Transradial versus transfemoral access without closure device for transarterial chemoembolization in patients with hepatocellular carcinoma: a randomized trial.

OBJECTIVES: To compare patient satisfaction, procedural variables, and safety with transradial access (TRA) and transfemoral access (TFA) in patients undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From February 2019 to August 2021, 130 patients undergoing TACE for HCC were randomly allocated to the TRA (n = 65) or TFA (n = 65) group. Vascular closure devices were not used after TFA-TACE. All patients completed the post-catheterization questionnaire and 8-item Short-Form Health Survey 1 day after TACE. RESULTS: Technical success rate, crossover rate, contrast agent dose, fluoroscopy time, procedure time, air kerma, dose-area product, length of hospital stay, and total cost were similar between the two groups (all p > 0.05). The incidence and severity of adverse events were also similar between the two groups (all p > 0.05). However, overall discomfort, difficulty going to the bathroom, difficulty feeding or self-caring, difficulty walking, general health, physical function, role physical function, social function, mental health, and role emotional function were better in the TRA group than in the TFA group (all p < 0.001). Consequently, more patients preferred the current access for their next procedure in the TRA group than in the TFA group (90.8% vs. 24.6%; p < 0.001). CONCLUSION: In patients undergoing TACE for HCC, using TRA instead of TFA can improve patient satisfaction without compromising procedural variables and safety. KEY POINTS: • Transradial access (TRA) enabled early ambulation after transarterial chemoembolization (TACE), resulting in significant increase in activities of daily living and health-related quality of life (HRQoL) compared to transfemoral access (TFA) when vascular closure devices were not used. • Procedural variables (contrast agent dose, fluoroscopy time, procedure time, air kerma, dose-area product, length of hospital stay, and total cost) were not significantly different between patients who received TRA-TACE and TFA-TACE. • The incidence and severity of adverse events were similar between patients who received TRA-TACE and TFA-TACE.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Gastric Variceal Bleeding in Patients with Hepatocellular Carcinoma.

A total of 42 cirrhotic patients (mean age, 51.7 years ± 10.8; 38 men) with hepatocellular carcinoma who underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for controlling acute gastric variceal bleeding (GVB) were included in this multicenter retrospective study. Of these, 37 (88.1%) patients underwent emergent TIPS creation as the first-line treatment to control acute GVB. Five (11.9%) patients underwent emergent TIPS creation as a rescue/salvage treatment to control acute GVB after emergent endoscopic therapy and pharmacotherapy. Emergent TIPS creation was technically successful in 40 (95.2%) patients. Two (4.8%) patients had severe and moderate procedural adverse events. The median follow-up duration was 16.9 months (range, 0.1-100.8 months). Failure to control acute bleeding and failure to prevent rebleeding occurred in 8 (19.0%) patients during follow-up. Eighteen (42.9%) patients died during follow-up. Three (7.1%) patients had shunt dysfunction during follow-up. Overt hepatic encephalopathy occurred in 6 (14.3%) patients during follow-up.

Silver nanoparticle-coated self-expandable metallic stent suppresses tissue hyperplasia in a rat esophageal model.

BACKGROUND: To evaluate the efficacy of a silver nanoparticle (AgNP)-coated self-expandable metallic stent (SEMS) for suppressing tissue hyperplasia in a rat esophageal model. METHODS: Twenty-four male Sprague-Dawley rats were randomly assigned to four groups. Animals in group A underwent uncoated SEMS placement, whereas animals in groups B, C, and D underwent 6, 12, and 24 mg/mL AgNP-coated SEMS placement, respectively. All animals were euthanized 4 weeks after SEMS placement, and a gross examination and histological analyses were performed. RESULTS: All rats achieved technical success and survived until the end of the study. The gross examination showed moderate to severe tissue hyperplasia in 5 rats in group A and 2 rats in group B. In contrast, no animals in groups C and D had moderate or severe tissue hyperplasia. The gross examination revealed no complications. The percentage of granulation tissue area, number of epithelial layers, thickness of submucosal fibrosis, percentage of connective tissue area, inflammatory cell infiltration grade, degree of collagen deposition, and degrees of Ki67, TUNEL, and α-SMA-positive deposition were significantly lower in groups C and D than in group A (all p < 0.05). However, only the percentage of granulation tissue area, number of epithelial layers, thickness of submucosal fibrosis, and percentage of connective tissue area were significantly lower in group B than in group A (all p < 0.05). No histological parameters were significantly different between group D and group C (all p > 0.05). CONCLUSION: AgNP-coated SEMSs suppressed tissue hyperplasia in a rat esophageal model.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with portal vein thrombosis: a multicenter study.

OBJECTIVES: To evaluate the effectiveness of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). METHODS: Consecutive cirrhotic patients with PVT who underwent RTO for the prevention of variceal rebleeding between January 2002 and June 2019 were included in this multicenter retrospective study. The primary outcome measure was rebleeding. The secondary outcome measures were survival, other complications of portal hypertension, liver function, and PVT. RESULTS: Forty-five patients (mean age, 66.0 ± 10.6 years; mean Model for End-Stage Liver Disease (MELD) score, 13.9 ± 5.5) were included. The 1-year actuarial probability of remaining free of rebleeding was 92.8 ± 4.0%. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 79.8 ± 6.0%, 48.8 ± 7.7%, and 46.1 ± 7.9%, respectively. MELD score (hazard ratio (HR), 1.09 (95% confidence interval (CI), 1.01-1.17); p = .013) and ascites (HR, 2.84 (95% CI, 1.24-6.55); p = .014) were identified as significant predictors of survival. The 1-year actuarial probabilities of remaining free of new or worsening ascites and esophageal varices were 81.2 ± 8.7% and 89.2 ± 6.0%, respectively. No patients had overt hepatic encephalopathy during follow-up. MELD score significantly increased by a mean of 3.8 (95% CI, 1.7-6.0) at 3 months (p = .001). PVT had improved in 32.0%, worsened in 12.0%, and remained unchanged in 56.0% of patients at 3 months. CONCLUSION: RTO may be effective for the prevention of variceal rebleeding in cirrhotic patients with PVT. KEY POINTS: • Retrograde transvenous obliteration may prevent variceal rebleeding in cirrhotic patients with portal vein thrombosis. • The risks of other complications of portal hypertension may not be high after retrograde transvenous obliteration in cirrhotic patients with portal vein thrombosis. • Portal vein thrombosis may improve in approximately one-third of cirrhotic patients within 3 months after retrograde transvenous obliteration.

Transjugular Intrahepatic Portosystemic Shunt Creation for the Prevention of Gastric Variceal Rebleeding in Patients with Hepatocellular Carcinoma: A Multicenter Retrospective Study.

PURPOSE: To evaluate the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastric variceal rebleeding in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This multicenter retrospective study included 126 cirrhotic patients (mean age, 54.1 ± 10.2 years; 110 men) with HCC who underwent TIPS creation for the prevention of gastric variceal rebleeding. Of these, 110 (87.3%) patients had gastroesophageal varices and 16 (12.7%) patients had isolated gastric varices. Thirty-five (27.8%) patients had portal vein tumor thrombus. RESULTS: TIPS creation was technically successful in 124 (98.4%) patients. Rebleeding occurred in 26 (20.6%) patients during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 98.3% ± 1.2% and 81.2% ± 3.9%, respectively. Forty-nine (38.8%) patients died during the follow-up period. The 6-week and 1-year actuarial probabilities of survival were 98.4 ± 1.1% and 65.6 ± 4.4%, respectively. Two (1.6%) patients had major procedure-related complications, including acute liver failure (n = 1) and intra-abdominal bleeding (n = 1). Thirty-three (26.2%) patients had at least 1 episode of overt hepatic encephalopathy during the follow-up period. Shunt dysfunction occurred in 15 (11.9%) patients after a median follow-up time of 11.4 months (range, 1.4-41.3 months). Lung metastasis occurred in 3 (2.4%) patients, 3.9-32.9 months after TIPS creation. CONCLUSIONS: TIPS creation may be effective and safe for the prevention of gastric variceal rebleeding in patients with HCC.

Intragastric satiety-inducing device reduces food intake and suppresses body weight gain in a rodent model.

BACKGROUND: An intragastric satiety-inducing device (ISD) (Full Sense Device; Baker, Foote, Kemmeter, Walburn, LLC, Grand Rapids, MI) is a novel weight-loss device, which may induce satiety by applying continuous pressure on the gastric cardia. This study investigated the effect of the ISD on food intake and body weight gain in a rodent model. METHODS: Thirty-two male Sprague-Dawley rats (weight, 250-300 g) were randomly divided into four groups of eight individuals. Single-disk (SD) and double-disk (DD) group animals underwent peroral placement of a single- or double-disk ISD, respectively, under fluoroscopic guidance. The ISD comprised a 4 mm × 1.5 cm nitinol stent placed in the lower esophagus and one (single-disk) or two (double-disk) 2.5-cm-diameter star-shaped nitinol disks placed in the gastric fundus. Esophageal stent (ES) and sham-operated (SO) group animals underwent peroral placement of the ES part of the ISD and a sham operation, respectively. RESULTS: Food intake was significantly different among the four groups over the 4-week study period (P < 0.001); food intake was significantly lower in the SD and DD groups than in the SO group (P = 0.016 and P = 0.002, respectively) but was not significantly different between the SD and DD groups (P > 0.999) and between the ES and SO groups (P = 0.677). Body weight was significantly different among the four groups by the end of the study period (P < 0.001); body weight was significantly lower in the DD group than in the SD, ES, and SO groups (P = 0.010, P < 0.001, and P < 0.001, respectively) and in the SD group than in the SO group (P = 0.001), but it was not significantly different between the ES and SO groups (P = 0.344). CONCLUSION: ISD reduced food intake and suppressed body weight gain in a rodent model.

Lymphangiography with or without Embolization for the Treatment of Postoperative Chylous Ascites.

BACKGROUND: Lymphatic interventions have recently been increasingly used for treating lymphatic leak of the abdomen and pelvis. This retrospective case study series and systematic review evaluated the efficacy and safety of lymphatic interventions for the treatment of postoperative lymphatic leak of the abdomen and pelvis. METHODS: A total of 15 consecutive patients with postoperative lymphatic leak of the abdomen and pelvis treated with lymphatic interventions (i.e., diagnostic intranodal or pedal lymphangiography [LAG], i.e., potentially therapeutic or diagnostic LAG with intention to treat through embolization) at our institution were reviewed. The data of 72 patients from 13 relevant articles identified through a literature search of the MEDLINE/PubMed, EMBASE, and Cochrane databases were extracted. RESULTS: The data of 87 patients (mean age, 59 [range, 24-84] years) were pooled. The technical success rate of LAG (intranodal approach, 78.2% [68/87]; pedal approach, 21.8% [19/87]) was 97.7% (85/87; 95% confidence interval [CI], 91.5-99.9%). Of the 85 patients in whom technical success of LAG was achieved, data on clinical success were available for 47 patients (55.3%). The clinical success rate of LAG was 68.1% (32/47; 95% CI, 53.8-79.7%). Of the 85 patients in whom technical success of LAG was achieved, 38 (44.7%) underwent embolization. The technical success rate of embolization was 97.4% (37/38; 95% CI, 85.3-99.9%). The clinical success rate of embolization was 70.3% (26/37; 95% CI, 54.1-82.6%). Major complications did not occur. The overall primary and secondary clinical success rates were 65.5% (57/87; 95% CI, 55.0-74.7%) and 78.2% (68/87; 95% CI, 68.3-85.6%), respectively. CONCLUSIONS: Lymphatic interventions are safe and relatively effective adjunct to conservative therapy, with the primary and secondary clinical success rate of 65.5% and 78.2%, for postoperative lymphatic leak of the abdomen and pelvis.

Changes in arterial oxygenation after portal decompression in Budd-Chiari syndrome patients with hepatopulmonary syndrome.

OBJECTIVES: To evaluate the changes in arterial oxygenation after portal decompression in Budd-Chiari syndrome (BCS) patients with hepatopulmonary syndrome (HPS). METHODS: From June 2014 to June 2015, all patients with BCS who underwent balloon angioplasty or transjugular intrahepatic portosystemic shunt (TIPS) creation at our institution were eligible for inclusion in this study. Arterial blood gas analysis was performed with the patient in an upright position and breathing room air at 2-3 days and 1 and 3 months after the procedure. RESULTS: Eleven patients with HPS and 14 patients without HPS were included in this study. The procedure was technically successful in 24 patients. One patient with HPS had technically unsuccessful TIPS creation. Reobstruction or TIPS dysfunction was not detected in any patient within 3 months after the procedure. For patients with HPS, the alveolar-arterial oxygen gradient (A-aO2) remained comparable to baseline 2-3 days after the procedure (-3.2 ± 11.9 mmHg; p = .412), significantly improved 1 month after the procedure (-11.7 ± 6.4 mmHg; p < .001), and then returned to baseline 3 months after the procedure (-1.3 ± 12.5 mmHg; p = .757). For patients without HPS, the A-aO2 remained comparable to baseline at all three time points after the procedure (+1.4 ± 8.3 mmHg, +3.5 ± 8.1 mmHg, and +1.3 ± 8.2 mmHg; p = .543, p = .137, and p = .565). CONCLUSIONS: Arterial oxygenation transiently improves after portal decompression in BCS patients with HPS. KEY POINTS: • Intrapulmonary vascular dilation and hepatopulmonary syndrome are common in patients with Budd-Chiari syndrome. • Arterial oxygenation transiently improves after portal decompression in Budd-Chiari syndrome patients with hepatopulmonary syndrome.

Effect of Transjugular Intrahepatic Portosystemic Shunt Creation on Pulmonary Gas Exchange in Patients with Hepatopulmonary Syndrome: A Prospective Study.

PURPOSE: To evaluate effect of transjugular intrahepatic portosystemic shunt (TIPS) creation on pulmonary gas exchange in patients with hepatopulmonary syndrome (HPS). MATERIALS AND METHODS: All patients with cirrhosis or Budd-Chiari syndrome undergoing elective TIPS creation at a single institution between June 2014 and June 2015 were eligible for inclusion. Twenty-three patients with HPS (age 55.0 y ± 14.4; 11 men; Model for End-Stage Liver Disease score 10.2 ± 2.7) who achieved technical success were included in the analysis. Diagnosis of HPS was established by contrast-enhanced echocardiography demonstrating intrapulmonary vascular dilatation and arterial blood gas analysis demonstrating arterial oxygenation defects. RESULTS: Mean portosystemic gradient was reduced from 21.7 mm Hg ± 8.3 before TIPS creation to 10.8 mm Hg ± 5.1 after TIPS creation. Among the 5 (21.7%) patients who experienced dyspnea, 4 (80.0%) reported improvement after TIPS creation. This improvement was not maintained at 3 months after TIPS creation in 2 (50.0%) patients. Compared with before TIPS creation, mean change in alveolar-arterial oxygen gradient for patients with HPS was statistically significant at 1 month (-9.2 mm Hg ± 8.0; P < .001) after TIPS creation, but not at 2-3 days (-0.9 mm Hg ± 10.5; P = .678) or 3 months (-3.4 mm Hg ± 11.8; P = .179) after TIPS creation. CONCLUSIONS: TIPS creation can transiently improve pulmonary gas exchange in patients with HPS.

Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract.

PURPOSE: To retrospectively evaluate the safety and efficacy of the percutaneous obliteration of urinary leakage after partial nephrectomy (PN) using coils and N-butyl-cyanoacrylate (NBCA). MATERIALS AND METHODS: Data of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA between February 2016 and May 2018 were retrospectively reviewed. A urinary fistulography was performed via the drainage catheter. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA was performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Outcomes and complications were assessed by reviewing medical records and computed tomography (CT). RESULTS: In 7 (70%) patients who showed obvious urinary fistulous tract, coil embolization of the urinary fistulous tract, followed by sealing of the urinoma cavity with NBCA, was performed. Obliteration of the urinoma without coil embolization of the fistula tract was performed in 3 patients (30%) in whom a distinct fistulous tract could not be visualized. The median number of treatment sessions required to achieve clinical success was 1 (range, 1-5). Four patients underwent multiple repeated procedure with successful results. All patients showed gradual decrease in size or complete disappearance of urinoma on follow-up CT without evidence of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11-117 weeks). There were no procedure-related complications. CONCLUSIONS: Percutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective.

Developmental endothelial locus-1 prevents development of peritoneal adhesions in mice.

Postoperative peritoneal adhesions, fibrous bands formed in the peritoneal cavity following surgery, represent a common, challenging and costly problem faced by surgeons and patients, for which effective therapeutic options are lacking. Since aberrant inflammation is one of the key mechanisms underlying peritoneal adhesion formation, here we set out to study the role of developmental endothelial locus-1 (Del-1), which has been recently identified as an endogenous inhibitor of inflammation, in the formation of postoperative peritoneal adhesions using a mouse model of peritoneal adhesions induced by ischemic buttons. Del-1-deficient mice had a higher incidence of adhesions, and their adhesions had higher quality and tenacity scores. Del-1 deficiency also led to enhanced inflammation mediators and collagen production. Finally, Del-1 supplementation decreased the incidence and severity of postoperative peritoneal adhesions. Taken together, these results indicate a protective role for Del-1 in postoperative peritoneal adhesion formation.

Sirolimus-eluting Biodegradable Poly-l-Lactic Acid Stent to Suppress Granulation Tissue Formation in the Rat Urethra.

Purpose To investigate the use of sirolimus-eluting biodegradable stents (SEBSs) to suppress granulation tissue formation after stent placement in a rat urethral model. Materials and Methods All experiments were approved by the animal research committee. A total of 36 male Sprague-Dawley rats were randomized into three equal groups after biodegradable stent placement. Group A received control biodegradable stents. Groups B and C received stents coated with 90 µg/cm2 and 450 µg/cm2 sirolimus, respectively. Six rats in each group were sacrificed after 4 weeks; the remaining rats were sacrificed after 12 weeks. The therapeutic effectiveness of SEBSs was assessed by comparing the results of retrograde urethrography and histologic examination. Analysis of variance with post hoc comparisons was used to evaluate statistical differences. Results SEBS placement was technically successful in all rats. Urethrographic and histologic examinations revealed significantly less granulation tissue formation at both time points in the rats receiving SEBSs (groups B and C) compared with those that received control stents (group A) (P < .05 for all). There were no significant differences in urethrographic and histologic findings between groups B and C (P > .05 for all). However, the mean number of epithelial layers in group B was higher than that in group C at 4 weeks after stent placement (P < .001). Apoptosis increased in group C compared with groups A and B (P < .05 for all). Conclusion The use of SEBSs suppressed granulation tissue formation secondary to stent placement in a rat urethral model; local therapy with SEBSs may be used to decrease stent-related granulation tissue formation. © RSNA, 2017.

Pulmonary transit time derived from pulmonary angiography for the diagnosis of hepatopulmonary syndrome.

BACKGROUND & AIMS: Pulmonary transit time (PTT) is the transit time of blood from the right side of the heart to the left side of the heart. The aim of the present study was to evaluate the role of the PTT derived from pulmonary angiography in the diagnosis of hepatopulmonary syndrome (HPS). METHODS: From December 2014 to September 2015, all patients with chronic liver disease and/or portal hypertension undergoing a venous interventional radiologic procedure at our institution were eligible for inclusion in this prospective study. Pulmonary angiography was performed in all patients, and the PTT, which was defined as the time between opacification of the pulmonary trunk and the right border of the left atrium, was determined. RESULTS: A total of 53 patients were included, 20 of whom had a positive contrast-enhanced echocardiography result and an elevated alveolar-arterial oxygen gradient were considered to have HPS. PTT was significantly shorter in patients with HPS than in those without [median, 3.34 (interquartile range, 3.01-3.67) seconds vs 4.0 (interquartile range, 3.67-4.17) seconds; P < .001]. The area under the receiver operating characteristic curve of PTT for diagnosing HPS was 0.83 (95% confidence interval, 0.70-0.92). The optimal cut-off value of PTT for diagnosing HPS, based on Youden's index, was 3.55 seconds. The sensitivity, specificity and accuracy of PTT < 3.55 seconds for diagnosing HPS were 70%, 85% and 79% respectively. CONCLUSIONS: Pulmonary transit time derived from pulmonary angiography is useful for diagnosing HPS, especially for patients with intracardiac shunts and inadequate echocardiographic windows.

Fluoroscopy-guided balloon dilation in patients with Eustachian tube dysfunction.

OBJECTIVES: To prospectively evaluate the technical feasibility and safety of fluoroscopy-guided balloon dilation in patients with Eustachian tube (ET) dysfunction. METHODS: Patients who could not do a Valsalva manoeuvre for more than 6 months and diagnosed with chronic otitis media or ET dysfunction were prospectively enrolled. A 0.035-in. guide wire and 6-mm long balloon catheter with a diameter of 2 mm were used to dilate the cartilaginous portion of the ET under fluoroscopic guidance. The balloon was inflated by manual injection twice for 1 min each time. Clinical outcomes were assessed by the patient's ability to perform a Valsalva manoeuvre, and symptoms were assessed using the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score. RESULTS: Balloon dilation was attempted in a total of ten adult patients from October 2016 to March 2017. Technical success was achieved in all procedures (10/10). Ninety percent (9/10) of the balloons were fully dilated without waist deformity. There were no major complications. All patients were able to perform a Valsalva manoeuvre at the time of their last visit and/or improvement of at least one ETDQ-7 score. CONCLUSION: Fluoroscopy-guided balloon dilation seems to be technically feasible and safe in the treatment of ET dysfunction. KEY POINTS: • Fluoroscopy-guided balloon dilation without general anaesthesia was well-tolerated in all patients. • Location of the balloon catheter can be monitored during the procedure. • Inflation state of the balloon catheter can be monitored during the procedure. • Using guide-wire during the procedure would prevent false passage creation. • All patients had clinical improvement within 3 months after balloon dilation.

Lymphatic Interventions for Chylothorax: A Systematic Review and Meta-Analysis.

PURPOSE: To perform a systematic review and meta-analysis of published studies to evaluate the efficacy of lymphatic interventions for chylothorax. MATERIALS AND METHODS: The MEDLINE, EMBASE, and Cochrane databases were searched for English-language studies until March 2017 that included patients with chylothorax treated with lymphangiography (LAG), thoracic duct embolization (TDE), or thoracic duct disruption (TDD). Exclusion criteria were as follows: a sample size of less than 10 patients, no extractable data, or data included in subsequent articles or duplicate reports. RESULTS: The cases of 407 patients from 9 studies were evaluated. The pooled technical success rates of LAG and TDE were 94.2% (95% confidence interval [CI], 88.4%-97.2%; I2 = 46.7%) and 63.1% (95% CI, 55.4%-70.2%; I2 = 37.3%), respectively. The pooled clinical success rates of LAG, TDE, and TDD, on a per-protocol basis, were 56.6% (95% CI, 45.4%-67.2%; I2 = 5.4%), 79.4% (95% CI, 64.8%-89.0%; I2 = 68.1%), and 60.8% (95% CI, 49.4%-71.2%; I2 = 0%), respectively. The pooled major complication rate of LAG and TDE was 1.9% (95% CI, 0.8%-4.3%; I2 = 0%) and 2.4% (95% CI, 0.9%-6.6%; I2 = 26.4%), respectively. The pooled overall clinical success rate of lymphatic interventions, on an intention-to-treat basis, was 60.1% (95% CI, 52.1%-67.7%; I2 = 54.3%). Etiology of chylothorax was identified as a significant source of heterogeneity for the pooled clinical success rate of TDE and overall clinical success rate. CONCLUSIONS: Lymphatic interventions have a respectable efficacy for the treatment of chylothorax.

Self-Expandable Metal Stent Use to Palliate Malignant Esophagorespiratory Fistulas in 88 Patients.

PURPOSE: To identify predictors associated with clinical outcomes (initial clinical failure, stent patency, and survival) after self-expandable metal stent (SEMS) placement for malignant esophagorespiratory fistulas (ERFs). MATERIALS AND METHODS: Using logistic and Cox regression analyses, this study reviewed 88 patients (mean age 59.4 y ± 8.4; 84 men [95.5%] and 4 women [4.5%]) who underwent fluoroscopic SEMS placement for palliating malignant ERF from January 2000 to December 2016. RESULTS: Technical success was achieved in all patients. Initial clinical success was achieved in 78.4% (69/88; 95% confidence interval [CI], 68.7%-85.7%). Among the 69 patients in whom initial clinical success was achieved, aspiration symptoms recurred in 37.7% (26/69; 95% CI, 27.2%-49.5%). Overall major complication rate was 25.0% (22/88; 95% CI, 17.1%-35.0%). Cumulative stent patency and cumulative survival rates at 1, 3, 6, and 12 months were 72.8%, 38.9%, 32.4%, and 21.6% and 81.4%, 51.9%, 30.5%, and 13.3%, respectively. Stricture of the upper esophagus was an independent predictor of initial clinical failure (odds ratio, 3.760; 95% CI, 1.207-11.811) and shorter stent patency (hazard ratio [HR], 2.036; 95% CI, 1.170-3.544). Initial clinical failure was an independent predictor of shorter survival (HR, 2.902; 95% CI, 1.587-5.305). CONCLUSIONS: SEMS placement offers sufficient short-term relief despite considerable major complications. Stricture of the upper esophagus is an independent predictor of initial clinical failure and shorter stent patency. Initial clinical failure is an independent predictor of shorter survival.

In Vivo Fluorescence Microendoscopic Monitoring of Stent-Induced Fibroblast Cell Proliferation in an Esophageal Mouse Model.

PURPOSE: To evaluate the feasibility of self-expanding metal stent (SEMS) placement and fluorescence microendoscopic monitoring for determination of fibroblast cell proliferation after stent placement in an esophageal mouse model. MATERIALS AND METHODS: Twenty fibroblast-specific protein (FSP)-1 green fluorescent protein (GFP) transgenic mice were analyzed. Ten mice (Group A) underwent SEMS placement, and fluoroscopic and fluorescence microendoscopic images were obtained biweekly until 8 weeks thereafter. Ten healthy mice (Group B) were used for control esophageal values. RESULTS: SEMS placement was technically successful in all mice. The relative average number of fibroblast GFP cells and the intensities of GFP signals in Group A were significantly higher than in Group B after stent placement. The proliferative cellular response, including granulation tissue, epithelial layer, submucosal fibrosis, and connective tissue, was increased in Group A. FSP-1-positive cells were more prominent in Group A than in Group B. CONCLUSIONS: SEMS placement was feasible and safe in an esophageal mouse model, and proliferative cellular response caused by fibroblast cell proliferation after stent placement was longitudinally monitored using a noninvasive fluorescence microendoscopic technique. The results have implications for the understanding of proliferative cellular response after stent placement in real-life patients and provide initial insights into new clinical therapeutic strategies for restenosis.

Radiation-induced esophageal strictures treated with fluoroscopic balloon dilation: clinical outcomes and factors influencing recurrence in 62 patients.

Background Balloon dilation is safe and effective for the treatment of radiation-induced esophageal stricture (RIES), with favorable short-term and mid-term outcomes; however, few reports of long-term outcomes exist. Few studies have evaluated factors associated with recurrence after balloon dilation. Purpose To evaluate the long-term outcome of balloon dilation in patients with RIES and to identify factors associated with stricture recurrence. Material and Methods The medical records of 62 consecutive patients who had undergone fluoroscopic balloon dilation for RIES at our institution between December 1998 and June 2016 were reviewed. Results One hundred and twenty balloon dilation sessions were performed in 62 patients (mean = 1.9 sessions per patient). Clinical success was achieved in 53 (86%) patients after single (n = 37) or multiple (n = 16) dilation sessions. Complications occurred in 27% of the dilation sessions. The primary patency rates at one, two, three, and five years were 60%, 56%, 52%, and 52%, respectively. Secondary patency rates at one, two, three, and five years were 87%, 85%, 85%, and 80%, respectively. Multivariate logistic regression analysis identified an interval from radiation therapy (RT) to stricture of ≥6 months (hazard ratio [HR] = 0.205; P < 0.001), strictures located at the cervical esophagus (HR = 5.846; P < 0.001), and stricture length of ≥2 cm (HR = 2.923; P = 0.006) as significant predictors of recurrence. Conclusion Despite the high incidence of ruptures and recurrences, fluoroscopic balloon dilation is valuable as an initial therapeutic option for patients with RIES.

EW-7197, an activin-like kinase 5 inhibitor, suppresses granulation tissue after stent placement in rat esophagus.

BACKGROUND AND AIMS: Self-expanding metallic stent (SEMS) placement is a well-established method for treating malignant esophageal strictures; however, this procedure has not gained widespread acceptance for treating benign esophageal strictures because of granulation tissue formation. The aim of the present study was to investigate whether EW-7197, a novel per-oral transforming growth factor-ß type I receptor kinase inhibitor, suppressed granulation tissue formation after SEMS placement in the rat esophagus. METHODS: Sixty rats underwent SEMS placement and were randomly divided into 4 groups. Group A (n = 20) received vehicle-treated control for 4 weeks. Group B (n = 20) received 20 mg/kg/day EW-7197 for 4 weeks. Group C (n = 10) received 20 mg/kg/day EW-7197 for 4 weeks followed by vehicle-treated control for 4 weeks. Group D (n = 10) received 20 mg/kg/day EW-7197 for 8 weeks. RESULTS: SEMS placement was technically successful in all rats. Eleven rats, however, were excluded because of stent migration (n = 9) and procedure-related death (n = 2). The luminal diameter in group A was significantly smaller than those in groups B, C, and D (all P < .001). The percentage of granulation tissue area, number of epithelial layers, thickness of submucosal fibrosis, percentage of connective tissue area, and degree of collagen deposition were significantly higher in group A than in groups B, C, and D (all P < .001); however, there were no significant differences among groups B, C, and D. EW-7197 decreased the expression levels of phospho-Smad 3, N-cadherin, fibronectin, α-smooth muscle actin, and transforming growth factor-ß1 and increased the expression level of E-cadherin (all P < .01). CONCLUSIONS: EW-7197 suppressed granulation tissue formation after SEMS placement in the rat esophagus.

Transcatheter Arterial Embolization of Gastrointestinal Bleeding with N-Butyl Cyanoacrylate: A Systematic Review and Meta-Analysis of Safety and Efficacy.

PURPOSE: To evaluate the safety and efficacy of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for the treatment of gastrointestinal (GI) bleeding via a meta-analysis of published studies. MATERIALS AND METHODS: The MEDLINE/PubMed and EMBASE databases were searched for English-language studies from January 1990 to March 2016 that included patients with nonvariceal GI bleeding treated with transcatheter arterial embolization with NBCA with or without other embolic agents. The exclusion criteria were a sample size of < 5, no extractable data, or data included in subsequent articles or duplicate reports. RESULTS: The cases of 440 patients (mean age, 63.8 y ± 14.3; 319 men [72.5%] and 121 women [27.5%]) from 15 studies were evaluated. Of these patients, 261 (59.3%) had upper GI bleeding (UGIB) and 179 (40.7%) had lower GI bleeding (LGIB). Technical success was achieved in 99.2% of patients with UGIB (259 of 261) and 97.8% of those with LGIB (175 of 179). The pooled clinical success and major complication rates in the 259 patients with UGIB in whom technical success was achieved were 82.1% (95% confidence interval [CI], 73.0%-88.6%; P = 0.058; I2 = 42.7%) and 5.4% (95% CI, 2.8%-10.0%; P = 0.427; I2 = 0.0%), respectively, and those in the 175 patients with LGIB in whom technical success was achieved were 86.1% (95% CI, 79.9%-90.6%; P = 0.454; I2 = 0.0%) and 6.1% (95% CI, 3.1%-11.6%; P = 0.382; I2 = 4.4%), respectively. CONCLUSIONS: Transcatheter arterial embolization with NBCA is safe and effective for the treatment of GI bleeding.