Leakage Of Contrast Medium Research Articles

Occlusive Properties of Transrenal Ureteral Occlusion Self-Expandable Metallic Stents: 3D-Printed Phantom and Ex Vivo Studies

Newly developed transrenal ureteral occlusion self-expanding metallic stents (SEMSs) are applied in patients with inoperable fistulas. In this study, the occlusive properties of M- and D-type occlusion SEMSs were investigated in 3D-printed phantom and ex vivo porcine urinary tracts. In the former, the mean bursting pressure causing leakage of contrast medium through the occlusion SEMS was relatively higher in M-types (42.8 ± 3.8 mmHg) than in D-types (38.8 ± 3.8 mmHg), without a statistical difference (p = 0.075). In the latter, the bursting pressure causing leakage through the M-type occlusion SEMS (110.7 ± 8.6 mmHg) was significantly higher than that of the D-type occlusion SEMS (93.8 ± 11.2 mmHg, p = 0.015); however, the mean bursting pressures causing contrast blowout did not differ between the two types (178.7 ± 11.2 mmHg vs. 176.2 ± 11.8 mmHg, p = 0.715). In conclusion, M- and D-type occlusion SEMSs showed similar efficacy in occlusive properties in the 3D phantom study; however, the M-type was superior in the ex vivo porcine urinary tract model. Further in vivo experimental studies are required to confirm these experimental results.

Relationship between Transient Cortical Blindness and Contrast Medium Leakage That Occurs after Endovascular Treatment of Posterior Circulation Aneurysms.

The mechanism of transient cortical blindness after endovascular treatment-a rare phenomenon-has not been elucidated; however, it is assumed to be related to contrast medium leakage (CML). We investigated the relationship between postoperative CML and cortical blindness in patients who underwent endovascular treatment for vascular lesions of posterior circulation. This retrospective cohort study included 28 patients who underwent endovascular treatment for posterior circulation aneurysms at our hospital between January 2014 and December 2018. Cerebral CT was performed immediately after endovascular treatment and 24 h later. CT images were retrospectively evaluated with special interest in the presence and distribution of leakage of the contrast medium (CM). Patients were classified into the following three groups based on CT findings: Group A, no CML (11 patients); Group B, unilateral CML (5 patients); and Group C, bilateral CML (9 patients). The posterior circulation aneurysms were located in the basilar artery in 13 (52.0%) cases, in the posterior cerebral artery in 1 (4.0%) case, and in the vertebral artery in 11 (44.0%) cases. There was no difference regarding the adjunctive technique used for endovascular treatment between the groups. Patients in Group C used a significantly larger amount of CM than those in the other two groups. A longer operation time was associated with a larger amount of CM used during treatment. VerifyNow assay revealed that the P2Y12 reaction unit was significantly lower in Groups B and C. Cortical blindness was transiently observed in 2 of 9 patients (22.2%) in Group C, both of which showed CML surrounding the bilateral parieto-occipital sulcus. Both patients with cortical blindness showed bilateral CML, both of which showed CML surrounding the bilateral parieto-occipital sulcus. The CM-induced blood-brain barrier disruption may be the cause of cortical blindness.

Application of Flat-Panel Volume Computed Tomography to Evaluate Cerebral Hemorrhage After Mechanical Thrombectomy of Acute Embolic Stroke of the Anterior Circulation.

The aim of the study was to evaluate cerebral hemorrhage (CH) and contrast media leakage (CML or commonly synonymous with "contrast staining") differentiation on flat-panel volume computed tomography (FPVCT) after intra-arterial mechanical thrombectomy. We evaluated patients with hyperattenuation on FPVCT after intra-arterial mechanical thrombectomy between 2018 and 2021 by multiple parameters on CT angiography, FPVCT, CT, and/or magnetic resonance imaging. The CH (n = 43) versus CML (n = 24) groups revealed: (1) regional anatomical characteristics (preserved and distorted): 7 of 43 (9.6%) and 36 of 43 (83.7%) versus 22 of 24 (91.7%) and 2 of 24 (8.3%, P < 0.001); (2) thrombus in proximal two-thirds versus distal one-thirds M1 segment of middle cerebral artery (preserved and distorted): 17 of 21 (81.0%) and 4 of 21 (19.0%) versus 5 of 11 (45.5%) and 6 of 11 (54.5%, P = 0.040); and (3) average density ratio: 1.83 ± 0.65 versus 1.35 ± 0.13 (P = 0.004). Contrast media leakage can be differentiated from CH by preserved regional anatomical characteristics and relatively low average density ratio on FPVCT. Patients with CML who have embolism in proximal two thirds of M1 segment are more likely to develop hyperattenuation with preserved regional anatomy.

Endovascular aortic repair for abdominal aortic injury complicated with bowel injury due to blunt abdominal trauma: A case report.

Introduction and importanceBlunt abdominal aortic injury (BAAI) resulting from blunt abdominal trauma is rare; therefore, there are no standard guidelines for its treatment. Herein, we report the successful treatment of BAAI via endovascular aortic repair (EVAR) performed immediately after emergency laparotomy to repair a bowel injury.Case presentationA 78-year-old man was injured after being caught between a shovel car and the bumper of his own car for approximately 15 s. Upon arrival at the hospital, the patient was conscious and had stable vital signs, abdominal and low back pain, and numbness in the right lower limb. Computed tomography revealed contrast medium leakage into the mesentery, as well as aortic dissection and rupture. Hemostasis and intestinal resection were completed, and EVAR was performed immediately after abdominal closure. The patient was discharged from the hospital at 35 days after surgery.Clinical discussionIn this case, there existed a risk of artificial blood vessel infection if reconstruction was simultaneously performed with intestinal resection. Symptoms of lower limb ischemia that were observed prior to surgery resolved. After open surgery, bleeding was controlled, and the patient's vital signs were stable. EVAR was performed as treatment for aortic injury, thereby reducing the risk of direct implant infection and enabling minimally invasive treatment.ConclusionEVAR may be useful for the treatment of BAAI in the presence of intestinal injuries, reduce the risk of implant infection, and allow for a one-time, minimally invasive treatment.

Validation of a bioabsorbable device that seals perforations after Tuohy needle dural puncture in an ovine model

BackgroundWe designed a device to close accidental dural puncture via the offending puncturing epidural needle directly after diagnosis of the puncture and before removing the needle. The aim of this...

Embolization for massive bleeding due to spontaneous left external iliac vein rupture: report of a successful case

BackgroundSpontaneous rupture of the iliac vein has rarely been reported. Its associated hypovolemic shock-related symptoms and signs, including syncope and hypotension, have been observed in most of these cases. Successful transcatheter venous embolization for massive bleeding due to spontaneous rupture of the external iliac vein was herein reported.Case presentationAn 82-year-old female patient developed sudden left lower abdominal and back pain. Immediately, she lost consciousness and went into shock. CT images of her abdomen revealed a huge retroperitoneal hematoma, with leakage of contrast medium in the hematoma in the left flank. These findings suggested left external iliac vein rupture.Open surgery was considered; however, since the patient’s condition may have deteriorated further due to the time needed to prepare for surgery, including general anesthesia, transcatheter venous embolization of the left iliac vein was selected. A 5.2-Fr compliant balloon catheter (nominal diameter of 10 mm) was inflated at the distal site of the external iliac vein to reduce extravasation. N-butyl-2-cyanoacrylate (NBCA) was mixed with Lipiodol at a ratio of 1:2. The left Iliac vein was filled and completely embolized with the NBCA/Lipiodol mixture (total injected volume, 5 mL) using a 1.8-Fr microcatheter. After embolization, the patient quickly. An inferior vena cava filter was placed 1 day after embolization.ConclusionSpontaneous rupture of the iliac vein is a very rare and lethal condition. Transcatheter venous embolization may control potentially life-threatening bleeding. Rapid bleeding control in a critical condition is facilitated by this minimally invasive approach.

Bidirectional endovascular treatment for axillary artery injury secondary to proximal humerus fracture: a case report.

BackgroundAxillary artery injury secondary to proximal humerus fracture is a rare but serious complication. The management of this injury has traditionally involved surgical treatment.Case summaryA 66-year-old female with gait disturbance slipped and fell off her wheelchair at home. She presented to a local hospital with right shoulder pain and was subsequently urgently transferred to our hospital by helicopter because of suspicion of axillary artery injury. Computed tomography angiography revealed disruption of the right axillary artery. We decided to perform endovascular treatment instead of surgical treatment for axillary artery injury. However, since endovascular treatment via the right femoral artery was impossible, we performed bidirectional (right femoral and right brachial artery approaches) endovascular treatment. We expanded the occluded lesion using a 3.5 mm × 40 mm sized balloon and placed a 5.0 mm × 50 mm stent graft (Gore® Viabahn®) across the lesion. The final subclavian injection confirmed that distal flow to the brachial artery was preserved and that there was no leakage of contrast medium from the axillary artery.DiscussionWe performed endovascular treatment for axillary artery injury secondary to proximal humerus fracture. Although surgical repair is typically performed for this kind of injury, our experience suggests that endovascular treatment might be an option in patients with axillary artery injury.

High-resolution Micro-CT Myelography to Assess Spinal Subarachnoid Space Changes After Spinal Cord Injury in Rats.

The spinal subarachnoid space (SSAS) is vital for neurologic function. Although SSAS alterations are known to occur after spinal cord injury (SCI), there is a lack of high-resolution imaging studies of the SSAS after SCI in rodents. Therefore, the aim here was to assess changes in the SSAS of rats subjected to graded SCI, using high-resolution micro-CT myelography. Long-Evans adult rats were subjected to mild or severe spinal cord contusion at T9. Imaging studies of SSAS features were carried out in injured rats at acute (day 1) and subacute (day 15) stages postinjury, as well as in control rats, using high-resolution micro-CT myelography with a contrast-enhanced digital subtraction protocol. We studied a total of 33 rats randomly allocated into five experimental groups. Micro-CT myelograms were assessed by expert observers using both qualitative and quantitative criteria. Qualitative and quantitative analyses showed that SCI induces changes in the SSAS that vary as a function of both injury severity and time elapsed after injury. SSAS blockage was the main alteration detected. Moreover, the method used here allowed fine details to be observed in small animals, such as variations in the preferential pathways for contrast medium flow, neuroimaging nerve root enhancement, and leakage of contrast medium due to tearing of the dural sac. Micro-CT myelography provides high-resolution images of changes in the SSAS after SCI in rats and is a useful tool for further experimental studies involving rat SCI in vivo.

Urgent distal pancreatectomy for intraperitoneal hemorrhage due to the spontaneous rupture of a pancreatic metastatic tumor from synovial sarcoma: a case report

BackgroundSynovial sarcoma is a soft tissue malignancy that frequently affects the extremities, adjacent to the large joints. Synovial sarcoma has a high rate of distant metastasis; however, pancreatic metastasis is extremely rare, and to our knowledge, there has been no report of bleeding due to spontaneous tumor rupture. This study reports the case of a patient with synovial sarcoma pancreatic metastasis causing tumor rupture and bleeding, which was successfully managed with emergent distal pancreatectomy.Case presentationA 27-year-old woman underwent extensive resection of the primary tumor and partial lung resection after chemotherapy for left femoral synovial sarcoma and multiple lung metastases 4 years prior. During the follow-up, a 35-mm tumor was noted in the pancreatic tail on abdominal computed tomography (CT), and no other distant metastases were detected via positron emission tomography CT. Laparoscopic distal pancreatectomy was scheduled for pancreatic metastasis of synovial sarcoma. However, before the scheduled pancreatectomy could be conducted, the patient visited the emergency department because of abdominal pain that occurred after consuming a small amount of alcohol, and CT showed ascites with high CT values and leakage of contrast media. She was diagnosed with intra-abdominal hemorrhage due to a ruptured metastatic pancreatic tumor, and an emergency operation was performed. In total, 1500 mL of blood was evacuated from the abdomen, and the bleeding pancreatic tail tumor was resected. Histopathological findings revealed synovial sarcoma metastasis and a ruptured tumor capsule, and tumor cells were observed in the hematoma. After discharge on postoperative day 18, the patient was carefully monitored and confirmed to be in relapse-free survival, without chemotherapy, at 6 months post-surgery.ConclusionsWhile the rate of tumor growth varies depending on the grade of the tumor, the possibility of rupture should be considered even in metastatic pancreatic tumors. In the case of pancreatic tumor rupture with stable circulation, radiological evaluation for oncology is necessary, and primary resection may be compatible with resectable cases.

難治性上部消化管穿孔症例に対する内視鏡的フィブリン接着剤局注療法の応用(Application of endoscopic local injection of fibrin glue to treat refractory perforation cases in the upper digestive tract)

要旨内視鏡的止血法の1つとして，フィブリン接着剤（fibrin glue: FG）局注療法が報告されている。今回我々は，難治性上部消化管穿孔例に，FG局注療法を応用し，良好な結果を得た。症例1は79歳の女性。上腹部痛を主訴に救急搬送された。壊疽性胆嚢炎，胆石性膵炎の診断にて消炎後，胆嚢摘出術を施行した。その後，膵炎に合併した仮性膵嚢胞と接する胃体後壁に穿孔を認め，内視鏡的にFG局注療法を施行した。結果，約2週間で同部の閉鎖を見た。症例2は82歳の男性。嘔気と腹痛を主訴に救急搬送された。下部食道の特発性食道破裂の診断のもと，食道破裂部単純閉鎖術を施行した。約1か月後，縫合部の再穿孔を認め，内視鏡的にFG局注療法を施行した。その後，上皮形成を認め，閉鎖した。難治性上部消化管穿孔例に対し，内視鏡的FG局注療法は有用な閉鎖術になりうると考えられた。

Flow-controlled fluoroscopic angiography for the assessment of vascular integrity in bioengineered kidneys.

Perfusion decellularization has been proposed as a promising method for generating nonimmunogenic organs from allogeneic or xenogeneic donors. Several imaging modalities have been used to assess vascular integrity in bioengineered organs with no consistency in the methodology used. Here, we studied the use of fluoroscopic angiography performed under controlled flow conditions for vascular integrity assessment in bioengineered kidneys. Porcine kidneys underwent ex vivo angiography before and after perfusion decellularization. Arterial and venous patencies were defined as visualization of contrast medium (CM) in distal capillaries and renal vein, respectively. Changes in vascular permeability were visualized and quantified. No differences in patency were detected in decellularized kidneys compared with native kidneys. However, focal parenchymal opacities and significant delay in CM clearance were detected in decellularized kidneys, indicating increased permeability. Biopsy-induced leakage was visualized in both groups, with digital subtraction angiography revealing minimal CM leakage earlier than nonsubtracted fluoroscopy. In summary, quantitative assessment of vascular permeability should be coupled with patency when studying the effect of perfusion decellularization on kidney vasculature. Flow-controlled angiography should be considered as the method of choice for vascular assessment in bioengineered kidneys. Adopting this methodology for organs premodified ex vivo under normothermic machine perfusion settings is also suggested.

Subdural contrast effusion during endovascular therapy: case report

Accumulation of contrast medium in the subdural space after diagnostic intraarterial contrast administration is a rare observation. The authors report the case of a subdural contrast effusion (SCE) presenting during endovascular treatment of an intracranial dural arteriovenous fistula (DAVF) mimicking an acute subdural hematoma. Differentiation between the two by computed tomography (CT) or intraprocedural Dyna CT and early neurological examination can be crucial for patient management. We believe that repeated large-volume contrast injections via large-bore intermediate catheters into the territory of an (even partly) occluded DAVF may induce leakage of contrast medium into the extravascular subdural space thereby causing a SCE.

P14.34 Priority of comet tail sign in the planning of stereotactic irradiation for the treatment of brain metastases

Abstract BACKGROUND A highly enhanced cap attached to the surface of metastatic tumours in the brain parenchyma is occasionally encountered on magnetic resonance (MR) images. This atypical cap termed “comet tail sign (CTS)” is attributed to leakage of contrast medium from the tumour body into the oedema surrounding it and is containing no neoplastic tissue (Mitsuya, et al. 2016. J Neurooncol). The purpose of this study was to demonstrate our clinical results of excluding CTS in the planning of stereotactic irradiation (STI) for brain metastases to avoid radiation necrosis. METHODS We selected 16 consecutive cases of newly diagnosed brain metastases with CTS treated with STI between May 2007 and January 2019. Patients underwent STI with target fields including CTS until December 2014 (Group A, n=4), while STI with fields excluding CTS from January 2015 (Group B, n=12). CTS was carefully diagnosed using contrasted T1-weighted images and T2-weighted images by radiation oncologists and neurosurgeons. Treatment outcome and toxicity were compared among two groups. RESULTS Primary cancers were lung in 13 and colon in 3 patients. Ten (63%) were male, and the median age was 68 years (range, 47 to 78). The median follow-up time was 13.5 months from STI. There was no significant difference of the mean tumour volume between two groups (4.28ml vs. 4.68ml). Disease control rates were 25% in Group A and 92% in Group B. Symptomatic radiation necrosis was observed in two (50%) patients of Group A but none (0%) of Group B. CONCLUSION CTS could be excluded from STI target planning to increase local control and to decrease radiation toxicity. Prospective study is needed to clarify optimal STI planning for patients with brain metastasis accompanied CTS in the future.

Abdominal lymphatic drainage after thoracic duct ligation and cisterna chyli ablation in clinically normal cats.

To characterize abdominal lymphatic drainage in cats after thoracic duct ligation (TDL) and cisterna chyli ablation (CCA). 7 purpose-bred research cats. Baseline CT lymphangiography was performed. A popliteal lymph node was injected with iohexol, and images were acquired at 5-minute intervals for 15 minutes. Cats underwent TDL and CCA; methylene blue was used to aid in identifying lymphatic vessels. The CT lymphangiography was repeated immediately after and 30 days after surgery. All cats were euthanized and necropsied. Results of baseline CT lymphangiography were unremarkable for all 7 cats. Only 5 cats completed the study. Leakage of contrast medium at the level of the cisterna chyli was seen on CT lymphangiography images obtained from all cats immediately after surgery. Evaluation of 30-day postoperative CT lymphangiography images revealed small branches entering the caudal vena cava in 2 cats, leakage of contrast medium into the caudal vena cava with no visible branches in 1 cat, and no contrast medium in the caudal vena cava in 2 cats. Contrast medium did not flow beyond the level of the cisterna chyli in any cat. Gross examination during necropsy revealed that all cats had small lymphatic vessels that appeared to connect to local vasculature identified in the region of the cisterna chyli. Abdominal lymphaticovenous anastomoses formed after TDL and CCA in cats. This would support use of these procedures for treatment of cats with idiopathic chylothorax, although additional studies with clinically affected cats are warranted.

A Novel Technique of Urine Drainage from Bilateral Kidneys with a Single Catheter

A 69-year-old woman who underwent posterior pelvic exenteration and sacral resection for rectal cancer presented with urine leakage from a vesicocutaneous fistula at the sacral resection site (Figs 1, 2). She had bladder dysfunction after surgery. To stop urine leakage, bilateral nephrostomy catheters and a urinary catheter were placed, and embolization of the fistula with coils, glue, Amplatzer vascular plugs (Abbott, St. Paul, Minnesota), and a modified covered stent was performed. Urine leakage decreased but persisted. Her activity was severely restricted by 3 catheters and a gauze pad that was always needed at the fistula site. Therefore, we attempted to use a single catheter to drain the bilateral renal pelvis and reduce the number of catheters, while maintaining bilateral renal function. A guide wire inserted via the right renal pelvis was grasped in the bladder by a snare inserted via the left renal pelvis (Fig 3), and through-and-through access was obtained. An 80-cm-long 7-F catheter (Percuflex Urinary Diversion Stent; Boston Scientific, Marlborough, Massachusetts) with handmade proximal side holes was coaxially inserted through the left nephrostomy route into the right renal pelvis to drain the bilateral renal pelvis (Fig 4). Consequently, urine from the bilateral renal pelvis was drained by the single catheter, and urine leakage from the vesicocutaneous fistula stopped. The patient has been doing well for 15 months with the single catheter, which is exchanged regularly. This technique may be useful to improve activity levels of patients by reducing the number of nephrostomy catheters without compromising bilateral renal function. Figure 2Lateral x-ray of pelvis during cystography demonstrating leakage of contrast medium from urinary bladder (arrowheads) through the skin defect (star) via the vesicocutaneous fistula (arrow). View Large Image Figure Viewer Download Hi-res image Figure 3Oblique x-ray of pelvis during establishment of through-and-through access. The snare (arrowheads) was inserted through the left renal pelvis and advanced into urinary bladder to grasp the guide wire (arrow), which was inserted through the contralateral side. View Large Image Figure Viewer Download Hi-res image Figure 4Abdominal x-ray demonstrating long catheter (arrow) draining bilateral renal pelvis. A modified covered stent and several coils (arrowhead) were placed within the vesicocutaneous fistula. The stent lumen was sealed off by tying a string around its center; additional coils were placed around it to further occlude the fistula. View Large Image Figure Viewer Download Hi-res image

Spontaneous ureteral rupture caused by iliac aneurysm: a case report

BackgroundRupture of the ureter with extravasation resulting from an iliac aneurysm is extremely rare. Herein, we report a case of ureteric rupture with urinary extravasation secondary to an iliac aneurysm.Case presentationAn 80-year-old man was admitted to our hospital for sudden onset of severe abdominal pain. Contrast-enhanced computed tomography demonstrated a large left internal iliac aneurysm (6.5 cm in diameter) and a ureteric rupture with leakage of contrast media from the left ureter, indicating a spontaneous ureteral rupture. The patient was treated with placement of a ureteral double-J stent under endoscopic and X-ray fluoroscopic guidance and endovascular aortic repair. His postoperative course was uneventful and he was discharged on postoperative day 20. A computed tomography scan at 2 weeks after surgery showed no contrast extravasation from the ureter or end leak.ConclusionCombination treatment with ureteral and endovascular stenting is effective in avoiding aneurysmal rupture and the serious consequences of a ureteral rupture, which include a perinephric or retroperitoneal collection, abscess formation, subsequent urosepsis, and graft infection.

TOI 6. Heart in Abdomen: Challenge to Deal With Pseudoaneurysm of Superior Mesenteric Artery With Tetralogy of Fallot

A 28-year-old man underwent total correction of tetralogy of Fallot in 2003. He was diagnosed with infective endocarditis 2 months before and received treatment in a cardiac unit. After discharge, he developed periumbilical pain associated with early satiety and decreased appetite. On examination of this thinly built patient, a pulsatile mass (0 × 10 cm) was palpable in the periumbilical region, more on the left side. Echocardiography showed a secundum-type atrial septal defect measuring 17 mm (left to right shunt), residual perimembranous ventricular septal defect (bidirectional shunt), severe mitral regurgitation with eccentric jet, tricuspid regurgitation (moderate), and pulmonary regurgitation (mild). Computed tomography angiography of the abdomen showed leakage of contrast material from the superior mesenteric artery (SMA) into an aneurysmal sac (6.8 × 7 cm) that occupied almost half the capacity of the peritoneum/abdominal cavity. Digital subtraction angiography showed distal SMA aneurysm with high flow; coil embolization could not be done because of the chance of gut ischemia and persistent pressure symptoms afterward; therefore, the open surgical approach was decided on. On opening of the peritoneal cavity, a beating heart wrapped in mesentery with surrounding inflammation was encountered. Proximal SMA control was taken just near to the aneurysm; the sac was opened and the hematoma evacuated, and the SMA was ligated inside the aneurysmal sac. Dusky proximal bowel found intraoperatively improved after evacuation of hematoma and ligation of the SMA aneurysmal branch, suggestive of impaired circulation from pressure of the sac. No revascularization was required. SMA pseudoaneurysm is rarely encountered in vascular practice. An aneurysmal sac of such size with distorted anatomy is a challenge to deal with, especially in a patient with such comorbidities.

Application of the reversed π-shaped esophagojejunal anastomosis in laparoscope-assisted total gastrectomy for gastric cancer

Objective To investigate the safety and feasibility of the reversed π-shaped esophagojejunal anastomosis in laparoscope-assisted total gastrectomy (LATG) for gastric cancer (GC). Methods The retrospective corss-sectional study was conducted. The clinicopathological data of 18 GC patients who were admitted to the Subei People′s Hospital of Jiangsu Province between January 2015 and October 2016 were collected. All the 18 GC patients underwent LATG, surgical procedures included free stomach and lymph node dissection firstly, side-to-side jejunal anastomosis secondly and laparoscopic gastrointestinal reconstruction using reversed π-shaped anastomosis finally. Observation indicators : (1) surgical situations: side-to-side jejunal anastomosis method, conversion to open surgery, operation time, reversed π-shaped anastomosis time, volume of intraoperative blood loss and number of lymph node dissected; (2) postoperative situations: time for initial out-of-bed activity, time to initial anal exsufflation, time for postoperative water intake, time of drainage tube removal, postoperative complications and duration of hospital stay; (3) postoperative pathological examination; (4) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect diet intake, anastomosis patency, gastrointestinal obstruction and patients′ survival up to March 2017. Measurement data with normal distribution were represented as ±s. Results (1) Surgical situations: 18 patients underwent successful LATG and reversed π-shaped esophagojejunal anastomosis, without conversion to open surgery and perioperative death. Five patients used in vitro hand-sewn side-to-side esophagojejunal anastomosis through small incision of specimens sampling, and 13 completed all surgery under laparoscopy. Operation time, reversed π-shaped anastomosis time, volume of intraoperative blood loss and number of lymph node dissected of 18 patients were (187±12)minutes, (37±5) minutes, (735±18)mL and 29±2, respectively. (2) Postoperative situations: time for initial out-of-bed activity, time to initial anal exsufflation, time for postoperative water intake and time of drainage tube removal in 18 patients were (1.6±0.5) days, (2.3±0.4) days, (2.5±0.5) days and (7.5±1.5)days, respectively. One patient complicated with esophagojejunal anastomosis fistula at postoperative day 3 was cured by drainage and symptomatic treatment and then discharged from hospital. Eighteen patients received regularly angiography using oral water-soluble contrast medium after recovering fluid diet intake, showing anastomosis patency and no contrast medium leakage, and then discharged from hospital. Duration of hospital stay of 18 patients was (12±11)days. (3) Postoperative pathological examination: of 18 patients, 15 were diagnosed with adenocarcinoma and 3 with signet-ring cell carcinoma. T2, T3 and T4 of T staging were respectively detected in 3, 3 and 12 patients. N0, N1, N2 and N3 of N staging were respectively detected in 8, 3, 2 and 5 patients. Stage Ⅰ, Ⅱ and Ⅲ of TNM stage were detected in 3, 5 and 10 patients, respectively. (4) Follow-up and survival situations: 17 of 18 patients were followed up for 6-25 months, with a median time of 12 months. During the follow-up, 2 patients were complicated with sour regurgitation and vomiting after eating at month 6 and 12 postoperatively and received gastrointestinal contrast examination, showing anastomotic stenosis, and then were cured by endoscopic dilation and discharged form hospital. Other patients had good diet and survival, without anastomotic complications. Conclusion The reversed π-shaped esophagojejunal anastomosis in LATG for GC is safe and feasible, with good short-term outcomes. Key words: Gastric neoplasms; Total gastrectomy; Reversed π-shaped esophagojejunal anastomosis; Laparoscopy

Endovascular repair with extracorporeal membrane oxygenation as a rescue strategy for aortobronchial fistula: a case report

Aortobronchial fistula (ABF) is a rare and potentially lethal complication of thoracic aortic replacement surgery. Currently, thoracic endovascular aortic repair (TEVAR) has emerged as a less invasive alternative to open surgery for ABF to facilitate prompt hemostasis. However, there are no published reports of TEVAR for ABF, particularly for presentation with life-threatening respiratory failure from massive hemoptysis.A 48-year-old male patient, who had recently undergone aortic root and arch replacement due to aortic dissection, was transferred to the emergency department with massive hemoptysis and severe dyspnea. A single-lumen endotracheal tube was immediately placed in the right main bronchus to protect the nonbleeding lung from spillage of blood. Chest computed tomography (CT) showed leakage of contrast material from the distal anastomosis of the aortic graft and consolidated lung tissue adjacent to the leakage. He was diagnosed with an ABF following aortic arch replacement, and an emergency TEVAR was performed. After adequate hemostasis, severe hypercapnia remained uncorrected despite the maximum ventilatory support. Thus, venovenous extracorporeal membrane oxygenation (VV ECMO) was immediately initiated, and severe respiratory acidosis improved dramatically. Furthermore, VV ECMO facilitated prompt bronchoscopic washout of the remaining blood clot without any danger of respiratory collapse and was weaned off successfully after 5 days as ventilation improved.This case demonstrates that emergency TEVAR in combination with VV ECMO can be a rescue strategy for massive hemoptysis from an ABF.

Freehand direct arthrography of the shoulder using near real-time guidance in an open 1.0-T MRI scanner.

To assess the technical success and duration of magnetic resonance imaging (MRI)-guided freehand direct shoulder arthrography (FDSA) with near real-time imaging implemented in a routine shoulder MRI examination on an open 1.0-T MRI scanner, and to assess the learning curve of residents new to this technique. An experienced MRI interventionalist (the expert) performed 125 MRI-guided FDSA procedures, and 75 patients were treated by one of three residents without previous experience in MRI-guided FDSA. Technical success rate and duration of MRI-guided FDSA of the expert and the residents were compared. The residents' learning curves were assessed. The occurrence of extra-articular deposition and leakage of contrast media from the puncture site and the subsequent impairment of image interpretation were retrospectively analyzed. Overall technical success was 97.5%. The expert needed overall fewer puncture needle readjustments and was faster at puncture needle positioning (p < 0.01). The learning curve of the residents, however, was steep. They leveled with the performance of the expert after ≈ 15 interventions. With a minimal amount of training all steps of MRI-guided FDSA can be performed in ≤10min. Magnetic resonance-guided FDSA in an open 1.0-T MRI scanner can be performed with high technical success in a reasonably short amount of time. Only a short learning curve is necessary to achieve expert level.