A case of stent-graft implantation for postpancreaticoduodenectomy hemorrhage in a patient with a reconstructed gastric tube.

In patients with a reconstructed gastric tube, the right gastroepiploic artery is a very important feeding artery of the tube, which must be preserved when performing a pancreaticoduodenectomy. A 76-year-old man with a reconstructed gastric tube underwent pancreaticoduodenectomy for distal bile duct carcinoma. On postoperative day 8, he had an arterial hemorrhage from a drain, apparently from a ligation of the anterior superior duodenal artery. He, therefore, underwent stent-graft placement in the gastroduodenal artery. The stent-grafts were temporarily occluded, and the gastric tube was necrotizing. However, thrombolytic therapy allowed the stent-grafts to reopen and prevented gastric tube necrosis. We believe our case of stent-graft implantation in the gastroduodenal artery is the first of this kind to successfully prevent lethal necrosis of the gastric tube.

Acute Unilateral Isolated Oculomotor Nerve Palsy in an Adult Patient with Influenza A.

An otherwise healthy 44-year-old woman exhibited isolated unilateral oculomotor nerve palsy accompanied by an influenza A infection. An intra-orbital MRI scan revealed that her right third intracranial nerve was enlarged and enhanced. She recovered completely during the first month after treatment with oseltamivir phosphate. Although intracranial nerve disorders that result from influenza infections are most frequently reported in children, it is noteworthy that influenza can also cause focal intracranial nerve inflammation with ophthalmoparesis in adults. These disorders can be diagnosed using intra-orbital MRI scans with appropriate sequences and through immunological assays to detect the presence of antiganglioside antibodies.

Comparisons of I-123 diagnostic and I-131 post-treatment scans for detecting residual thyroid tissue and metastases of differentiated thyroid cancer.

OBJECTIVE: We assessed the performance of 37 MBq I-123 as a diagnostic imaging agent in patients with differentiated thyroid cancer using comparisons with their corresponding high-dose post-treatment I-131 scans. METHODS: We reviewed diagnostic I-123 whole-body scans and post-treatment I-131 scans of 69 patients who underwent I-131 therapy for differentiated thyroid carcinoma (47 papillary and 22 follicular). Diagnostic scans were performed 24 h following the oral administration of 37 MBq of I-123. I-131 doses were administered 3 days after the I-123 diagnostic scans using 2.22-7.4 GBq (median = 5.55 GBq). All images for diagnostic I-123 scans and the corresponding post-treatment I-131 scans were interpreted by consensus of at least 2 experienced radiologists. They evaluated the accumulations of radioiodine in the following 5 sites: thyroid bed, cervical and mediastinal lymph nodes, lung, bone and others. The concordance rates between I-123 scans and I-131 scans were calculated. RESULTS: A total of 108 sites were identified on the post-treatment I-131 scans. Seventy-seven sites (71%) were also identified on the I-123 diagnostic scans. The concordance rates between I-123 diagnostic scans and I-131 post-treatment scans were high for thyroid bed and bone metastases (89 and 86%, respectively), while they were low for lymph node and lung metastases on post-treatment scans (61 and 39%, respectively). CONCLUSIONS: Diagnostic scanning with relatively low dose I-123 is not always predictive of subsequent therapeutic I-131 uptake, especially for lymph node and lung metastases of differentiated thyroid cancer.

Diagnostic whole-body scanning before radioiodine therapy for pulmonary metastases of differentiated thyroid cancer: predictive value and recommendations.

RATIONALE: Radioiodine therapy improves the survival of patients with pulmonary metastases of differentiated thyroid cancer (DTC). It is controversial whether the diagnostic whole-body I-131 scan (DWS) before therapy is essential. We determined whether DWS could predict the efficacy of I-131 therapy for pulmonary metastases. METHODS: We undertook a retrospective review of records of 42 patients (28 women and 14 men, mean age 52.7 years). The patients had received 62 rounds of I-131 therapy for lung metastases of DTC at our institution between June 2002 and June 2006. On the same day that the DWS (dose of 185 MBq) (5 mCi) was completed, the patient received I-131 therapy (dose of 3700-7400 MBq) (100-200 mCi). Post-therapy whole-body scans (PWS) were performed after 3 to 4 days and 7 to 8 days. For all therapies, chest CT images were obtained before I-131 therapy, and 3 and 6 months after therapy for evaluation of therapeutic effectiveness. In addition, serum thyroglobulin (Tg) values were measured before and after the radioiodine therapy for all treatments. RESULTS: In the group demonstrating I-131 accumulation for pulmonary metastases on DWS, 72% of patients showed a reduction of pulmonary metastases on follow-up CT. On the other hand, in the group that failed to accumulate I-131 on DWS, only 5% of patients showed a reduction of pulmonary metastases. After therapy, serum Tg levels decreased significantly in the group that initially showed accumulation of I-131 in DWS (P = 0.045). In contrast, no remarkable changes between pre- and post-therapy Tg levels were observed in patients who failed to accumulate I-131 in DWS. CONCLUSION: A whole-body I-131 diagnostic scan before I-131 therapy has a predictive value for the efficacy of therapeutic radioiodine treatment for pulmonary metastases of differentiated thyroid cancer.

Endovascular management of ruptured pancreaticoduodenal artery aneurysms associated with celiac axis stenosis.

The purpose of this study was to assess the efficacy of transcatheter arterial embolization for ruptured pancreaticoduodenal artery (PDA) aneurysms associated with celiac axis stenosis (CS). Seven patients (four men and three women; mean age, 64; range, 43-84) were treated with transcatheter arterial embolization between 2002 and 2007. They were analyzed with regard to the clinical presentation, radiological finding, procedure, and outcome. All patients presented with sudden epigastric pain or abdominal discomfort. Contrast-enhanced CT showed a small aneurysm and retroperitoneal hematoma around the pancreatic head in all patients. The aneurysms ranged from 0.3 to 0.9 cm in size. In one patient, two aneurysms were detected. The aneurysms were located in the pancreaticoduodenal artery (n = 5) and the dorsal pancreatic artery (n = 3). Embolization was performed with microcoils in all aneurysms (n = 8). N-Butyl 2-cyanoacrylate (n = 1) and gelatine particle (n = 1) were also used. Complete occlusion was achieved in four patients. In the other three patients, a significantly reduced flow to the aneurysm remained at final angiography. However, these aneurysms were thrombosed on follow-up CT within 2 weeks. And there was no recurrence of the symptoms and bleeding during follow-up (mean, 28 months; range, 5-65 months) in all patients. In conclusion, transcatheter arterial embolization for PDA aneurysms associated with CS is effective. Significant reduction of the flow to the aneurysm at final angiography may be predictive of future thrombosis.