Effect of Abdominal Visceral Fat Change on the Regression of Erosive Esophagitis: A Prospective Cohort Study.

Background/Aims: Although abdominal visceral fat has been associated with erosive esophagitis in cross-sectional studies, there are few data on the longitudinal effect. We evaluated the effects of abdominal visceral fat change on the regression of erosive esophagitis in a prospective cohort study. Methods: A total of 163 participants with erosive esophagitis at baseline were followed up at 34 months and underwent esophagogastroduodenoscopy and computed tomography at both baseline and follow-up. The longitudinal effects of abdominal visceral fat on the regression of erosive esophagitis were evaluated using relative risk (RR) and 95% confidence intervals (CIs). Results: Regression was observed in approximately 49% of participants (n=80). The 3rd (RR, 0.13; 95% CI, 0.02 to 0.71) and 4th quartiles (RR, 0.07; 95% CI, 0.01 to 0.38) of visceral fat at follow-up were associated with decreased regression of erosive esophagitis. The highest quartile of visceral fat change reduced the probability of the regression of erosive esophagitis compared to the lowest quartile (RR, 0.10; 95% CI, 0.03 to 0.28). Each trend showed a dose-dependent pattern (p for trend <0.001). The presence of baseline Helicobacter pylori increased the regression of erosive esophagitis (RR, 2.40; 95% CI, 1.05 to 5.48). Conclusions: Higher visceral fat at follow-up and a greater increase in visceral fat reduced the regression of erosive esophagitis in a dose-dependent manner.

All-treatment array of hepatocellular carcinoma from initial diagnosis to death: observation of cumulative treatments.

PURPOSE: In clinical practice, most patients with hepatocellular carcinoma require subsequent treatments for remaining, progressing, or recurring tumors. We investigated all-treatment array and outcomes in an HCC cohort from initial diagnosis to death. METHODS: We enrolled 1687 consecutive patients with HCC who underwent initial diagnosis and treatment at the National Cancer Center, Korea, from January 2004 to December 2009. RESULTS: In total, 1357 patients (80.4%) showed RPRTs during median 20.4-month follow-up. Initial transplantation resulted in the least rate (32.3%) of RPRTs. Median treatment frequency was 3.0 times (range 1-20) and 382 patients (27.3%) received treatments ≥6 times. The median treatment frequency was different based on four factors (p < 0.05): age, tumor stage, tumor type and initial treatment modality. Patients with Barcelona Clinic Liver Cancer stage 0 received less frequent treatments. As the stage progressed from 0 to B, the median treatment frequency increased. Radiofrequency ablation as initial treatment was associated with the longest median treatment interval at 19.0 weeks, followed by resection at 14.1 weeks. The median treatment interval was significantly shorter as the stage progressed (p < 0.01). TACE was most frequently performed for RPRTs; the median number of subsequent TACE was 3 (range 1-19). Subsequent treatment array was very heterogeneous, and no certain pattern was found. CONCLUSIONS: Our findings suggest that the survival outcome of patients with HCC is based on the results of cumulative multiple treatments rather than an initial treatment. It is time to consider prospective studies evaluating sequential treatment array of HCC.

Effect of abdominal visceral fat on the development of new erosive oesophagitis: a prospective cohort study.

OBJECTIVES: Although abdominal visceral fat has been associated with erosive oesophagitis in cross-sectional studies, there are no data that describe its longitudinal effects. We aimed to evaluate the longitudinal effects of abdominal visceral fat on the development of new erosive oesophagitis in patients who did not have erosive oesophagitis at baseline. MATERIALS AND METHODS: This was a single-centre prospective study. A total of 1503 participants without erosive oesophagitis at baseline were followed up for 34 months and they underwent oesophagogastroduodenoscopy and computed tomography at both baseline and during follow-up. The longitudinal effects of abdominal visceral fat on the development of new erosive oesophagitis were evaluated using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: New oesophagitis developed in 83 patients. Compared with the first quartile, the third (OR=3.96, 95% CI: 1.54-10.18) and the fourth (OR=4.67, 95% CI: 1.79-12.23) of baseline visceral fat quartiles, the third (OR=3.03, 95% CI: 1.14-8.04) and the fourth (OR=7.50, 95% CI: 2.92-19.25) follow-up visceral fat quartiles, and the fourth visceral fat change quartile (OR=2.76, 95% CI: 1.47-5.21) were associated with increased development of new erosive oesophagitis, and the P value for each trend was less than 0.001. New erosive oesophagitis was inversely related to the follow-up Helicobacter pylori status and it was associated positively with the presence of a hiatal hernia and smoking during follow-up, but it was not associated with reflux symptoms, the H. pylori status, presence of a hiatal hernia or smoking at baseline. CONCLUSION: Higher level of visceral fat at baseline and follow-up visceral fat, and greater changes in the visceral level were associated linearly with the development of new erosive oesophagitis in this longitudinal study.

Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases.

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

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.

Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation.

Although celiac axis stenosis is a frequently encountered occlusive vascular disease, clinically significant ischemic bowel disease caused by celiac axis stenosis is rarely reported due to rich collateral circulation from the superior mesenteric artery (SMA). The most important and frequently encountered collateral vessels from the SMA in patients with celiac axis stenosis are the pancreaticoduodenal arcades and the dorsal pancreatic artery. Subtypes of collateral pathways via the dorsal pancreatic artery include a longitudinal pathway between the celiac branches and the SMA or its branches and a transverse pathway to either the splenic or gastroduodenal artery. A communicating channel between the right hepatic artery and the SMA can be a route for collateral circulation. Hepatic artery variants cause the development of unique collateral pathways that have different characteristics depending on the type of variant. These collateral pathways include intrahepatic interlobar collateral vessels, right gastric to left gastric arterial anastomoses, left hepatic to left gastric arterial anastomoses, and peribiliary arterial plexuses. Major collateral pathways in patients with celiac axis stenosis can be identified with spiral CT, and knowledge concerning this collateral circulation may be important for certain medical procedures such as interventional procedures for the management of hepatic tumors, pancreaticobiliary surgery, and liver transplantation.