Intractable chylous leak after radical esophagectomy treated with radiotherapy.

Postoperative chylous leak after esophagectomy is a rare but potentially life-threatening complication that results in hypovolemia, electrolyte imbalance, malnutrition, and immunologic deficiency. However, the management of postoperative chylous leak remains controversial. Following a diagnosis of esophageal cancer, a 64-year-old man was treated by video-assisted thoracoscopic esophagectomy, laparoscopic gastric tube formation, prophylactically thoracic duct ligation, and reconstruction with esophagogastrostomy at the neck level. Massive postoperative drainage from the thorax and abdomen did not initially meet the diagnostic criteria for chylothorax, which was ultimately diagnosed 3 weeks after the operation. Despite various treatments including total parenteral nutrition, octreotide and midodrine, reoperation (thoracic duct ligation and mechanical pleurodesis), and thoracic duct embolization, the chylous leak persisted. Finally, low-dose radiation therapy was administered with a daily dose of 2 Gy and completed at a total dose of 14 Gy. After this, the amount of pleural effusion gradually decreased over 2 weeks, and the last drainage tube was removed. The patient was alive and well at 60 months postoperatively. Herein, we describe a patient with intractable chylous leak after esophagectomy, which persisted despite conservative treatment, thoracic duct ligation, and embolization, but was finally successfully treated with radiotherapy.

Unusual Duodenal Ulcer: Metastatic Urothelial Carcinoma of the Renal Pelvis.

Metastatic urothelial carcinoma of the renal pelvis (MUCP), a type of metastatic upper tract urothelial carcinoma (MUTUC), is a rare malignancy, and some patients with MUCP present with distant metastasis at the time of diagnosis. MUCP in the gastrointestinal tract is even rarer. Herein, we report a 78-year-old man with MUCP that presented as a duodenal ulcer. He complained of anorexia, dizziness, and melena for one month. Endoscopic examination at a local clinic revealed a duodenal hemorrhagic and ulcerative lesion, and the patient was referred. He noted dark-colored stools with increasing frequency, but he denied hematochezia, coffee ground emesis, weight changes, or abdominal pain. Gastroduodenoscopic examination at our hospital demonstrated an ulcerofungating lesion of the second portion of the duodenum. Colonoscopic findings showed no abnormality. Computed tomography showed a 6.7 cm sized mass abutting the inferior vena cava, second portion of the duodenum, lower pole of the right kidney, and right iliopsoas. The mass showed heterogeneous enhancement and internal hemorrhagic necrosis and infiltrated the perinephric soft tissues, the second portion of the duodenum, the right psoas muscle, the right renal vein, and the right adrenal gland. Duodenal biopsy showed moderately differentiated squamous cell carcinoma. Immunohistochemistry (IHC) showed diffuse and strong positivity for CK5/6. Tissue from the liver biopsy showed similar histopathologic features and showed GATA3 positivity on IHC. The imprint cytology smears of the liver tissue showed "cercariform" cell features. We confirmed the diagnosis as MUCP. This case illustrated a rare cause of a secondary duodenal tumor, MUCP.

Association between Posttreatment Serum Platelet-to-Lymphocyte Ratio and Distant Metastases in Patients with Hepatocellular Carcinoma Receiving Curative Radiation Therapy.

BACKGROUND: We sought to investigate whether serum immune and inflammatory parameters can help to predict distant metastasis (DM) in patients with unresectable hepatocellular carcinoma (HCC) undergoing curative radiation therapy (RT). METHODS: A total of 76 RT courses were analyzed. The following variables were included in the analysis: systemic inflammation index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio (PLR), prognostic nutritional index (PNI), absolute lymphocyte count, lymphocyte-to-monocyte ratio, albumin, albumin-to-alkaline phosphatase ratio, RT-related parameters, and levels of total protein, hemoglobin, α-fetoprotein, and PIVKA-II. Distant control (DC) and overall survival (OS) rates were calculated and compared. RESULTS: The mean age was 61.4 years, and most patients were men (n = 62, 81.6%). The median RT fraction number and fractional doses were 12 (range, 4-30) and 5 (range, 2-12) Gy, respectively. With a median follow-up of 12 (range, 3.1-56.7) months, the 1-year DC and OS rates were 64.4% and 55.2%, respectively. The development of DM significantly deteriorated OS (p = 0.013). In the multivariate analysis, significant independent prognostic indicators for DC and OS rates were the highest posttreatment PLR (≤235.7 vs. >235.7, p = 0.006) and the lowest posttreatment PNI (≤25.4 vs. >25.4, p < 0.001), respectively. CONCLUSIONS: Posttreatment serum PLR might be helpfully used as a predictive biomarker of DM in unresectable HCC patients undergoing RT. Future research is necessary to confirm our findings.

[Torsion of a Myomatous Uterus in a Non-Gravid Female: A Case Report]. / ë¹„ìž„ì‹ ì—¬ì„±ì—ì„œì˜ ìžê¶ê·¼ì¢ ì— 의한 ìžê¶ì—¼ì „: 증례 ë³´ê³ .

The torsion of the uterus is a rare gynecological emergency. It occurs mainly in the gravid uterus and extremely rarely in the non-gravid uterus. In this article, we report a case of a torsion of non-gravid uterus accompanied by a huge intramural leiomyoma with focus on CT and MR imaging findings.

Monitoring Radiation Doses during Diagnostic and Therapeutic Neurointerventional Procedures: Multicenter Study for Establishment of Reference Levels.

PURPOSE: To assess patient radiation doses during diagnostic and therapeutic neurointerventional procedures from multiple centers and propose dose reference level (RL). MATERIALS AND METHODS: Consecutive neurointerventional procedures, performed in 22 hospitals from December 2020 to June 2021, were retrospectively studied. We collected data from a sample of 429 diagnostic and 731 therapeutic procedures. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time (FT), and total number of image frames (NI) were obtained. RL were calculated as the 3rd quartiles of the distribution. RESULTS: Analysis of 1160 procedures from 22 hospitals confirmed the large variability in patient dose for similar procedures. RLs in terms of DAP, CAK, FT, and NI were 101.6 Gy·cm2, 711.3 mGy, 13.3 minutes, and 637 frames for cerebral angiography, 199.9 Gy·cm2, 3,458.7 mGy, 57.3 minutes, and 1,000 frames for aneurysm coiling, 225.1 Gy·cm2, 1,590 mGy, 44.7 minutes, and 800 frames for stroke thrombolysis, 412.3 Gy·cm2, 4,447.8 mGy, 99.3 minutes, and 1,621.3 frames for arteriovenous malformation (AVM) embolization, respectively. For all procedures, the results were comparable to most of those already published. Statistical analysis showed male and presence of procedural complications were significant factors in aneurysmal coiling. Male, number of passages, and procedural combined technique were significant factors in stroke thrombolysis. In AVM embolization, a significantly higher radiation dose was found in the definitive endovascular cure group. CONCLUSION: Various RLs introduced in this study promote the optimization of patient doses in diagnostic and therapeutic interventional neuroradiology procedures. Proposed 3rd quartile DAP (Gy·cm2) values were 101.6 for diagnostic cerebral angiography, 199.9 for aneurysm coiling, 225.1 for stroke thrombolysis, and 412.3 for AVM embolization. Continual evolution of practices and technologies requires regular updates of RLs.

[Multidetector CT Findings of Solid Organ Injury Based on 2018 Updated American Association for the Surgery of Trauma Organ Injury Scaling System]. / 2018 ê°œì • ë¯¸êµ­ì™¸ìƒìˆ˜ìˆ í˜‘íšŒ ë³µë¶€ê³ í˜•ìž¥ê¸° 손상척도에 따른 다중검출 CT 소견.

The newly revised 2018 Organ Injury Scale (OIS) has a similar format to the previous American Association for Surgery and Trauma (AAST) Emergency General Surgery Grading System, dividing the criteria for grading solid organ damage into three groups; imaging, operation, and pathology. The most significant alteration in the OIS system 2018 revision is the incorporation of multidetector CT (MDCT) findings of vascular injury including pseudoaneurysm and arteriovenous fistula. Similar to the previous OIS, the highest of the three criteria is assigned the final grade. In addition, if multiple grade I or II injuries are present, one grade is advanced for multiple injuries up to grade III. This pictorial essay demonstrates the MDCT findings of solid organ injury grades based on the 2018 OIS system.

Lipiodol Pneumonitis Following Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma.

Transcatheter arterial chemoembolization (TACE) is a useful palliative therapeutic modality for hepatocellular carcinoma (HCC). Postembolization syndromes, such as fever, abdominal pain, and elevated liver enzyme levels are commonly known complications of TACE. One post-TACE pulmonary complication, lipiodol pneumonitis, is rarely reported. Lipiodol pneumonitis after TACE appears to be associated with chemical injury due to accidental perfusion of lipiodol to the lung vasculature, promoted by arteriovenous shunts within the hypervascular HCC. Here, we report a 42-year-old man with unresectable HCC and hepatic vein thrombosis. The patient was initially treated with TACE. The following day after TACE, acute respiratory symptoms such as dyspnea and cough developed with decreased oxygen saturation. Chest X-ray and computed tomography showed multiple patches and diffuse ground-glass opacities in both lung fields, suggesting of lipiodol pneumonitis. The patient's condition and radiologic abnormalities subsequently improved after 2 weeks of conservative treatment alone.

Ultrasound-Guided Percutaneous Biopsy of the Native Kidney: An Axial Approach Along Brödel Avascular Plane of the Lower Pole.

PURPOSE: This study demonstrates the feasibility and safety of the axial approach for real-time ultrasound-guided percutaneous renal biopsy along Brödel avascular plane. METHODS: In this retrospective analysis of 41 percutaneous biopsies performed from June 2014 to June 2015, patients' medical records, pathology results, complication rate, and pain score before and during the procedure were reviewed. RESULTS: The average number of sampled glomeruli was 16.1 ± 7.2 (mean ± SD). There were no major complications. The 2 minor complications, transient macrohematuria and small perirenal hematoma, occurred at a rate of 4.89% but regressed spontaneously in both cases. CONCLUSIONS: The axial approach along Brödel avascular plane is a feasible alternative approach for percutaneous biopsy of the native kidney.

Does oxygen therapy increase the resolution rate of primary spontaneous pneumothorax?

BACKGROUND: Patients with small pneumothoraces are usually treated with oxygen therapy. However, evidence that oxygen therapy increases resolution rate is based on small populations with secondary spontaneous pneumothorax. Therefore, this study aimed to confirm whether oxygen therapy increases the resolution rate of primary spontaneous pneumothorax (PSP). METHODS: We retrospectively reviewed records of patients with PSP who had undergone outpatient observation (room air group) and those who were admitted for oxygen therapy (O2 group) between March 2005 and February 2016. The initial chest posteroanterior (PA) radiograph was compared with the last chest PA radiograph before the pneumothorax disappeared. The size of the pneumothorax was measured using the Collins' method. RESULTS: A total of 175 episodes were identified in 160 patients. Of these, 128 episodes (73.1%) occurred in patients in the O2 group. The mean age was 19.24±4.74 years. The mean initial size of the pneumothorax was smaller in the room air group (23.32%±7.00% vs. 20.26%±6.78%, P=0.011). The resolution rate was higher in the O2 group [(4.27%±1.97%) vs. (2.06%±0.97%)/day, P<0.001]. The initial size of the pneumothorax, time interval between radiographs, and use of oxygen therapy were significantly associated with the resolution rate in multivariate analysis. CONCLUSIONS: Oxygen therapy increases the resolution rate of PSP. However, routine use of oxygen therapy in patients with small pneumothoraces should be considered more carefully. Well-controlled prospective studies are required to confirm the indication of oxygen therapy.

Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: A Multicenter Study.

PURPOSE: To assess patient radiation doses during cerebral angiography and embolization of intracranial aneurysms across multi-centers and propose a diagnostic reference level (DRL). MATERIALS AND METHODS: We studied a sample of 490 diagnostic and 371 therapeutic procedures for intracranial aneurysms, which were performed at 23 hospitals in Korea in 2015. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time and total angiographic image frames were obtained and analyzed. RESULTS: Total mean DAP, CAK, fluoroscopy time, and total angiographic image frames were 106.2 ± 66.4 Gy-cm(2), 697.1 ± 473.7 mGy, 9.7 ± 6.5 minutes, 241.5 ± 116.6 frames for diagnostic procedures, 218.8 ± 164.3 Gy-cm(2), 3365.7 ± 2205.8 mGy, 51.5 ± 31.1 minutes, 443.5 ± 270.7 frames for therapeutic procedures, respectively. For diagnostic procedure, the third quartiles for DRLs were 144.2 Gy-cm(2) for DAP, 921.1 mGy for CAK, 12.2 minutes for fluoroscopy times and 286.5 for number of image frames, respectively. For therapeutic procedures, the third quartiles for DRLs were 271.0 Gy-cm(2) for DAP, 4471.3 mGy for CAK, 64.7 minutes for fluoroscopy times and 567.3 for number of image frames, respectively. On average, rotational angiography was used 1.5 ± 0.7 times/session (range, 0-4; n=490) for diagnostic procedures and 1.6 ± 1.2 times/session (range, 0-4; n=368) for therapeutic procedures, respectively. CONCLUSION: Radiation dose as measured by DAP, fluoroscopy time and image frames were lower in our patients compared to another study regarding cerebral angiography, and DAP was lower with fewer angiographic image frames for therapeutic procedures. Proposed DRLs can be used for quality assurance and patient safety in diagnostic and therapeutic procedures.

Clinical results of intraarterial thrombolysis according to tPA administration and perfusion/diffusion mismatching.

BACKGROUND: IA-Tx and advanced dynamic imaging studies have been adopted for ischemic stroke patient treatment. Many patients are treated with IV-tPA, but this treatment is not always feasible. In this study, IA-Tx was used for patients for whom IV-tPA was not indicated or when IV-tPA did not result in recanalization. METHODS: A total of 156 patients treated with IA-Tx were retrospectively reviewed. Of these, 72 patients were treated with a full dose of IV-tPA before receiving the IA-Tx; the remaining 84 patients only received IA-Tx. An initial imaging study using CTA and acute stroke MRI followed. Patients' demographics and clinical results were recorded and compared according to P/D mismatching and IV-tPA. RESULTS: Among P/D-mismatched patients, the recanalization rate was 80 % and the symptomatic intracranial hemorrhage rate was 14.5 %, while among P/D-matched patients, the rates were 63 % and 41.3 % respectively (p < 0.05). A favorable clinical outcome occurred in 49.1 % of P/D-mismatched, but only in 21.7 % of P/D-matched patients (p < 0.05). Among patients who were treated with IV-tPA before undergoing IA-Tx, the recanalization rate was 79.2 % and the sICH rate was 27.8 %, while it was 71.4 % and 17.9 % in patients who did not receive IV-tPA (p < 0.05). CONCLUSIONS: Patients who have P/D mismatching and are treated with IA-Tx have higher recanalization rates and a greater probability of a favorable outcome than patients who have P/D matching and receive IA-Tx. For patients who do not undergo successful recanalization after IV-tPA or who are not indicated for IV-tPA, the authors recommend IA-Tx after undergoing appropriate imaging evaluation.

Emphysematous pyelonephritis initially presenting as a spontaneous subcapsular hematoma in a diabetic patient.

Emphysematous pyelonephritis (EPN) is a life-threatening infection characterized by the formation of gas. Complications of EPN include septic shock, acute renal failure, and disseminated intravascular coagulation. Spontaneous subcapsular hematoma (SCH) has also been reported as a rare complication of EPN, although there have been no reports to date of this occurring prior to the presentation of EPN. We report a case of EPN that initially presented as spontaneous SCH. The patient was admitted for left flank pain, and initial computed tomography revealed SCH without any air shadows. Laboratory findings and clinical symptoms suggested the presence of urinary tract infection and the patient was started on antibiotics. Fever developed 24 hours after admission. On follow-up computed tomography 7 days later, EPN was newly observed, and a percutaneous drain was inserted. Blood, urine, and drainage fluid cultures all revealed growth of extended-spectrum ß-lactamase-negative Escherichia coli.

Retrospective review of angiography before cannulation of newly created vascular accesses in hemodialysis patients.

PURPOSE: To investigate vascular access status before first cannulation and the clinical implications of angiography performed before cannulation. MATERIALS AND METHODS: A retrospective review of 300 consecutive patients who underwent angiography after vascular access surgery and before cannulation between August 2004 and April 2010 was performed. Angiography was performed 4-6 weeks after the surgery but before the first cannulation. RESULTS: Angiography revealed 94 (31.3%) cases of severe stenosis (≥ 50% luminal narrowing) that required percutaneous transluminal angioplasty (PTA) or a second operation. No stenosis was observed in 122 (40.7%) cases, and mild stenosis (< 50% luminal narrowing) was observed in 84 (28%) cases. For the 94 cases with severe stenosis, PTA was performed in 66, and a second operation was performed in 16. In the other cases (n = 12), HD was maintained by a permanent catheter, or the patients were transferred to another institution. PTA was an immediate success in all patients who underwent the procedure except two. Of 84 patients with mild stenosis, 70 were followed for 1 year; vascular access dysfunction occurred in 15, and 11 of these underwent successful PTA. Of the 122 patients with normal angiographic findings, 102 were followed for 1 year, and vascular access dysfunction did not occur in any of these patients. CONCLUSIONS: Early postoperative angiography before the first hemodialysis is helpful for the early detection and treatment of vascular access dysfunction.

Transcatheter N-butyl cyanoacrylate embolization of pseudoaneurysms.

PURPOSE: To report clinical experience with N-butyl cyanoacrylate (NBCA) for embolization of pseudoaneurysms at various locations. MATERIALS AND METHODS: Retrospective study of patients with pseudoaneurysms treated with NBCA over a 4-year period was conducted. Seventeen consecutive patients were evaluated, including three women and 14 men ranging in age from 25 to 77 years (mean, 60.6 y). NBCA was the only embolic agent used in 15 patients; in two patients, a liquid coil and a microcoil were placed before administration of NBCA. NBCA was mixed with iodized oil in a 1:3 ratio to control its polymerization time and to make it radiopaque. Diagnostic angiography and embolization were performed at the same session. Embolized sites included gastrointestinal tract (n = 6), spleen (n = 5), liver (n = 2), kidney (n = 1), chest (n = 1), oral cavity (n = 1), and buttock (n = 1). RESULTS: NBCA embolization was successful in 16 of 17 patients (94%), with complete occlusion of pseudoaneurysms. In one patient with a gastroduodenal artery stump pseudoaneurysm, NBCA embolization failed, and a stent-graft (8 mm/40 mm) was placed in the hepatic artery, excluding the pseudoaneurysm and preserving the hepatic artery. No major complications occurred, and there were no recurrences of pseudoaneurysms. CONCLUSIONS: NBCA embolization was an effective method for the treatment of pseudoaneurysms.

Small dose contrast venography as venous mapping in predialysis patients.

PURPOSE: This study was designed to evaluate radiocontrast-induced nephrotoxicity (RIN), and the image quality and findings of venography using small doses of radiocontrast as a venous mapping method in pre-dialysis patients. METHODS: Twenty-eight patients with stage 4 and 5 chronic kidney disease underwent arm venography with 10-15 ml of dilute contrast medium. Image quality, venographic findings and glomerular filtration rate (GFR) before and after the procedure were evaluated. RESULTS: Mean GFR was 19.3+/-5.8 ml/min/1.73 m2 (7-30 ml/min/1.73 m2). Image quality of venography in the forearm and upper arm veins was good in all patients. Central veins were visualized well in 26 (92.8%) patients. Eight (28.5%) patients showed cephalic veins inadequate for creation of radiocephalic arteriovenous fistula (AVF) because of occlusion or small diameter veins. There was no significant difference in GFR between the pre- and post-study (19.3+/-5.8 vs. 19.2+/-6.2 ml/min/1.73 m2, p=0.693). RIN developed (GFR: 17 to 13 ml/min/1.73 m2) in only one patient but without sequelae, and the GFR completely recovered to baseline level 7 days after the study. CONCLUSION: Small dose venography is safe and effective for venous mapping in pre-dialysis patients.

Arteriovenous fistula of the superior gluteal artery as a complication of posterior iliac crest bone graft harvesting: 3D-CT angiography and arterial embolization.

Superior gluteal artery injuries are rare, but potentially serious complications that occur during posterior iliac crest bone graft harvesting. The authors reported an arteriovenous fistula of the superior gluteal artery, which occurred as a complication during posterior iliac crest bone graft harvesting and was diagnosed with 3D-CT angiography, then treated with arterial embolization.

A multi-center, randomized, clinical study to compare the effect and safety of autologous cultured osteoblast(Ossron) injection to treat fractures.

BACKGROUND: We performed a multicenter, open, randomized, clinical study of autologous cultured osteoblast injection for long-bone fracture, to evaluate the fracture healing acceleration effect and the safety of autologous cultured osteoblasts. METHODS: Sixty-four patients with long-bone fractures were randomly divided into two groups, i.e. those who received autologous cultured osteoblast injection and those who received no treatment. The sum of the difference in the callus formation scores after four and eight weeks, was used as the first efficacy variable. RESULTS: The autologous cultured osteoblast injection group showed fracture healing acceleration of statistical significance, and there were no specific patient complications when using this treatment. CONCLUSION: Autologous cultured osteoblast injection should therefore be considered as a successful treatment option for treating long-bone fracture.

Successful management of a ruptured hepatic artery pseudoaneurysm with a stent-graft.

Hepatic artery pseudoaneurysm is a rare and potentially life-threatening vascular disorder. Careful consideration and early management of this lesion can be life-saving. The authors report a case of a hepatic artery pseudoaneurysm which was successfully controlled by endovascular repair using a covered stent-graft.