Yung-Jen Ho

Emergent Transcatheter Arterial Embolization in Hemodynamically Unstable Patients With Blunt Splenic Injury

RATIONALE AND OBJECTIVES Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury. MATERIALS AND METHODS In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture. RESULTS Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications. CONCLUSIONS TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.

Children with Chest Pain Visiting the Emergency Department

BACKGROUND Chest pain is a common complaint in children visiting the emergency department (ED). True organic problems like cardiac disease are rare. We assess and analyze the etiology of chest pain among children visiting a pediatric ED in one medical center. METHODS We retrospectively reviewed the medical records of children with chest pain who visited our ED between September 2002 and June 2005. Any case of trauma-associated chest pain was excluded from this study. RESULTS A total of 103 patients (64 boys, 39 girls; mean age, 13 years; age range, 4-17 years) were enrolled into this study; 101 patients had chest radiograms (98.1%). Pneumonia was identified in five patients and pneumothorax in three. Eighty-seven patients had electrocardiogram study (84.5%) and four of them showed abnormalities. Additional diagnostic tests were performed in 64 patients (62.1%), including complete blood count analysis and echocardiography. Echocardiograms were performed in 15 (14.6%) patients. Six of them showed minor abnormality. Panendoscopy was done in six (5.8%) patients, and gastroesophageal reflux was found in three. Eleven (10.7%) patients were admitted to hospital because of pneumonia, pneumothorax or arrhythmia. Overall, idiopathic chest pain was the most common diagnosis (59.2%). Other associated disorders were pulmonary (24.3%), musculoskeletal (6.7%), gastrointestinal (5.8%), cardiac (2.0%) and miscellaneous (2.0%). CONCLUSION The most common cause of chest pain prompting a child to visit the ED is idiopathic chest pain. Careful physical examination can reveal important clues and save much unnecessary examinations.

Computed tomographic imaging in determining the need of embolization for high-grade blunt renal injury.

BACKGROUND It is well documented that transarterial embolization (TAE) can successfully stop bleeding in renal trauma patients and reduce the failure rate of conservation treatment. However, there is no consensus on the indications for TAE. The aim of this study was to evaluate the criteria for computed tomography (CT) to predict the need for TAE for patients with high-grade blunt renal trauma. METHODS Of the 137 patients with blunt renal trauma between 2005 and 2010, 81 had a high-grade injury (grade ≥3) with stable hemodynamics, who were treated conservatively, were included in the study. CT criteria included contrast extravasation (CE), perirenal hematoma rim distance (PRD), and extent of hematoma. The patients were divided into two groups according to the extent of hematoma on CT, as either Group 1 with localized hematomas or Group 2 with extensive hematomas. We compared the CT and angiographic findings and examined the correlation between patient management and outcome. The CT criteria, alone or in combination, for predicting the subsequent requirement for TAE were evaluated. RESULTS Of the 81 patients, 35 were in Group 1 and 46 were in Group 2, with 35 having CE. The 22 patients who received TAE were all in Group 2 and had CE. Mean PRD was larger for the patients who received TAE than for those who did not. CE, extent of hematoma, and PRD correlated significantly with the need for TAE (all p < 0.001). Overall, the combination of CT criteria for CE and extent of hematoma showed the highest accuracy for predicting the need for TAE. CONCLUSION CE, extent of hematoma, and PRD were simple and sensitive indicators of patients who required TAE. The combination of CE criteria and extent of hematoma markedly increased the predictive value for predicting the need for TAE. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Preoperative Diagnosis of Right Paraduodenal Hernia by Multidetector Computed Tomography

Right paraduodenal hernia is an unusual congenital malformation that causes intestinal obstruction. It is seldom diagnosed preoperatively and a small bowel follow-through series is the best diagnostic method. However, multidetector computed tomography (MDCT) can be an alternative diagnostic method. We report the first case of right paraduodenal hernia that was diagnosed preoperatively by MDCT. A 15-year-old boy presented with right lower abdominal pain, nausea and vomiting. Abdominal MDCT with coronal reformation images clearly revealed encapsulated small bowel loops in the right side of the abdomen and displacement of the ascending colon to the left side. He received surgical repair and recovered uneventfully.

Child With Ataxia Telangiectasia Developing Acute Myeloid Leukemia

An 11-year-old boy, who was diagnosed as having ataxia telangiectasia (AT) at 5 years of age, was referred to our hospital because of a right submandibular progressive enlarged mass for 2 months. He also suffered from being unstable to stand and recently had twisting of the trunk and tremor in all areas of his body. On physical examination, the patient looked pale and had multiple cervical lymphadenopathies and telangiectasia of the bulbar conjunctiva. His gums easily bled, and he had mild gingival hypertrophy. No hepatosplenomegaly or mucocutaneous petechiae were noted. Neurologic examination revealed nystagmus, squint, dysarthric speech, diminished reflexes, dysmetria, and ataxic gait. Laboratory investigations showed leukocytosis, anemia, and thrombocytopenia (WBC count 28,500/ L; platelets 59,000/ L; hemoglobin 5.2 g/L; hematocrit 27.5%). Biochemistry tests revealed ALT of 27 U/L, AST of 29 U/L, blood urea nitrogen of 9 mg/dL, creatinine of 0.5 mg/dL, and lactate dehydrogenase of 352 U/L. The -fetoprotein level was high (242 ng/mL). There were decreased levels of immunoglobulin (Ig) A (6.67 mg/dL) and IgE ( 0.1 mg/dL). Electrophysiologic study showed mild to moderate motorpredominant spinal motor pathology with sensory involvement. Brain magnetic resonance images revealed isolated cerebellar atrophy with small size of vermis (Fig 1). The ventricles were all normal. Analysis of the ATM gene revealed compound heterozygous mutation (2413 C to T, arg805ter; 1402-3 del AA, lys468fs). Bone marrow examination showed hypercellularity with an excess of blastic cells (80% to 85%) with primitive nuclear morphology, little cytoplasm, easily discernible nucleoli, and distinct nuclear membrane and markedly depleted hematopoietic cells (Fig 2). These blasts were positive in peroxidase stain (Fig 3) but negative in periodic acid-Schiff stain. Flow cytometric analysis of the bone marrow aspirate revealed the following: CD13, 42.51%; CD33, 77.33%; CD34, 43.64%; HLA-DR, 34.71%; and negative for Band T-cell markers. The karyotype of the bone marrow cells was 45,XY, 7, 10,t(12;14)(p11.2;q32), 14, 22. Acute myeloid leukemia (AML) was diagnosed. After AML was diagnosed, the patient received chemotherapy according to the Taiwan Pediatric Oncology Group AML-97A protocol. Induction treatment consisted of cytarabine (100 mg/m, continuous infusion, days 1 to 7) and idarubicin (9 mg/m, intravenous push, days 1 to 3). Intrathecal methotrexate (15 mg) was administered on day 1. However, the patient did not achieve remission after two courses of induction therapy and consequently died as a result of severe pneumonia. Fig 2.

Hepatic Artery Reconstruction in Living Donor Liver Transplantation: Running Suture Under Surgical Loupes by Cardiovascular Surgeons in 180 Recipients

OBJECTIVES The aim of our study was to retrospectively investigate the outcomes of hepatic artery (HA) reconstruction by cardiovascular surgeons in adult-to-adult living donor liver transplantation (A-A LDLT). METHODS From April 2007 to April 2011, 187 recipients underwent A-A LDLT. After excluding seven ABO-incompatible transplant recipients, we reviewed the courses of 180 patients including 125 men and 55 women of mean age 52.5±9.2 years (range=23-71). One hundred seventy-seven patients received right-lobe grafts with inclusion of middle hepatic vein (MHV); two, right-lobe grafts without MHV; and one, left-lobe graft. A continuous, single-stitch, running suture with the parachute technique was used for HA reconstruction. The anastomosis was performed by cardiovascular surgeons employing surgical loupes with 4.5× magnification. RESULTS The mean time for an arterial reconstruction was 10.7±4.0 minutes (median=10, range=4-30). Hepatic arterial thrombosis (HAT) was encountered in 3 (1.66%) patients. One HAT that developed on postoperative day 1 was successfully rescued by the intra-arterial infusion of urokinase. Another patient required reoperation due to a redundant kinked HA. A third HAT patient underwent successful retransplantation with a cadaveric graft on postoperative day 6. In our series, no delayed HAT was detected and no recipient deaths were related to HAT. CONCLUSION HA reconstruction with a running suture under surgical loupes is a feasible technique in A-A LDLT. A speedy reconstruction can be performed by an experienced cardiovascular surgeon with a low incidence of HAT.

A high model for end-stage liver disease score should not be considered a contraindication to living donor liver transplantation

OBJECTIVE To analyze the outcomes of patients with high Model for End-Stage Liver Disease (MELD) scores who underwent adult-to-adult live donor liver transplantation (A-A LDLT). MATERIALS AND METHODS From September 2002 to October 2010, a total of 152 adult patients underwent A-A LDLT in our institution. Recipients were stratified into a low MELD score group (Group L; MELD score≤30) and a high MELD score group (Group H; MELD score>30) to compare short-term and long-term outcomes. RESULTS Of the 152 adult patients who underwent A-A LDLT, 9 were excluded from the analysis because they received ABO-incompatible grafts. Group H comprised 23 and Group L 120 patients. The median follow-up was 21.5 months (range, 3 to 102 m). The mean MELD score was 15.6 in Group L and 36.7 in Group H. There were no significant differences in the mean length of stay in the intensive care unit (Group L: 3.01 days vs Group H: 3.09 days, P=.932) or mean length of hospital stay (Group L: 17.89 days vs. Group H: 19.91 days, P=0.409). There were no significant differences in 1-, 3-, or 5-year survivals between patients in Groups L versus H (91.5% vs 94.7%; 86.4% vs 94.7%; and 86.4% vs 94.7%; P=.3476, log rank). CONCLUSION The short-term and long-term outcomes of patients with high MELD scores who underwent A-A LDLT were similar to those of patients with low MELD scores. Therefore, we suggest that high MELD scores are not a contraindication to LDLT.

Pulmonary actinomycosis with remote lower chest wall involvement in an immunocompetent child

Pulmonary actinomycosis is rare in children and is commonly confused with other chronic suppurative lung disease or with malignancy because of its non-specific clinical presentation. The diagnosis is dependent on either the characteristic histologic findings of sulfur granules or the isolation of actinomyces on culture. A long course of penicillin is the treatment of choice. There have been a few reports on children with primary pulmonary actinomycosis in recent 10 years, but coincident remote lower chest wall involvement has never been reported. We report here a 10-year-old immunocompetent girl presenting with chest pain and pulmonary infiltrate, who was found to have pulmonary actinomycosis with remote chest wall involvement. Computed tomography (CT) as an adjunct in diagnosis is also discussed.

Innovative Technique to Reconstruct Two Branches of the Right Hepatic Artery in Living Donor Liver Transplantation

Hepatic arterial thrombosis is a critical complication in living donor liver transplantation (LDLT). Two separate branches of the right hepatic artery (RHA) are sometimes observed and addressed by anastomosis of the larger branch first, then checking backflow from the smaller branch. If not good, the smaller branch must be reconstructed. We used the cystic artery as a conduit for the reconstruction. Meticulous dissection was performed to identify all branches of the hepatic artery in the donor operation. The length of cystic artery preserved was as long as possible. The cystic arterial stump was anastomosed to the stump of the posterior branch the of RHA under microscopic guidance on the back table. Patency was checked through the stump of the anterior branch of the RHA. With this technique, only one orifice, the stump of right anterior hepatic artery, was used for hepatic artery reconstruction. We have performed this technique in two patients. Both had good arterial flow after living donor liver transplantation. This innovative technique is easy and safe, and requires only one anastomosis, which, in theory, decreases the adds of developing hepatic arterial thrombosis.

Fatal Duodenal Hemorrhage Complicated After Living Donor Liver Transplantation: Case Report

Fatal hemorrhage caused by duodenal ulcer is rarely seen after liver transplantation. We report a case with penetrating duodenal ulcer resulting in massive gastrointestinal tract hemorrhage from a ruptured pseudoaneurysm of the hepatic artery. The patient, a 54-year-old man, had undergone living donor liver transplantation with a graft from his son. Massive hematelnesis occurred 7 days after transplantation. Endoscopy revealed a penetrating duodenal ulcer. Repeated episodes of hemorrhage resulted in shock. Angiography showed a ruptured pseudoaneurysm of the proper hepatic artery. Embolization controlled the bleeding; however, the grafted liver became ischemic. The patient subsequently developed ischemic cholangitis, which was treated with percutaneous transhepatic cholangial drainage. Repeat transplantation was performed 30 months later. The patient was doing well at 10-month follow-up.