Percutaneous placement of H-configured triple biliary and enteral stents through a single access: A solution for complex bilio-enteric obstruction

A 75-year-old male with recurrent pancreatic adenocarcinoma after a previous Whipple's procedure presented with jaundice. The local advancement of the tumor caused obstructions of the common bile duct, intrahepatic bile duct hilum, and small bowel. Endoscopic stent insertion was precluded by the Roux-en-Y reconstruction. A successful transhepatic percutaneous single-access stenting of the whole biliary tree and intestine was achieved by H-configured triple stenting by combining T-configured dual stent placement in the biliary system with a duodenal stent insertion across the bottom of the anastomosis after looping a wire in the afferent limb. The ‘H-configured’ stents remained patent for 10 months without major or minor complications. This technique adds a new minimal-invasive and effective palliative option for patients with obstruction of a bilio-enteric anastomosis inaccessible to endoscopy.

Thyroid Radiofrequency Ablation: Updates on Innovative Devices and Techniques

Radiofrequency ablation (RFA) is a well-known, effective, and safe method for treating benign thyroid nodules and recurrent thyroid cancers. Thyroid-dedicated devices and basic techniques for thyroid RFA were introduced by the Korean Society of Thyroid Radiology (KSThR) in 2012. Thyroid RFA has now been adopted worldwide, with subsequent advances in devices and techniques. To optimize the treatment efficacy and patient safety, understanding the basic and advanced RFA techniques and selecting the optimal treatment strategy are critical. The goal of this review is to therefore provide updates and analysis of current devices and advanced techniques for RFA treatment of benign thyroid nodules and recurrent thyroid cancers.

De novo hepatico-gastric stent placement for biliary stricture via percutaneous transhepatic biliary approach

Biliary stricture formation is a known complication of hepatic surgery in cases of adult living donor liver transplant. In our case, successful percutaneous placement of a hepatico-gastric stent was performed for the drainage of an isolated bile duct after right liver transplant with Roux-en-Y biliary anastomosis in a 42-year-old male. The patient initially presented with cholangitis and a percutaneous transhepatic cholangiogram revealed an isolated stricture of the posterior bile duct. Multiple attempts at regaining continuity of the isolated bile duct with the jejunum were unsuccessful. Thus a tract was created via a percutaneous transhepatic and transluminal approach between the isolated duct and the stomach using a covered stent. The patient had no complications at 18-month follow-up.

Updates on Percutaneous Radiologic Gastrostomy/Gastrojejunostomy and Jejunostomy

Gastrostomy placement for nutritional support for patients with inadequate oral intake has been attempted using surgical, endoscopic, and, more recently, percutaneous radiologically guided methods. Surgical gastrostomy has been superseded by both endoscopic and radiologic gastrostomy. We describe herein the indications, contraindications, patient preparations, techniques, complications, and aftercare with regard to radiologic gastrostomy. In addition, we discuss the available tube types and their perceived advantages. There remain some controversies regarding gastropexy performance and primary percutaneous gastrojejunostomy. Percutaneous jejunostomy is indicated for patients whose stomach is inaccessible for gastrostomy placement or for those who have had a previous gastrectomy.

Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules Smaller Than 5 mm in the Maximum Diameter: Assessment of Efficacy and Pathological Findings

OBJECTIVE: The aim of this study was to determine the efficacy of the use of an ultrasound-guided fine-needle aspiration biopsy (US-FNAB) to diagnose thyroid nodules smaller than 5 mm in the maximum diameter and to evaluate pathological findings of small thyroid malignancies. MATERIALS AND METHODS: From May 2007 to April 2008, we evaluated the findings of US-FNABs of small thyroid nodules less than 5 mm in the maximum diameter. The cytopathological findings were retrospectively reviewed and the diagnostic performance of the use of an US-FNAB was examined in all patients. RESULTS: Of 201 small thyroid nodules in 180 patients, there were 162 adequate specimens (81%). Among 180 patients, 75 patients underwent thyroid surgery and 50 malignant and 33 benign nodules were identified based on a pathological examination. All small malignant thyroid nodules were identified as papillary thyroid microcarcinomas (PTMCs). There were 34 (55%) true positive, 0 (0%) false positive, 23 (37%) true negative and five (8%) false negative results for malignancy after performing a first US-FNAB in 62 surgically confirmed nodules. The sensitivity (87%), specificity (100%), positive predictive value (100%), negative predictive value (82%), accuracy (92%), false positive rate (0%) and false negative rate (8%) for an US-FNAB were determined. In 23 patients with a primary PTMC, capsular invasion (9%, 2 of 23), a perithyroidal lymph node metastasis (30%, 7 of 23), the rate of multifocality (9%, 2 of 23) and bilaterality (4%, 1 of 23) were also determined. CONCLUSION: An US-FNAB of thyroid nodules smaller than 5 mm in the maximum diameter is an effective diagnostic procedure.

Renal Intracystic Massive Hemorrhage after Blunt Trauma / 대한비뇨기과학회지

Spontaneous and post-traumatic renal intracystic hemorrhages are extremely rare, but are a potential danger to patients with cystic kidney disease. We report two cases of post-traumatic intracystic massive hemorrhage in renal cysts. One patient was a 27-year-old male who presented with left flank pain and gross hematuria after slipping on the stairs 2 days previously. The other patient was a 58-year-old male who presented with back pain due to an accident. The circulatory states of the two patients were deteriorated and renal intracystic hemorrhages were detected on computed tomography. One patient underwent a simple nephrectomy and the other patient was treated with arterial embolization. We present two cases of renal intracystic hemorrhage, emphasizing early diagnosis and the treatment of choice.

Performance of Interventional Procedures in a Day-hospital System

PURPOSE: We wanted to describe the practice and results of applying the day-hospital system in an interventional radiology clinic. MATERIALS AND METHODS: From Oct. 2004 to Dec. 2005, the day-hospital system was applied to various interventional procedures with using a part of the recovery room of an angiography suite as a facility for hospital admission. The study included 91 cases in 73 patients. The source of the patient referral, the procedures, hospital courses and complications were analyzed and questionnaire surveys were conducted for the available 55 patients. RESULTS: Among the patients, 70% (n=64) were referred from other departments, 5% (n=5) from other hospitals, 5% (n=4) were new patients and 20% (n=18) were re-admissions. The procedures included gastrointestinal, biliary, urinary, hemodialysis related- and implantable port related interventions. 96% (n=87) of the patients were successfully discharged in a day and admission to the general ward was only 4% (n=4). Minor complications occurred after discharges in 3% (n=3). The questionnaire survey revealed that 96% (n=53) of the patients were satisfied with the service and they were not anxious after discharge. CONCLUSION: Most of common interventional procedures were safely done under the day-hospital system with the patients being highly satisfied. The day-hospital system can be a good tool for establishing admitting privileges for an interventional radiology clinic.

Performance of Interventional Procedures in a Day-hospital System

PURPOSE: We wanted to describe the practice and results of applying the day-hospital system in an interventional radiology clinic. MATERIALS AND METHODS: From Oct. 2004 to Dec. 2005, the day-hospital system was applied to various interventional procedures with using a part of the recovery room of an angiography suite as a facility for hospital admission. The study included 91 cases in 73 patients. The source of the patient referral, the procedures, hospital courses and complications were analyzed and questionnaire surveys were conducted for the available 55 patients. RESULTS: Among the patients, 70% (n=64) were referred from other departments, 5% (n=5) from other hospitals, 5% (n=4) were new patients and 20% (n=18) were re-admissions. The procedures included gastrointestinal, biliary, urinary, hemodialysis related- and implantable port related interventions. 96% (n=87) of the patients were successfully discharged in a day and admission to the general ward was only 4% (n=4). Minor complications occurred after discharges in 3% (n=3). The questionnaire survey revealed that 96% (n=53) of the patients were satisfied with the service and they were not anxious after discharge. CONCLUSION: Most of common interventional procedures were safely done under the day-hospital system with the patients being highly satisfied. The day-hospital system can be a good tool for establishing admitting privileges for an interventional radiology clinic.

Transarterial Embolization of Acute Intercostal Artery Bleeding

PURPOSE: To report our experiences of transarterial embolization for acute intercostal artery bleeding. MATERIALS AND METHODS: A retrospectively analysis of the causes, clinical manifestations, angiographic findings and transarterial embolization technique in 8 patients with acute intercostal artery bleeding, with a review of the anatomical basis. RESULTS:The causes of intercostal artery bleeding were iatrogenic and traumatic in 88 and 12% of cases, respectively. Active bleeding from the collateral intercostal or posterior intercostal arteries was angiographically demonstrated in 75 and 25% of cases, respectively. Transarterial embolization successfully achieved hemostasis in all cases. However, two patient with hypovolemic shock expired due to a massive hemothorax, despite successful transarterial embolization. CONCLUSION: Intercostal access should be performed through the middle of the intercostal space to avoid injury to the collateral intercostal artery. Transarterial embolization is an effective method for the control of intercostal artery bleeding.

Radiological Findings of Angiosarcoma in Breast: A Case Report

Angiosarcoma is a rare primary malignancy occurring anywhere in the body, but most often in the skin, liver or breast. The radiological findings of angiosarcoma of the breast have rarely been reported. We encountered a case in which the condition involved a 32-year-old woman in whom mammography revealed a obscuved-marginated and lobular-shaped high-density lesion, and ultrasonography demonstrated an ovalshaped, microlobular-marginated, inhomogenous hypoechoic mass which metastasized to the whole body after surgery. We report the radiological findings of this case of angiosarcoma of the breast, and review the literature.

Gd(DTPA)2--enhanced, and Quantitative MR Imaging in Articular Cartilage

PURPOSE: Early degeneration of articular cartilage is accompanied by a loss of glycosaminoglycan (GAG) and the consequent change of the integrity. The purpose of this study was to biochemically quantify the loss of GAG, and to evaluate the Gd(DTPA)2--enhanced, and T1, T2, rho relaxation map for detection of the early degeneration of cartilage. MATERIALS AND METHODS: A cartilage-bone block in size of 8mmx10 mm was acquired from the patella in each of three pigs. Quantitative analysis of GAG of cartilage was performed at spectrophotometry by use of dimethylmethylene blue. Each of cartilage blocks was cultured in one of three different media: two different culture media (0.2 mg/ml trypsin solution, 1mM Gd (DTPA)2- mixed trypsin solution) and the control media (phosphate buffered saline (PBS)). The cartilage blocks were cultured for 5 hrs, during which MR images of the blocks were obtained at one hour interval (0 hr, 1 hr, 2 hr, 3 hr, 4 hr, 5 hr). And then, additional culture was done for 24 hrs and 48 hrs. Both T1-weighted image (TR/TE, 450/22 ms), and mixed-echo sequence (TR/TE, 760/21-168ms; 8 echoes) were obtained at all times using field of view 50 mm, slice thickness 2 mm, and matrix 256x512. The MRI data were analyzed with pixel-by-pixel comparisons. The cultured cartilage-bone blocks were microscopically observed using hematoxylin & eosin, toluidine blue, alcian blue, and trichrome stains. RESULTS: At quantitation analysis, GAG concentration in the culture solutions was proportional to the culture durations. The T1-signal of the cartilage-bone block cultured in the Gd(DTPA)2- mixed solution was significantly higher (42% in average, p0.05). However the focal increase in T1 relaxation time at superficial and transitional layers of cartilage was seen in Gd(DTPA)2- mixed culture. Toluidine blue and alcian blue stains revealed multiple defects in whole thickness of the cartilage cultured in trypsin media. CONCLUSION: The quantitative analysis showed gradual loss of GAG proportional to the culture duration. Microimagings of cartilage with Gd(DTPA)2--enhancement, relaxation maps were available by pixel size of 97.9x195 micrometer. Loss of GAG over time better demonstrated with Gd(DTPA)2--enhanced images than with T1, T2, rho relaxation maps. Therefore Gd(DTPA)2--enhanced T1-weighted image is superior for detection of early degeneration of cartilage.

A Case Report of Malignant Localized Fibrous Tumor of the Pleura with Chest Wall Invasion

A localized fibrous tumor of the pleura (LFTP) is a slow growing, rare primary pleural neoplasm. Typically, it takes the form of a well-delineated large mass lesion based on the pleura. Several radiologic descriptions of benign LFTP have been published, but the radiologic findings of malignant LFTP involving invasion of the chest wall have not been reported. We describe a case of malignant LFTP with chest wall invasion, confirmed pathologically, and review the literature.

Recurrent Bleeding After Arterial Embolization in Patients with Hemoptysis: Comparison of Angiographic Findings and Relapsing Period

PURPOSE: To describe the angiographic findings of patients with recurrent hemoptysis after bronchial artery embolization (BAE) according to the point at which relapse occurred. MATERIALS AND METHODS: From 125 patients who underwent BAE due to hemoptysis between 1996 and 2000, we selected 18 of 23 who underwent additional BAE due to recurrent bleeding after initial BAE . Depending on the point at which relapse occurred, they were divided into two groups (I and II, according to whether additional BAE was performed within two weeks of initial BAE or more than two weeks after this). We retrospectively compared the two groups in terms of angiographic findings, number of embolized arteries, and character of feeding arteries at initial and additional BAE. RESULTS: Nine patients in group I (additional BAE: n=10) and nine in group II (additional BAE: n=13) were admitted for recurrent hemoptysis within two weeks of initial BAE and more than two weeks after this, respectively. In group I(n=29) and II(n=31), angiography demonstrated two direct and 27 indirect, and two direct and 29 indirect signs of hemorrhage, respectively. No statistically significant differences were observed (x2=0.005, p=0.945). Among the embolized feeder ressels in group I (n=30) there were 20 bronchial artery and 10 non bronchial systemic collaterals, while for group II(n=35), the corresponding totals were 21 and 14. Again, no statistically significant differences were encountered(x2=0.308; p=0.579). In group I, feeders were newly developed in one case(10%), previously embolized in five(50%), and missed in four(40%), while in group two the corresponding figures were none, twelve(92.3%), and one(7.7%). No significant differences were noted, though the incidence of previously embolized feeders in Group II was very high (x2=5.383, p=0.068). CONCLUSION: Among patients in whom hemoptysis after BAE recurred at different times, the angiographic findings and number of embolized arteries were not significantly different, but differences in the nature of the feeder were noted. Patients in whom hemoptysis recurred more than two weeks after BAE showed more recanalization of previously embolized feeders than those in whom there was recurrence within two weeks.

Transcatheter Embolization Therapy of the Gastrointestinal Hemorrhage

PURPOSE: To evaluate the effectiveness of transcatheter embolization for the treatment of massive gastrointestinal arterial bleeding. MATERIALS AND METHODS: The study was based on retrospective analysis of twelve cases(8 men, 4 women) including two patients with hemobilia in which transcatheter embolization was attempted for the control of massive gastrointestinal bleeding from March 1987 to October 1993. Clinical diagnoses of these patients were peptic ulcer(5), pseudoaneurysm formation(3) following percutaneous transhepatic biliary drainage or traffic accident, stomach cancer(I), typhoid fever(I), duodenal leiomyoma(1) and Osler-Weber-Rendu disease (1). RESULTS: Embolized vessels are as follows: gastroduodenal artery(6), left gastric artery(2), ileocolic artery(2), and hepatic artery(2). Embolization was effective in immediate control of bleeding in all patients. Although five of the six patients who had undergone embolization of the gastroduodenal artery developed rebleeding within 24 hour, only 2 reguired surgery and none showed serious complication. CONCLUSION: Embolization therapy is safe and effective initial treatment of choice for life-threatening massive gastrointestinal bleeding.

Clinical Results of the Transjugular Intrahepatic Portosystemic Shunt

PURPOSE: To evaluate the cilinical results of transjugular intrahepatic portosystemicshunt(TIPS) for the control of variceal bleeding. MATERIALS AND METHODS: TIPS creation was attempted in 23 patients with endoscopically confirmed variceal bleeding. Most patients had multiple episodes of bleeding in the past and have been treated with multiple endoscopic sclerotherapies. Pre- and post-procedural hepatic and portal vein pressures were measured. After creation of TIPS patients were followed up at regular intervals. RESULTS: TIPS has been successfully accomplished in 22 of 23 patients using Wallstent(n=21 ) and Strecker stent(n=1 ). Immediate bleeding control was achieved in all patients with shunt creation. No procedure-related complication was noted. Portal vein pressure was reduced from 30.7+/-5.8 mmHg to 20.8+/-4.7 mmHg. The mean pressure gradient of portosystemic shunt dropped from 22.8+/-6.0 prior to TIPS to 12.2+/-4.1 immediately after. During the follow-up period (6-556 days, mean; 10months), seven patients died; progressive hepatic failure (n=4), variceal rebleeding(n=2), and respiratory failure(n=1). Hepatic encepha-Iopathy after TIPS was noted in 7 patients(31.8%). Variceal rebleeding occurred in 3 patients(13.6%). The remaining 15 patients have survived an average of 11 months. CONCLUSION: This results suggest that TIPS is a safe and effective method for lowering portal pressure and controlling variceal bleeding. Furthermore if these initial results are encourged by further long-term observation, TIPS could replace endoscopic and risky surgical intervention.

Percutaneous transheptic removal of biliary stones:clinical analysis of 16 cases

Percutaenous transhepatic biliary drainage (PTBD) is widely used to control cholangitis, sepsis, or jaundice caused by biliary tree obstruction. The PTBD tract can be used in percutaneous biliary stone extraction in pre-or post-operative state when ERCP is failed or operation is contraindicated. We performed 16 cases of percutaneous transhepatic biliary stone removal. Locations of biliay stones are combined intrahepatic and extrahepatic in 8 cases (50%), only extrahepati in 7 cases (44%), and only intrahepatic in 1 case (6%). The number of stones was single in 6 cases and multiple in 10 cases. Over all success rate was 81% (13/16), 93% (14/15) in extrahepatic stones and 78% (7/9) in intrahepatic stones. In 5 of 6 cases, complete stone removal was impossible due to marked tortuosity of T-tube tract or peripherally located stones, complete removal of biliary stones was achieved via a new PTBD tract. No significant pre-or post-procedure complication was occured. Percutaneous removal of biliary stones via PTBD tract is an effective and safe alternative method in difficult cases in the menagement of biliary tract stones.