Minimally invasive treatment of abdominal lymphocele: A review of contemporary options and how to approach them.

Lymphoceles are lymphatic fluid collections resulting from lymphatic vessel disruption after surgery or trauma. They are most often described following retroperitoneal surgeries such as cystectomies, prostatectomies, renal transplants, and gynecologic surgeries. Most lymphoceles are asymptomatic and resolve spontaneously without treatment. If persistent, they can become infected or exert mass effect on adjacent structures causing pain, urinary, or lower limb edema particularly for lymphoceles in the pelvis Symptomatic lymphoceles should be treated to relieve symptoms and prevent functional compromise of vital adjacent structures. Although surgery has been traditionally accepted as the gold standard treatment, advances in imaging and interventional technology allow for less invasive, percutaneous treatment. Available minimally invasive treatment options include percutaneous aspiration, catheter drainage, sclerotherapy, and lymphangiography with lymphatic embolization. A review of these treatment options and a suggested algorithm for managing lymphoceles is presented.

Value of diffusion-weighted images in diagnosis of locoregionally recurrent rectal tumors.

INTRODUCTION: To assess the value of referring to Diffusion-weighted images in evaluation of T2-weighted images of patients clinically suspicious of locoregional rectal cancer recurrence. METHODS: After ethics committee approval and informed consent were obtained, 37 consecutive patients (male/female of 22/15; mean age 56 ± 13.5 SD) clinically suspicious of recurrent rectal tumor were prospectively included in the study over a two-year period. T2-weighted images of the patients were reviewed and the results were recorded. Right after that, the corresponding DWI images were provided for the radiologist and new ratings were given to the patients after taking into account the DWI findings. Finally, the patients underwent tissue biopsy. Receiver Operating Characteristic (ROC) analysis was performed, and Area Under the Curve (AUC) of the "T2-weighted alone" and "T2-weighted + DWI" methods were calculated and compared. RESULTS: "T2-weighted alone" and "T2-weighted + DWI" methods had an AUC of 0.64 (95% CI 0.47 to 0.79) and 0.75 (95% CI 0.58 to 0.88), respectively. The Difference between the two AUCs was 0.11 (P = 0.16). In the subgroup of patients having equivocal ratings in T2-weighted images, DWI images correctly identified 81% (13/16) of patients with true tumor recurrence and 66% (8/12) of patients without recurrence. CONCLUSION: Our results suggest that referring to DWI does not significantly change the overall diagnostic performance of T2-weighted images. However, DWI is of great value in evaluation of the subgroup of patients with equivocal findings in T2-weighted images. Studies with larger sample sizes are needed to confirm these findings. IMPLICATIONS FOR PRACTICE: When T2-weighted images are equivocal, DWI images may be helpful in evaluation of patients with suspected locoregional recurrence of rectal tumor.

New concepts in embolotherapy of HCC.

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related deaths worldwide with rapidly growing incidence rates in the USA and Europe. Despite improving surveillance programs, most patients are diagnosed at intermediate to advanced stages and are no longer amenable to curative therapies, such as ablation, surgical resection and liver transplantation. For such patients, catheter-based image-guided embolotherapies such as transarterial chemoembolization (TACE) represent the standard of care and mainstay therapy, as recommended and endorsed by a variety of national guidelines and staging systems. The main benefit of these therapies is explained by the preferentially arterial blood supply of liver tumors, which allows to deliver the anticancer therapy directly to the tumor-feeding artery while sparing the healthy hepatic tissue mainly supplied by the portal vein. The tool box of an interventional oncologist contains several different variants of transarterial treatment modalities. Ever since the first TACE more than 30 years ago, these techniques have been progressively refined, both with respect to drug delivery materials and with respect to angiographic micro-catheter and image-guidance technology, thus substantially improving therapeutic outcomes of HCC. This review will summarize the fundamental principles, technical and clinical data on the application of different embolotherapies, such as bland transarterial embolization, Lipiodol-based conventional transarterial chemoembolization as well as TACE with drug-eluting beads (DEB-TACE). Clinical data on 90Yttrium radioembolization as an emerging alternative, mostly applied for niche indications such as HCC with portal vein invasion, will be discussed. Furthermore, we will summarize the principle of HCC staging, patient allocation and response assessment in the setting of HCC embolotherapy. In addition, we will evaluate the role of cone-beam computed tomography as a novel intra-procedural image-guidance technology. Finally, this review will touch on new technical developments such as radiopaque, imageable DEBs and the rationale and role of combined systemic and locoregional therapies, mostly in combination with Sorafenib.

Pattern of Pseudomonas aeruginosa drug resistance in Tabriz Children Hospital.

Regarding the different reports about increasing drug resistance of Pseudomonas, this study was done in Tabriz Pediatric Medical Center. In a cross sectional study, during 3 years, 84 positive culture of pseudomonas were obtained from the records of microbiology laboratory. Information about the patients and pattern of drug resistance were analyzed statistically. 81.9% of patients were below 2 years of age and all of them had one or more medical intervention. Most of the positive cultures were isolated from bronchial and eye discharges. Eighty one percent of positive cultures were from intensive care unit and neonatal wards. Resistance to Ampicillin, Ceftizoxime, Cotrimoxasol and Cefotoxime has been more than 95%. Resistance to Ceftazidime was seen in 50% and lowest resistance was to Ciprofloxacin. At present time Ciprofloxacin is relatively effective antibiotic for Pseudomonas infection. Since, there is increasing resistance to this drug and limited use of this drug in children, newer antibiotic discs should be used in antibiogram.

High-sensitivity C-reactive protein (hs-CRP) and tumor necrotizing factor-alpha (TNF-alpha) after on- and off- pump coronary artery bypass grafting.

INTRODUCTION: Coronary artery bypass grafting (CABG) is one of the most frequently performed operations around the world. The aim of this study is to evaluate high-sensitivity C-reactive protein (hs-CRP) and tumor necrosis factor-alpha (TNF-alpha) differences between on-pump and off-pump coronary surgery. METHODS: In this prospective study, 90 patients with coronary artery disease referred for CABG were enrolled from July 2006-November 2007. Levels of hs-CRP and TNF-alpha were measured by ELISA using commercial kits RESULTS: hs-CRP levels significantly (p<0.001) increase after CABG. But no difference between off-pump and on-pump groups was noted for hs-CRP and TNF-alpha levels (p=0.4, p=0.8). CONCLUSIONS: There was no difference in high-sensitivity C-reactive protein (hs-CRP) and TNF-alpha between on-pump and off-pump CABG surgery.

Clinical, electrodiagnostic and pedobarographic assessments of leprotic patients with trans-tibial amputation.

The aim of present study was to investigate clinical, electrodiagnostic and pedobarographic findings of non-amputee limb in chronic leprotic patients with unilateral trans-tibial amputation to determine neuropathy and plantar foot pressure in non-amputee limb. During the present prospective cross-sectional study, 10 chronic leprotic patients with unilateral trans-tibial amputation were evaluated. The study was conducted in Tabriz Bababaghi and Imam Reza Hospitals at summer of 2008. Sensory nerve conduction (SNAP) and Compound Motor Action Potentials (CMAP) studies were performed in association with pedobarographic assessment. No reliable response was detected from tested sensory and motor nerves, except a very low amplitude finding in deep preoneal nerve of one patient. In comparing with healthy group, static total plantar area, dynamic total plantar area, static rarefoot peak pressure and dynamic rarefoot peak pressure were lower in leprotic patients (p = 0.047, p = 0.004, p = 0.029 and p < 0.001), while static forefoot peak pressure and dynamic forefoot peak pressure were higher in these patients (p = 0.011 and p = 0.031). All of leprotic patients with unilateral trans-tibial amputation suffered from severe neuropathy. Also, these patients have high plantar pressure under the forefoot. Collectively, severe neuropathy and abnormal plantar foot pressure expose in non-amputee foot expose leprotic patients to the higher risk of secondary amputation.

Origination angle of renal artery has no role in renal artery pattern.

INTRODUCTION: Renal artery (RA) anatomy plays a critical role in selecting donors. During the present study, we sought to evaluate the physiological role of RA origination angle for the presence of an accessory RA or its early branching. METHODS: During the present cross-sectional study (August 2005-October 2007), 143 candidates for kidney donation underwent RA angiography by 64 multidetector computed tomographic angiography. We assessed the RA diameter, distance to first branching, presence of accessory RA, and early branching, as well as the origination angle of RA from aorta in coronal plane (alpha angle). RESULTS: The male-to-female ratio was 96:47 with an overall mean age of 27.42 +/- 4.55 years. The alpha angle, sine, cosine of the alpha angle and the deviation factor were not significantly different between kidneys with versus without an accessory artery or between the RA with versus without an early branching. Only the RA diameter (P = .047) and the distance of RA to the branching (P < .001) in kidneys with an accessory RA were significantly lower and higher than those without an accessory RA, respectively. Also the distance of the RA to the branching was significantly less in kidneys with an early branching (P < .001). The RA diameter directly correlated with the RA origination angle (r = .191, P = .001), while there was no correlation between the distance to RA branching and the RA origination angle (r = -.060, P = .311). CONCLUSION: The origination angle of the RA from aorta has no role in the early branching or accessory RA development. There was a direct correlation between the RA diameter and the RA origination angle.

Development of a varicocele following left-sided nephrectomy in kidney donors.

INTRODUCTION: Most kidney transplantation surgeons tend to prefer the left-sided kidney for donation. Because one of the veins to join the left renal vein is the left testicular (gonadal) vein, its flow may be damaged by manipulation of the left renal vein during left-sided nephrectomy. We sought to evaluate changes of the left-sided pampiniform venous plexus and testis following left-sided nephrectomy in kidney donors. METHODS: During the present cross-sectional study (June 2007-July 2008), 54 healthy males who were candidates for left kidney donation underwent an ultrasound study of the left-sided pampiniform venous plexus diameter as well as the left testis size before and 4 months after left-sided nephrectomy. RESULTS: The patient mean age was 25.07 +/- 2.49 years. The mean diameters of left pampiniform vein before versus 4 months after nephrectomy were 1.37 +/- 0.40 versus 2.04 +/- 0.49 mm, respectively. The mean sizes of left testis before and 4 months after nephrectomy were 21.86 +/- 2.47 versus 21.50 +/- 2.17 mL, respectively. The mean left pampiniform vein diameter significantly increased at 4 months after left-sided nephrectomy (P < .001), but the mean left testis size was not significantly changed (P = .136). CONCLUSION: Four months after left-sided nephrectomy, the left pampiniform venous plexus diameter increased, whereas there was no significant change in left testis size. Therefore, in patients with left-sided nephrectomy, a high risk of varicocele may be predicted.

Comparison of outcome and quality of life: haemodialysis versus peritoneal dialysis patients.

INTRODUCTION: Ever since peritoneal dialysis (PD) was introduced as a form of renal replacement therapy, its efficacy and complications have been compared with that of haemodialysis (HD). The aim of this study was to determine the efficacy and outcome of PD in comparison to HD in our region. METHODS: We compared 60 patients on PD with 60 matched patients on HD in Tabriz's Sina Hospital during the period 2004-2006. The technique, patients' survival and quality of life were compared by means of a health-related quality-of-life questionnaire (GHQ-28). RESULTS: There was no significant difference in the mean age and duration of dialysis between patients on PD and HD. Survival of diabetic patients was better with HD than PD, but in non-diabetic patients, there was no difference in the survival rates between the two groups. Among patients on PD, diabetics had a 25 percent higher mortality rate and non-diabetic patients had a three percent higher mortality rate than their corresponding counterparts on HD. In all four axes of the questionnaire, i.e. psychophysical dysfunction, stress and sleep disorders, social dysfunction and major depression, PD patients had lower scores than HD patients (p-values are less than 0.001, less than 0.001, equal to 0.002 and less than 0.001, respectively), indicating that patients on PD had a better quality of life compared to those on HD. CONCLUSION: In this study, technique, patients' survival and their quality of life were better on PD than on HD. However, survival and mortality of diabetic patients on HD were better than those on PD.

Anatomical differences in the right and left renal arterial patterns.

The aim of this study was to determine the pattern and character of the renal arteries in patients referred for preoperative or diagnostic evaluation of the renal or abdominal arteries by multi-detector computed tomography and, by comparing the arterial anatomy of the right and left kidneys, to evaluate the effect of differences in their anatomical position on the characteristics of the arteries. During a cross-sectional study from August 2005 to October 2007, 117 patients underwent contrast-enhanced 64-slice multi-detector computed tomography renal angiography in Tabriz Imam Khomeini Hospital (Parsian Centre). The number of arteries, the number of branches and the presence of accessory arteries and early branching were assessed in the renal arteries on both sides. In all, the data for 117 patients data were analysed, 76 (65%) of whom were male and 41 (35%) female. The mean of age of the patients was 39.26 +/- +/- 17.03 years. The mean diameters of the aorta and renal artery were 2.62 +/- +/- 1.55 mm and 0.62 +/- 0.11 mm respectively and the distance to branching was 3.39 +/- 1.59 mm. There was no significant difference in diameter between the left and right renal arteries or in the distance to branching (0.62 +/- 0.11 vs. 0.61 +/- 0.12 mm; p = 0.35; 3.24 +/- 1.2 vs. 3.56 +/- 1.77 mm; p = 0.11). An accessory artery was presented in 58 kidneys and this significantly more often occurred on the right side than on the left side: 38 of 117 (32.47%) right kidneys vs. 20 of 117 (17.09%) left kidneys (p = 0.01). There was early branching in 42 subjects (35.89%). In a comparison of early branching of the arteries of the right and left kidneys, no significant difference was found, despite the higher incidence of branching on the right side. The diameters of the right and left renal arteries and the distances to branching did not differ. Apart from width, there was no difference in kidney size. An accessory artery occurred more frequently in the right renal artery than in the left.

Doppler ultrasonographic indices after renal transplantation as renal function predictors.

OBJECTIVES: Doppler ultrasonography is mostly used for assessment of both graft and native kidney vascular status. In this study, correlation between Doppler sonographic indices and transplanted kidney function was evaluated. METHODS: In our retrospective study, we reviewed data on 273 renal transplanted (RTx) patients. The Doppler ultrasonographic evaluation included resistive index (RI), pulsatility index (PI) in interlobar arteries as well as stenosis (TRAS) or thrombosis of renal arteries and veins. Serum creatinine (Cr) and cyclosporine levels (CsA) were measured just prior to sonography. RESULTS: The mean age of 154 male and 119 female patients was 36.67 +/- 13.13 years. Both RI and PI showed significant linear correlations with serum Cr (P = .033 and P = .002, respectively). Also, direct linear correlations existed between patient age and RI and PI values (P = .004; r = +.174 and P = .003; r = +.183 respectively). The prevalence of TRAS was 11.35%. Among patients with TRAS or thrombosis the mean Cr level (2.08 +/- 1.7 mg/dL) was significantly higher than that among patients without TRAS or thrombosis (1.48 +/- 0.97 mg/dL; P = .004). Despite this finding, RI and PI were significantly lower among patients with TRAS or thrombosis than those with a patent renovascular tributary (0.59 +/- 0.15 vs 0.65 +/- 0.11; P = .029 vs 1.02 +/- 0.40 vs 1.18 +/- 0.46; P = .049). CONCLUSIONS: Both RI and PI were two valuable Doppler ultrasonographic markers to evaluate renal allograft function and related vascular complications.

Kidney transplantation candidates and cardiovascular risk factors.

OBJECTIVE: We sought to determine the prevalence of cardiovascular disease and risk factors among chronic renal failure (CRF) patients on the transplantation waiting list. METHODS: Fifty CRF patients on chronic hemodialysis who underwent evaluation for transplantation were compared with 60 hypertensive patients matched for age. We used Framingham scoring to calculate the absolute risk; relative risk was calculated based on the low-risk Framingham cohort. RESULTS: According to traditional risk factors, a significant difference was observed in systolic blood pressure and total cholesterol (greater in the hypertensive group), and in the prevalence of the male gender, smoking, and diabetes, which were greater in the CRF group. The latter had a greater degree of left ventricular hypertrophy, lower diastolic blood pressure, and a lower prevalence of familial history of cardiovascular disease and obesity. Patients with CRF had a greater relative risk compared with the Framingham control population, but it did not differ from that observed in the group of hypertensive individuals. CONCLUSION: The prevalence of cardiovascular disease and traditional risk factors is high among renal transplantation candidates. The Framingham equations do not adequately quantify the real cardiovascular risk; other risk factors specific for that population probably contribute to their greater cardiovascular risk.

Vascular complication and Doppler ultrasonographic finding after renal transplantation.

OBJECTIVES: Vascular complications are common after renal transplantation. In this study we correlated Doppler sonographic indices and transplant kidney function. METHODS: We reviewed data on 244 renal transplant patients. Doppler ultrasonographic evaluation was performed during the first 2 weeks after renal transplantation. We determined resistive index (RI) and pulsatility index (PI) in the interlobar arteries and thrombosis of renal and lower limb veins. Serum creatinine (Cr) and cyclosporine levels were evaluated prior to sonographic assessment. RESULTS: The mean age of the 142 male and 102 female patients was 36.31 +/- 3.30 years. Prevalence of real artery stenosis was 9.5%. In these patients the mean serum Cr level (2.21 +/- 1.83 mg/dL) was significantly higher than among patients with patent renovascular tributary (1.49 +/- 1.00 mg/dL; P=.03). RI and PI were also significantly correlated with serum Cr(P=.05 and .001, respectively). There was no relationship between cyclosporine level or panel-reactive antibody with RI and PI. Retransplant patients showed higher RI than first renal allograft recipients (0.72 +/- 0.16 vs 0.63 +/- 0.11; P=.006). Serum Cr level was higher among renal allograft recipients with Doppler evidence of thrombosis of the lower limb veins (3.1 +/- 0.98 mg/dL versus 1.56 +/- 1.13 mg/dL; P=.04). CONCLUSIONS: RI and PI are two valuable Doppler ultrasonographic markers to determine renal allograft function and related vascular complications.