Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

Usefulness of Stent Implantation for Treatment of Intracranial Atherosclerotic Stenoses / 신경중재치료의학

PURPOSE: We evaluated the usefulness of intracranial stent implantation for treating patients with atherosclerotic stenosis and with recurrent, ischemic, neurological symptoms despite having undergone medical therapy. MATERIALS AND METHODS: Between March 2004 and April 2010, we attempted intracranial, stent-assisted angioplasty in 77 patients with 85 lesions (anterior circulation 73 cases, posterior circulation 12 cases) and who had ischemic neurological symptoms with more than 50% major cerebral artery stenosis. We analyzed the results regarding the technical success rate, complication rate, and restenosis rate during the mean 29.4 month follow-up period. RESULTS: Intracranial stent implantation was successfully performed in 74 cases (87.1%). In nine cases among the 11, failed cases, stent implantation failure was due to the tortuosity of the target vessel. One patient experienced middle cerebral artery rupture during the procedure, and we embolized the vessel using a microcoil. Five patients developed cerebral infarction in three weeks after the procedure, three of whom improved using conservative management, although the other, two patients expired. The mean number of residual stenoses decreased from 72.3% to 14.7%. Three patients demonstrated significant in-stent restenosis, i.e. more than 50%, during the follow-up period. CONCLUSION: As stent-assisted angioplasty in intracranial, atherosclerotic stenosis is effective and relatively safe, it can be considered as an alternative treatment for patients with recurrent, ischemic, neurologic symptoms despite having undergone medical therapy.

Foreign Body Removal by Snare Loop: During Intracranial Stent Procedure / 신경중재치료의학

We present a case of successful retrieval of an intracranial stent using a snare wire. A 52-year-old woman presented with left border zone infarction. On cerebral angiography, the C6 segment of the left internal carotid artery (ICA) showed significant stenosis. We attempted stenting of the lesion, although stent dislodgement occurred in the ICA C4 segment. We successfully removed it using a snare loop, and there were no complications during the procedure.

Genetic Identification and Phylogenetic Analysis of Anaplasma and Ehrlichia Species in Haemaphysalis longicornis Collected from Jeju Island, Korea

A total of 1,395 Haemaphysalis longicornis ticks collected from Jeju Island of Korea were examined by 16S rRNA gene-based nested PCR for the presence of infection with Anaplasma and Ehrlichia species. Template DNAs to detect the tick-borne pathogens were prepared from a total 506 tick pools. Eight genera of Anaplasma and six Ehrlichia by 16S rRNA gene PCR and sequencing analysis were identified. A. phagocytophilum was the most prevalent (27 [1.9%]) by nested PCR, followed by A. bovis (5 [0.4%]), E. chaffeensis (4 [0.2%]), and A. centrale (1 [0.1%]). In the phylogenetic analysis based on 16S rRNA sequences, eight genera of Anaplasma group (> 99.4% homology) and six Ehrlichia group (> 99.5% homology) were close to deposited A. marginale strains (AF309867, AF414874, and FJ226454) and Ehrlichia sp. (DQ324547), respectively. Three Anaplasma species groups A. phagocytophilum (group A), A. bovis (group B), and A. centrale (group C) and one Ehrlichia species E. chaffeensis (group D) were determined by comparing with Anaplasma and Ehrlichia related sequences. First, twenty-eight A. phagocytophilum clones belonging to group A were divided into 7 genotypes. The sequence similarity among genotypes A1 to A4 was very high (> 99.6%). Genotype B2 was close to A. bovis from Korea (99.7%). Genotype D1 was close to known E. chaffeensis strains (M73222, AF147752, and AY350424) and their similarity value was 99.7%. In conclusion, the genera of Anaplasma/Ehrlichia, A. phagocytophilum, and E. chaffeensis identified in predominant H. longicornis ticks were ubiquitous throughout the Jeju Island. The various native groups have been found through sequence identities and phylogenetic analysis.

Newly Designed Sheaths for Gastroduodenal Intervention: An Experimental Study in a Phantom and Dogs

OBJECTIVE: To evaluate the usefulness of newly designed sheaths for gastroduodenal intervention in a gastric phantom and dogs. MATERIALS AND METHODS: A regular sheath was made using a polytetrafluoroethylene tube (4 mm in diameter, 90 cm long) with a bent tip (4 cm long, 100 degree angle). For the supported type of sheath, a 5 Fr catheter was attached to a regular sheath to act as a side lumen. To evaluate their supportability, we measured the distance of movement of the sheath's tip within a silicone gastric phantom for three types of sheath, the regular type, supported type, and supported type with a supporting guide wire. The experiments were repeated 30 times, and the results were analyzed using ANOVA with the postHoc test. In addition, an animal experiment was performed in six mongrel dogs (total: 12 sessions) to evaluate the torque and supportability of the sheaths in the stomach, while pushing a guide wire or coil catheter under fluoroscopic guidance. RESULTS: In the guide wire application, the distances of movement of the sheath tip in the three types of sheath, the regular type, supported type, and supported type with supporting guide wire, were 8.40+/-0.51 cm, 6.23+/-0.41 cm, and 4.47+/-0.32 cm, respectively (p < 0.001). In the coil catheter application, the corresponding values were 7.22+/-0.70 cm, 5.61+/-0.31 cm and 3.91+/-0.59 cm, respectively (p < 0.001). All three types of sheath rotated smoothly and enabled both the wires and catheters to be guided toward the pylorus of the dog in all cases. CONCLUSION: The newly designed sheaths can be useful for gastroduodenal intervention.

Prominent Papilla of Vater at CT: Differentiation between Benign and Malignant Lesion

PURPOSE: To establish the criteria for differential diagnosis between malignant tumor and benign prominenceof papilla of Vater, as seen on CT. METHOD AND MATERIALS: Sixteen consecutive patients with prominent papilla ofVater, as seen on CT during a ten-month period were includedin this study. Final diagnosis was papilla of Vatercancer (n=5), chronic inflammation (n =3), benign tumor (n=3), or and normal (n=5), and this was confirmed bysurgery in 11 cases, and endoscopy in five. Papilla size and attenuation, the presence of accompanied dilatationof the bile or pancreatic duct, and lymph node enlargement were analyzed by two experienced radiologists, whoreached a conensus. A past history of stone disease, laboratory findings such as serum bilirubin, serum alkalinephosphatase, or endoscopic findings of duodenal diverticulum were additionally analyzed. RESULT: Papilla size wasthe only significantly different CT finding between malignant and benign lesions, and serum alkaline phosphataselevels were also significantly different between the two groups. The smallest malignant tumor was 18 mm and thelargest benign lesion was 15 mm. The presence of bile or pancreatic duct dilatation, serum bilirubin level,attenuation of the mass, a history of stone disease, and lymph node enlargement were not significantly differentbetween the two groups. CONCLUSION: In patients with prominent papilla of Vater, as seen on CT, a mass largerthan 18 mm is the only reliable radiologic finding to indicate malignant tumor of papilla of Vater. Serum alkalinephosphatase levels can, in addition, be helpful for the differential diagnosis of benign and malignant lesions.

Clinical Review of the Double Stapling Technique for Lower Rectal Cancer

From January 1993 to December 1995, 47 patients with rectal carcinomas underwent a rectal anastomosis using the double stapling technique at the Surgical Department of Kwang-ju Christian Hospital. The major advantages of the double stapling technique for lower rectal cancer over the single stapling technique or a hand-sewn operation are as follows:1) Insertion of a purse-string suture is eliminated, and application of a linear stapler to close the distal rectum may be performed with greater ease. 2) In addition, fecal contamination and spillage of tumor cells from the rectal segment are minimized. 3) Differences in the sizes of the colons and rectums are not a concern in constructing the anastomosis. 4) The operating time is shorter. The following results were obtained by a comparison with 24 patients with rectal carcinoma who had undergone a rectal anastomosis using the double stapling technique from January 1989 to December 1992 which was reported in a previous study:1) Anastomotic stenosis was decreased from 8.3% to 4.2% because of reduced ischemia due to the double row of staples and the reduced injury due to compression of tissue between the anvil and the cartridge with experience. In addition, it resulted from reduced tension of the anastomosis due to sufficients mobilization of the proximal colon and from selection of large cartridge (33 mm). 2) Anastomotic leakage, even though the same location as the tumor and in the advanced age group, was decreased from 4.2% to 0% because the blood circulation was maintained and unnecessary tension was reduced with experience. In addition, it resulted from reinforced suture of the anastomotic site which was performed after anastomosis. 3) Systemic recurrence was the same result as that of the previous study(4.2/4.3%). 4) Local recurrence, even though at the same distal distance from the margin of the cancer, was increased from 0% to 2.1% because of advancing the pathologic stage (B2, C1>B1, B2) and increasing the poorly differentiated pathologic type.

Clinical Review of the Double Stapling Technique for Lower Rectal Cancer

From January 1993 to December 1995, 47 patients with rectal carcinomas underwent a rectal anastomosis using the double stapling technique at the Surgical Department of Kwang-ju Christian Hospital. The major advantages of the double stapling technique for lower rectal cancer over the single stapling technique or a hand-sewn operation are as follows:1) Insertion of a purse-string suture is eliminated, and application of a linear stapler to close the distal rectum may be performed with greater ease. 2) In addition, fecal contamination and spillage of tumor cells from the rectal segment are minimized. 3) Differences in the sizes of the colons and rectums are not a concern in constructing the anastomosis. 4) The operating time is shorter. The following results were obtained by a comparison with 24 patients with rectal carcinoma who had undergone a rectal anastomosis using the double stapling technique from January 1989 to December 1992 which was reported in a previous study:1) Anastomotic stenosis was decreased from 8.3% to 4.2% because of reduced ischemia due to the double row of staples and the reduced injury due to compression of tissue between the anvil and the cartridge with experience. In addition, it resulted from reduced tension of the anastomosis due to sufficients mobilization of the proximal colon and from selection of large cartridge (33 mm). 2) Anastomotic leakage, even though the same location as the tumor and in the advanced age group, was decreased from 4.2% to 0% because the blood circulation was maintained and unnecessary tension was reduced with experience. In addition, it resulted from reinforced suture of the anastomotic site which was performed after anastomosis. 3) Systemic recurrence was the same result as that of the previous study(4.2/4.3%). 4) Local recurrence, even though at the same distal distance from the margin of the cancer, was increased from 0% to 2.1% because of advancing the pathologic stage (B2, C1>B1, B2) and increasing the poorly differentiated pathologic type.