Varying Outcomes among Patients with Large Angiomyolipomas according to the Treatment Method.

PURPOSE: This study aimed to evaluate the outcomes of large angiomyolipoma (AML) treatment by selective arterial embolization (SAE) versus nephron-sparing surgery (NSS) using a robotic surgical system. MATERIALS AND METHODS: Between January 2011 and June 2018, we retrospectively reviewed 25 patients who underwent robot-assisted partial nephrectomy (RAPN) or SAE for large AMLs. Ten patients underwent RAPN, and 15 underwent SAE. Patient demographics, AML characteristics, and operative and postoperative clinical outcomes were recorded and analyzed. Outcomes were compared between patients who underwent RAPN and patients who underwent SAE. Specifically, changes in renal function and size were evaluated after the treatment. RESULTS: The mean age of the patients was 52.9 years, and 22 of 25 patients were female. The mean maximum AML diameter on computed tomography was 8.9 cm, and 8 patients had multiple masses. Twenty-two of 25 patients had moderate to high RENAL complexity. Patients who underwent SAE had more symptoms (p = 0.018) and higher RENAL complexity scores (p = 0.013) on average. On average, tumor size decreased by 99% among RAPN patients and by 58% among SAE patients (p = 0.001). Although the mean pretreatment estimated glomerular filtration rate (eGFR) was higher among RAPN patients (99.8 vs. 80.0 mL/min/1.73 m2, p = 0.043), there were no significant changes in eGFR in either group after the treatment. One patient in the RAPN group experienced complications, but the postoperative ileus resolved without intervention. CONCLUSIONS: Both RAPN and SAE were effective and feasible treatment options for large AMLs. The AML characteristics and the condition of the patient might be important in determining the appropriate treatment method.

Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND: Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial. PURPOSE: To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients. METHODS: This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes. RESULTS: Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points. CONCLUSION: Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.

Delayed, life-threatening hemorrhage after self-expandable metallic biliary stent placement: clinical manifestations and endovascular treatment.

BACKGROUND: Life-threatening, delayed hemorrhage after self-expandable metallic stent (SEMS) insertion for malignant biliary obstruction is very rare. Clinical manifestations, radiologic characteristics, treatment, and prognosis of this complication are not well-known. PURPOSE: To present the clinical manifestations, radiologic findings, and endovascular treatment of life-threatening, delayed hemorrhage secondary to SEMS placement. MATERIAL AND METHODS: A total of six patients (five men and one woman; mean age, 65.5 years) with life-threatening, delayed arterial bleeding after SEMS placement for malignant bile duct obstruction were recruited between 2000 and 2011 from three different hospitals in Korea. The original SEMS placement in all patients utilized either percutaneous (n = 3) or endoscopic approaches (n = 3). We retrospectively reviewed the clinical presentations, computed tomography (CT) and angiographic findings, endovascular treatments, and prognoses of these patients. RESULTS: All patients presented with life-threatening gastrointestinal bleeding such as melena (n = 4), hematochezia (n = 1), and hematemesis (n = 1). Mean time period between biliary metallic stent insertion and presentation with bleeding was 75 days (range, 15-152 days). All stents were encased by primary or metastatic cancer along with nearby arteries on CT images. Digital subtraction angiogram (DSA) revealed pseudoaneurysm close to the stent (n = 2), in-stent pseudoaneurysm (n = 2), arteriobiliary fistula (n = 1), or pseudoaneurysm with arteriobiliary fistula (n = 1). The origins of hemorrhage were the gastroduodenal artery (n = 3), the aberrant right posterior hepatic artery from the gastroduodenal artery (n = 2), and the right hepatic artery (n = 1). Hemorrhages were successfully controlled after intra-arterial coil embolization in five patients followed by placement of a stent graft and direct puncture N-butyl-2-cyanoacrylate (NBCA) embolization in one patient. CONCLUSION: Life-threatening, delayed hemorrhage within a metallic biliary stent may occur if a stent is placed across the bulky bile duct tumor or tumor encases the stent. Bleeding can be successfully treated with endovascular treatment. However, the overall prognosis was poor.

Can the 1.8 mm transnasal biopsy forceps instead of standard 2.2 mm alter rapid urease test and histological diagnosis?

BACKGROUND AND AIM: Biopsy specimens are taken during transnasal esophagogastroduodenoscopy with 1.8 mm forceps. The aims of this study were to compare the concordance of the Campylobacter-like organism (CLO) test and histological diagnoses between biopsies taken with 1.8 mm and 2.2 mm forceps and to determine whether the concordance of the CLO test could be improved by increasing the number of specimens using 1.8 mm forceps. METHODS: A total of 200 patients were enrolled. We first performed the CLO test twice using each sample taken with both forceps in 100 patients. The CLO test was conducted three times again after confirming the difference in the CLO test between two forceps: (i) one sample with 1.8 mm forceps; (ii) two with 1.8 mm; and (iii) one with 2.2 mm in the other 100 patients. Additionally, each specimen was taken from the same gastric lesions in 200 patients for the histological diagnosis using both forceps types. RESULTS: The concordance rate of the CLO test between each sample with 1.8 mm and 2.2 mm forceps was 83% (κ-value, 0.64), and that between two samples with 1.8 mm and one with 2.2 mm was 92% (κ-value, 0.83). The concordance rate of the histological diagnosis with 1.8 and 2.2 mm was 97% (κ-value, 0.84). CONCLUSIONS: At least two samples using 1.8 mm forceps might be needed to obtain similar results on the CLO test using 2.2 mm. But, the size difference between two forceps did not influence the histological diagnosis.

Ultrasonographic analysis of subcutaneous angiolipoma.

OBJECTIVE: To describe and analyze the ultrasonographic appearance of subcutaneous angiolipoma in pathology-proven cases. MATERIALS AND METHODS: We retrospectively searched the January 2004 to May 2011 surgical pathology database for cases of pathology-proven angiolipoma. The ultrasonographic findings were analyzed for angiolipoma size, shape, margin, echo texture, echogenicity, acoustic enhancement, calcifications, and color Doppler flow. RESULTS: Of 31 angiolipomas, 19 lesions occurred in an upper extremity, one in a lower extremity, nine in the chest and abdominal wall, and two in the back. The mean tumor size was 17.7 mm. Twenty-five cases (80%) appeared as oval mass and all tumors had well-defined margins. All cases showed hyperechoic; 14 (45%), homogeneous; 17 (55%), heterogeneous. Seven cases (23%) showed blood flow in the mass. Acoustic enhancement and calcification was not shown in any cases. A correct preoperative diagnosis was made in three cases (10%) by ultrasonography. CONCLUSIONS: Most subcutaneous angiolipomas are oval-shaped, have well-defined margins, and hyperechoic appearance on ultrasonography. Although color Doppler flow of subcutaneous angiolipoma is not seen in many cases, it may helpful in differentiating angiolipoma from ordinary subcutaneous lipoma.

Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients.

INTRODUCTION: Intra-arterial (IA) thrombolysis with plasminogen activator is well-known, but the use of IA tirofiban as an adjuvant for IA thrombolysis is not well-known. We investigated the feasibility of IA tirofiban as an adjuvant after unsuccessful IA recanalization with urokinase (UK) for acute ischemic stroke. METHODS: We retrospectively analyzed all 16 consecutive patients (11 men and five women; mean age, 61.3 years; range, 36-85 years) who were treated with IA tirofiban after isolated IA thrombolysis with UK or bridging therapy with systemic recombinant tissue plasminogen activator (rt-PA; 0.6 mg/Kg) and IA UK for acute ischemic stroke. Outcome measures included angiographic recanalization (thrombolysis in cerebral infarction, TICI), symptomatic and asymptomatic intracerebral hemorrhage (ICH), mortality, and functional independence at 3 months (modified Rankin Scale, 0-2). RESULTS: Among the 16 patients treated with IA tirofiban as an adjuvant, 10 patients had conventional dose (<25 ug/kg, bolus) and six patients had high dose (≥25 ug/kg, bolus) of IA tirofiban after unsuccessful IA thrombolysis whether systemic rt-PA used or not. Successful angiographic recanalization (TICI grade 2b or 3) was achieved in 13 patients (13/16) and a functional independence at 3 months in eight patients (8/16). Three months after therapy, three patients had died. There were two patients of symptomatic ICH and four asymptomatic ICH. CONCLUSION: Conventional dose of IA tirofiban as an adjuvant during IA thrombolysis for acute ischemic stroke seems feasible. However, further dose escalation studies should be performed regarding the IA use of tirofiban for acute ischemic stroke.

Classification of persistent primitive trigeminal artery (PPTA): a reconsideration based on MRA.

BACKGROUND: Persistent primitive trigeminal artery (PPTA) is the most common permanent carotid-basilar anastomosis. Magnetic resonance angiography (MRA) has become the primary non-invasive imaging technique for evaluation of cerebral vascular anatomy and can provide detailed 3D imaging of intracranial vessels. PURPOSE: To evaluate the usefulness of MRA for the detection of PPTA and to re-classify its variations based on the embryologic types of PcomA and its relationship with the basilar artery and its branches. MATERIAL AND METHODS: Of the total 7329 patients who underwent MRA at our institution from March 2008 through November 2010, we retrospectively analyzed the MRAs of 24 patients with a PPTA. Special attention was given to defining the relationship of the PPTA and the basilar artery with PcomA and to determine the site of origin, size, and course of the PPTA. The PPTA classification included five types based on their anatomic relationship to the neighboring arteries. Clinical features and associated vascular anomalies are also described. RESULTS: Twenty-four (17 women and seven men, 34 ~ 81 years of age, mean age 59.67 years) of the 7329 patients had a PPTA (0.33 %). Eleven cases (45.8%) were classified as type 1, three (12.5%) as type 2, five (20.8%) as type 3, one (4.2%) as type 4, and four (16.7%) as type 5b. Fifteen PPTAs (62.5%) were located on the left side and nine were located (37.5%) on the right side. The basilar artery proximal to the insertion of the PPTA showed severe to moderate hypoplasia in 13 cases (54%). Nine intracranial artery aneurysms were detected in seven (29%) of the 24 study patients. CONCLUSION: This study revealed five types of PPTA and necessitates an adjustment of the previous classification of PPTA on the basis of our MRA examinations. A PPTA should be considered by both the clinician and the radiologist who interpret MR angiography.

Acute kidney injury after transarterial chemoembolization for hepatocellular carcinoma: a retrospective analysis.

BACKGROUND: Transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) may result in acute kidney injury (AKI) like other angiographic interventions. METHODS: To investigate the incidence, risk factor and outcomes of AKI after TACE, defined by Acute Kidney Injury Network (AKIN) criteria, we retrospectively analyzed 442 TACE treatment sessions in 236 HCC patients. RESULTS: The incidence of AKI in the first 48 h after TACE was 9.8% (23 of 236 patients at risk). Presence of hypertension (OR 3.24, 95% CI 1.21-8.72, p = 0.02), lower baseline serum albumin (OR 0.29, 95% CI 0.15-0.56, p < 0.01) and higher creatinine level (OR 12.02, 95% CI 3.49-41.39, p < 0.01) were independent risk factors of AKI. Prolonged renal insufficiency after 1 month was observed in 24.1% of AKI episodes. CONCLUSION: AKI is a common complication after TACE and we have to pay attention to the prevention and early recognition of AKI occurrence in high-risk patients.

Renal artery embolization of perirenal hematoma in hemorrhagic fever with renal syndrome: a case report.

Hemorrhagic fever with renal syndrome (HFRS) is an acute viral disease characterized by fever, hemorrhage and renal failure. Among the various hemorrhagic complications of HFRS, spontaneous rupture of the kidney and perirenal hematoma are very rare findings. We report here on a case of HFRS complicated by massive perirenal hematoma, and this was treated with transcatheter arterial embolization.

[Hemobilia from pancreatic arteriovenous malformation: successful treatment with transportal coil embolization of draining veins].

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

Suppressive effect of Zedoariae rhizoma on pulmonary metastasis of B16 melanoma cells.

The inhibitory effect of Curcuma zedoaria Roscoe (WE-CZ) on experimental pulmonary metastasis of B16 melanoma cells was investigated. The intake of WE-CZ at doses of 250 and 500 mg/kg for 6 weeks from 2 weeks before tumor inoculation significantly reduced the number of metastatic surface nodules in the lung, resulting in an extended life span. When the duration of WE-CZ intake was examined, survival time was not affected by pre-intake before B16 melanoma cell inoculation and was slightly extended by post-intake after B16 melanoma cell inoculation, although the life span was prolonged by intake throughout the experiment. To address the mechanism underlying the anti-metastatic effect of WE-CZ, we examined the issue of whether WE-CZ modulated macrophage function, which is involved in killing tumor cells. The intake of WE-CZ for 6 weeks increased nitric oxide (NO) production by macrophages following stimulation with lipopolysaccharide in a dose-dependent manner. The elevated NO was found to serve as a cytotoxic mediator against B16 melanoma cells in co-culture with macrophages. On the contrary, B16 melanoma-conditioned medium reduced NO production by macrophages. However, WE-CZ treatment significantly reversed the reduction in NO production by the conditioned medium. These findings indicate that WE-CZ possesses anti-migratory effects on B16 melanoma cells and that the macrophage function-modulating activity by WE-CZ appears to underlie its anti-metastatic activity, which leads to a decrease in the number of lung metastatic surface nodules and the extension of life span. These results suggest that WE-CZ may play important roles in the inhibition of cancer metastasis.

The Hemoptysis and the Subclavian Artery Pseudoaneurysm due to a Fishbone Injury: A Case Report.

Ingestion of a foreign body is a common cause of esophageal injury, but hemoptysis is a rare manifestation of the esophageal penetration by a swallowed foreign body. The swallowing of a fishbone is hard to diagnose and the definite diagnosis is usually made during surgery. We describe the case of a 50-year-old man with direct injury to the lung parenchyma, the azygos vein, and the subclavian artery pseudoaneurysm due to a fishbone penetration from the upper esophagus into the lung. To our knowledge, this is the first case report that we know of in which a swallowed foreign body that penetrated from the upper esophagus into the lung caused vascular injuries and lung damage and it was solved by minimally invasive surgery and an endovascular stent.We successfully diagnosed and treated a case with the migration of the fishbone from the upper esophagus into the lung. A contrast-enhanced computed tomography (CT) scan is recommended to clarify the fact of vascular injury before surgery. Thoracoscopic operation (VATS) combined with endovascular treatment could be a safer and a more feasible treatment option in this rare condition.

Synovial sarcoma of the head and neck: a case of predominantly cystic mass.

We report a case of predominantly cystic synovial sarcoma partly adherent to the hyoid bone in the submental area. The mass demonstrated posterior acoustic enhancement at sonography and a complex cystic mass with mural nodules and solid septa at CT.

A new model of tracheal stenosis in dogs using combined bronchoscopic electrocautery and ethanol injection.

PURPOSE: To establish a new animal model of tracheal stenosis in dogs that involves combined bronchoscopic electrocautery and ethanol injection. MATERIALS AND METHODS: Ten mongrel dogs were included in the study. With flexible bronchoscopic and fluoroscopic guidance, a combination of electrocautery (30 W) and ethanol injection (total volume 2 mL) was circumferentially applied to the trachea at the third thoracic vertebra level. Dogs were euthanized 4 weeks later and the stenosis diameter and histologic findings were evaluated. RESULTS: All procedures were successful. Eight of the 10 dogs survived to 4 weeks, whereas two died from respiratory failure before the planned endpoint. For the eight full-term dogs, the mean percentage diameter stenosis (+/-SD) was 70.8%+/-9.3%, with a range of 56%-81%. Microscopic analysis showed that the maximum tracheal wall thickness was 2.48 mm+/-0.77. The degree of inflammatory cell infiltration varied, but cartilage destruction and mucosal ulceration were evident in all cases. CONCLUSIONS: A new tracheal stenosis model was developed in dogs with use of combined bronchoscopic electrocautery and ethanol injection. This animal model is a technically simple, reliable, and tracheotomy-free model for the creation of tracheal stenosis.

Operator-dependent techniques for graded compression sonography to detect the appendix and diagnose acute appendicitis.

OBJECTIVE: The objective of our prospective study was to evaluate the value of various operator-dependent techniques that allow graded compression sonography to detect normal or abnormal vermiform appendix. SUBJECTS AND METHODS: A total of 877 subjects were included in this study. This sample population consisted of two groups: 202 control subjects and 675 patients who were suspected of having acute appendicitis. If detection of the appendix failed after a sufficient number of trials using graded compression scanning, appropriate operator-dependent techniques were used to help graded compression scanning to increase the detectability of the appendix further. The detection rate for the appendix in both groups and the diagnostic accuracy for acute appendicitis were obtained. RESULTS: The initial graded compression sonography examination depicted the appendix in 170 (84%) of 202 subjects in the control group and 601 (89%) of the 675 patients in the patient group. We then added operator-dependent techniques to graded compression sonography for the remaining patients in whom the appendix could not be detected. The additional use of the posterior manual compression technique, low-frequency convex transducer, upward graded compression technique, or left oblique lateral decubitus change of body position allowed graded compression sonography to depict the appendix in an additional 10, eight, six, and four patients in the control group, respectively, and in an additional 27, 23, 11, and seven patients in the patient group. The number of identified appendixes was increased to 198 (98%) of the 202 patients in the control group and to 669 (99%) of the 675 patients in the patient group. Graded compression sonography with operator-dependent techniques in the patient group yielded a sensitivity of 99% (319/321 patients), specificity of 99% (350/354), and an accuracy of 99% (669/675) for acute appendicitis. CONCLUSION: The addition of various operator-dependent techniques to graded compression sonography is useful for allowing improved visualization of both normal and abnormal appendixes.

Graded compression sonography with adjuvant use of a posterior manual compression technique in the sonographic diagnosis of acute appendicitis.

OBJECTIVE: We evaluated the usefulness of graded compression sonography with the adjuvant use of a posterior manual compression technique for detection of the vermiform appendix and the diagnosis of acute appendicitis. SUBJECTS AND METHODS: Five hundred seventy consecutive patients referred for suspected acute appendicitis were prospectively examined by original, graded compression sonography with a 5- or a 7.5-MHz linear transducer. A posterior manual compression technique was added for 85 patients whose vermiform appendix was not identified with graded compression sonography. For consensus, another experienced radiologist or a resident observer was in attendance throughout the examination. The detection rate for the vermiform appendix and the diagnostic accuracy for acute appendicitis before and after the adjuvant use of a posterior manual compression technique were obtained, respectively, and final diagnoses were established with the official radiology reports, surgical results, and clinical follow-up. RESULTS: Graded compression sonography enabled visualization of the vermiform appendix in 485 (85%) of 570 patients. After the adjuvant use of a posterior manual compression technique, the vermiform appendix was found in an additional 57 of 85 patients, with the number of identified vermiform appendices increasing to 542 (95%) of 570 patients. The 57 patients with an additionally found appendix included 11 patients with acute appendicitis. The sonographic diagnosis of acute appendicitis was determined in 312 of 542 patients. Acute appendicitis was proven by surgery in 311 of 332 patients. Sonography was used to establish the diagnosis in 302 of the 311 patients with proven appendicitis; there were 10 false-positive diagnoses and nine false-negative diagnoses. One false-positive diagnosis was acquired after use of the posterior manual compression technique. These results showed more improvement than those of the probabilities for acute appendicitis with single use of graded compression sonography. CONCLUSION: Graded compression sonography with adjuvant use of a posterior manual compression technique seems to be useful for detecting the vermiform appendix and for diagnosing acute appendicitis.