Progressive atrophy in a deformed liver as a contributor to sigmoid volvulus.

The effect of a prior defect on secondary liver atrophy is unknown. We describe a case of sigmoid volvulus that was facilitated by progressive atrophy in a deformed liver. A 75-year-old man with abdominal pain and fullness was referred to our hospital. Computed tomography (CT) revealed reduced left hepatic lobe volume and a whirl sign, characteristic of sigmoid volvulus. The sigmoid volvulus was successfully detorted with endoscopy. Retrospective evaluation of liver morphology on CT and magnetic resonance imaging showed that the portal vein at the liver hilum was denuded due to a parenchymal defect of the medial segment, with compression by the crossing artery. As pulse Doppler ultrasonography demonstrated reduced portal blood flow in the region where liver atrophy developed, compression of the denuded portal vein presumably facilitated secondary atrophy and contributed to sigmoid volvulus. The present case shows that a deformed liver itself can be a cause of secondary atrophy. Therefore, continued monitoring of liver morphology and evaluation of portal blood flow to predict liver atrophy may be required, when an individual with a partial liver defect is encountered.

Spontaneous Celiac and Splenic Artery Dissection.

Dissection of the splanchnic artery unrelated to an aortic lesion is extremely rare. We describe a patient with dissection of the celiac and splenic arteries causing splenic circulatory impairment. A 55-year-old Japanese man was referred to our hospital for left back pain that suddenly occurred 3 days previously and spread to the left flank. He had complicated sleep apnea syndrome well controlled with continuous positive airway pressure, and had been prophylactically taking aspirin (100 mg/day) because of asymptomatic cerebral lacunar infarcts. Contrast-enhanced computed tomography (CT) in the arterial phase revealed dissection from the celiac root extending to the entire splenic artery, the caliber of which was irregularly narrowed, causing malperfusion in the spleen. Because of hemodynamic stability and lack of impending sequelae, the patient was carefully observed with rest, strict blood pressure control, and aspirin administration. One month later, CT revealed restoration of the caliber of the dissected arteries and regression of the organizing false lumen, which confirmed the patient's recovery. Despite the extreme rarity or nonspecific symptoms, splanchnic artery dissection should be considered a potentially life-threatening emergency. This case supports the possible benefit of starting antithrombotic treatment early to prevent thrombotic sequelae such as organ infarction and aneurysmal formation.

VEGF-A and its isoform VEGF121 mRNA expression measured by quantitative real-time RT-PCR: correlation with F-18 FDG uptake and aggressiveness of lung adenocarcinoma: preliminary study.

OBJECTIVE: To investigate the correlation of vascular endothelial growth factor (VEGF) A and its isoform VEGF121 mRNA expression with F-18 fluorodeoxyglucose (FDG) uptake and aggressiveness in lung adenocarcinoma. METHODS: Twenty-three patients with lung adenocarcinoma underwent FDG PET before surgery. As semi-quantitative analysis for FDG uptake, partial volume corrected standardized uptake value (PVC-SUV) of the tumor was calculated. Total RNA from lung adenocarcinoma tissue was prepared from the frozen specimens. Using the real-time reverse transcription polymerase chain reaction method, we analyzed the mRNA level of VEGF-A and VEGF-A isoform VEGF121 mRNA level. 18S ribosomal RNA was used as an endogenous control. RESULTS: VEGF-A and VEGF121 mRNA levels had significantly positive correlation with PVC-SUV in lung adenocarcinoma (r = 0.477, p = 0.021, r = 0.539, p = 0.008, respectively), while they were not correlated with tumor size (≤3 or >3 cm). VEGF-A and VEGF121 mRNA levels of the low FDG uptake group were significantly lower than those of the high FDG uptake group (p = 0.005 and p = 0.004, respectively). FDG uptake (PCV-SUV) of aggressive lung adenocarcinoma was higher than that of non-aggressive lung adenocarcinoma (p = 0.01). VEGF-A and VEGF121 mRNA levels of aggressive lung adenocarcinoma were higher than those of non-aggressive lung adenocarcinoma (p = 0.0001 and p = 0.0001, respectively). CONCLUSION: VEGF-A and VEGF121 mRNA levels may correlate with FDG uptake and aggressiveness in lung adenocarcinoma. These findings support the hypothesis that VEGF-A and VEGF121 may help in predicting the outcome in patients with lung adenocarcinoma.

Assessment of VEGF-D expression measured by immunohistochemical staining and F-18 FDG uptake on PET as biological prognostic factors for recurrence in patients with surgically resected lung adenocarcinoma.

OBJECTIVE: To assess whether the combined evaluation of vascular endothelial growth factor D (VEGF-D) expression and fluorodeoxyglucose (FDG) uptake correlates with lymph node metastasis and post-operative recurrence in patients with lung adenocarcinoma. METHODS: Forty-six patients with lung adenocarcinomas, who had undergone both preoperative FDG PET imaging and thoracotomy, were enrolled in this study. The surgically resected tumor specimens were used to assess the protein levels of VEGF-D as measured by immunohistochemical assay. RESULTS: The patients were divided into the following four groups: those who were VEGF-D negative and had low FDG uptake (group I, 3 patients), VEGF-D positive and had low FDG uptake (group II, 20 patients), VEGF-D negative and had high FDG uptake (group III, 13 patients), and VEGF-D positive and had high FDG uptake (group IV, 10 patients). Lymph node metastases were seen only in group III. The 5-year disease-free survival rates were 66.7% in group I, 83.9% in group II, 8.3% in group III, and 64.0% in group IV (p < 0.0001). Thus, patients in group III exhibited the most unfavorable prognoses for recurrence. In multivariate analysis, the combined evaluation of VEGF-D expression and FDG uptake was an independent parameter for post-operative recurrence (p = 0.018). CONCLUSION: A combination of low VEGF-D expression and high FDG uptake may be a biological indicator of lymph node metastasis and post-operative recurrence in patients with lung adenocarcinoma.

Efficacy of covered metallic stents in the treatment of unresectable malignant biliary obstruction.

We evaluated the efficacy of covered stents for malignant biliary obstruction. We studied 62 patients with obstruction distal to the hilar confluence who survived longer than 10 weeks and divided them into a covered stent group (group 1, n = 22), a Z stent group (group 2, n = 19), and a mesh stent group (group 3, n = 21), according to their type of the stent. Patency rates of each group were compared. Early stent revision was required after 3 days in 18% (4/22) of group 1, 26% (5/19) of group 2, and 0% (0/21) of group 3. The 10, 20, and 40-week primary patency rates were 77%, 77%, and 59% (group 1), 42%, 25%, and 8% (group 2), and 76%, 71%, and 55% (group 3), respectively. Primary patency rates of groups 1 and 3 were significantly higher than those of group 2 (p < 0.05), and there was no statistically difference between those of group 1 and group 3. The 10, 20, and 40-week assisted primary (secondary) patency rates were 96%, 96%, and 96% (group 1), 68%, 49%, and 39% (group 2), and 86%, 74%, and 58% (group 3), respectively. Assisted primary patency (secondary) rates of group 1 were significantly higher than those of groups 2 and 3 (p < 0.01 and p < 0.05, respectively). Our study suggests that the primary patency rates of the covered stents are equal to those of mesh stents, but these may be improved further if covered stents, which avoid the need for early revision, are used.

Transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma fed by the cystic artery.

PURPOSE: To evaluate the safety, technical success rate, and effectiveness of transcatheter arterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) fed by the cystic artery. MATERIALS AND METHODS: Treatment of 27 tumors in 25 patients fed by the cystic artery was attempted with TACE. Twenty-two patients had previously undergone one to eight TACE sessions (mean, four sessions), and the duration after initiation of treatment of HCC was 4-69 months (mean, 24). In three patients, parasitization of the cystic artery was revealed at initial angiography. TACE was performed only when the microcatheter could be inserted into the tumor feeding branch and the stain of the gallbladder wall disappeared. The therapeutic effects and complications were retrospectively analyzed. RESULTS: Seventeen tumors were completely fed by the cystic artery and 10 were fed by both the hepatic artery and cystic artery. Attenuation or occlusion of the hepatic artery was observed in 56%. The tumor feeding branch arising from the cystic artery could be successfully embolized in 18 tumors (67%) of 16 patients without severe complications. Adequate iodized oil accumulation was achieved in 14 tumors (52%) of 12 patients. Percutaneous therapy (n = 7), radiation (n = 4), and TACE after cholecystectomy (n = 1) were added for tumors with incomplete or unsuccessful TACE. Local progression was observed in three (21%) of 14 tumors treated by TACE alone during a mean follow-up period of 18 months. CONCLUSION: TACE via the cystic artery was safe and technically possible in 67% of patients. If adequate iodized oil accumulation is obtained, which was only achieved in 52% of patients, sufficient therapeutic effect may be expected.

Percutaneous cholecystocholedochostomy for cholecystitis and cystic duct obstruction in gallbladder carcinoma.

Percutaneous cholecystocholedochostomy was performed in a patient with acute cholecystitis caused by cystic duct obstruction by gallbladder carcinoma, but removal of the percutaneous cholecystostomy catheter was unsuccessful because of continuing discharge. After creation of a cholecystocholedochostomy through the cholecystostomy tract with use of a transjugular liver access set and a 21-gauge needle, self-expandable metallic stents were placed in the narrowed common bile duct and the newly created tract between the gallbladder and the common hepatic duct. The external cholecystostomy catheter was successfully removed after the procedure. Jaundice occurred 70 days later as a result of tumor invasion above the segment with the stent, and an additional stent was placed. The patient died of diffuse metastasis 143 days after creation of the cholecystocholedochostomy without recurrence of cholecystitis.

Abdominal aortic aneurysm with a dilated common iliac artery: treatment using a handmade bifurcated stent-graft with a wide iliac limb end.

The purpose of this study was to evaluate the usefulness of a bifurcated stent-graft with a wide iliac limb end (WILE) in the treatment of abdominal aortic aneurysm (AAA) with a dilated common iliac artery (CIA) to avoid occlusion of the internal iliac artery (IIA). The WILE, covered with an expanded polytetrafluoroethylene graft which was constructed of large diameter stents according to the individual CIA diameter, was connected to a two-piece bifurcated stent-graft covering a polyester graft. The WILE was placed in eight dilated CIAs of six patients. All but one WILE fitted the dilated CIA well. One did not fit, and coil embolization of the leak was needed. All eight IIA derived from the dilated CIA avoided occlusion. Perigraft leak due to other causes was identified in another two patients. Limb kinking was observed in two patients. Our stent is useful in the treatment of AAA with dilated CIA to avoid occlusion of the IIA, and may extend the indication of endoluminal repair of AAA.