively with embolization of varices or balloon-occluded retrograde transvenous obliteration of varices (BRTO). This article briefly describes the procedures, their results, and their current status in the treatment of portal hypertension.

Use of StarClose Device under Ultrasound Guidance in Inadvertent Carotid Artery Puncture.

evidence of thrombosis, bleeding, or hematoma was found. When the patient presented at the clinic 8 days later for his first visit after the procedure, his swelling had gone down significantly. In-office ultrasound demonstrated patency of the stents and the left femoral vein and right common femoral vein at the access sites. Access site venous bleeding can lead to longer hospital stays, pain, and immobility (1,2), so mitigating this risk has significant value. A few prior studies suggested that vascular closure devices are effective in closing venous access sites even in anticoagulated patients (3,4). The VASCADE device successfully closed the two venous punctures in this case effectively and quickly. Potential advantages of the VASCADE closure device in the venous system include the lack of a thrombogenic intravascular component, a radiopaque disc allowing accurate positioning, and the ability to close holes made by a 10-F (and potentially larger) sheath. The VASCADE vascular closure device is promising; however, further studies are needed to assess the benefits and risks of the VASCADE device in venous access site closure.

Percutaneous Nephrostomy and Antegrade Ureteric Stenting

Symptoms of upper urinary tract obstruction include flank or abdominal pain, nausea, vomiting, and fever (if urinary tract infection); seldom aysmptomatic (incidentally diagnosed on imaging or during evaluation of urinary tract infection). If obstruction involves a solitary functioning kidney or both kidneys simultaneously, symptoms of acute renal failure (oliguria/anuria, nausea, vomiting, pedal edema, and altered sensorium) may be noted. May also be complicated by symptoms related to electrolyte imbalance and acidosis.