Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up

AIM: To determine the best method out of the three types of interventional procedure for achalasia based on a longterm follow-up.METHODS: The study cohort was comprised of 133 patients of achalasia. Among them, 60 patients were treated under fluoroscopy with pneumatic dilation (group A), 8 patients with permanent uncovered or antireflux covered metal stent dilation (group B), and 65 patients with temporary partially covered metal stent dilation (group C).RESULTS: One hundred and thirty dilations were performed on the 60 patients of group A (mean 2.2 times per case).The mean diameter of the strictured cardia was 3.3±2.1 mm before dilation and 10.6±3.8 mm after dilation. The mean dysphagia score was 2.7±1.4 before dilation and 0.9±0.3after dilation. Complications in group A were chest pain (n=30), reflux (n=16), and bleeding (n=6). Thirty-six patients (60 %) in group A exhibited dysphagia relapse during a 12-month follow-up, and 45 patients (90 %) out of 50 exhibited dysphagia relapse during a 36-month followup. Five uncovered and 3 antireflux covered expandable metal stents were permanently placed in the 8 patients of group B. The mean diameter of the strictured cardia was 3.4±1.9 mm before dilation and 19.5±1.1 mm after dilation.The mean dysphagia score was 2.6±1.3 before dilation and 0.4±0.1 after dilation. Complications in group B were chest pain (n=6), reflux (n＝5), bleeding (n=3), and hyperplasia of granulation tissue (n=3). Four patients (50 %) in group B exhibited dysphagia relapse during a 12-month followup, and 2 case (66.7 %) out of 3 patients exhibited dysphagia relapse during a 36-month follow-up. Sixty-five partially covered expandable metal stents were temporarily placed in the 65 patients of group C and withdrawn after 3-7 days via gastroscopy. The mean diameter of the strictured cardia was 3.3±2.3 mm before dilation and 18.9±3.5 mm after dilation. The mean dysphagia score was 2.4±1.3 before dilation and 0.5±0.2 after dilation. Complications in group C were chest pain (n=26), reflux (n=13), and bleeding (n=8).6 patients (9.2 %) out of 65 exhibited dysphagia relapse during a 12-month follow-up, and 8 patients (14.5 %) out of 55 exhibited dysphagia relapse during a 36-month followup. All the stents were inserted and withdrawn successfully.The follow-up in groups A-C lasted 12-96 months.CONCLUSION: Temporary partially covered metal stent dilation is one of the best methods with interventional procedure for achalasia in terms of long-term follow-up.

Assessment of hepatocellular carcinoma vascularity before and after transcatheter arterial chemoembolization by using first pass perfusion weighted MR imaging

AIM:To assess the vascularity of hepatocellular carcinoma (HCC) before and after transcatheter arterial chemoembolization (TACE) with the quantitative parameters obtained by first pass perfusion weighted MR imaging (FP-MRI). METHODS:Seventeen consecutive patients with one to three lesions in liver underwent FP-MRI before treatment. FP-MRI was also performed one,three,six,nine months, and one year after TACE.The baseline signal intensity (SO) of pre-TACE and one month after TACE was analyzed,the vascularity of HCC assessed by steepest slope of the signal intensity versus time curves (SS) was blindly correlated with their DSA feature and clinical outcome. RESULT:No significant difference was found on baseline signal intensity (S0) between pre-TACE and one month after TACE (F=0.309,P=0.583),The SS (mean,32% per second) of lesion one month after TACE was lower than that of pre-TACE (mean,69% per second),but with no statistical significance (F=3.067,P=0.092).When local recurrence occurred,the time intensity curves became steeper.The vascularity of HCC before and after TACE graded by SS closely correlated with that by DSA (K=0.453,P<0.05). CONCLUSION:FP-MRI is a useful criterion for selecting effective interventional treatment for patients with HCC in their initial treatment and during follow up.

Changes of tumor microcirculation after transcatheter arterial chemoembolization:First pass perfusion MR imaging and Chinese ink casting in a rabbit model

AIM: To observe the change of tumor microcirculation after transcatheter arterial chemoembolization (TACE) with bletilla microspheres by using first pass perfusion MR imaging (FP) and Chinese ink casting.METHODS: VX2 carcinoma cells were surgically implanted into the left and right lobes of liver of 30 New Zealand white rabbits, which were divided into 3 groups at random. Emulsion of lipiodol mixed with mitomydn C, and 5-FU bletilla microspheres were injected into the hepatic artery respectively, and saline was used as control agent. MR imaging was performed with turbo-flash sequence 14 d after tumor implantation and 7 d after interventional therapy. The steepest slopes (SS) of the signal intensity versus time curves were created for quantitative analysis, 7.5% Chinese ink gelatin solution was injected through ascending artery (17 cases) or portal vein(2 cases) for lesion microvessel area (MVA) measurement after the last MRI examination.The correlation between perfusion imaging and MVA was studied blindly.RESULTS: The SS values at the rim of tumor in lipiodol group (mean, 49% per second) and bletilla group (mean,35% per second) were significantly decreased (P<0.05) as compared with control group (mean, 124% per second), no difference was found between lipiodol and bletilla groups(P>0.05). In lipiodol group, the MVAs (24 974±11 836μm^2) in the center of the tumor were significantly smaller than those of the control group (35 510±15 675 μm^2) (P<0.05),while the MVAs (80 031±22 745 μm^2) around the tumor were significantly increased because small and dense plexuses appeared around the tumor which correlated to intense reaction of granulation tissue. None of the vessels was seen in the tumor in bletilla group, the peripheral MVAs of the tumor were significantly smaller than those of the control group (P<0.05) and lipiodol group (P<0.05). There was a good correlation between SS and MVAs in control group (rsl, 0.985, P<0.0001) and bletilla group (rsl, 0.743,P<0.05), the correlation was not significant in lipiodol group(rsl, 0.527, P>0.05).CONCLUSION: TACE with bletilla microspheres may enhance its anti-tumor effect by inhibiting the angiogenesis,and FP-MRI provides useful information to assess the TACE effect by depicting tumor vascularization and perfusion,

Temporary partially-covered metal stent insertion in benign esophageal stricture

AIM: To study the therapeutic efficacy of temporary partiallycovered metal stent insertion on benign esophageal stricture.METHODS: Temporary partially-covered metal stent was inserted in 83 patients with benign esophageal stricture. All the patients had various dysphagia scores.RESULTS: Insertion of 85 temporary partially-covered metal stents was performed successfully in 83 patients with benign esophageal stricture and dysphagia was effectively remitted in all the 83 cases. The dysphagia score was 3.20±0.63(mean±SD) and 0.68±0.31 before and after stent insertion,and 0.86±0.48 after stent removal. The mean diameter of the strictured esophageal lumen was 3.37±1.23 mm and 25.77±3.89 mm before and after stent insertion, and 16.15±2.96 mm after stent removal. Follow-up time was from 1 week to 96 months (mean 54.26±12.75 months). The complications were chest pain (n=37) after stent insertion,and bleeding (n=12) and reflux (n=13) after stent removal.CONCLUSION: Temporary partially-covered metal stent insertion is one of the best methods for treatment of benign esophageal stricture.

Comparison of different intervention procedures in benign stricture of gastrointestinal tract

AIM:To determine the most effective intervention procedure by evaluation of mid and long-term therapeutic efficacy in patients of stricture of the gastrointestinal tract (GTT). METHODS:Different intervention procedures were used to treat benign stricture of GIT in 180 patients including pneumatic dilation (group A,n=80),permanent (group B, n=25) and temporary (group C,n=75) placement of expandable metallic stents. RESULTS:The diameters of the strictured GIT were significantly greater after the treatment of all procedures employed (P<0.01).For the 80 patients in group A,160 dilations were performed (mean,2.0 times per patient). Complications in group A included chest pain (n=20),reflux (n=16),and bleeding (n=6).Dysphagia relapse occurred in 24(30%) and 48 (60%) patients respectively during 6-and- 12 momth follow-up periods in group A.In group B,25 uncovered or partially covered or antireflux covered expandable metallic stents were placed permantly, complications included chest pain (n=10),reflux (n=15), bleeding (n=3),and stent migration (n=4),and dysphagia relapse occurred in 5 (20%) and 3 patients (25%) during the 6-and-12 month follow-up periods,respectively.In group C,the partially covered expandable metallic stents were temporarily placed in 75 patients and removed after 3 to 7 days via gastroscope,complications including chest pain (n=30),reflux (n=9),and bleeding (n=12),and dysphagia relapse occurred in 9 (12%) and 8 patients (16%) during the 6-and-12 month follow-up periods,respectively.The placement and withdrawal of stents were all successfully performed.The follow-up of all patients lasted for 6 to 96 months (mean 45.3±18.6 months). CONCLUSION:The effective procedures for benign GIT stricture are pneumatic dilation and temporary placement of partially-covered expandable metallic stents.Temporary placement of partially-covered expandable metallic stents is one of the best methods for benign GIT strictures in mid and long-term therapeutic efficacy.

Complications of stent placement for benign stricture of gastrointestinal tract

AIM:To observe the frequent complications of stent placement for stricture of the gastrointestinal tract and to find proper treatment.METHODS:A total number of 140 stents were inserted in 138 patients with benign stricture of the gastrointestinal tract.The procedure was cornpleted under fluoroscopy in all of the patients.RESULTS:Stents were successfully placed in all the 138 patients.Pains occurred in 23 patients (16.7%),slight or dull pains were found in 21 patients and severe chest pain in 2 respectively.For the former type of pain,the patients receivedonly analgesia or even no treatment,while peridural anesthesics was conducted for the latter condition. Reflux occurred in 16 of these patients (11.6%) after stent placement.It was managed by common antireflux procedures. Gastrointestinal bleeding occurred in 13 patients (9.4%),and was treated by hemostat.Restenosis of the gastrointestinal tract occurred in 8 patients (5.8%),and was apparently associated with hyperplasia of granulation tissue.In 2 patients,the second stent was placed under X-ray guidance.The granulation tissue was removed by cauterization through hot-node therapy under gastroscope guidance in 3 patients,and surgical reconstruction was performed in another 3 patients. Stent migration occurred in 5 patients (3.6%),and were extracted with the aid of a gastroscope.Food-bolus obstruction was encountered in 2 patients (1.4%) and was treated by endoscope removal.No perforation occurred in all patients.CONCLUSION:Frequent complications after stent placement for benign stricture of the gastrointestinal tract include pain,reflux,bleeding,restenosis,stent migration and food-bolus obstruction.They can be treated by drugs,the second stent placement or gastroscopic procedures according to the specific conditions.

Follow-up evaluation for benign stricture of upper gastrointestinal tract with stent insertion

AIM: To determine the best mothod for benign stricture of the upper gastrointestinal tract (UGIT) with stent insertion by follow-up evaluation.METHODS: A total of 110 stents insertions were performed in 110 cases of benign stricture of the UGIT. Permanent (group A) and temporary (group B) placement of an expandable metal stent in 30 cases and 80 cases respectively. All cases were completed under fluoroscopy.RESULTS: In group A, 30 uncovered or antireflux covered or partially covered expandable metal stents were placed permanently. In group A, 5 cases (16.7 %) in 3-months, 5 cases (20.0 %) in 6-months, 6 cases (25 %) in the 1st year,6 cases (50 %) in the 3rd year, and 4 cases (80 %) in the 5th year exhibited dysphagia relapse. In group B, a partiallycovered expandable metal stent was temporarily placed in each patient and removed after 3-7 days via gastroscopy.Follow-up data in this group showed that 8 cases (7.5 %) in 3-months, 9 cases (12.0 %) in 6-months, 10 cases (15.4 %) in the 1st year, 6 cases (20 %) in the 3rd year, and 3 cases (25 %) in the 5th year exhibited dysphagia relapse. The placement and withdrawal of all stents were all performed successfully. The follow-up of all cases lasted for 3-99 months (mean 41.6±19.7 months).CONCLUSION: The best mothod for benign stricture of UGIT with stent insertion is temporary placement of a partially-covered expandable metal stent.

Influential factors and formation of extrahepatic collateral artery in unresectable hepatocellular carcinoma

AIM:To analyze the influence factors and formation of extrahepatic collateral arteries (ECAs) in unresectable hepatocellular carcinoma (HCC) with or without chemoe-mbolization. METHODS: Detailed histories of 35 patients with 39 ECAs of HCC and images including computerized tomography scan, digital subtraction angiography were reviewed carefully to identify ECAs of HCC, ECAs arising from, and anatomic location of tumors in liver. Tumor sizes were measured, and relations of ECAs with times of chemoemb-olization, tumor size, and the anatomic tumor location were analyzed. Complications were observed after chemoemb-olization through ECAs of HCC with different techniques. RESULTS: Influence factors of formation of ECAs of HCC included the times of repeated chemoembolization, the location of tumors in liver, the tumor size and the types of chemoembolization. ECAs in HCC appeared after 3-4 times of chemoembolization (17.9%), but a higher frequency of ECAs occurred after 5-6 times of chemoembolization (56.4%). ECAs presented easily in peripheral areas (71.8%) of liver abutting to the anterior, posterior abdominal walls, the top right of diaphragm and right kidney. ECAs also occurred easily after complete obstruction of the trunk arteries supplying HCCs or the branches of proper hepatic arteries. Extrahepatic collaterals of HCC originated from right internal thoracic (mammary) artery (RTTA, 5.1%), right intercostal artery (RICA, 7.7%), left gastric artery (LGA, 12.8%), right inferior phrenic artery (RIPA, 38.5%), omental artery (OTA, 2.6%), superior mesenteric artery (SMA, 23.1%), and right adrenal and renal capsule artery (RARCA, 10.3%), respectively. The complications after chemoembolization attributed to no super selective cathet-erization. CONCLUSION: The formation of ECAs in unresectable HCC is obviously correlated with multiple chemoembolization, tumor size, types of chemoembolization, anatomic location of tumors. Extrahepatic collaterals in HCC are corresponding to the tumor locations in liver.

Restenosis following balloon dilation of benign esophagea stenosis

AIM: To elucidate the mechanism of restenosis following balloon dilation of benign esophageal stenosis.METHODS: A total of 49 rats with esophageal stenosis were induced in 70 rats using 5 ml of 50 % sodium hydroxide solution and the double-balloon method, and an esophageal restenosis (RS) model was developed by esophageal stenosis using dilation of a percutaneous transluminal coronary angioplasty (PTCA) balloon catheter. These 49 rats were divided into two groups: rats with benign esophageal stricture caused by chemical burn only (control group, n=21) and rats with their esophageal stricture treated with balloon catheter dilation (experimental group, n=28). Imaging analysis and immunohistochemistry were used for both quantitative and qualitative analyses of esophageal stenosis and RS formation in the rats, respectively.RESULTS: Cross-sectional areas and perimeters of the esophageal mucosa layer, muscle layer, and the entire esophageal layers increased significantly in the experimental group compared with the control group. Proliferating cell nuclear antigen (PCNA) was expressed on the 5th day after dilation, and was still present at 1 month. Fibronectin (FN)was expressed on the 1st day after dilation, and was still present at 1 month.CONCLUSION: Expression of PCNA and FN plays an important role in RS after balloon dilation of benign esophageal stenosis.