Radiologic staging of esophageal and gastroesophageal junction carcinoma

Pretreatment radiologic staging can, theoretically, improve the effectiveness and results of surgical treatment in esophageal and gastroesophageal junction carcinoma. Ideally, on these studies it is possible to select only patients with limited local disease for surgery, whereas those with nonresecta.ble tumors or metastases to distant sites are excluded from surgery and submitted to other treatment modalities. The purpose of this study was to evaluate the utility of CT, US and US-guided FNAB for pretreatment staging of esophageal and gastroesophageal junction carcinoma. In assessing distant metastases, these techniques were evaluated at different sites, Because little has been published regarding the examination of supraclavicular lymph nodes in esophageal and gastroesophageal junction carcinoma, a retrospective stndy was first performed to determine the number of patients with squamous cell carcinoma of the intrathoracic esophagus in whom supraclavicular metastases could be demonstrated with us and usguided FNAB (Chapter 2), Subsequently, palpation, CT and US were prospectively evaluated for assessing supraclavicular metastases in patients with either esophageal or gastroesophageal junction carcinoma (Chapter 3). Accuracy of either CT, US, or a combination of both studies, to assess distant metastases in general and at the various sites was determined (Chapter 4). The utility of US-guided FNAB for diagnosing metastases was evaluated (Chapter 5). Assessment of resectability of the primary tnmor was analyzed on CT stndies alone because, generally, this cannot be displayed on US stndies (Chapter 6). Finally a survival analysis was performed to estimate the influence on survival of distant metastases, assessed on US or CT studies, or diagnosed by means of US-guided FNAB and cytologic stndy (Chapter 7)

Mammographic and sonographic spectrum of non-puerperal mastitis

The goal of this study was to explore possible specific mammographic and sonographic features in women with non-puerperal mastitis (NPM), in order to make an accurate diagnosis and prevent unnecessary surgical procedures. From a group of 93 patients with NPM diagnosed between 1987 and 1992, the mammograms of 41, the sonograms and cytology of 47, and the histology of seven patients were retrospectively reviewed. Follow-up was performed on those without histology. In 20 of the 47 patients the inflammation was located subareolarly. In 50% of those with non-subareolar lesions, mammography showed a circumscribed lesion. Sonographically, all patients had an identifiable lesion either well or poorly defined. The majority of the lesions were cystic, but in 23 of 47 cases solid components were seen. Signs of infection in cystic lesions were observed in 25 of 47 cases. Posterior shadowing was not observed. During the follow-up period no breast malignancy was found. It is concluded that NPM has no specific mammographic or sonographic sign. Diagnosis should be made with additional diagnostic assessment, such as FNAB, which was diagnostic in all cases

Percutaneous cholecystostomy for patients with acute cholecystitis and an increased surgical risk

Purpose: To evaluate percutaneous cholecystostomy in patients with acute cholecystitis and an increased surgical risk. Methods: Thirty-three patients with acute cholecystitis (calculous, n = 22; acalculous, n = 11) underwent percutaneous cholecystostomy by means of a transhepatic (n = 21) or transperitoneal (n = 12) access route. Clinical and laboratory parameters were retrospectively studied to determine the benefit from cholecystostomy. Results: All procedures were technically successful. Twenty-two (67%) patients improved clinically within 48 hr; showing a significant decrease in body temperature (n = 13), normalization of the white blood cell count (n = 3), or both (n = 6). There were 6 (18%) minor/moderate complications (transhepatic access, n = 3; transperitoneal access, n = 3). Further treatment for patients with calculous cholecystitis was cholecystectomy (n = 9) and percutaneous and endoscopic stone removal (n = 8). Further treatment for patients with acalculous cholecystitis was cholecystectomy (n = 2) and gallbladder ablation (n = 2). There were 4 deaths (12%) either in hospital or within 30 days of drainage; none of the deaths was procedure-related. Conclusions: Percutaneous cholecystostomy is a safe and effective procedure for patients with acute cholecystitis. For most patients with acalculous cholecystitis percutaneous cholecystostomy may be considered a definitive therapy. In calculous disease this treatment is often only temporizing and a definitive surgical, endoscopic, or radiologic treatment becomes necessary

Determinants of Acute Kidney Injury and Renal Function Decline After Endovascular Abdominal Aortic Aneurysm Repair

Orthopaedics, Trauma Surgery and Rehabilitatio

Systemic arterial calcium burden in patients with chronic limb-threatening ischemia

Introduction: 5-year mortality of chronic limb-threatening ischemia (CLTI) is 50–60% and coronary artery disease (CAD) is the main cause of death of CLTI patients, followed by stroke. The aim of this study is to quantify and qualify the calcium load in different arterial territories in patients with CLTI. Methods: Prospectively, 60 patients with CLTI were included and received a full-body CT scan. 6 patients were excluded. Different arterial territories (the peripheral lower extremity arteries, coronary arteries, extracranial and intracranial carotid arteries, thoracic and abdominal aorta) were analyzed. Analysis and interrelations of both quantitative and semi-quantitative CT measurements was performed. Results: Mean age was 72 years (range 47–95; SD 11.4). Almost all CLTI patients had calcified arterial beds (femoropopliteal 100%, crural 98.1%, coronary 100%, carotid bifurcation 96.2%, internal carotid artery 98.1%, thoracic aorta 96.2%, abdominal aorta 92.3%). Nearly all arterial territories had severe calcifications. 57% had a very high coronary Agatston score (>1000), and 35% extremely high (>2000). Calcifications in the lower extremity were significantly correlated to CAC score, carotid artery bifurcation calcification score, and to a lesser extent correlated to annular calcifications in the aorta. Very high and extremely high total CAC scores were strongly correlated with severe lower extremity arterial calcifications and severe carotid and intracranial internal carotid artery, thoracic and abdominal aorta calcifications in patients with CLTI patients. Conclusions: In CLTI patients nearly all arterial territories are severely calcified, suggesting that systemic calcification plays an important role in the poor outcome of this disease

Evaluation of a New Balloon Catheter for Difficult Calcified Lesions in Infrainguinal Arterial Disease: Outcome of a Multicenter Registry

The purpose of this study was to assess the technical performance and immediate procedure outcome of a new balloon catheter in the treatment of calcified lesions in infrainguinal arterial disease. Seventy-five patients with infrainguinal arterial disease were prospectively entered into the registry. The catheter (ReeKross Clearstream, Ireland) is a 5- to 6-Fr balloon catheter with a rigid shaft intended for enhanced pushability. Only technical procedural outcome was recorded. Treated calcified lesions (range: 5–30 cm), assessed angiographically, were located in the superficial femoral, popliteal, and crural arteries. In 67 patients the lesion was an occlusion. Guidewire passage occurred subintimally in 68 patients. In 24 patients a standard balloon catheter was chosen as first treatment catheter: 5 failed to cross the lesion, 8 balloons ruptured, and in 11 patients there was an inadequate dilatation result. In only one of the five patients did subsequent use of the ReeKross catheter also fail in lesion crossing. The ReeKross was successful as secondary catheter in the other 23 cases. In 50 patients the ReeKross was used as primary catheter. In total the ReeKross crossed the lesions in 74 patients. After passage and dilatation with this catheter in 73 patients (1 failed true-lumen reentry), 19 had >30% residual lesions, of which 11 were not treated and 8 were successfully stented. No ReeKross balloons ruptured. We conclude that in the treatment of difficult calcified lesions in arterial stenotic or occlusive disease, the choice of a high-pushability angioplasty catheter, with more calcification-resistant balloon characteristics, like the ReeKross, warrants consideration

Detection of distant metastases in patients with oesophageal or gastric cardia cancer: a diagnostic decision analysis

Computed tomography (CT) is presently a standard procedure for the detection of distant metastases in patients with oesophageal or gastric cardia cancer. We aimed to determine the additional diagnostic value of alternative staging investigations. We included 569 oesophageal or gastric cardia cancer patients who had undergone CT neck/thorax/abdomen, ultrasound (US) abdomen, US neck, endoscopic ultrasonography (EUS), and/or chest X-ray for staging. Sensitivity and specificity were first determined at an organ level (results of investigations, i.e., CT, US abdomen, US neck, EUS, and chest X-ray, per organ), and then at a patient level (results for combinations of investigations), considering that the detection of distant metastases is a contraindication to surgery. For this, we compared three strategies for each organ: CT alone, CT plus another investigation if CT was negative for metastases (one-positive scenario), and CT plus another investigation if CT was positive, but requiring that both were positive for a final positive result (two-positive scenario). In addition, costs, life expectancy and quality adjusted life years (QALYs) were compared between different diagnostic strategies. CT showed sensitivities for detecting metastases in celiac lymph nodes, liver and lung of 69, 73, and 90%, respectively, which was higher than the sensitivities of US abdomen (44% for celiac lymph nodes and 65% for liver metastases), EUS (38% for celiac lymph nodes), and chest X-ray (68% for lung metastases). In contrast, US neck showed a higher sensitivity for the detection of malignant supraclavicular lymph nodes than CT (85 vs 28%). At a patient level, sensitivity for detecting distant metastases was 66% and specificity was 95% if only CT was performed. A higher sensitivity (86%) was achieved when US neck was added to CT (one-positive scenario), at the same specificity (95%). This strategy resulted in lower costs compared to CT only, at an almost similar (quality adjusted) life expectancy. Slightly higher specificities (97–99%) were achieved if liver and/or lung metastases found on CT, were confirmed by US abdomen or chest X-ray, respectively (two-positive scenario). These strategies had only slightly higher QALYs, but substantially higher costs. The combination of CT neck/thorax/abdomen and US neck was most cost-effective for the detection of metastases in patients with oesophageal or gastric cardia cancer, whereas the performance of CT only had a lower sensitivity for metastases detection and higher costs. The role of EUS seems limited, which may be due to the low number of M1b celiac lymph nodes detected in this series. It remains to be determined whether the application of positron emission tomography will further increase sensitivities and specificities of metastases detection without jeopardising costs and QALYs

Treatment of arterial calcification in patients with chronic limb threatening ischemia with etidronate: protocol of an investigator-initiated multicenter, double blind, placebo-controlled, randomized clinical trial

BACKGROUND: Pathologic studies have shown that in patients with critical limb threatening ischaemia (CLTI) medial arterial calcifications are frequently found and may be responsible for aggravating the disease. These extensive calcifitcations are found not only in arteries of the leg but also in the coronary arteries and the aorta. The progression of these calcifications is fast and they stiffen the vessel wall and may thus increase the cardiovascular risk. Reduction of progression of calcification may not only reduce the burden of CLTI but may also reduce the high residual cardiovascular risk. Medial calcifications have been halted by etidronate in other trials. Its potential to reduce the burden from peripheral vascular disease in CLTI and residual cardiovascular risk remains to be established. METHODS: This is an investigator-initiated multicenter, double blind, placebo-controlled, randomized trial comparing the effects of etidronate versus placebo in patients with CLTI. Subjects will be randomized to either treatment with etidronate for 12 months (cyclical 20 mg/kg for 2 weeks on and 10 weeks off) orally or placebo for 12 months (in a similar routine). The primary endpoint is the change in arterial calcification as quantified by CT-scan. Secondary endpoints are the number of amputations above and below the ankle, mortality, number of vascular interventions and quality of life. DISCUSSION: Up to now, the inert end stage of vascular disease in patients with CLTI, has been considered calcification of vessel walls. We believe there is reason to reverse causation and hypothesize that calcification causes vascular disease. This reversal can be proven in a clinical trial if halting the calcification process improves the outcome of the patient. Therefore we use etidronate, a bisphosphate that has proven to stop the calcification in several rare monogenetic calcifying diseases. We aim to perform this mechanistic proof-of-concept study hopefully leading to a clinical outcome study later on