A 60-year-old man was admitted to a hospital for evaluation of intermittent fever, dysphagia, hoarseness, and general chest discomfort. Great vessel mycotic aneurysm was suspected when antibiotic trials failed and chest X-ray showed paraaortic mass with pleural effusion mimicking mediastinitis. Although the correct diagnosis of mycotic aneurysm of innominate artery was made thereafter and vigorous treatment was initiated immediately, this patient succumbed to overwhelming sepsis, probably due to a 2-week delay in another hospital. This case is reported to remind readers of the possibility of this unusual location of mycotic aneurysm. A high index of suspicion should be maintained to make an earlier diagnosis and obtain better prognosis. Computed tomography and 3D magnetic resonance angiography also significantly improve the diagnosis when mycotic aneurysm location is unusual and presentation is equivocal.

Abscess↗

PubMed1998

Ductal dilatation and stenting for residual hepatolithiasis: a promising treatment strategy.

BACKGROUND AND AIMS: Hepatolithiasis is prevalent in south-east Asia and presents a difficult management problem. Intrahepatic strictures with or without awkward ductal angulation of the biliary tree are the main reasons for the reported high incidence of postoperative residual stones. Without proper treatment, biliary strictures and residual stones can lead to repeated episodes of cholangitis, liver abscess, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The purposes of our treatment strategy were to achieve complete clearance of the stones and relief of bile stasis. METHODS: From January 1991 to July 1992, 90 patients with residual postoperative hepatolithiasis and intrahepatic strictures were treated. Postoperative ductal dilatation with percutaneous transhepatic cholangioscopy tube stenting through a mature T tube tract was performed. Choledochoscopic electrohydraulic lithotripsy was applied when impacted or large stones were encountered. RESULTS: Complete clearance of stones was achieved in 78 patients (87%). Mild haemobilia occurred in five patients (5.5%) and fever developed in seven patients (7.7%), and these patients recovered after conservative treatment. The rate of stone recurrence after a mean follow up of 43 months was 8%. Intrahepatic cholangiocarcinoma developed in one patient (1.1%). CONCLUSION: Postoperative ductal dilatation and stenting, combined with endoscopic electrohydraulic lithotripsy when indicated, is an effective and safe treatment with a low recurrence rate for complicated residual hepatolithiasis with biliary stricture.

Adult↗

PubMed1998

Intraoperative Doppler ultrasound in liver transplantation.

The purpose of this study was to determine the utility of intraoperative Doppler ultrasound for the diagnosis and reduction of the vascular complications in liver transplantation. This study included 19 pediatric and 5 adult patients. In the pediatric group, 12 patients received living related liver transplantation (LRLT), two splitting liver transplantation (SLT), three reduced-size liver transplantation (RLT) and two full-size pediatric liver transplants (FPLT). The hemodynamics and waveform of the hepatic vein, portal vein and hepatic artery were evaluated by intraoperative Doppler ultrasound (US) after reperfusion of the graft. Unsatisfactory hemodynamics was identified in nine cases, including decrease hepatic venous flow (6-9 cm/s) with non-pulsative flat waveform (adults, n = 2 and LRLT, n = 2); portal vein thrombosis (LRLT, n = 1); decrease portal flow (8 mL/min/kg) (LRLT, n = 1); occlusion of the portal vein (SLT, n = 1); poor arterial flow with dampened artery waveform (FPLT, n = 2). These abnormalities were all successfully re-reconstructed by surgical procedures and achieved a graft survival rate of 100%. Two late vascular complications including hepatic venous thrombosis and recurrent portal vein stenosis with splenorenal shunt were discovered 1 month later. They were treated effectively by surgical thrombolectomy and percutaneous balloon dilatation and metallic coils embolization respectively. Three patients died of non-vascular complications and all patients who underwent LRLT survived with a resultant 87.5% overall survival rate. In conclusion, intraoperative Doppler US is efficient in detecting abnormal hepatic hemodynamics, which permits early intervention and hence a better prognosis for the patients. Re-reconstructive procedures were monitored closely under Doppler US guidance until proper flow and wave-form were established. This reduces post-transplant vascular complications and thereby eliminates the likelihood of a lethal complication that might call for re-transplantation.

Adolescent↗

PubMed1998

Spontaneous cellulitis in adults with idiopathic nephrotic syndrome.

BACKGROUND: Susceptibility to infection is a common problem in a patient with nephrotic syndrome. The spontaneous cellulitis is not uncommon in pediatric patients with nephrotic syndrome, whereas there have been few cases reported in adults. In order to clarify the clinical course of this complication, we present 17 adult idiopathic nephrotic patients with spontaneous cellulitis. MATERIALS AND METHODS: A series of 17 adult idiopathic nephrotic patients with spontaneous cellulitis were retrospectively reviewed in Chang Gung Memorial Hospital, Kaohsiung from 1986 through 1996. We analyzed their physical conditions, clinical manifestations, and outcome. All patients received renal biopsies and had pathologic diagnoses. RESULTS: The medical records of 17 patients were collected, 12 men and 5 women, with ages ranging from 16 to 63 years (mean 29.5 years). The pathologic diagnoses of renal biopsies included minimal change disease (13/17), membranous glomerulonephritis (2/17), mesangioproliferative glomerulonephritis (1/17) and focal/segmental glomerulosclerosis (1/17). All patients had generalized edematous state. The clinical presentations of these patients were variable. The mean serum albumin and daily urinary protein excretion were 1.28+/-0.64 g/dl and 8.75+/-5.16 g, respectively. The results of blood cultures were E. coli (3/17), Gram-negative bacilli (1/17), Streptococcus viridans (1/17), Streptococcus pneumoniae (1/17) and no growth (11/17). All patients responded to antibiotic treatment except one patient who died due to overwhelming sepsis. CONCLUSION: The related factors of spontaneous cellulitis in patients with nephrotic syndrome are edematous skin, hypoalbuminemia, immunosuppressive drugs and defective immunity. Our patients had accordant conditions. The prognosis was good if diagnosis and treatment are made early.

Adolescent↗

PubMed1998

Post-transplant changes of segment 4 after living related liver transplantation.

The purpose of this study was to evaluate the outcome of the medial segment of the graft after living related liver transplantation (LRLT). Of the 12 pediatric recipients who underwent LRLT, 2 received whole left liver graft, 1 left lateral segment graft, and 9 extended left lateral segment grafts. The hepatic veins of the donor were reviewed and the volume of the medial segment and left lateral liver was measured before and 6 months after liver transplantation. The flow velocity and direction of the portal vein in the medial segment graft was also evaluated by Doppler ultrasound. The grafted livers of all recipients showed a substantial increase in volume of 9-120% 6 months after LRLT. For the left lateral segment, an increase in volume was found in all cases ranging from 21 to 245%. For the medial segment, volume increases of 5-48% were found in seven cases with normal hepatopetal flow detected inside the segment 4 intrahepatic portal vein. In four cases, the partial medial segment graft of the extended left lateral liver graft decreased in volume from 33 to 69%. Among these four cases, slow flow (n = 2) and hepatofugal flow (n = 1) were also detected in the intrahepatic portal vein of the medial segment. Mapping of the tributary of the hepatic veins of the graft revealed inadequate venous drainage of the partial segment 4 graft, which may be considered as the cause of the atrophic change of the partial segment 4 graft. In conclusion, different regenerative rates between the left lateral segment and the medial segment were noted, with a greater rate in the left lateral segment. The venous drainage of the medial segment is of primary concern in the determination of the outcome of the regeneration. Atrophic change occurs when inadequate hepatic venous drainage is encountered. Therefore, if an extended left lateral liver graft is required, the corresponding draining veins of the partial medial segment must be preserved. Otherwise, whole left liver or left lateral segment graft would be a better choice.

Blood Flow Velocity↗

PubMed1997

Variations of the middle and inferior right hepatic vein: application in hepatectomy.

We evaluated the anatomic variations of the middle right hepatic vein (MRHV) and inferior right hepatic vein (IRHV) and their clinical application to the possibility of right subtotal hepatectomy. In 400 of normal livers studied with ultrasound, the IRHV was found to drain segment 6 of the liver and flow into the inferior vena cava (IVC) in 72 (18%) cases. In 22 (5.5%) cases, the MRHV was found to drain segment 5 of the liver and flow into the IVC. The size of the IRHV ranged from 0.1 cm to 0.8 cm with an average of 0.46 cm. For the MRHV, the sizes ranged from 0.1 cm to 0.9 cm with an average of 0.34 cm. In 10/79 (12.6%) cases the IRHV and in 4/ 22 (18.1%) cases the MRHV were bigger than the right hepatic vein (RHV). The distance between the RHV and IRHV ranged from 3 cm to 5 cm with an average of 3.7 cm. The distance between the RHV and MRHV ranged from 3 cm to 3.3 cm with an average of 3.1 cm. A hyperechoic edge, similar to that of the portal vein, was observed at the wall of the hypertrophic IRHV and was 0.3 cm or larger in size. Preoperative delineation of this complex venous anatomy is very important. It provides vital information in the preoperative evaluation needed before performing a right subtotal hepatectomy with preservation of segment 6 or segment 5 of the liver, and with RHV resection. Prior to undertaking a right hepatectomy, clamping the hypertrophic MRHV and IRHV electively may minimize intra-operative blood loss and extrahepatic spread of the malignancy.

Adolescent↗

PubMed1997

Nasal administration of retinal antigens maintains immunosuppression of uveoretinitis in cyclosporin-A-treated Lewis rats: future treatment of endogenous posterior uveoretinitis?

PURPOSE: Current treatment of autoimmune endogenous posterior uveoretinitis (EPU) is limited by drug toxicity, unpredictable relapses on dose reduction and resistance to therapy. Administration of autoantigens via gastrointestinal or respiratory mucosa prior to antigen exposure induces immune hyporesponsiveness (mucosal tolerance) to further antigen sensitisation. In this study we assessed whether mucosal tolerance induction was possible after immunisation with retinal antigens in experimental autoimmune uveoretinitis (EAU) in animals that were short-term immunosuppressed with cyclosporin A (CsA) to determine whether mucosal administration of retinal antigens can maintain immunosuppression in sensitised and immunosuppressed individuals. METHODS: Female Lewis rats were immunised with retinal extract (RE) and then treated as follows. Group 1 received no specific therapy and served as control; group 2 were fed CsA from day 7 to day 20 post-immunisation; group 3 received inhalational tolerance therapy with RE in addition to CsA; tolerance therapy was continued after day 20 when CsA was stopped. Experiments varying the timing and dosage of both tolerising and immunising antigen were also performed, the details of which are described. Incidence, day of onset and clinical activity were recorded and histopathological assessment of intraocular inflammation, in particular the extent of autoimmune target-organ damage, was graded semiquantitatively. RESULTS: Compared with controls and group 2, group 3 showed both a marked delay in disease onset and a reduction in disease severity. This effect was both dose and dose-timing dependent. Tissue damage assessed in terms of preservation of rod outer segments was significantly less in group 3. CONCLUSIONS: The success of combination therapy, clinically, remains unknown at present but these results support continuing present clinical trials of mucosal tolerance therapy and in particular have future implications for either maintaining or inducing immunosuppression in autoimmune diseases in combination with present immunosuppressive therapies.

Administration, Intranasal↗

PubMed1997

CT findings at lupus mesenteric vasculitis.

PURPOSE: To describe the spectrum of early CT findings of lupus mesenteric vasculitis (LMV) and to assess the utility of CT in the management of this uncommon entity. METHODS: Abdominal CT was performed within 1-4 days (average 2.2 days) of the onset of severe abdominal pain and tenderness in 15 women with systemic lupus erythematosus. Prompt high-dose i.v. corticosteroid was administered in 11 patients after the CT diagnosis of LMV was made. CT was performed after abdominal symptoms subsided. RESULTS: Eleven cases revealed CT features suggestive of LMV including conspicuous prominence of mesenteric vessels with palisade pattern or comb-like appearance (CT comb sign) supplying focal or diffuse dilated bowel loops (n = 11), ascites with slightly increased peritoneal enhancement (n = 11), small bowel wall thickening (n = 10) with double halo or target sign (n = 8). Follow-up CT before high-dose steroid therapy revealed complete or marked resolution of the abnormal CT findings. CONCLUSION: CT is helpful for confirming the diagnosis of LMV, especially the comb sign which may be an early sign. Bowel ischemia due to LMV is less ominous than previously expected, and the abnormal CT findings were reversible when early diagnosis and prompt i.v. steroid therapy could be achieved.

Abdominal Pain↗

PubMed1997

Unusual imaging presentations in renal transitional cell carcinoma.

PURPOSE: To report on unusual imaging presentations in renal transitional cell carcinoma (TCC). MATERIAL AND METHODS: Imaging studies of 140 cases of pathologically proven renal TCC were retrospectively studied with the focus on unusual presentations. RESULTS: Unusual imaging manifestations were found in 20 cases (14.3%). These findings were classified into 5 categories: perirenal abscesses or perirenal hematomas in 6 cases; parenchymal masses in 5; undue thickening of the hydronephrotic wall in 4; "tuberculoid" pyelograms in 3; and tumors with massive necrosis in 2. CONCLUSION: Deceptive imaging presentations may occur in renal TCC. Recognition of these presentations may help to prevent delay in diagnosis.

Abscess↗

PubMed1997

Living related donor liver transplantation.

Living related liver transplantation (LRLT) has been developed in response to the paediatric organ donor shortage. According to the International Living Donor Registry, 521 transplants had been performed in 515 patients between December 8 1988 and January 19 1996 in 30 centres worldwide. The overall actuarial patient and graft survival rates were 82.7 and 80%, respectively. Between June 17 1994 and November 30 1996, the authors performed 11 LRLT at the Chung Gung Memorial Hospital. The living donors consisted of 10 mothers and one father. The mean graft weight was 303 g and the mean graft recipient weight ratio was 2.2%. Donor hepatectomy was performed without vascular inflow occlusion. The intra-operative blood loss ranged from 30 mL to 120 mL with an average of 61 mL, and blood transfusion was not required in all donors both intra-operatively and during the postoperative period. Underlying diseases of the recipients were biliary atresia (n = 10) and glycogen storage disease (n = 1). The mean graft cold ischaemia time was 106 min, the mean second warm ischaemia time was 51 min and the mean interval between portal and arterial reperfusion was 81 min. The initial LRLT results were promising with all donors having been discharged without complication. The recipients experienced a few complications, all of which were manageable with early intervention. All 11 recipients are alive and well. These are encouraging results and the authors hope to expand the use of live donors for liver transplantation to cope with demand.

Adolescent↗

PubMed1997

[Effect of 6-dimethylaminopurine on the resumption of meiosis and parthenogenetic activation in mouse oocytes].

Chromatin condensation and germinal vesicle breakdown (GVBD) in mouse cumulus free oocytes was blocked by 2 mmol/L of 6-DMAP in vitro. Mouse oocytes (M II) from superovulated female mice could be activated by 6-DMAP. The activation rates of oocytes (18-19 h post hCG) cultured in CZB medium with 2 mmol/L 6-DMAP for 0.5, 1, 2, 3 h, were 26.1%, 75.2%, 75.8%, 77.3% respectively (Table 1), and the cleavage rates of these activated oocytes were 88.2%, 73.2%, 67.0%, 58.4% respectively (Table 2). The parthenogenetic activation type induced by 6-DMAP was different from that produced by ethanol (Fig.1).

Adenine↗

PubMed1997

Magnetic resonance venography in potential pediatric liver transplant recipients.

Vascular anomalies may be hazardous to liver transplantation, and pre-operative vascular evaluation is important for a safe and successful operation. The purpose of this study was to assess the utility and accuracy of time-of-flight (TOF) magnetic resonance venography (MRV) with three-dimensional (3D) reconstruction as an alternative for conventional catheter angiography in evaluating the portal venous system and inferior vena cava (IVC) in potential pediatric liver transplant recipients. Twenty consecutive cases of small children with biliary atresia were evaluated with TOF MRV with 3D reconstruction by Advantage Window workstation. All 20 cases underwent conventional angiography; two cases received transhepatic portography and three cases received splenoportographic study. The whole MRV examination and filming required less than 30 min. Findings of portal vein and IVC completely agreed with or were superior to the successful catheter angiographic images. The portal vein was occluded in five cases, and patent in fifteen cases which included: twelve hepatopetal flow, two hepatofugal flow and one small caliber portal vein. Varices were found in 18 cases. In the case of the IVC, 18 of them were normal and 2 had congenital abnormalities which included paired vena cava and hypoplasia vena cava with compensatory enlargement of the azygos and hemiazygos systems. Eight of the cases received liver transplantation, and the MRV findings totally correlated with the final anatomy as found intraoperatively. MRV is accurate for evaluating the condition of the portal venous system and IVC, detection, and determining the distribution and extents of the varices. It is a reliable, noninvasive and rapid technique which can be considered as an alternative workup for the invasive angiography and or portography in small children for pre-transplantation evaluation.

Angiography, Digital Subtraction↗