Diagnosis and management of splanchnic ischemia

Splanchnic or gastrointestinal ischemia is rare and randomized studies are absent. This review focuses on new developments in clinical presentation, diagnostic approaches, and treatments. Splanchnic ischemia can be caused by occlusions of arteries or veins and by physiological vasoconstriction during low-flow states. The prevalence of significant splanchnic arterial stenoses is high, but it remains mostly asymptomatic due to abundant collateral circulation. This is known as chronic splanchnic disease (CSD). Chronic splanchnic syndrome (CSS) occurs when ischemic symptoms develop. Ischemic symptoms are characterized by postprandial pain, fear of eating and weight loss. CSS is diagnosed by a test for actual ischemia. Recently, gastro-intestinal tonometry has been validated as a diagnostic test to detect splanchnic ischemia and to guide treatment. In single- vessel CSD, the complication rate is very low, but some patients have ischemic complaints, and can be treated successfully. In multi-vessel stenoses, the complication rate is considerable, while most have CSS and treatment should be strongly considered. CT and MR-based angiographic reconstruction techniques have emerged as alternatives for digital subtraction angiography for imaging of splanchnic vessels. Duplex ultrasound is still the first choice for screening purposes. The strengths and weaknesses of each modality will be discussed. CSS may be treated by minimally invasive endoscopic treatment of the celiac axis compression syndrome, endovascular antegrade stenting, or laparotomy-assisted retrograde endovascular recanalization and stenting.The treatment plan is highly individualized and is mainly based on precise vessel anatomy, body weight, co- morbidity and severity of ischemia.

Tumor-stroma ratio as prognostic factor for survival in rectal adenocarcinoma: A retrospective cohort study

AIM To evaluate the prognostic value of the tumor-stroma ratio(TSR) in rectal cancer.METHODS TSR was determined on hematoxylin and eosin stained histological sections of 154 patients treated for rectal adenocarcinoma without prior neoadjuvant treatment in the period 1996-2006 by two observers to assessreproducibility. Patients were categorized into three categories: TSR-high [carcinoma percentage(CP) ≥ 70%], TSR-intermediate(CP 40%, 50% and 60%) and TSR-low(CP ≤ 30%). The relation between categorized TSR and survival was analyzed using Cox proportional hazards model.RESULTS Thirty-six(23.4%) patients were scored as TSR-low, 70(45.4%) as TSR-intermediate and 48(31.2%) as TSRhigh. TSR had a good interobserver agreement(κ = 0.724, concordance 82.5%). Overall survival(OS) and disease free survival(DFS) were significantly better for patients with a high TSR(P = 0.01 and P = 0.02, respectively). A similar association existed for disease specific survival(P = 0.06). In multivariate analysis, patients without lymph node metastasis and an intermediate TSR had a higher risk of dying from rectal cancer(HR = 5.27, 95%CI: 1.54-18.10), compared to lymph node metastasis negative patients with a high TSR. This group also had a worse DFS(HR = 6.41, 95%CI: 1.84-22.28). An identical association was seen for OS. These relations were not seen in lymph node metastasis positive patients. CONCLUSION The TSR has potential as a prognostic factor for survival in surgically treated rectal cancer patients, especially in lymph node negative cases.

Methods of computed tomography screening and management of lung cancer in Tianjin: design of a population-based cohort study

Objective: European lung cancer screening studies using computed tomography(CT) have shown that a management protocol based on measuring lung nodule volume and volume doubling time(VDT) is more specific for early lung cancer detection than a diameter-based protocol. However, whether this also applies to a Chinese population is unclear. The aim of this study is to compare the diagnostic performance of a volume-based protocol with a diameter-based protocol for lung cancer detection and optimize the nodule management criteria for a Chinese population.Methods: This study has a population-based, prospective cohort design and includes 4000 participants from the Hexi district of Tianjin, China. Participants will undergo low-dose chest CT at baseline and after 1 year. Initially, detected lung nodules will be evaluated for diameter and managed according to a routine diameter-based protocol(Clinical Practice Guideline in Oncology for Lung Cancer Screening, Version 2.2018). Subsequently, lung nodules will be evaluated for volume and management will be simulated according to a volume-based protocol and VDT(a European lung nodule management protocol). Participants will be followed up for 4 years to evaluate lung cancer incidence and mortality. The primary outcome is the diagnostic performance of the European volume-based protocol compared to diameter-based management regarding lung nodules detected using low-dose CT.Results: The diagnostic performance of volume-and diameter-based management for lung nodules in a Chinese population will be estimated and compared.Conclusions: Through the study, we expect to improve the management of lung nodules and early detection of lung cancer in Chinese populations.

Coronary-cameral fistulas in adults: Acquired types(second of two parts)

Acquired coronary artery fistulas(CCFs)are infrequently detected during conventional coronary angiography.To delineate the characteristics of congenital(first part)and acquired(second part)CCFs in adults,a PubMed search was conducted for papers dealing with congenital or acquired CCFs.None of the publications describing patients with coronary-vascular fistulas were included.Papers dealing with pediatric subjects were excluded.From the world literature,a total of 243adult patients were selected who had congenital(n=159/243,65%)and acquired(n=84/243,35%)CCFs.Among the acquired types(n=72,85.7%)were traumatic(iatrogenic(n=65/72,90%),accidental(n=7/72,10%)and(n=12,14.3%)spontaneously developing in relation to severe coronary atherosclerosis or myocardial infarction.A high incidence of spontaneousresolution of iatrogenic CCFs resulting from endomyocardial biopsy or following post-septal myectomy was reported.Spontaneous CCFs associated with myocardial ischemia or infarction resolved completely in 8%of the subjects.Early surgical intervention was the treatment of choice in acquired traumatic accidental CCFs.The congenital types are addressed in a previous issue of this journal(first part).In this review(second of two parts,partⅡ),we describe the acquired coronarycameral fistulas.

A black perforated esophagus treated with surgery:Report of a case

A case of a perforated black esophagus treated with minimal invasive surgery is presented.A 68-year-old women underwent a right-sided hemihepatectomy and radio frequency ablation of two metastasis in the left liver lobe.Previous history revealed a hemicolectomy for an obstructive colon carcinoma with post-operative chemotherapy.Postoperatively she developed severe dyspnea due to a perforation of the esophagus with leakage to the pleural space.Video-assisted thoracoscopic surgery(VATS) to adequately drain the perforation was performed.Gastroscopy revealed a perforated black esophagus.The black esophagus,acute esophageal necrosis or Gurvits syndrome is a rare entity with an unknown aetiology which is likely to be multifactorial.The estimated mortality rate is high.To our knowledge,this is the first case published of early VATS used in a case of perforated black esophagus.

Coronary-cameral fistulas in adults(first of two parts)

This is a case series and review of the literature adding11 new cases.Coronary-cameral fistulas(CCFs)are infrequent anomalies which are in general co-incidentally found during diagnostic coronary angiography(CAG).To delineate the characteristics of congenital and acquired CCFs in adults,we performed a PubMed search for papers dealing with congenital or acquired CCFs in adults.Publications on coronary-vascular fistulas or paediatric subjects were not included.From the world literature,a total of 243 adult patients were identified who had congenital(65%)or acquired(35%)CCFs.In this review,which is part one of a two-part series on CCFs,we describe and discuss the congenital fistulas,give an overview on the published literature and report details of our own series of 11 patients with MMFs and solitary macro CCFs.Of the congenital group,56%were small or large solitary macro CCFs(cut-off 1.5mm)and 9%were coronary artery-ventricular multiple micro-fistulas(MMFs).Apical hypertrophic cardiomyopathy was reported in some of the reviewed subjects with MMFs(3/24=13%)but not was seen in our own series.Conservative medical management was generally the treatment of choice in congenital MMFs;prophylactic implantable cardioverter defibrillators(ICD)were implanted in 2/24(8%)of subjects,especially when extensive micro-fistulisations were involved.None of the patients of our own series required an ICD,as the MMFs were of limited size.Congenital or acquired CCFs in adults are infrequent anomalies having a wide spectrum of clinical presentation may varies from asymptomatic to severely devastating states requiring different treatment modalities.

Spontaneous Regression of Clear Cell Carcinoma of the Endometrium

This report documents a rare case of complete spontaneous regression of clear cell carcinoma of the endometrium. An elderly woman with paranoid schizophrenia was admitted to the hospital because of vaginal bleeding. Diagnostic curetting and biopsy were performed and she was diagnosed with clear cell carcinoma of endometrium. Anti-tumour therapy was not possible because of her poor psychiatric status. 13 months later the woman died of a natural cause and at autopsy the endometrial tumour could no longer be identified. Myocardial infarction, aggravated by poor functional status of organism due to sepsis, was concluded to be the cause of death.

基线斑块负荷与粥样硬化冠状动脉左主干继发重构的关系:一项长期(≥12个月)随访的系列血管内超声研究

目的:Glagov的病理组织学所见和非系列血管内超声研究(IVUS)推断:当动脉粥样斑块负荷达到40%时,代偿性冠状动脉重构便会减少。作者应用系列IVUS对此假设进行检验。方法与结果:应用系列IVUS检查了46例无狭窄的粥样硬化冠状动脉左主干(时间间隔18±8个月),对结果进行分析以评估基线斑块负荷[(斑块面积+中膜面积)/血管面积]和系列重构(基线时血管面积-随访时血管面积)的关系。共有25例基线斑块负荷【40%(30.1%±6.6%,A组),21例基线斑块负荷≥40%(46.1%±5.8%,B组)。

重塑指数与采用长期(≥12月)连续血管内超声所评估粥样硬化性左冠状动脉实际血管重塑的比较

OBJECTIVES: We present the remodeling index(RI) versus serial intravascular ul trasound(IVUS) data. BACKGROUND: The RI, derived by comparing lesion external el astic membrane(EEM) cross-sectional area versus the reference at one time point , is used in various IVUS studies as a substitute of true remodeling(change in E EM over time), assuming that it represents true remodeling. METHODS:We studied 4 6 non-stenotic left main arteries using serial IVUS(follow-up 18±8 months). P laques were divided into subgroups according to the follow-up RI: follow-up RI >1(n=27) versus follow-up RI ≤1(n=19). RESULTS: Lesions with a follow-up RI >1 had an increase in lumen despite an increase in plaque because of an increase in EEM. Conversely, lesions with a follow-up RI ≤1 had a reduction in lumen a s a result of both a plaque increase and EEM decrease. Overall, the follow-up R I correlated directly with changes in lesion site EEM(baseline-to-follow-up). Although there was no correlation between the follow-up RI and changes in refe rence EEM area, changes in reference EEM area did correlate directly with change s in lesion EEM area. In nearly 90%of lesions with a follow-up RI >1, there wa s a previously documented increase in EEM area. Using multivariate linear regres sion analysis, the follow-up RI was dependent on the baseline RI, the increase in lesion EEM area, and the decrease in reference EEM area. The follow-up RI wa s not dependent on changes in lesion plaque area. CONCLUSIONS: The vast majority of left main lesions with a remodeling index >1 had evidence of a previous incr ease in lesion-site EEM area.