Endoscopic ultrasonography drainage and debridement of an infected subcapsular hepatic hematoma:A case report

BACKGROUND Endoscopic ultrasonography(EUS)has evolved in the last years making it not only a diagnostic modality but a therapeutic procedure.EUS is now used as an alternative technique to percutaneous and surgical drainage.Even though EUS is a challenging procedure and not always suitable compared to percutaneous drainage,there is a need for developing new therapeutic approaches to the liver for when percutaneous drainage is not feasible.CASE SUMMARY We present the case of a 82 years old male who developed an infected subcapsular hepatic hematoma(SHH)of the left lobe following percutaneous biliary drainage.After 2 failed attempts of percutaneous drainage of the SHH and because the patients couldn’t withstand surgery,we conducted a EUS drainage and debridement of the SHH.Using a lumen apposing metal stent(LAMS)by a transgastric approach,we were able to gain endoscopic access to the SHH.With our experience in the debridement of walled off pancreatic necrosis using this technique,we were confident it was the right approach.After four debridement sessions,the computed tomography scan showed a clear regression of the SHH.CONCLUSION To our knowledge,this is the first case of successful endoscopic debridement of a SHH using a LAMS which appear to be feasible and safe in this specific case.

Pancreatic cancer–Endosonography

EUS is the most sensitive imaging procedure for the detection of small solid pancreatic masses and is accurate in determining vascular invasion of the portal venous system. Even compared to the new CT-techniques EUS provides excellent results in preoperative staging of solid pancreatic tumors. Compared to helical CT-techniques EUS is less accurate in detecting tumor involvement of superior mesenteric artery. EUS staging and EUS-guided FNA can be performed in a single-step procedure, to establish the diagnosis of cancer. There is no known negative impact of tumor cell seeding due to EUS-FNA. Without FNA EUS and additional methods are not able to reliably distinguish between inflammatory and malignant masses.

Microwave ablation of colorectal liver metastases adjacent to the cardiophrenic angle:Parallel versus non-parallel placement of the antenna relative to the diaphragm

Purpose:Microwave ablation(MWA)is difficult to perform in colorectal liver metastases(CRLMs)adjacent to the cardiophrenic angle.Therefore,a modified approach involving antenna array placement parallel to the diaphragm was initially attempted.Its safety and efficacy were compared with those involving non-parallel placement.Methods:Sixty-three patients with CRLMs adjacent to the cardiophrenic angle(lesions within 10 mm of the diaphragm)who underwent MWA were included in the study.All patients were further classified into parallel and non-parallel groups according to the method of antenna placement.The distance between the lesion and diaphragmatic surface before MWA,complications,and local tumor progression(LTP)at the last imaging follow-up were recorded.LTPs in the two groups were compared using the log-rank test.Prognostic factors for LTP were assessed using the Cox proportional hazards regression model.Results:Thirty and 33 lesions were ablated using parallel and non-parallel antenna placement,respectively.During the mean follow-up duration of 19.7±8.2 months,the LTP rate in the parallel and non-parallel placement groups were 3.3%(1/30)and 24.2%(8/33),respectively.The log-rank test showed that parallel antenna placement was associated with delayed LTP(p=0.018).Multivariate Cox regression analysis showed that parallel antenna placement was an independent predictor of delayed LTP after adjusting for possible risk factors,including age,sex,tumor size,and KRAS mutation(hazard ratio,0.1;95%confidence interval,0.00,0.80;p=0.034).Conclusion:The placement of the antenna parallel to the diaphragm is an alternative and effective method for MWA of CRLMs near the cardiophrenic angle and can contribute to the reduction of the LTP rate.

A novel and inexpensive ballistic gel phantom for ultrasound training

BACKGROUND: Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel.METHODS: Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations.RESULTS: The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy.CONCLUSIONS: The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

Relationship between hs-CRP, proMMP-1, TIMP-1 and coronary plaque morphology: intravascular ultrasound study

Background Rupture of unstable plaque with subsequent thrombus formation is the common pathophysiological substrate of the acute coronary syndrome （ACS）. It is of potential significance to explore the blood indexes predicting plaque characteristics. Little studies have focused on this field. Therefore we investigated the relationship between hypersensitive C-reactive protein （hs-CRP）, pro-matrix metalloproteinase-1 （proMMP-1）, tissue inhibitors of matrix metalloproteinase-1 （TIMP-1） and coronary plaque morphology. Methods Intravascular ultrasound （IVUS） examination was done in 152 patients with confirmed coronary heart disease before percutaneous coronary intervention from February 2003 to July 2005. Plasma samples of arterial blood were collected prior to the procedure. The level of hs-CRP, proMMP-1 and TIMP-1 were respectively measured by enzyme-linked immunosorbent assay （ELISA）. Results Unstable and ruptured plaque were found more frequently in patients with acute myocardial infarction and unstable angina. External elastic membrane cross-sectional area （EEM CSA）, plaque area, lipid pool area and plaque burden were significantly larger in ruptured and unstable plaque group. Positive remolding, thinner fabric-cap, smaller minimal lumen cross-sectional area （MLA）, dissection and thrombus were significantly more frequent in ruptured and unstable plaque group. The levels of plasma hs-CRP, proMMP-1 and TIMP-1 were higher in ruptured plaque group, hs-CRP〉8.94 mg/L was used to predict ruptured plaque with a ROC curve area of 0.76 [95% confidence interval （CI）, 67.0%-85.8%], sensitivity of 71.8%, specificity of 77.0% and accuracy of 69.2% （P〈0.01）, similarly for proMMP-1〉0.12 ng/ml with a ROC curve area of 0.69 [95% CI, 58.2%- 80.2%], sensitivity of 69.2%, specificity of 75.2% and accuracy of 66.2% （P〈0.01）, and TIMP-1〉83.45 ng/ml with a ROC curve area of 0.67 [95% CI, 56.2%-78.3%], sensitivity of 66.7%, specificity of 61.9% and accuracy of 66.2% （P〈0.01）. Conclusion The plaque characteristics correlate with the clinical presentation. The elevation of hs-CRP, oroMMP-1 and TIMP-1 are related to the plaque instability and rupture.

Comparison of coronary plaque composition among patients with acute coronary syndrome and stable coronary artery disease

Background The identification of vulnerable plaques before rupture is an important clinical goal. The purpose of the present study was to assess the difference in plaque composition among patients with acute coronary syndrome （ACS） and stable coronary artery disease （SCAD） by intravascular ultrasound virtual histologic analysis. Methods One hundred and thirty-nine patients were divided into ACS group and SCAD group according to clinical presentation. A total of 229 de novo lesions with 〉50% stenosis in native coronary arteries with diameters 〉2.5 mm were studied with intravascular ultrasonography. Geometric and compositional data were obtained using intravascular ultrasound virtual histology software. Results There were no significant differences in overall lesions for fibrous （（52.0±11.9）% vs （54.3±8.5）%, P〉0.05）, fibrolipidic （（12.3±10.1）% vs （13.8±9.5）%,P〈0.05）, calcium （（14.0±9.1）% vs （19.3±13.1）%, P〉0.05）, or necrotic core （（22.0±11.1）% vs （19.7±5.4）%, P〉0.05） percentages in ACS and SCAD patients, respectively. There were also no significant differences in culprit lesions for fibrous （（46.4±12.0）% vs （53.6±8.8）%, P〉0.05）, fibrolipidic （（9.1±9.0）% vs （12.9±9.7）%, P〉0.05）, calcium （（16.6±9.7）% vs （21.8±26.3）%, P〉0.05）, or necrotic core （（28.0±12.6）% vs （20.6±5.2）%, P〉0.05） percentages in ACS and SCAD patients, respectively. High density lipoprotein-cholesterol levels 〉1.04 mmol/L were associated with more fibrolipidic （（14.5±10.4）% vs （7.1±6.5）%, P〈0.05） and less necrotic core （（20.6±9.7）% vs （27.9±12.6）%,P〈0.05） percentages in the cohort with ACS. Conclusions In this study, coronary plaque composition assessed by intravascular ultrasound virtual histologic analysis was not significantly different between ACS and SCAD patients. The anatomic relationship of the specific plaque components to the lumen of the vessel was more important than the quantitative information of plaque composition for plaque stability.

Spontaneous coronary dissection associated with myocardial bridge causing acute myocardial infarction

Spontaneous coronary artery dissection （SCAD） is a rare cause of myocardial ischemia, myocardial infarction and sudden-cardiac death.This disease mainly occurs in young women with oral contraceptive or during the peripartum period, without risk factors for coronary artery disease. Although SCAD results in a hemorrhagic separation of the intima and the media, and creates a false lumen, leading to distal myocardial ischemia, infarction and sudden death, the causes and the optimal management for this challenging condition are still controversial.