PURPOSE: To compare the effectiveness of device closure and medical therapy in prevention of recurrent embolic event in the Korean population with cryptogenic stroke and patent foramen ovale (PFO). MATERIALS AND METHODS: Consecutive 164 patients (men: 126 patients, mean age: 48.1 years, closure group: 72 patients, medical group: 92 patients) were enrolled. The primary end point was a composite of death, stroke, transient ischemic attack (TIA), or peripheral embolism. RESULTS: Baseline characteristics were similar in the two groups, except age, which was higher in the medical group (45.3±9.8 vs. 50.2±6.1, p<0.0001), and risk of paradoxical embolism score, which was higher in the closure group (6.2±1.6 vs. 5.7±1.3, p=0.026). On echocardiography, large right-to-left shunt (81.9% vs. 63.0%, p=0.009) and shunt at rest/septal hypermobility (61.1% vs. 23.9%, p<0.0001) were more common in the closure group. The device was successfully implanted in 71 (98.6%) patients. The primary end point occurred in 2 patients (2 TIA, 2.8%) in the closure group and in 2 (1 death, 1 stroke, 2.2%) in the medical group. Event-free survival rate did not differ between the two groups. CONCLUSION: Compared to medical therapy, device closure of PFO in patients with cryptogenic stroke did not show difference in reduction of recurrent embolic events in the real world's setting. However, considering high risk of echocardiographic findings in the closure group, further investigation of the role of PFO closure in the Asian population is needed.
Adult ; Aged ; Aged, 80 and over ; Cardiac Catheterization/adverse effects ; Disease-Free Survival ; Embolism/etiology/*prevention & control ; Female ; Fibrinolytic Agents/adverse effects/*therapeutic use ; Foramen Ovale, Patent/complications/*drug therapy/mortality/*surgery ; Humans ; Ischemic Attack, Transient/*drug therapy/mortality/*surgery ; Male ; Middle Aged ; Republic of Korea/epidemiology ; Risk ; Secondary Prevention/methods ; *Septal Occluder Device/adverse effects ; Stroke/etiology/prevention & control ; Treatment Outcome

Endovascular aneurysm repair (EVAR) is a safe alternative to open surgical repair for an abdominal aortic aneurysm. However, unfavorable aortic anatomy of the aneurysm has restricted the widespread use of EVAR. Anatomic limitation is most often related to characteristics of the proximal neck anatomy. In this report, we described a patient with a severely angulated proximal neck who underwent EVAR, but required repeat intervention because of thrombotic occlusion of stent graft limbs.
Aneurysm ; Aortic Aneurysm, Abdominal* ; Blood Vessel Prosthesis* ; Extremities* ; Humans ; Neck* ; Stents*

BACKGROUND/AIMS: Liver stiffness (LS) as assessed by transient elastography (TE) can change longitudinally in patients with chronic hepatitis B (CHB). The aim of this study was to identify the factors that improve LS. METHODS: Between April 2007 and December 2012, 151 patients with CHB who underwent two TE procedures with an interval of about 2 years were enrolled. Ninety-six of the 151 patients were treated with nucleos(t)ide analogues [the antiviral therapy (+) group], while the remaining 55 patients were not [the antiviral therapy (-) group]. The two groups of patients were stratified according to whether they exhibited an improvement or a deterioration in LS during the study period (defined as an LS change of < or =0 or >0 kPa, respectively, over a 1-year period), and their data were compared. RESULTS: No differences were observed between the antiviral therapy (+) and (-) groups with respect to either their clinical characteristics or their initial LS. The observed LS improvement was significantly greater in the antiviral therapy (+) group than in the antiviral therapy (-) group (-3.0 vs. 0.98 kPa, P=0.011). In the antiviral therapy (+) group, the initial LS was higher in the LS improvement group (n=63) than in the LS deterioration group (n=33; 7.9 vs. 4.8 kPa, P<0.001). However, there were no differences in any other clinical characteristic. In the antiviral therapy (-) group, the initial LS was also higher in the LS improvement group (n=29) than in the LS deterioration group (n=26; 8.3 vs. 6.5 kPa, P=0.021), with no differences in any other clinical characteristic. CONCLUSIONS: A higher initial LS was the only factor associated with LS improvement in patients with CHB in this study.
Adult ; Aged ; Alanine Transaminase/blood ; Antiviral Agents/therapeutic use ; DNA, Viral/blood ; Elasticity Imaging Techniques ; Female ; Hepatitis B e Antigens/blood ; Hepatitis B virus/genetics ; Hepatitis B, Chronic/drug therapy/pathology/*ultrasonography ; Humans ; Logistic Models ; Longitudinal Studies ; Male ; Middle Aged

BACKGROUND/AIMS: Nonalcoholic fatty liver disease (NAFLD) may be one of the important causes of cryptogenic hepatocellular carcinoma (HCC). The aim of this study was to evaluate whether patients with cryptogenic HCC share clinical features similar to that of NAFLD. METHODS: Cryptogenic HCC was defined as HCC that occurs in patients with the following conditions: HBsAg(-), anti-HCV(-), and alcohol ingestion of less than 20 g/day. All patients diagnosed with cryptogenic HCC from 2005 to 2012 (cryptogenic HCC group), and all patients diagnosed with HBV associated HCC between 2008 and 2012 (HBV-HCC group) were enrolled in the present study. Clinical features, BMI, lipid profiles, presence of diabetes mellitus, hypertension, and metabolic syndrome were compared between the two groups. RESULTS: Cryptogenic HCC group was composed of 35 patients (19 males and 16 females) with a mean age of 70+/-11 years. HBV-HCC group was composed of 406 patients (318 males and 88 females) with a mean age of 56+/-7 years. Patients in the cryptogenic HCC group were older (p=0.001) and female dominant (p=0.042) than those in the HBV-HCC group. There were no differences in the laboratory test results including lipid profiles and Child-Turcotte-Pugh class between the two groups. Patients in the cryptogenic HCC group had higher prevalence of diabetes (37% vs. 17%, p=0.015), hypertension (49% vs. 27%, p=0.051), metabolic syndrome (37% vs. 16%, p=0.001), and higher BMI (25.3 kg/m2 vs. 24.1 kg/m2, p=0.042) than those in the HBV-HCC group. The tumor stage was more advanced (stage III and IV) at diagnosis in the cryptogenic HCC group than in the HBV-HCC group (60% vs. 37%, p=0.007). CONCLUSIONS: Cryptogenic HCC has clinical features similar to that of NAFLD and is diagnosed at a more advanced tumor stage.
Age Factors ; Aged ; Body Mass Index ; Carcinoma, Hepatocellular/*diagnosis/etiology/pathology ; Diabetes Complications ; Diabetes Mellitus/pathology ; Female ; Hepatitis B/complications ; Humans ; Hypertension/complications ; Lipids/blood ; Liver Neoplasms/*diagnosis/etiology/pathology ; Male ; Metabolic Syndrome X/complications ; Middle Aged ; Neoplasm Staging ; Non-alcoholic Fatty Liver Disease/*diagnosis/pathology ; Risk Factors ; Severity of Illness Index ; Sex Factors

BACKGROUND/AIMS: The ballooning time in endoscopic papillary large balloon dilation (EPLBD) remains controversial. The aim of this study was to evaluate the significance of the ballooning time comparing an immediate balloon deflation method with a conventional ballooning time of > 45 seconds. METHODS: Between January 2010 and December 2010, 126 patients with bile duct stones treated with EPLBD and endoscopic sphincterotomy were divided according to the ballooning time: the immediate deflation group (n=56) and the conventional inflation group (ballooning time 45s to < 60s) (n=70). RESULTS: The overall success rate and the success rate of the first attempt of ERCP (endoscopic retrograde cholangio-pancreatography) were 96.4% (54/56) and 80.4% (45/56) in the immediate group and 97.1% (68/70) and 77.1% (54/70) in the conventional inflation group. There were no statistically significant differences in the overall success and the first attempt of ERCP success rate (p=0.99, p=0.66). The frequency of mechanical lithotripsy was 0% in the immediate deflation group and 7.1% in the conventional inflation group (p=0.065). Complications occurred in 3.6% (2/56) patients in the immediate deflation group and 8.6% (4/70) patients in the conventional inflation group (p=0.298). CONCLUSIONS: The ballooning time in EPLBD does not affect the outcomes of the treatment for bile duct stones. And the feasibility of the immediate deflation method in EPLBD is acceptable.
Bile Ducts* ; Cholangiopancreatography, Endoscopic Retrograde ; Choledocholithiasis ; Humans ; Inflation, Economic ; Lithotripsy ; Sphincterotomy, Endoscopic

An epidermoid cyst arising from intrapancreatic accessory spleen (ECIPAS) is a rare disease. Most patients with an ECIPAS are detected incidentally and could be misdiagnosed as a pancreatic cystic neoplasm such as mucinous cystic neoplasm (MCN) or intraductal p ancreatic mucinous neoplasm (IPMN). We described an ECIPAS with high cystic fluid carcinoembryonic antigen (CEA), which was misdiagnosed as a MCN of pancreas. Fifty one-year-old female was presented with a 2 cm sized non-enhancing pancreas cystic mass on the outside CT scan. Endoscpic ultrasonography (EUS) guided aspiration was performed. It showed a 2.3 x 1.9 cm unilocular cyst nearby 1.6 x 1.1 cm homogenous hypoechoic mass in pancreas tail, and cystic fluid CEA was 1564.18 ng/mL. On the basis of EUS results with elevated fluid CEA level, the presumptive diagnosis is likely to MCN of pancreas, and she underwent a laparoscopic distal pancreatectomy. The final pathology was the epidermal cyst in the intrapancreatic accessory spleen.
Carcinoembryonic Antigen ; Diagnosis ; Epidermal Cyst* ; Female ; Humans ; Mucins* ; Pancreas* ; Pancreatectomy ; Pancreatic Cyst ; Pathology ; Rare Diseases ; Spleen* ; Tomography, X-Ray Computed ; Ultrasonography

Gastric ulcer bleeding is commonly encountered in emergency situations for gastroenterologist. Usually depth of gastric ulcer does not exceed the muscle layer. We report a case of a 67-year-old male with massive gastric ulcer bleeding caused by direct connection to the splenic artery. Bleeding control was not effectively performed by endoscopy due to massive bleeding with unstable vital sign. Angiography for embolization was performed. Active extravasation of contrast agents at the splenic artery stenosis was noted on splenic arteriogram. Bleeding stopped after embolization with histoacryl and lipiodol was successfully performed. After 1 month, complete ulcer healing was confirmed by follow up endoscopy. There was no evidence of invasive disease on biopsy.
Aged ; Angiography ; Biopsy ; Constriction, Pathologic ; Contrast Media ; Emergencies ; Enbucrilate ; Endoscopy ; Ethiodized Oil ; Follow-Up Studies ; Hemorrhage* ; Humans ; Male ; Splenic Artery* ; Stomach Ulcer* ; Ulcer ; Vital Signs

Lumbar spinal stenosis is a commonly treated with epidural injections of local anesthetics and corticosteroids, however, these therapies may relieve leg pain for weeks to months but do not influence functional status. Furthermore, the majority of patients report no substantial symptom change over the repeated treatment. Utilizing balloon catheters, we successfully treated with three patients who complained persistent symptoms despite repeated conventional steroid injections. Our results suggest that transforaminal decompression using a balloon catheter may have potential in the nonsurgical treatment of spinal stenosis by modifying the underlying pathophysiology.
Adrenal Cortex Hormones ; Anesthetics, Local ; Catheters ; Decompression ; Humans ; Injections, Epidural ; Leg ; Spinal Stenosis

BACKGROUND: With advances in immunosuppression, graft and patient survival rates have increased significantly, but acute cellular rejection remains an important problem following liver transplantation (LT), and late acute rejection (LAR) occurs in a small percentage of recipients. Some risk factors for LAR have been identified, yet the cause of LAR has not been completely investigated. The efficacy of mycophenolate mofetil (MMF) administered in combination with calcineurin inhibitor (CNI) for reduction of LAR has been demonstrated. METHODS: Between January 2006 and August 2007, adult LT recipients (n=309) were enrolled in this study. Biopsy-proven acute rejection that occurred >6 months after LT was defined as LAR. The immunosuppression regimens, CNI or CNI plus MMF, were used continuously for at least 6 months after LT. The mean follow-up period was 34.8 months (range, 25~46 months). RESULTS: LAR occurred in 17 cases (5.5%). The incidence of LAR in the CNI (n=138) or CNI plus MMF groups (n=171) was 8.6% (n=12) and 2.9% (n=5), respectively (P=0.015). Multivariate Cox regression confirmed that CNI plus MMF versus CNI therapy is associated with a decreased risk of LAR (relative risk, 0.33; P=0.04). CONCLUSIONS: The incidence of LAR in the CNI plus MMF group was significantly lower than the CNI group. Thus, continuous use of CNI plus MMF may represent a better immunosuppression regimen to decrease the rate of LAR in LT recipients.
Adult ; Calcineurin ; Follow-Up Studies ; Humans ; Immunosuppression ; Incidence ; Liver ; Liver Transplantation ; Mycophenolic Acid ; Rejection (Psychology) ; Risk Factors ; Survival Rate ; Transplants

PURPOSE: Splenectomy during living donor liver transplantation (LDLT) in a hepatitis C virus (HCV)-related cirrhotic recipient was performed by a Tokyo group to enhance the patient's tolerability to post-operative anti-viral treatment by improving complete blood count (CBC) profiles. At our institution, interruption of the splenic artery (SPA) by ligation or embolization in lieu of splenectomy, has been performed in LDLT to modulate portal blood flow in small-for-size graft LDLT or to prevent rupture of SPA aneurysms in recipients. We aimed to determine if interruption of the SPA can serve as an alternative management to splenectomy in LDLT recipients based on our data. METHODS: Patients were classified into the splenic artery ligation group (SAL; n=26) and splenic artery embolization group (SAE; n=19), respectively. Among the recipients without SPA interruption, age-, gender-, and severity of cirrhosis-matched 25 recipients were selected as a control group. Post-operative CBC profiles and spleen size were reviewed retrospectively and compared between the groups. RESULTS: After SAL, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 1 month, respectively (p<0.05). After SAE, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 3 months, respectively. There were no significant complications related to interruption of the SPA. CONCLUSION: Interruption of the SPA may have a role in improving neutrophil and platelet counts in LDLT recipients with severe pancytopenia or in whom antiviral treatment for HCV in anticipated.
Aneurysm ; Blood Cell Count ; Blood Platelets ; Hepacivirus ; Humans ; Ligation ; Liver ; Liver Transplantation ; Living Donors ; Neutrophils ; Pancytopenia ; Platelet Count ; Retrospective Studies ; Rupture ; Spleen ; Splenectomy ; Splenic Artery ; Tokyo ; Transplants