Hemothorax caused by spontaneous rupture of a metastatic mediastinal lymph node in hepatocellular carcinoma: a case report

No abstract available.

Comparison of Intraperitoneal and Retroperitoneal/Pelvic Contrast Extravasation: The Characteristics and Prognosis of the Each Patient Group with Arterial Embolization according to the Abdominal Computed Tomography Scanning after Blunt Trauma

PURPOSE: This study compared the characteristics of and the prognosis for intraperitoneal and retroperitoneal/pelvic contrast extravasation, which had been confirmed by enhanced abdominal CT scan, after blunt trauma in patients who had undergone angiographic embolization. METHODS: From January 2001 to March 2009, data were retrospectively collected regarding patients who had undergone contrast extravasation (CE) on CT scanning and arterial embolization after blunt trauma. The study patient group was divided into the intraperitoneal and the retroperitoneal/pelvic groups according to the area of contrast extravasation. We reviewed the initial demographic data, the location of injury, the solid organ injury, the embolized vessel, and the clinical outcome. RESULTS: The mean age of the study subjects was 40.2+/-2.6 years old, and there were 24 male patients. The intraperitoneal group included 10 patients, and retroperitoneal/pelvic group was comprised of 17 patients. The amount of transfusion from presentation to intervention and during the first 24 hours was greater in the retroperitoneal/pelvic group than in the intraperitoneal group. The intraperitoneal group showed a higher frequency and severity of liver injury than the retroperitoneal/pelvic group. Angiography revealed that the hepatic artery (n=4) was the most frequently embolized vessel in the intraperitoneal group, while the internal iliac artery (n=6), followed by the renal artery (n=4), internal pudendal artery (n=3), and the gluteal artery (n=2), were the most frequently injured vessels in the retroperitoneal/pelvic group. CONCLUSION: In patients with intra-abdominal contrast extravasation found on CT scanning and arterial embolization after blunt trauma, the need for transfusion was less in the intra-abdominal group than in the retroperitoneal/pelvic group. Liver injury was also more frequent and severe in the intraperitoneal group than in the retroperitoneal/pelvic group.

Calcified Thyroid Nodules: Review of the Significance of Peripheral Calcifications

Thyroid calcification may occur in both benign and malignant thyroid disease, but previous literature reports have indicated that calcification is more common in malignant lesions than it is in benign ones. Various patterns of calcification are seen, including microcalcification, coarse dense macrocalcification, and peripheral calcification. Microcalcification and coarse dense macrocalcification are two of the most specific features of thyroid malignancy. However, to date, the clinical significance of peripheral calcification remains unclear and therefore controversial. In this pictorial review, we describe the ultrasonographic features of calcified thyroid nodules and seek to delineate the spectrum and determine the clinical significance of peripheral calcification by correlating it with pathologic results. A broad spectrum of benign to malignant tumors is associated with peripheral calcification. Peripheral calcification in a thyroid nodule should be considered to indicate an indeterminate lesion, and ultrasonography-guided FNAB or core biopsy should be performed in order to exclude malignancy.

Comparison of Survival in Pelvic Bone Fractures with Arterial Embolization

PURPOSE: This study was to evaluate the effect of arterial embolization on survival in patients with pelvic bone fractures and arterial bleeding. METHODS: From January 2001 to December 2007, in all, 18 patients with pelvic bone fractures that had been treated with interventional arterial embolization were included in this retrospective study. The Injury Severity Score (ISS), the Revised Trauma Score (RTS), the initial hemodynamic status, the blood gas analysis, blood transfusion data, and mortality were the main outcome measurements. RESULTS: Pelvic bone fractures were classified into lateral compression (LC), antero-posterior compression (APC), vertical shear (VS), and combined (CM) type according to the Young-Burgess classification. The Survivor group included 11 patients (61.1%), and the non-survivor group included 7 patients (38.9%). The mean ages for the survivor and the non-survivor groups were 40.0 and 45.6 years (p=0.517). The types of pelvic bone fractures were LC 11 (61.1%), APC 6 (33.3%), and VS 1 (5.6%): LC 7 (63.6%), and APC 4 (36.4%) in the survivor group and LC 4 (57.1%), APC 2 (28.6%), and VS 1 (14.3%) in the non-survivor group. The internal iliac artery was the predominant injured vessel among both the survivors (n = 5, 45.5%) and the non-survivors (n = 4, 57.1%). No differences in initial blood pressures, ISS, and RTS existed between the two groups, but the arterial pH was lower in the non-survivor group (pH 7.09 (+/-0.20) vs 7.30 (+/-0.08), p=0.018). The number of transfused 24-hour units of packed RBC was greater in the non-survivor group (24.1+/-12.5 vs 14.4+/-6.8, p=0.046). CONCLUSION: No differences in initial blood pressure and trauma scores existed between survivors and nonsurvivors with pelvic bone fractures, who had been treated with arterial embolization, but arterial pH was lower the in non-survivors.

Renal Ruptures with Active Bleeding Treated with Emergency Selective Renal Arterial Embolization / 대한비뇨기과학회지

Selection of a treatment modality for traumatized renal rupture depends on the renal injury grade, hemodynamic stability, combined organ injury, and the physician's experience. Treatment for renal injury tends to be conservative to maintain renal function and lessen the morbidity of surgery. If renal injuries were well-staged and selected by radiologic evaluation, hemodynamically stable patients with significant injuries (grades II through V) can usually be managed without surgical exploration. We report 3 cases of grade 4 renal injuries successfully treated with selective renal arterial embolization.

A Primary Leiomyoma in the Neural Foramen of the Lumbar Spine: A Case Report

A primary leiomyoma in the neural foramen of the lumbar spine is a very rare condition. We examined a 23-year-old female presented with back and right flank pain. A plain radiography showed a well-defined, osteolytic lesion in the L3 body. In addition, MR images showed a mass lesion with intense enhancement, after intravenous injection with contrast material, in the right neural foramen at the L2/3 level. A histopathologic examination of the resected specimen revealed a benign leiomyoma.

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 / 대한소화기학회지

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.

A Case of Broncho-esophageal Fistula Treated by Histoacryl(R) Injection Therapy / 대한소화기내시경학회지

Broncho-esophageal fistula is a disease of varying etiologies. Spontaneous fistula occurs as a result of malignancy, radiotherapy or inflammatory disease. The majority of fistulas are caused by iatrogenic causes. Treatment of fistula usually consists of surgery and conservative management. Recently, it has been reported that broncho-esophageal fistula can be treated endoscopically using tissue adhesive agent such as Histoacryl(R) and fibrin glue. We report a case of broncho-esophageal fistula as a complication of tuberculosis that was successfully treated by radiological Histoacryl(R) injection therapy with a review of literatures.

Endoscopically Exposed Coil after Embolization for Bleeding Duodenal Ulcer / 대한소화기내시경학회지

Endoscopy has been the method of choice for the initial diagnosis and treatment of gastrointestinal bleeding. However, in the case of difficult localization or endoscopic failure, angiographic or surgical alternative may be recommended. The role of angiography has been emphasized recently to control upper GI bleeding. We experienced a case with deep ulcer displaying exposed vessel along the duodenal bulb, which imposed serious rebleeding risk. Although, active bleeding was controlled by the epinephrine injections in that patient, rebleeding risk was still high. So the patient underwent emergency angiography with embolization of the pancreaticoduodenal artery and gastroduodenal artery using multiple microcoils. Follow-up endoscopic examinations showed a coil protruding into the lumen from the ulcer bed, and the exposed coil at the ulcer base was completely by the regenerated epithelium three months later. Here in, we describe the rare case of a endodcopically exposed coil after embolization for bleeding duodenal ulcer which is the first case ever reported in Korea.

Endovascular stent-graft repair of aortocaval fistula complicated by the rupture of abdominal aortic aneurysm / 대한내과학회지

The incidence of infrarenal aneurym is about 6 percent after the age 60 years. A primary aortocaval fistula is present in less than 1% of all abdominal aortic aneurysms. Atherosclerotic abdominal aortic aneurysm account for about 90% of spontanous aortocaval fistula. The most common site of fistulation is the inferior vena cava. Until recently, surgical repair was the only method of treatment and was associated high incidence of morbidity and motality. With rapid development of aortic stent-graft technique, endovascular stent-graft repair may offer an alterative to the management of this often fatal condition. We report a case of 72-years old male with aortocaval fistula in the abdominal aorta, which was treated with endovascular stent-graft implantation. About 30 days before procedure, the patient diagnosed inferior acute myocardial infarction with triple vessel disease and also suffered from chronic obstructive pulmonary disease. After the stent-graft inserting, no further communication from aorta to inferior vena cava and improving symptoms and sign of congestive heart failure. He was discharged without complication, about 2 months after admission.

Angiographic Embolization as a Treatment of Postoperative Bleeding / 대한정형외과학회잡지

PURPOSE: To evaluate the usefulness of the angiographic embolization for the treatment of postoperative bleeding. MATERIALS AND METHODS: Six patients who suffered massive postoperative bleeding underwent angiographic embolization from March 1998 to June 1999. The initial diagnosis was femoral fractures in 4 patients, infected total hip arthroplasty in a patient, and open humerus fracture in a patient. When angiography revealed arterial tear, embolization was performed. The authors evaluated the effectiveness and the complication of angiographic embolization. RESULT: Five patients had arterial tear and one patient had diffuse bleeding from the granulation tissue. Angiographic embolization was performed in all patients. There were 3 cases of injury of the deep femoral artery, a case of injury of a branch of the subclavian artery, and a case of injury of the superior gluteal artery. After the procedure swelling subsided and the amount of transfusion diminished in all patients. There was no complication related to angiographic embolization. CONCLUSION: When there is suspicion of arterial injury after the operation, angiographic embolization can be used to confirm arterial injury and to control bleeding.

Safety of Superselective Transcatheter Arterial Chemoembolization through Cystic Artery for Treatment of Hepatocellular Carcinoma

PURPOSE: To report on the safety and efficacy of superselective transcatheter arterial chemoembolization( TACE) of tumor feeding branches originating from the cystic artery for the treatment of hepatocellular. MATERIALS AND METHODS: From, May 1995 to, September 1999, eleven HCC patients aged between 38 and 82 (mean, 57.4) years with tumor-feeding branches originating from the cystic artery underwent TACE. In eight, for whom superselection of these branches was possible, TACE was done with the use of Gelfoam and a mixture of Lipiodol and cisplatin, while for three, for whom superselection was impossible, a mixture of Lipiodol and cisplatin only was used. Immediately after TACE, remnant tumor staining was angiographically evaluated,and tumor response was determined by follow-up CT at one month. After procedure, the development of cholecystitis was assessed clinically. RESULTS: Post-TACE angiography showed remnant tumor staining in one patient who underwent embolization with Gelfoam and the mixture of Lipiodol and cisplatin, and in one for whom the mixture of Lipiodol & cisplatin only was used. Among the eight for whom Gelfoam and the mixture of Lipiodol and cisplatin was used,one-month follow-up CT showed compact Lipiodol uptake in five, partial Lipiodol uptake in three, no change in tumor size in six, increased tumor size in one, and decreased tumor size in one. Among the three for whom the mixture of Lipiodol and cisplatin only was used, one-month follow-up CT showed neither Lipiodol uptake nor change in tumor size in one patient, partial Lipiodol uptake and increased tumor size in one, and compact Lipiodol uptake and decreased tumor size in one. Cholecystitis developed in only one patient who underwent embolization with Gelfoam and the mixture of Lipiodol and cisplatin, but was cured by conservative treatment. CONCLUSION: Superselective TACE of tumor feeding branches originating from the cystic artery seems to be a safe and effective method for the treatment of hepatocellular carcinoma.

Ferumoxides-enhanced MR in the Detection of Hepatocellular Carcinoma: Comparison with Combined CT During Arterial Portography and CT Hepatic Arteriography

PURPOSE: Purpose: To compare the diagnostic accuracy of ferumoxides-enhanced MR with that of combined CT during arterial portography (CTAP) and CT hepatic arteriography (CTHA) in the preoperative detection of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: For preoperative evaluation, 20 patients with HCC underwent ferumoxides-enhanced MR and combined CTAP and CTHA. The MR protocol included fat-suppressed respiratory-triggered fast spin echo, T2*-weighted fast multiplanar gradient-recalled acquisition in the steady state, proton density-weighted fast multiplanar spoiled gradient-recalled echo, and breath-hold in-phase T1-weighted fast multiplanar spoiled gradient-recalled echo. In all patients, laparotomy was performed. The presence or absence of HCC was confirmed by pathologic examination in the resected liver and by intraoperative ultrasonography of remaining liver, or by follow up. Images were reviewed by three radiologists working independently; regarding the presence or absence of HCC in each segment, each observer assigned one of five confidence levels. A receiver operating characteristic (ROC) curve was fitted to these confidence ratings, and the diagnostic accuracy of each modality was evaluated by calculating the Az value (area under the ROC curve) and compared with that of other modalities. The sensitivity and specificity of each modality in the detection of HCC were also calculated and compared, and using a κstatistic, inter-observer agreement for each modality was assessed. RESULTS: In 28 of 160 liver segments, 30 HCCs were present. For ferumoxide-enhanced MR the mean Az value was 0.958, and for combined CTAP and CTHA this value was 0.948. The difference was not statistically significant. The mean sensitivities of ferumoxide-enhanced MR and combined CTAP and CTHA were 92.9% and 90.9%, respectively, the difference being statistically insignificant. The mean specificities of these modalities were, respectively, 98.9% and 93.6%. The difference was statistically significant. For both ferumoxide-enhanced MR and combined CTAP and CTHA, interobserver agreement was excellent. CONCLUSION: In the preoperative detection of HCC, ferumoxide-enhanced MR imaging of the liver showed a diagnostic accuracy similar to that of combined CTAP and CTHA. Its specificity, however, was higher.

Factors Associated with Residual Pleural Thickening After Chemotherapy in Tyberculous Pleurisy / 결핵

BACKGROUND: Residual pleural thickening is frequently seen following treatment for tuberculous pleurisy, and pleural decortication is performend occasionally in patients with severe residual pleural thickening. However, predictive factors for the development of residual pleural thickening are uncertain at the initial diagnosis of the tuberculous pleurisy. Therefore, the purpose of this study was to identify the associated factors for residual pleural thickening at initial diagnosis. METHODS: We separated 63 patients diagnosed as tuberculous pleurisy into two groups; group 1 consisted of patients without residual pleural thickening and group 2 comprised patients with residual pleural thickening at the end of tuberculous pleurisy treatment. We analyzed the clinical characteristics, radiological findings, pleural biopsy and characteristics of pleural fluid between group 1 and group 2. RESULTS: The study population and clinical symptoms of the two groups were not significantly different and the duration of symptoms before treatment and the peripheral WBC were similar between the two groups. The presence of pulmonary tuberculosis, pleural fluid loculation or the amount of pleural effusion sid not differ significantly between the thwo groups. The incidence of positive AFB staining(group 1 : 8%, group 2 : 38%) and granuloma(group 1 : 30%, group 2 : 62%) on pleural biopsy specimens was significantly higher in group 2 than in group 1. Pleural fluid WBC and differential count, adenosine deaminase level, pH, preotein level or glucose level did not differ between the two groups. However, group 2 had higher LDH levels (1370±208mg/dl) than group 1 (860±71mg/dl, p<0.05). CONCLUSION: In tuberculous pleurisy, patients with residual pleural thickening following treatment demonstrated a higher incidence of posivive AFB staining and granuloma on the pleural biopsy specimens or higher LDH level in the pleural fluid than patients wihtout residual pleural thickening From these results, we speculate that the amonut of tuberculous bacilli and granuloma are probably correlated with residual pleural thickening in the tuberculous pleurisy.

Anomalous Systemic Arterial Supply to Normal Basal Segments of Left Lower Lobe: A Report of Two Cases / 결핵

Two cases of an anomalous systemic arterial supply to the basal segments of the left lower lobe without pulmonary wequestration are presented. In the first case, a preoperative diagnosis was made by chest CT, and confirmed by angiograpy, in a 22-year old man who had a recurrent hemoptysis. There was systemic arterial supply that originated from the thoracic descending aorta and no pulmonary arterial supply to the basilar segment of the left lower lobe. However, the pulmonary parenchyma was normal without sequestration. Ligation of the abnormal artery and a left lower lobectomy were performed without complication. In the second case, there were characteristic features of this anomaly on chest CT and the angiogram in a 31-year-old man with symptoms of hemoptysis. The patient refused surgery.

Transcatheter Arterial Embolization of Splanchnic Arterial Pseudonaneurysm: Focus on the Method of Embolization

PURPOSE: To evaluate the effectiveness of transarterial embolization of splanchnic arterial pseudoaneurysm and to analyze the embolization technique. MATERIALS AND METHODS: Between 1991 and 1999, 38 patients with splanchnic arterial pseudoaneurysm underwent tarnsarterial coil embolization. The parent artery was embolized just distal and proximal to the neck of the pseudoaneurysm in 26 cases, and proximal to the aneurysmal neck in nine. In four patients, embolization involved the use of gelfoam, and in the other two patients, coil packing of the pseudoaneurysm sac was performed. RESULTS: Initial bleeding was controlled in 34 of the 38 patients (89%) treated by transarterial embolization (in 24 of 26 who underwent distal and proximal embolization, in seven of nine whose treatment involved proximal embolization and in two of four in whom gelfoam embolization was undertaken). In seven patients (18%), rebleeding occurred within 0 -14 (mean, 6.4) days of initial embolization. In two cases, bleeding reoccurred from the same artery initially treated by gelfoam embolization, in two others from that in which coil packing of the pseudoaneurysmal sac had been performed, and in three, from a different artery. Among these seven patients, one died from bleeding and the remaining six were successfully treated by repeated embolization. In spite of successful bleeding control, nine patients (24%) died of subsequent bleeding-related complications, namely sepsis (n=4), acute respiratory failure (n=3), and multi-organ failure (n=2). CONCLUSION: For the treatment of splanchnic arterial Pseudoaneurysm, transarterial embolization was a relatively simple and effective procedure. Proximal and distal coil embolization at the pseudoaneurysmal neck successfully isolated the of pseudoaneurysm and prevented the recanalization of blood flow.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

OBJECTIVE: To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

OBJECTIVE: To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Postoperative Intraabdominal Fluid Collections: A Modified Percutaneous Drainage Method using a Surgical Drain Track

In the management of postoperative fluid collection, the conventional percutaneous drainage method can be employed. Because of abdominal incisions and various types of surgical drains and/or T-tubes, the application of this method is not always easy, however. We inserted a drainage catheter through a pre-existing percutaneous track formed by a surgical drain located adjacent to the site of abnormal fluid collection. There was no need to remove the drain nor make an additional puncture in the abdominal wall. A dilator was inserted along the drain, and a guide wire was used to negotiate its intraperitoneal track and readch the accumulated fluid. The procedure was simple and safe. We briefly deseribe our experience of this modified percutaneous drainage technique, as used in three cases involving postoperative fluid collection.