Case of Ectopic Variceal Bleed Managed With Percutaneous Transhepatic Portal Vein Recanalization.

A variety of complications and associated clinical presentations may be seen in patients with cirrhotic and non-cirrhotic portal hypertension. We present one such case of Upper GI hemorrhage from ectopic duodenal varices in a case of pre-hepatic portal hypertension due to Extrahepatic Portal Venous Obstruction (EHPVO). The case was managed successfully with endovascular Portal Vein Recanalization (PVR) and metallic stent deployment. With adequate technical success, improved symptoms, and laboratory parameters, the patient was discharged on long-term anticoagulation and interval follow-up.

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature.

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.

Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Alpha-fetoprotein producing gastric cancer with divergent differentiation: Report of a rare case with review of literature.

ABSTRACT: Alpha-fetoprotein-producing gastric cancer is a rare variant of gastric adenocarcinoma. This tumor is likely to be misdiagnosed, particularly in patients with liver metastasis. This rare subgroup of gastric carcinoma may show divergent differentiation on histology and may pose a diagnostic challenge to the pathologist. They have an aggressive course with a dismal prognosis.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients.

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Challenges to manage primary chylopericardium in children.

Primary chylopericardium (PC) is a rare entity in the pediatric population with very few reported cases. Most cases of chylopericardium manifest after trauma or following cardiac surgery. The other etiologies which may lead to chylopericardium are malignancy, tuberculosis, or congenital lymphangiomatosis. We report two cases of PC in the pediatric population with contrasting outcomes. Both failed conservative management with dietary modification and octreotide. Surgery with pleuropericardial and pleuroperitoneal windows was performed in both. The first case had a thoracic duct ligation. The first patient died, and the second survived.

Combined Bile Duct Ablation and Fistulous Tract Embolization Using N-Butyl Cyanoacrylate to Manage a Biliary-Cutaneous Fistula Following Percutaneous Transhepatic Biliary Drainage (PTBD) for Hilar Cholangiocarcinoma.

Biliary fistula and bile leak are known complications following hepatobiliary surgery, trauma, and percutaneous biliary interventions. In the case of an isolated biliary system with a prolonged indwelling percutaneous transhepatic biliary drainage (PTBD) catheter, a biliary-cutaneous fistula (BCF) may develop after catheter blockage or its accidental slippage. Due to the absence of internal drainage, secreted bile flows through the matured PTBD tract to form a fistula. If left untreated, chronic BCF will result in malabsorption, infection, and delayed wound healing. Here, we report a case of left-sided BCF following prolonged PTBD for Bismuth type II cholangiocarcinoma (metastatic disease), which was initially managed by bile duct ablation using N-butyl cyanoacrylate. The patient further needed fistulous tract embolization to obliterate the BCF.

Inclusion of Perineural Invasion with AJCC-TNM Staging: Outcomes from a South Asian Cohort of Curatively Treated Gastric Cancer Patients.

BACKGROUND: The incidence of perineural invasion (PNI) in patients with gastric cancer (GC) is high, and patients with PNI positive disease have a poor prognosis compared to PNI-negative disease. The present study aims to study the incidence and evaluate the impact of PNI on the survival outcome of a cohort of South Asian GC patients. MATERIAL AND METHODS: All consecutive patients undergoing curative gastrectomy were included in the study. The incidence of PNI and correlation with different clinico-pathological features and overall survival was performed. RESULTS: A total of 59.54% had PNI-positive disease and the median OS of PNI + ve patients was 29.3 months, while it was not reached in PNI-ve patients. The PNI positivity was a significant prognostic factor for overall survival both on univariate and multivariate analysis. On TNM-PNI staging, those with TNM stage I/II patients with PNI + ve disease had similar OS to all stage III patients (p = 0.835) and were worse than that of PNI-ve patients (p < 0.05). CONCLUSION: The incidence of PNI in gastric cancer is high. The inclusion of PNI with AJCC-TNM staging may better stratify prognostic staging in curatively treated gastric cancer patients.

Impact of COVID-19 pandemic on pediatric cardiac services in India.

BACKGROUND: COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India. AIMS: The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries. SETTINGS AND DESIGN: This is a retrospective, multicentric, observational study. METHODS: We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019. RESULTS: The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%). CONCLUSIONS: The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

Outcome of COVID-19-positive children with heart disease and grown-ups with congenital heart disease: A multicentric study from India.

BACKGROUND: Outcome data of children with heart disease who acquired COVID-19 infection are limited. AIMS: We sought to analyze outcome data and identify risk factors associated with mortality in children with heart disease and grown-ups with congenital heart disease (GUCH) who had a laboratory-confirmed COVID-19 infection. SETTINGS AND DESIGN: This is a retrospective, multicentric, observational study. MATERIALS AND METHODS: The study included children with heart disease and GUCH population, who presented with either symptomatic or asymptomatic COVID-19 infection to any of the participating centers. COVID-19-negative patients admitted to these centers constituted the control group. RESULTS: From 24 pediatric cardiac centers across India, we included 94 patients with a median age of 12.5 (interquartile range 3-96) months and 49 (52.1%) patients were males. Majority (83 patients, 88.3%) were children. One-third of the patients (n = 31, 33.0%) had acyanotic congenital heart disease, and 41.5% (n = 39) were cyanotic, with > 80% of the patients being unoperated. Only 30 (31.9%) patients were symptomatic for COVID-19 infection, while the rest were incidentally detected positive on screening. A total of 13 patients died (case fatality rate: 13.8%). The in-hospital mortality rate among hospitalized patients was significantly higher among COVID-19-positive cases (13 of 48; 27.1%) as compared to COVID-negative admissions (9.2%) during the study period (P < 0.001). On multivariate analysis, the independent predictors of mortality among COVID-19-positive cases were severity of illness at admission (odds ratio [OR]: 535.7, 95% confidence interval [CI]: 6.9-41,605, P = 0.005) and lower socioeconomic class (OR: 29.5, 95% CI: 1.1-814.7, P = 0.046). CONCLUSIONS: Children with heart disease are at a higher risk of death when they acquire COVID-19 infection. Systematic preventive measures and management strategies are needed for improving the outcomes.

Outcome of 40 consecutive cases of modified Ross procedure using novel Dacron valved conduit.

OBJECTIVE: The Ross procedure is an established option for aortic valve disease in children. Due to limited availability of pulmonary homograft, we devised a novel technique for right ventricular outflow tract (RVOT) reconstruction by preparing indigenous Dacron valved conduit. METHODS: Forty consecutive cases of modified Ross procedure done at our center (2013-2018) were analyzed. Thirty-seven patients (95%) were followed up with median duration of 2.5 (0.08-5.5) years. Median age was 12 (5-39) years. Nineteen (47.5%) patients had rheumatic aortic valve disease, while 19 (47.5%) had congenital aortic valve disease. Aortic root replacement with pulmonary autograft was performed in all patients. Dacron conduit for RVOT reconstruction was used with on table sewn bileaflet valve using Dacron patch (n = 22), expanded polytetrafluoroethylene (ePTFE) membrane (n = 10), bioprosthetic valve (n = 4), and pericardium (n = 4). Additional surgical procedures included mitral valve repair (n = 10), septal myectomy (n = 2), ascending aorta replacement (n = 1), ruptured sinus of valsalva (RSOV) repair (n = 1), and ventricular septal defect (VSD) closure (n = 1). RESULTS: There was one in-hospital mortality while one late death occurred at 3.5 years postoperatively. The neo-aortic valve regurgitation on echocardiographic evaluation at last follow-up was trivial (n = 28), mild (n = 7), and moderate (n = 2). Mild RVOT obstruction was present in 8 patients while 18 patients had mild pulmonary regurgitation. No patient required reintervention during follow-up. CONCLUSION: Our early results of modified Ross procedure are encouraging, however, long-term follow-up is required.

Pulmonary root translocation and Senning procedure for congenitally corrected transposition of great arteries with pulmonary stenosis: a case report.

Congenitally corrected transposition of the great arteries (CCTGAs) is a condition, which includes atrioventricular and ventriculoarterial discordant connections along with ventricular septal defect (VSD), pulmonary stenosis (PS), or pulmonary atresia (PA). Without treatment, progressive systemic ventricular failure begins, which is followed by sudden cardiac death by the fourth or fifth decade. We report a case of a 4-year-old with CCTGA, VSD, and PS operated by Senning procedure and pulmonary root translocation (PRT) with uneventful postoperative recovery. PRT overcomes problems with the right ventricle to the pulmonary artery conduit and maintains pulmonary valve function and growth capacity. Our initial experience with PRT in CCTGA indicates that it is a feasible surgical alternative for such patients.

Anaplastic Thyroid Carcinoma (ATC) with Superior Vena Cava (SVC) Syndrome, Cardiac Tamponade and Pleural Effusion: An Unusual Clinical Presentation.

Superior vena cava (SVC) syndrome and cardiac tamponade are potentially life-threatening conditions that are not uncommon in the oncological setting but their occurrence together in a patient is infrequent. Herein, we present a case of 50-year-old male who presented with SVC syndrome and pleural effusion; developed recurrent cardiac tamponade in the hospital. Fine needle aspiration cytology (FNAC) of left supraclavicular lymph node which appeared during hospital stay revealed high grade carcinoma and diagnosis of anaplastic thyroid carcinoma was established by FNAC of thyroid nodule. Despite rarity, clinicians must be aware of such presentation of thyroid malignancy.

Evaluation of C677T polymorphism of the methylenetetra hydrofolate reductase gene and its association with levels of serum homocysteine, folate, and vitamin B12 as maternal risk factors for Down syndrome.

AIMS AND OBJECTIVE: Evaluation of C677T polymorphisms of the methylenetetra hydrofolate reductase (MTHFR) gene and its association with level of serum homocysteine, folate, and vitamin B12 as possible maternal risk factors for Down syndrome. DESIGN: This was a case-control study. MATERIAL AND METHODS: Fifty-two mothers (mean age 27.6 years) with babies having free trisomy 21 of North Indian ethnicity and 52 control nonlactating mothers (mean age 24.9 years) of same ethnicity attending services of genetic lab for bloodletting for other causes were enrolled after informed written consent. Fasting blood was collected and was used for determination of plasma homocysteine, vitamin B12, and folate (serum and RBC), and for PCR amplification of the MTHFR gene. RESULTS: The prevalence of MTHFR C677T polymorphism in north Indian mothers of babies with trisomy 21 Down syndrome was 15.38% compared to 5.88 % in controls. The difference between two groups was not statistically significant (P = 0.124). Low serum folate was demonstrated in 34.62% of cases vs. 11.54% in controls, which was significant (P = 0.005). Low RBC folate was found in 30.7% of cases versus 11.53% in controls, which was not significant (P = 0.059), when analyzed independently. But on multiple regression analysis the difference was statistically significant. Low serum vitamin B12 was found in 42.31% of cases versus 34.62% in controls, which was not significant (P = 0.118). The mean serum homocysteine in cases was 10.35 ± 0.68 while controls were 9.02 ± 0.535. CONCLUSION: Serum levels of folate were low in cases. The RBC folate levels were comparable in both groups. However the combined serum folate and RBC folate were low in cases compared to control groups. Homocysteine levels in our study were higher in Down syndrome mothers compared to controls; however high-serum level of Homocysteine had no association with MTHFR polymorphism. No association of serum vitamin B12 with MTHFR polymorphism in occurrence of Down syndrome births was found. Peri- or preconceptional folate supplementation may therefore lead to a decline in DS births, if supported by larger studies.