Percutaneous Enteral Stent Placement Using a Transhepatic Access for Palliation of Malignant Bowel Obstruction after Surgery

Objective@#To assess the safety and clinical efficacy of percutaneous transhepatic enteral stent placement for recurrent malignant obstruction in patients with surgically altered bowel anatomy. @*Materials and Methods@#Between July 2009 and May 2019, 36 patients (27 men and 9 women; mean age, 62.7 ± 12.0 years) underwent percutaneous transhepatic stent placement for recurrent malignant bowel obstruction after surgery. In all patients, conventional endoscopic peroral stent placement failed due to altered bowel anatomy. The stent was placed with a transhepatic approach for an afferent loop obstruction (n = 27) with a combined transhepatic and peroral approach for simultaneous stent placement in afferent and efferent loop obstruction (n = 9). Technical and clinical success, complications, stent patency, and patient survival were retrospectively evaluated. @*Results@#The stent placement was technically successful in all patients. Clinical success was achieved in 30 patients (83.3%). Three patients required re-intervention (balloon dilatation [n = 1] and additional stent placement [n = 2] for insufficient stent expansion). Major complications included transhepatic access-related perihepatic biloma (n = 2), hepatic artery bleeding (n = 2), bowel perforation (n = 1), and sepsis (n = 1). The 3- and 12-months stent patency and patient survival rates were 91.2%, 66.5% and 78.9%, 47.9%, respectively. @*Conclusion@#Percutaneous enteral stent placement using transhepatic access for recurrent malignant obstruction in patients with surgically altered bowel anatomy is safe and clinically efficacious. Transhepatic access is a good alternative route for afferent loop obstruction and can be combined with a peroral approach for simultaneous afferent and efferent loop obstruction.

Percutaneous Enteral Stent Placement Using a Transhepatic Access for Palliation of Malignant Bowel Obstruction after Surgery

Objective@#To assess the safety and clinical efficacy of percutaneous transhepatic enteral stent placement for recurrent malignant obstruction in patients with surgically altered bowel anatomy. @*Materials and Methods@#Between July 2009 and May 2019, 36 patients (27 men and 9 women; mean age, 62.7 ± 12.0 years) underwent percutaneous transhepatic stent placement for recurrent malignant bowel obstruction after surgery. In all patients, conventional endoscopic peroral stent placement failed due to altered bowel anatomy. The stent was placed with a transhepatic approach for an afferent loop obstruction (n = 27) with a combined transhepatic and peroral approach for simultaneous stent placement in afferent and efferent loop obstruction (n = 9). Technical and clinical success, complications, stent patency, and patient survival were retrospectively evaluated. @*Results@#The stent placement was technically successful in all patients. Clinical success was achieved in 30 patients (83.3%). Three patients required re-intervention (balloon dilatation [n = 1] and additional stent placement [n = 2] for insufficient stent expansion). Major complications included transhepatic access-related perihepatic biloma (n = 2), hepatic artery bleeding (n = 2), bowel perforation (n = 1), and sepsis (n = 1). The 3- and 12-months stent patency and patient survival rates were 91.2%, 66.5% and 78.9%, 47.9%, respectively. @*Conclusion@#Percutaneous enteral stent placement using transhepatic access for recurrent malignant obstruction in patients with surgically altered bowel anatomy is safe and clinically efficacious. Transhepatic access is a good alternative route for afferent loop obstruction and can be combined with a peroral approach for simultaneous afferent and efferent loop obstruction.

Efficacy and Safety of a Newly Developed Self- Expanding Open-Cell Type Nitinol Stent for Peripheral Arteries: A Preclinical Study in Minipigs

Purpose@#To evaluate the safety and efficacy of the newly designed open-cell type self-expandable nitinol stent (NiTi-stent) for peripheral arteries. @*Materials and Methods@#Twenty-eight limbs of 14 minipigs were randomly assigned to the NiTistent group or conventional nitinol stent group. Stents were symmetrically implanted into the iliac arteries of each animal using carotid artery approach and were observed for 1 month (n = 5) and 6 months (n = 9). The angiographic lumen diameter (ALD), late lumen loss, angiographic stenosis, histomorphometric lumen area, neointimal area, and area stenosis were analyzed and compared between the groups. @*Results@#Stent migration, stent fracture, or thrombus formation were not observed in either group. At the 1-month follow-up, the neointimal area (p = 0.008) and area stenosis (p = 0.016) were significantly smaller in the NiTi-stent group than in the control group. At the 6-months followup, the NiTi-stent group showed significantly larger ALD (p = 0.014), less late lumen loss (p = 0.019), less angiographic stenosis (p = 0.014), larger lumen area (p = 0.040), and smaller neointimal area and area stenosis (p = 0.004 and p= 0.014, respectively) compared with the control group. @*Conclusion@#The NiTi-stent is as safe and effective as the conventional nitinol stent and induces less neointimal hyperplasia in a minipig iliac artery model.

Comparison of Combined Therapy Using Conventional Chemoembolization and Radiofrequency Ablation Versus Conventional Chemoembolization for Ultrasound-Invisible Early-Stage Hepatocellular Carcinoma (Barcelona Clinic Liver Cancer Stage 0 or A)

OBJECTIVE: To compare the therapeutic efficacy between conventional transarterial chemoembolization (cTACE) and combined therapy using cTACE and radiofrequency ablation (RFA) in ultrasound (US)-invisible early stage hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From January 2008 to June 2016, 167 patients with US-invisible early stage HCCs were treated with cTACE alone (cTACE group; n = 85) or cTACE followed by immediate fluoroscopy-guided RFA targeting intratumoral iodized oil retention (combined group; n = 82). Procedure-related complications, local tumor progression (LTP), time to progression (TTP), and overall survival (OS) were compared between the two groups. Multivariate analyses were performed to identify prognostic factors. RESULTS: There was no major complication in either group. The cTACE group showed higher 1-, 3-, and 5-year LTP rates than the combined group; i.e., 12.5%, 31.7%, and 37.0%, respectively, in the cTACE group; compared to 7.3%, 16.5%, and 16.5%, respectively, in the combined group; p = 0.013. The median TTP was 18 months in the cTACE group and 24 months in the combined group (p = 0.037). Cumulative 1-, 3-, and 5-year OS rates were 100%, 93.2%, and 87.7%, respectively, in the cTACE group and 100%, 96.6%, and 87.4%, respectively, in the combined group (p = 0.686). Tumor diameter > 20 mm and cTACE monotherapy were independent risk factors for LTP and TTP. CONCLUSION: Combined therapy using cTACE followed by fluoroscopy-guided RFA is a safe and effective treatment in US-invisible early stage HCCs. It provides less LTP and longer TTP than cTACE alone.

Living-donor liver transplantation for giant hepatic hemangioma with diffuse hemangiomatosis in an adult: a case report

Hepatic hemangioma represents the most common benign primary hepatic neoplasm. Although most such tumors are small and asymptomatic, giant hepatic hemangioma is frequently symptomatic, and requires intervention. Moreover, diffuse multiple hepatic hemangiomatosis occupying almost the entire liver is extremely rare in adults, and the optimal management for this condition is unclear. We report a case of a rapidly growing, symptomatic giant hepatic hemangioma with diffuse hepatic hemangiomatosis in a 50-year-old female patient who was treated by living-donor liver transplantation. This case shows malignant behavior of a benign hemangioma that required liver transplantation. Although this case could not meet the criteria for transplantation according to the MELD (model for end-stage liver disease) score system, it should be considered as an exceptional indication for deceased-donor liver allocation. Further studies of the mechanism underlying hemangioma growth are warranted.

Percutaneous Pancreatic Stent Placement for Postoperative Pancreaticojejunostomy Stenosis: A Case Report

Stenosis of the pancreatico-enteric anastomosis is one of the major complications of pancreaticoduodenectomy (PD). Endoscopic stent placement, has limited success rate as a nonsurgical treatment due to altered gastrointestinal anatomy. Percutaneous treatment is rarely attempted due to the technical difficulty in accessing the pancreatic duct. We reported a case of pancreaticojejunostomy stenosis after PD, in which a pancreatic stent was successfully placed using a rendezvous technique with a dual percutaneous approach.

Post-Operative Hemorrhage after Myomectomy: Safety and Efficacy of Transcatheter Uterine Artery Embolization

OBJECTIVE: To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage. MATERIALS AND METHODS: We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted. RESULTS: The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients. CONCLUSION: Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Disappearance of Intrahepatic Bile Duct Hepatocellular Carcinoma after Endoscopic Retrograde Cholangiopancreatography and Transarterial Chemoinfusion: A Case Report / 대한소화기학회지

Invasion of the bile duct by hepatocellular carcinoma (HCC), which is called intrahepatic bile duct HCC, is rare and has a poor prognosis. Early diagnosis and surgical resection is important for treatment. A 58-year-old man who underwent hepatic resection for HCC 4 years ago and received transarterial chemoembolization (TACE) 2 years after the operation for recurred HCC presented with jaundice. CT scan revealed a tumor in the common bile duct without intrahepatic lesion. Therefore, ERCP was done to perform biopsy and biliary drainage. Histological examination was compatible with hepatocellular carcinoma. However, the tumor could not be visualized at angiography and thus, only transarterial chemoinfusion was performed without embolization. The tumor had disappeared on follow-up CT scan, and the patient has been disease free for 23 months without evidence of recurrence. Herein, we report a case of intrahepatic bile duct HCC which disappeared after ERCP.

The Surgical Procedure Is the Most Important Factor Affecting Continence Recovery after Laparoscopic Radical Prostatectomy

PURPOSE: We analyzed factors associated with early recovery of continence after laparoscopic radical prostatectomy. MATERIALS AND METHODS: Among 467 patients treated with laparoscopic radical prostatectomy for localized prostate cancer between 2007 and 2012, 249 patients who underwent a preoperative urodynamic study were enrolled. The patients' age, prostate volume, preoperative serum prostate-specific antigen (PSA), Gleason score, pathologic stage, and preoperative urodynamic parameters were recorded. The preoperative membranous and prostatic urethral length on magnetic resonance image, nerve sparing technique, and type of surgical procedure (extrafascial and intrafascial) were analyzed. Patients were considered to have early recovery of continence when they needed no pad in 3 months or less after surgery. RESULTS: Ninety-two patients were in the early recovery group and 157 were in the late recovery group. The membranous urethral lengths were 12.06+/-2.56 and 11.81+/-2.87 mm, and prostatic urethral lengths were 36.39+/-6.15 and 37.45+/-7.55 mm in each group, respectively. The membranous-posterior urethral length ratios were 0.25+/-0.06 and 0.24+/-0.06, and prostatic-posterior urethral length ratios were 0.75+/-0.06 and 0.76+/-0.06, respectively. In and of themselves, the membranous and prostatic urethral lengths were not associated with recovery duration however, the membranous-total and prostatic-total urethral length ratios were related (p=0.024 and 0.024, respectively). None of the urodynamic parameters correlated with continence recovery time. In the multivariate analysis, the type of surgical procedure (odds ratio [OR], 7.032; 95% confidence interval [CI], 2.660 to 18.590; p<0.001) and membranous urethral length (OR, 0.845; 95% CI, 0.766 to 0.931; p=0.001) were significantly related to early recovery of continence. CONCLUSIONS: The current intrafascial surgical procedure is the most important factor affecting early recovery of continence after laparoscopic radical prostatectomy.

Feasibility of Superficial Femoral Artery Intervention Using Mobile C-arms Compared to Fixed C-arms / 대한혈관외과학회지

PURPOSE: Endovascular therapy (ET) for peripheral arterial occlusive disease has increased dramatically in the past decade. ET is currently being performed by different specialists with available resources, with some of these resources being far superior to others, yet there have been no studies comparing the interventional outcomes according to the varying resources. The aim of this study was to analyze the outcomes of ET for superficial femoral artery (SFA) atherosclerosis using a mobile C-arm, in comparison to a historical control group. METHODS: Between March 2009 and December 2010, ET for SFA atherosclerosis was performed in 54 limbs from 47 patients using a mobile C-arm in the operation theater (mobile group). In contrast, a historical group for comparison consisted of 60 patients, for whom ET for SFA atherosclerosis was performed in 76 limbs using a fixed C-arm in the angiographic suite, between July 2003 and May 2008 (fixed group). The outcomes of ET for both groups were retrospectively analyzed by a medical chart review. RESULTS: There was no statistically significant difference in gender, age, risk factors, Trans-Atlantic Inter-Society Consensus (TASC) classification, intervention type, and postoperative blood creatinine levels between the two groups. However, procedural time was statistically higher in the mobile group. Patency rates at 1 year were 68.3% and 68.1% in the fixed and mobile group, respectively, which was not statistically significant. Subgroup analysis of 1 year patency rates for TASC A, B lesions and TASC C, D lesions were also similar. CONCLUSION: ET using the mobile C-arm in the operating theater is as effective as using the fixed C-arm, in the treatment of SFA atherosclerosis in terms of the technical success, patency, and early postoperative outcomes.

Effects of Arsenic Trioxide on Radiofrequency Ablation of VX2 Liver Tumor: Intraarterial versus Intravenous Administration

OBJECTIVE: Arsenic trioxide (As2O3) can be used as a possible pharmaceutical alternative that augments radiofrequency (RF) ablation by reducing tumor blood flow. The aim of this study was to assess the effect of intraarterial and intravenous administration of As2O3 on RF-induced ablation in an experimentally induced liver tumor. MATERIALS AND METHODS: VX2 carcinoma was grown in the livers of 30 rabbits. As2O3 (1 mg/kg) was administered through the hepatic artery (n = 10, group A) or ear vein (n = 10, group B), 30 minutes before RF ablation (125 mA +/- 35; 90 +/- 5degrees C). As a control group, 10 rabbits were treated with RF ablation alone (group C). RF was intentionally applied to the peripheral margin of the tumor so that ablation can cover the tumor and adjacent hepatic parenchyma. Ablation areas of the tumor and adjacent parenchymal changes among three groups were compared by the Kruskal-Wallis and Mann-Whitney U test. RESULTS: The overall ablation areas were 156 +/- 28.9 mm2 (group A), 119 +/- 31.7 (group B), and 92 +/- 17.4 (group C, p < 0.04). The ablation area of the tumor was significantly larger in group A (73 +/- 19.7 mm2) than both group B (50 +/- 19.4, p = 0.02) and group C (28 +/- 2.2, p < 0.01). The ratios of the tumoral ablation area to the overall ablation area were larger in group A (47 +/- 10.5%) than that of the other groups (42 +/- 7.3% in group B and 32 +/- 5.6% in group C) (p < 0.03). CONCLUSION: Radiofrequency-induced ablation area can be increased with intraarterial or intravenous administration of As2O3. The intraarterial administration of As2O3 seems to be helpful for the selective ablation of the tumor.

Safety and efficacy of laparoscopic radiofrequency ablation for hepatic malignancies / 대한외과학회지

PURPOSE: Radiofrequency ablation (RFA) is an accepted treatment option for primary and metastatic liver tumors. As percutaneous RFA has some limitations, laparoscopic RFA (LRFA) has been used as a therapeutic alternative for the treatment of hepatic malignancies. METHODS: Between March 2006 and September 2009, thirty patients with hepatic malignancies that were contraindicated for resection or percutaneous RFA underwent LRFA. Indications for this procedure were hepatocellular carcinoma (HCC, 21 patients), metastatic liver tumor (8 patients) and intrahepatic cholangiocarcinoma (1 patient). RESULTS: Among the 30 patients who underwent LRFA, 5 patients underwent concomitant laparoscopic liver resection. Intraoperative laparoscopic ultrasound detected new malignant lesions in 4 patients (13.3%). A total of 46 lesions were ablated by LRFA. There was no postoperative mortality. The three-year overall survival rate was 83.7% for the HCC group and 64.3% for the metastatic group. CONCLUSION: LRFA for hepatic malignancies proved to be a safe and effective treatment. Also, this procedure is indicated for lesions that are not amenable to percutaneous RFA or liver resection.

Efficacy and Safety of Hepatic Arterial Infusion of Fluorouracil with Leucovorin as Salvage Treatment for Refractory Liver Metastases from Colorectal Cancer

BACKGROUND/AIMS: Limited options remain for patients with metastatic colorectal cancer (CRC) after failure of standard systemic chemotherapy. Readministration of chemotherapeutic agents by hepatic arterial infusion (HAI) has the rationale of providing higher concentrations of chemotherapeutic agents to hepatic metastases. The present study was conducted to evaluate the efficacy and safety of HAI of fluorouracil with leucovorin (HAI 5-FU/LV) for patients with liver metastases from CRC. METHODS: Fourteen patients with liver metastases from CRC who received HAI 5-FU/LV after failure of systemic chemotherapy containing fluorouracil and leucovorin were identified and their medical records were reviewed. RESULTS: Of 10 patients evaluable for response, one partial response, six stable disease, and three progressive disease were reported. Additionally, the overall response and disease control rates were 7% and 50%, respectively. The median time to progression was 4.3 months (range, 2.9 to 5.6), to hepatic progression was 5.8 months (range, 4.7 to 6.9), and to extrahepatic progression was 5.8 months (range, 2.3 to 9.2). No grade 3/4 hematologic toxicities occurred and one case of abdominal pain and two cases of oral mucositis were the only grade 3 nonhematologic toxicities. Catheter-related complications occurred in three patients: one thrombosis, one infection, and one displacement. CONCLUSIONS: HAI 5-FU/LV was well tolerated and showed modest efficacy for patients with liver metastases from refractory CRC. Readministration of previously used chemotherapeutic agents via the hepatic artery could be an effective salvage option and warrants further investigation in a prospective trial.

Reactive Oxygen Species in the Internal Spermatic and Brachial Veins of Patients with Varicocele-Induced Infertility

PURPOSE: The aim of this study was to evaluate the relationship between the levels of reactive oxygen species (ROS) and the clinical characteristics of varicoceles among patients with varicocele-induced infertility. MATERIALS AND METHODS: Ninety-eight patients with infertile varicocele and 22 control subjects without varicocele were enrolled. Blood samples were drawn from the brachial vein (BV) and the dilated internal spermatic vein (ISV) on the side of the varicocele during surgery. ROS levels were determined by spectrophotometry, and comparisons between the varicocele and control groups were performed. In addition, the ROS levels were analyzed according to the characteristics of the varicocele, and ROS levels in the ISV and the BV were compared. RESULTS: The ROS levels measured in the ISV of men with varicocele were higher than in the control group regardless of the varicocele grade except for subclinical grade; however, in the BV, a difference was noted only for grade III. When the difference in testis volume between sides was greater than 3 ml, and the varicocele had been present for more than 3 years, ROS levels were higher in the ISV than in the BV. Sperm viability was significantly associated with ROS levels. Serum hormone levels were not correlated with ROS levels. CONCLUSIONS: Serum ROS levels were higher in infertile men with a varicocele than in controls. They were correlated with varicocele grade, varicocele duration, the degree of testicular hypotrophy, and sperm viability. In addition, ROS levels and their associations with clinical characteristics were higher in the ISV than in the BV.

Outcomes of Endovascular Intervention and Bypass Surgery for Femoral Artery Atherosclerosis

PURPOSE: The main treatment modality of peripheral arterial occlusive disease (PAOD) of the lower extremities has shifted from traditional bypass surgery (BS) to a less invasive endovascular intervention (EI), but there is still conflicting data about the differences in long-term patency between the two modalities The purpose of this study was to analyze restenosis rates of femoral EI and to compare both anatomical and functional results between EI and femorodistal BS. METHODS: Between July 2003 and June 2009, 88 limbs (61 patients) and 47 limbs (43 patients) with femoral artery PAOD were treated with EI and BS, respectively. A retrospective analysis of prospectively collected data was performed by reviewing medical records, radiologic images and noninvasive vascular studies. Patient demographics and risk factors were analyzed. Technical outcomes such as restenosis rates, patency rates and functional outcomes using modified questionnaires were evaluated. RESULTS: The restenosis rates for EI at 6 months, 1 year, 2 years and 3 years were 10.4%, 20.1%, 41.1% and 52.7%, respectively, and the mean restenosis duration was 36.5+/-3.24 months. Comparison of patency rates between EI and BS showed no significant difference (P=0.204) in TASC C and D lesions. Functional outcome analysis showed that both EI and BS improved functional status after treatment, and comparison between the two groups showed that BS had a better functional improvement than EI (P=0.010). CONCLUSION: EI could provide equivalent patency rates compared with BS, but for TASC C and D lesions, BS is still a preferred treatment modality based on better functional outcomes.

The Value of Preoperative Multidetector Computed Tomography for Deep Inferior Epigastric Artery Perforator Free Flap

PURPOSE: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. In a free transverse rectus abdominis myocutaneous(TRAM) or deep inferior epigastric artery perforator (DIEP) flap, a preoperative evaluation of the precise location of perforating vessels and vascular run-off systems is required. The objective of this report is to demonstrate the usefulness of multidetector computed tomography (MDCT) in the preoperative planning of patients undergoing breast reconstruction with abdominal flap. METHODS: From June 2006 to January 2008, 28 patients underwent MDCT evaluation before breast reconstruction. All subjects were females with an age ranged from 30 to 55 years. The CT scan was performed using a 64-slice MDCT scanner(Brilliance 64; Philips Medical Systems, Best, Netherlands). RESULTS: One perforator or two major perforators were marked on image in good relation with a hand-held Doppler examination and intraoperative findings. All vascular run-off systems were cleared before operation. CONCLUSION: Preoperative evaluation of perforator arteries with MDCT angiography is beneficial to the patients undergoing breast reconstruction. This technique provides a noninvasive approach of the vascular anatomy of the entire anterior abdominal wall.

Delayed Open Repair for Persistent Type I Endoleak after EVAR: A Case Report

Endovascular aneurysm repair (EVAR) is used with increasing frequency in the management of high-risk abdominal aortic aneurysm (AAA) patients. We report a delayed open repair for a persistent type I endoleak after EVAR in a patient with co-morbidities. An infrarenal AAA with a transverse diameter of 9.86 cm was detected on CT angiography; it extended from 8 mm below the renal artery to both common iliac arteries. The infrarenal angle was 90 degrees. After insertion of a Zenith stent graft (COOK, USA), a type I endoleak was detected on aortography, and several balloon dilatations were performed. The procedure was finished with a sustained type I endoleak. The endoleak persisted after 5 days on Doppler ultrasound, so open repair was performed. Total operative time was 240 minutes, and the duration of supra-celiac aorta clamping was approximately 35 minutes. The patient suffered an acute myocardial infarction on postoperative day 7 and recovered with conservative management. The patient was discharged on postoperative day 29.

The Impact of Peripheral Arterial Disease on the Treatment and Amputation of Diabetic Foot Ulcer

PURPOSE: Diabetic foot ulcers are one of the most important complications of patients with diabetes for their quality of life. Yet the data on factors that affect the treatment outcome and the guidelines for a multidisciplinary approach are limited. The purpose of this study was to assess the clinical characteristics that affect healing of diabetic foot ulcers, and especially when this is associated with peripheral arterial disease (PAD). METHOD: We retrospectively reviewed the clinicopathologic data of 112 patients who were admitted for the treatment of diabetic foot ulcers from May 2004 to December 2007 at Bundang Seoul National University Hospital. The patient's demography and co-morbidities, the laboratory and radiological details, the surgical data and the treatment outcomes were evaluated and analyzed according to the presence of PAD. RESULT: The mean age of the patients was 66 years old and the male to female ratio was 2.3:1. Except for simple dressing of the ulcers, skin graft, amputation or revascularization were performed for 77 patients. Ulcers healed in 74 patients (66.1%) and recurrence was observed in 42 patients (37.5%). Major amputation was performed on 11 patients (9.8%). The non-healing group had a higher incidence of male gender (P=0.049), end stage renal disease (P=0.038), coronary arterial disease (P=0.018), the presence of PAD (P=0.034) and a higher level of cholesterol (P=0.011) and triglyceride (P=0.039). Patients with PAD had a lower ankle-brachial index (P<0.001) and a higher rate of undergoing revascularization (P<0.001), overall amputation (P=0.003), non-healing (P=0.034) and recurrence (P<0.001). After revascularization, the rate of major amputation was not reduced (P=0.915). CONCLUSION: The risk of non-healing, overall amputation and recurrence is increased in the presence of PAD. Evaluating the PAD status and multidisciplinary treatment strategies are needed to treat these patients with diabetic foot ulcer.

Percutaneous Endovascular Stent-graft Treatment for Aortic Disease in High Risk Patients: The Early and Mid-term Results / 대한흉부외과학회지

BACKGROUND: Aortic surgery for high risk patients has high mortality and morbidity rates, and the necessity of performing aortic surgery in cancer patients is questionable because of their short life expectancy. Endovascular repair of aneurysm repair can be considered for high risk patients and cancer patients because it has relatively lower invasiveness and shorter recovery times than aortic surgery does. Especially, percutaneous endovascular stent graft treatment is more useful for high risk patients because it does not require general anesthesia. MATERIAL AND METHOD: From July 2003 to September 2007, twelve patients who had inoperable malignancy or who had a high risk of complication because of their combined diseases during aortic surgery underwent endovascular aortic aneurysm repair. The indications for endovascular repair were abdominal aortic aneurysm in 5 patients, descending thoracic aortic aneurysm in 6 patients and acute type B aortic dissection in one patient. The underlying combined disease of these patients were malignancy in 3 patients, respiratory disease in 6 patients, old age with neurologic disease in 6 patients, Behcet's diseae in one patient and chronic renal failure in one patient. RESULT: Stent grafts were inserted percutaneously in all cases. There were 4 hospital deaths and there were 3 delayed deaths during the follow-up periods. There were no deaths from aortic disease, except one hospital death. There were several complications: a mild cerebrovascular accident occurred in one patient, acute renal failure occurred in 2 patients and ischemic bowel necrosis occurred in one patient. Mild type I endoleak was observed in 2 patients and type II endoleak was observed in a patient after stent graft implantation. Newly developed type I endoleak was observed in a patient during the follow-up period. CONCLUSION: Percutaneous endovascular stent graft insertion is relatively safe procedure for high risk patients and cancer patients. Yet it seems that its indications and its long term results need to be further researched.

A New and Simple Practical Plane Dividing Hepatic Segment 2 and 3 of the Liver: Evaluation of Its Validity

OBJECTIVE: The conventional method of dividing hepatic segment 2 (S2) and 3 (S3) is subjective and CT interpretation is unclear. The purpose of our study was to test the validity of our hypothesis that the actual plane dividing S2 and S3 is a vertical plane of equal distance from the S2 and S3 portal veins in clinical situations. MATERIALS AND METHODS: We prospectively performed thin-section iodized-oil CT immediately after segmental chemoembolization of S2 or S3 in 27 consecutive patients and measured the angle of intersegmental plane on sagittal multiplanar reformation (MPR) images to verify its vertical nature. Our hypothetical plane dividing S2 and S3 is vertical and equidistant from the S2 and S3 portal veins (vertical method). To clinically validate this, we retrospectively collected 102 patients with small solitary hepatocellular carcinomas (HCC) on S2 or S3 the segmental location of which was confirmed angiographically. Two reviewers predicted the segmental location of each tumor at CT using the vertical method independently in blind trials. The agreement between CT interpretation and angiographic results was analyzed with Kappa values. We also compared the vertical method with the horizontal one. RESULTS: In MPR images, the average angle of the intersegmental plane was slanted 15 degrees anteriorly from the vertical plane. In predicting the segmental location of small HCC with the vertical method, the Kappa value between CT interpretation and angiographic result was 0.838 for reviewer 1 and 0.756 for reviewer 2. Inter-observer agreement was 0.918. The vertical method was superior to the horizontal method for localization of HCC in the left lobe (p < 0.0001 for reviewers 1 and 2). CONCLUSION: The proposed vertical plane equidistant from S2 and S3 portal vein is simple to use and useful for dividing S2 and S3 of the liver.