Percutaneous transhepatic treatment for biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation: a 9-year single-center experience.

OBJECTIVES: To investigate clinical outcomes of percutaneous transhepatic treatment for biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation (LDLT). METHODS: This retrospective study examined baseline characteristics, procedural details, clinical outcomes, drainage catheter removal rate within 8 months, and recurrence after catheter removal using patients' medical records and images. Risk factors for failure of drainage catheter removal within 8 months and recurrence of biliary stricture after drainage catheter removal were assessed via univariable and multivariable analyses. RESULTS: A total of 112 patients (53.4 ± 8.79 years, 91 men) were evaluated. Multiple drainage catheters were placed in 75 patients (70.0%). Drainage catheters were successfully removed in 107 patients (95.5%). Failure of drainage catheter removal within 8 months was associated with hepatic artery complications (p = 0.034) and strictures requiring alternative passage techniques (p = 0.034). The cumulative primary patency rates after drainage catheter removal at 1, 2, 3, and 5 years were 85.4%, 79.8%, 75.8%, and 68.4%, respectively. Recurrence of biliary stricture was associated with the presence of an untreated isolated sectoral duct (aHR, 3.632; 95% CI, 1.086-12.150, p = 0.037) and with concurrent bile leaks (aHR, 2.475; 95% CI, 1.090-5.621, p = 0.031). CONCLUSION: Percutaneous transhepatic treatment was effective for the treatment of biliary strictures after duct-to-duct biliary anastomosis in LDLT. Multiple drainage catheter maintenance was needed because multiple strictures often occurred in these patients. KEY POINTS: • Percutaneous transhepatic treatments are useful and effective for the treatment of biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation (LDLT), although an endoscopic approach is available for this type of reconstruction. • Multiple drainage catheters were frequently placed in these patients because of multiple complex strictures. • We found that recurrence after drainage catheter removal was associated with isolation of the sectoral duct and with concurrent bile leaks.

Feasibility and Midterm Results of Endovascular Treatment of Hepatic Artery Occlusion within 24 Hours after Living-Donor Liver Transplantation.

PURPOSE: To evaluate the feasibility and midterm results of endovascular treatment of hepatic artery occlusion within 24 hours after living-donor liver transplantation (LDLT). MATERIALS AND METHODS: From January 2012 to June 2014, 189 consecutive patients at a single institution underwent LDLT with right-lobe grafts. Among them, 10 were diagnosed with hepatic artery occlusion within 24 hours after LDLT. All 10 underwent endovascular treatment, including drug-eluting stent placement (n = 2), intraarterial thrombolysis (n = 5), or both (n = 3). Every patient received regular follow-up with multidetector computed tomography (CT). Data on primary technical success, primary and assisted primary patency, and biliary complications were analyzed. RESULTS: Primary technical success was achieved in all 10 cases. Primary patency rates at 1 week, 3 months, and 6 months were all 70% (7 of 10), and the respective assisted primary patency rates were all 80% (8 of 10). Bleeding at the anastomotic site developed in 2 failed cases, prompting repeat liver transplantation. All 8 successfully recanalized cases showed hepatic artery patency on CT throughout follow-up (mean, 643.6 d; range, 236-1,081 d). Six of these cases had anastomotic biliary stricture, 4 of which were successfully treated by multisession biliary intervention. One patient had nonanastomotic biliary stricture and died of hepatic failure despite lifelong external drainage. CONCLUSIONS: Endovascular treatment could be an alternative therapeutic option for patients with hepatic artery occlusion within 24 hours after LDLT. It could help achieve long-term patency of the hepatic artery, but biliary stricture can potentially occur, and bleeding at the anastomotic site is a serious complication.

Early Experience in the Management of Postoperative Lymphatic Leakage Using Lipiodol Lymphangiography and Adjunctive Glue Embolization.

PURPOSE: To evaluate the safety and efficacy of Lipiodol lymphangiography and 3 adjunctive N-butyl cyanoacrylate (NBCA) glue embolization techniques for the management of postoperative lymphatic leakage. MATERIALS AND METHODS: This retrospective study included 27 patients with postoperative lymphatic leakage (17 with ascites, 3 with chylothorax, 6 with lymphoceles, and 1 with a skin fistula) who underwent Lipiodol lymphangiography for diagnostic and therapeutic purposes in 3 tertiary referral centers between August 2010 and January 2016. Adjunctive glue embolization was performed as needed by using 3 different techniques: "lymphopseudoaneurysm" embolization, closest upstream lymph node embolization, or direct upstream lymphatic vessel embolization. RESULTS: Sixteen patients were observed to determine the therapeutic effect of lymphangiography, and 8 patients (50%) recovered without further embolization. In 16 patients, including 11 who underwent immediate embolization after lymphangiography and 5 who underwent delayed embolization, a total of 28 embolizations (12 lymphopseudoaneurysms, 14 lymph nodes, and 2 lymphatic vessels) were performed. The technical and clinical success rates of the adjunctive embolizations were 89% (25 of 28) and 94% (15 of 16), respectively. The overall clinical success rate was 85% (23 of 27). The median time from initial lymphangiography to recovery was 5 days. No procedure-related major complications were reported. CONCLUSIONS: Lipiodol lymphangiography and adjunctive glue embolization techniques appear safe and provide promising efficacy for the management of postoperative lymphatic leakage.

Long-term outcomes of second treatment after initial transarterial chemoembolization in patients with hepatocellular carcinoma.

BACKGROUND & AIMS: All outcome studies concerning the management of hepatocellular carcinoma (HCC) are based on the initial treatment. However, remaining, progressing or recurring tumours (RPRTs) after transarterial chemoembolization (TACE) are common; therefore, various second treatments are administered to HCC patients. Here, we investigated the long-term outcomes of second treatments for RPRT after initial TACE. METHODS: We enrolled 855 consecutive HCC patients who underwent TACE as the initial treatment at the National Cancer Center, Korea, from January 2004 to December 2010. RESULTS: The median follow-up was 43.4 months, and the median progression-free survival following initial TACE was 4.0 months, being 18.1 and 1.0 months for complete remission and progressive disease respectively. Second treatments were administered to 790 RPRT patients (92.4%); the most common was TACE (56.4%), followed by best supportive care (22.8%), systemic chemotherapy (9.4%), external radiotherapy (4.4%), radiation ablation (RFA; 2.9%), resection (2.0%) and liver transplantation (1.4%). Median overall survival (mOS) for initial TACE was 18.8 months [95% confidence interval (CI), 16.6-21.0 months]; after second treatments, it was 12.4 (95% CI, 10.6-14.2) months, differing significantly by mRECIST assessment, BCLC stage and RPRT type (28.0, 5.0 and 3.9 months for intrahepatic, vascular and extrahepatic RPRT, respectively; P < 0.001). Intrahepatic RPRT with a curative treatment as a second treatment showed the best OS. CONCLUSION: These novel insights into the patterns and long-term outcomes of second treatments for RPRT in HCC patients who underwent initial TACE are expected to aid in formulating treatment strategies for HCC patients.

Clinical outcomes of a cohort series of patients with hepatocellular carcinoma in a hepatitis B virus-endemic area.

BACKGROUND AND AIMS: To evaluate the clinical outcomes of patients with hepatocellular carcinoma (HCC) and compare the findings with that of a previous cohort. METHODS: Overall, 1972 HCC patients diagnosed and treated at the National Cancer Center, Korea between 2004 and 2009 were enrolled. The data of this cohort were compared with those of a previous cohort (2000-2003) from the same institution. RESULTS: In all (mean age, 56.4 years; 1642 men), 74.6% was hepatitis B virus (HBV) positive, 81.6% were Child-Pugh (CP) class A, and 64.4% was Barcelona Clinic Liver Cancer (BCLC) stage C. The modified Union for International Cancer Control (mUICC) stage I, II, III, IVa, and IVb was found in 8.9%, 29.6%, 24.8%, 23.1%, and 13.6% patients, respectively. The most common initial treatment was transarterial chemotherapy (58.3%), followed by resection (18.6%). The 5-year survival rate of BCLC stage 0, A, B, and C were 79.6%, 67.2%, 33.9%, and 17.1%, respectively. The performance status, BCLC stage, mUICC stage, CP class, model for end-stage liver disease score, tumor characteristics, portal vein tumor invasion, and serum alpha-fetoprotein level proved to be independent prognostic variables. Overall survival in the present cohort was better than that in the previous cohort (hazard ratio, 0.829; 95% confidence interval, 0.754-0.912), especially for advanced HCC patients with HBV-positive status. CONCLUSIONS: This cohort study provides valuable insights into the characteristics of HCC in Korean patients. Our findings may help develop clinical trials, treatment strategies, and prognosis systems for HCC patients in HBV-endemic areas.

Electrochemical DNA Cleavage Sensing for EcoRV Activity and Inhibition with an ERGO Electrode.

An electrochemically reduced graphene oxide (ERGO) electrode-based electrochemical assay was developed for rapid, sensitive, and straightforward analysis of both activity and inhibition of the endonuclease EcoRV. The procedure uses a DNA substrate designed for EcoRV, featuring a double-stranded DNA (dsDNA) region labeled with methylene blue (MB) and a single-stranded DNA (ssDNA) region immobilized on the ERGO surface. The ERGO electrode, immobilized with the DNA substrate, was subsequently exposed to a sample containing EcoRV. Upon enzymatic hydrolysis, the cleaved dsDNA fragments were detached from the ERGO surface, leading to a decrease in the MB concentration near the electrode. This diminished the electron transfer efficiency for MB reduction, resulting in a decreased reduction current. This assay demonstrates excellent specificity and high sensitivity, with a limit of detection (LOD) of 9.5 × 10-3 U mL-1. Importantly, it can also measure EcoRV activity in the presence of aurintricarboxylic acid, a known inhibitor, highlighting its potential for drug discovery and clinical diagnostic applications.

Facile Ligand Exchange of Ionic Ligand-Capped Amphiphilic Ag2S Nanocrystals for High Conductive Thin Films.

A surface ligand modification of colloidal nanocrystals (NCs) is one of the crucial issues for their practical applications because of the highly insulating nature of native long-chain ligands. Herein, we present straightforward methods for phase transfer and ligand exchange of amphiphilic Ag2S NCs and the fabrication of highly conductive films. S-terminated Ag2S (S-Ag2S) NCs are capped with ionic octylammonium (OctAH+) ligands to compensate for surface anionic charge, S2-, of the NC core. An injection of polar solvent, formamide (FA), into S-Ag2S NCs dispersed in toluene leads to an additional envelopment of the charged S-Ag2S NC core by FA due to electrostatic stabilization, which allows its amphiphilic nature and results in a rapid and effective phase transfer without any ligand addition. Because the solvation by FA involves a dissociation equilibrium of the ionic OctAH+ ligands, controlling a concentration of OctAH+ enables this phase transfer to show reversibility. This underlying chemistry allows S-Ag2S NCs in FA to exhibit a complete ligand exchange to Na+ ligands. The S-Ag2S NCs with Na+ ligands show a close interparticle distance and compatibility for uniformly deposited thin films by a simple spin-coating method. In photoelectrochemical measurements with stacked Ag2S NCs on ITO electrodes, a 3-fold enhanced current response was observed for the ligand passivation of Na+ compared to OctAH+, indicating a significantly enhanced charge transport in the Ag2S NC film by a drastically reduced interparticle distance due to the Na+ ligands.

Supra-ampullary duodenectomy in a patient with positive distal resection margin after subtotal gastrectomy for gastric cancer: a case report.

Resection margin involvement after curative intent resection for gastric cancer results in a poor prognosis and deprives the patient of the chance for a cure. Reoperation to achieve an R0 status should guarantee tolerable morbidity and achievement of negative margins. We performed laparoscopic distal gastrectomy with extracorporeal Billroth II reconstruction in a 56-year-old woman with gastric cancer following neoadjuvant chemotherapy. Scattered cancer cells were observed in the proximal and distal resection margins on immunohistochemical staining for cytokeratin. Two weeks postoperatively, remnant total gastrectomy and supra-ampullary duodenectomy were performed. Before reoperation, percutaneous transhepatic gallbladder drainage and angiocatheter placement outside the ampulla of Vater (AoV) via the cystic duct were performed to avoid pancreaticoduodenectomy and to obtain the maximal distal margin. Duodenal transection was performed 1 cm above the AoV. The resected duodenum was 4 cm in length. The patient had no postoperative complications and received adjuvant chemotherapy 1 month after the reoperation.

Phase II study of concurrent transarterial chemoembolization and sorafenib in patients with unresectable hepatocellular carcinoma.

BACKGROUND & AIMS: Transarterial chemoembolization (TACE) is an important palliative treatment for unresectable hepatocellular carcinoma (HCC), but TACE-induced ischemic injury can upregulate angiogenic factors and is associated with poor prognosis. The aim of this study was to evaluate the safety and efficacy of concurrent conventional TACE and sorafenib in patients with unresectable HCC. METHODS: The primary objectives of this prospective, single-arm, phase II study were to evaluate safety and time to progression (TTP). Sorafenib was given 3 days after TACE and was administered for up to 24 weeks. Repeated TACE was performed on demand. Tumor response was assessed every 8 weeks. RESULTS: Fifty patients were treated and followed from July 2009 to May 2011. All patients were in Barcelona Clinic Liver Cancer (BCLC) stage B (82%) or C (18%). The median time of follow-up was 14.9 months and a median of 1 TACE session was given (range, 1-4). The median dose intensity of sorafenib was 68.7% (range, 37.3-100) of 800 mg daily. The most common reasons for dose reduction were hand-foot syndrome and thrombocytopenia. Thirty patients completed the study and 17 patients discontinued sorafenib due to disease progression. The overall median TTP was 7.1 months (95% confidence interval (CI), 4.8-7.5 months): 7.3 months in BCLC stage B; 5.0 months in BCLC stage C. The 6-month progression-free survival rate was 52% (95% CI, 37.3-66.1). CONCLUSIONS: Concurrent treatment of unresectable HCC with conventional TACE and sorafenib demonstrates a manageable safety profile and a possibility of promising efficacy.

Severity and timing of progression predict refractoriness to transarterial chemoembolization in hepatocellular carcinoma.

BACKGROUND AND AIM: Patients with hepatocellular carcinoma (HCC) that is refractory to repeated transarterial chemoembolization (TACE) are considered for systemic therapy, but TACE refractoriness is not well defined. The aim of this study was to determine the characteristics of patients whose HCC is refractory to repetitive TACE. METHODS: We evaluated 264 patients with intermediate-stage HCC who underwent TACE between January 2006 and September 2009. We designated the development of vascular invasion or extrahepatic spread during follow up as "stage progression" (SP), and hypothesized that SP might be the surrogate end-point for TACE refractoriness. RESULTS: The median follow up was 18.2 months, and median number of TACE was 3.0 (range, 1-13). Median time-to-progression was 5.5 months (95% confidence interval, 4.8-6.2), and median overall survival was 25.3 months (95% confidence interval, 21.6-29.0). We classified the patients according to disease course as: no progressive disease (PD(-); n = 33); PD without SP (PD(+)SP(-); n = 113); PD followed by SP (PD→SP; n = 47); and simultaneous PD and SP (PD&SP; n = 64). PD(-) and PD(+)SP(-) groups showed no difference in overall survival, PD→SP group had worse overall survival than PD(-) and PD(+)SP(-) groups, and PD&SP group had the worst overall survival. The significant prognostic factors for SP-free survival were development of PD and need for three sessions of TACE during the first 6 months. CONCLUSIONS: SP-free survival can be regarded as an end-point for TACE refractoriness. Development of progression or need for three sessions of TACE within the first 6 months could be predictive of TACE refractoriness.

Tissue responses to endovascular stent grafts for saccular abdominal aortic aneurysms in a canine model.

We investigated tissue responses to endoskeleton stent grafts for saccular abdominal aortic aneurysms (AAAs) in canines. Saccular AAAs were made with Dacron patch in 8 dogs, and were excluded by endoskeleton stent grafts composed of nitinol stent and expanded polytetrafluoroethylene graft. Animals were sacrificed at 2 months (Group 1; n = 3) or 6 months (Group 2; n = 5) after the placement, respectively. The aortas embedding stent grafts were excised en bloc for gross inspection and sliced at 5 to 8 mm intervals for histopathologic evaluation. Stent grafts were patent in all except a dog showing a thrombotic occlusion in Group 2. In the 7 dogs with patent lumen, the graft overhanging the saccular aneurysm was covered by thick or thin thrombi with no endothelial layer, and the graft over the aortic wall was completely covered by neointima with an endothelial layer. Transgraft cell migration was less active at an aneurysm than at adjacent normal aorta. In conclusion, endoskeleton stent grafts over saccular aneurysms show no endothelial coverage and poor transgraft cell migration in a canine model.

Better survival of patients with hepatitis B virus-related hepatocellular carcinoma in South Korea: Changes in 16-years cohorts.

AIMS: The incidence and mortality of hepatocellular carcinoma (HCC) have decreased over time in South Korea, where hepatitis B virus (HBV) in endemic. This study investigated the changes in the characteristics and clinical outcomes of HCC patients in Korea. METHODS: Patients initially diagnosed with HCC and treated at the National Cancer Center, Korea between 2000 and 2015 (n = 4,291) were followed up until February 2017. Differences in patient characteristics and outcomes were compared between chronological cohorts: cohort A (2000-2004, n = 1,157) vs. B (2005-2009, n = 1,678) vs. C (2010-2015, n = 1,456). RESULTS: The median age of the patient cohort was 57 years (range, 13-98 years), and male predominance was noted (81.6%). HBV infection was the most common etiology (74.8%). The proportion of patients diagnosed with good liver function and small tumors (<2 cm) increased significantly over time: 74.6%, 79.9%, and 87.4% for Child-Pugh class A (p<0.001) and 8.0%, 8.5%, and 12.0% for modified UICC stage I (p<0.001) in cohorts A, B, and C, respectively. Median overall survival improved significantly over time: 14.4 months (95% confidence interval [CI], 12.0-16.8 months), 22.9 months (95% CI, 20.3-25.5 months), and 53.6 months (95% CI, 45.7-61.5 months) in cohorts A, B, and C, respectively. HBV-related patients showed significantly improved survival (12.7 vs. 20.4 vs. 64.5 months, p<0.001) associated with the use of antiviral treatments (adjusted hazard ratio, 0.72; 95% CI, 0.64-0.80). CONCLUSIONS: The survival of patients with HCC, especially HBV-related HCC, has improved significantly over time in Korea.

Newly designed flexible electrode for laparoscopic radiofrequency ablation: ex vivo and in vivo comparative studies with needle electrode in a porcine liver as technical study.

BACKGROUND: To compare the efficiency of radiofrequency ablation (RFA) using the newly designed flexible laparoscopic radiofrequency electrode and the internally cooled needle electrode for creating an ablation zone in ex vivo and in vivo porcine livers. MATERIALS AND METHODS: In the ex vivo ablation zone, 40 ablation areas were created using the flexible electrode (group A, n=5) and the needle electrode of the Cool-tip RF system (group B, n=5). These were done in an excised porcine liver with a 200 W generator. In each group, ablation durations were 3, 6, 9, and 12 min, respectively. The volume was compared in each group. In the in vivo ablation zone, under laparoscopy, we divided the surface of the porcine liver into four areas: anterior, cranial, right lateral, and caudal. At each area, a couple of RFA using the flexible and needle electrodes with 6 min ablation duration was performed, respectively, in line with 3 cm intervals in five porcine livers. A flexible electrode was administered in the peritoneal cavity via a laparoscopic cannula, and a needle electrode was administered via a transcutaneous route, which avoided a pulmonary injury. The volumes and shapes of the ablation zones in each group and area were compared in the excised liver. RESULTS: In the ex vivo experiments, the ablation volumes using the flexible and needle electrodes with 3, 6, 9, and 12 min ablation duration were 3.19±0.41 cm(3), 6.36±0.48 cm(3), 7.66±0.51 cm(3), 8.72±0.78 cm(3) (Group A) and 3.40±0.35 cm(3), 6.83±0.66 cm(3), 7.79±0.56 cm(3), 8.85±0.54 cm(3) (Group B). There was no statistical significance among all the ablated volumes in each group at the same duration. In the in vivo experiment, the differences in the short diameter and the volume of ablated zones in the caudal and right lateral areas were statistically significant (P<0.05). In the cranial, right lateral, and caudal areas, the shape of the ablated zone using the needle electrode was elliptical. However, the ablated zone using the flexible electrode was spherical. The difference of the long and short diameter ratio in the cranial and right lateral areas was statistically significant (P<0.05). CONCLUSION: The newly designed flexible laparoscopic RF electrode shows similar efficacies compared with the needle electrode in the ex vivo study. However, it shows superiority in efficacy and predictability with the increased volume and predictable shape of coagulation necrosis at the laparoscopic RFA in the porcine liver.

Survival of patients with advanced hepatocellular carcinoma: sorafenib versus other treatments.

BACKGROUND AND AIM: Although sorafenib is recommended for patients with advanced hepatocellular carcinoma (HCC), a substantial portion of HCC patients in Asia are still treated with other treatments, mainly due to the prohibitive cost of sorafenib. We aimed to evaluate the clinical outcome of patients treated with sorafenib and those treated with other modalities in a single-center cohort. METHODS: We reviewed the medical records of two groups of consecutive patients with advanced HCC, according to applied treatment modalities, between January 2007 and September 2009 as follows: patients who received sorafenib for 6 weeks or more (n=123) and patients who were treated with one or more of other treatments, including transarterial chemoembolization, radiation, and cytotoxic chemotherapy (n=253). RESULTS: Overall survival did not differ significantly between these two groups (8.4 vs 8.2 months; P=0.601). Significant prognostic factors were high α-fetoprotein (≥200 ng/mL), massive/infiltrative intrahepatic tumors, macrovascular invasion, extrahepatic spread, and higher tumor-node-metastasis stage. Subgroup analysis, according to these factors, showed that sorafenib resulted in superior survival in patients with extrahepatic spread (hazard ratio [HR]=0.539; P=0.003) and massive/infiltrative tumors (HR=0.680; P=0.036). In the absence of each prognostic factor, other treatments were better than sorafenib. CONCLUSIONS: Considering the survival benefit for sorafenib over other treatments in patients with extrahepatic spread and massive/infiltrative intrahepatic tumors, these characteristics might be regarded as compelling indications for sorafenib.

Injuries of adjacent organs by the expanded polytetrafluoroethylene grafts in the venoplasty of middle hepatic veins in living-donor liver transplantation: computed tomographic findings and possible risk factors.

OBJECTIVE: The objective of the study was to analyze computed tomography (CT) appearance and clinical features of adjacent-organ injuries related to expanded polytetrafluoroethylene (ePTFE) grafts after living-donor liver transplantation (LDLT). METHODS: We evaluated follow-up CT images of 204 patients who underwent venoplasty with ePTFE during LDLT and encountered 4 patients (1.96%) with adjacent-organ injuries related to ePTFE. Clinical imaging records were reviewed in terms of imaging findings and possible risk factors. RESULTS: In 3 patients, ePTFE graft perforated gastric antrum or duodenal bulb; in another patient, the common bile duct was injured. The mean interval between transplantation and identification of injury was 30 months. In patients with adjacent-organ injuries, biliary or perihepatic interventional treatments, adhesion of bowel and early occlusion of ePTFE grafts were commonly observed. CONCLUSIONS: Adjacent-organ injuries by ePTFE graft after LDLT were rare but present. Interventional procedures, adhesion of the bowel wall and early occlusion of the grafts were possible risk factors.

Extraluminal Recanalization for Biliary Duct-to-Duct Anastomotic Obstruction After Living Donor Liver Transplantation: Experience in Eight Patients.

PURPOSE: To investigate clinical outcomes and safety of extraluminal recanalization for duct-to-duct anastomotic obstruction after living donor liver transplantation (LDLT). MATERIALS AND METHODS: Extraluminal recanalization was performed as a salvage procedure after failure of intraluminal cannulation in eight patients who underwent percutaneous transhepatic treatment of duct-to-duct anastomotic obstruction 11.0 ± 5.27 months after LDLT between October 2012 and April 2019. Technical details, safety, and outcomes of extraluminal recanalization were investigated. RESULTS: Total ten sessions of extraluminal recanalization were performed in the eight patients with the stiff backend of a 0.035 inch hydrophilic guide wire, 22-gauge Chiba needle, or Colapinto needle. Percutaneous common bile duct access was performed in three sessions to obtain a straight course for the puncture. There was one instance of subcapsular and intraparenchymal hematoma requiring placement of an additional drainage catheter and conservative treatment. During a follow-up period ranging from 18.4 to 100.7 months, the drainage catheter was removed in seven of the eight patients, including three patients who had recurrent stricture requiring repeat percutaneous treatment and one who underwent a routine change of an endoscopic retrograde biliary drainage catheter. CONCLUSIONS: Extraluminal recanalization can be an effective and safe salvage procedure after failed intraluminal cannulation of duct-to-duct anastomotic obstruction in LDLT.

Multidetector CT predictors of incomplete resection in primary cytoreduction of patients with advanced ovarian cancer.

This study was designed to develop a preoperative predictor model using multidetector CT (MDCT) imaging findings for the prediction of surgical outcome in patients with advanced epithelial ovarian cancer (EOC). Seventy-seven patients with advanced EOC who had preoperative MDCT and who had undergone primary cytoreductive surgery between January 1999 and June 2008 were enrolled in the study. All MDCT examinations were analysed retrospectively, assessing nine imaging features without knowledge of the operative findings. The complete debulking rate and optimal debulking rate were 42.5% and 93.2%, respectively. Based on the use of univariate and multivariate analysis, one imaging feature that showed the presence of upper abdominal ascites was significantly associated with incomplete tumour resection (P = 0.019 on univariate analysis, P = 0.04 on multivariate analysis). The combination of the MDCT findings that showed the presence of upper abdominal ascites and diffuse subdiaphragmatic peritoneal nodularity was associated with an incomplete resection of a tumour (P = 0.04; specificity 80.0%; positive predictive value 76.9%). It is important that emphasis on the upper abdominal sites of the tumour is helpful when reporting preoperative MDCT results.

Ruptured Massive Hepatocellular Carcinoma Cured by Transarterial Chemoembolization.

Spontaneous tumor rupture is a serious but rare complication of hepatocellular carcinoma (HCC) and has a low survival rate. Here, we report a case of massive HCC that ruptured and was treated successfully with transarterial chemoembolization (TACE). A 55-year-old man with abdominal pain was diagnosed with a 12-cm-wide ruptured HCC at segment 8. The overall liver function was scored as Child-Pugh A, but the single nodule tumor had ruptured; therefore, TACE treatment was initiated. After the first TACE treatment, residual tumors were found; thus, secondary TACE was performed 5 months later. No new lesions or extrahepatic metastases were found 16 months after the first TACE treatment, so hepatic resection was performed for curative treatment. The postoperative pathology results did not reveal any cancer cells; hence, TACE alone resulted in a cure. We report this case because the cure has been maintained for more than 3 years after resection.

Prevalence and predictors of peripherally inserted central venous catheter associated bloodstream infections in cancer patients: A multicentre cohort study.

Despite increasing use, the exact prevalence and predictors of peripherally inserted central catheter-associated bloodstream infection (PICC-CLABSI) in hospitalized patients with cancer are not elucidated.This retrospective cohort study included consecutive patients who underwent peripherally inserted central catheter (PICC) placement in 4 institutions (during 12 months in 3 hospitals and 10 months in 1 hospital). The prevalence of PICC-CLABSI was evaluated. The association between predictors and PICC-CLABSI were analyzed using Cox proportional hazards regression models and Kaplan-Meier survival analysis with log-rank tests.During the study period, 539 PICCs were inserted in 484 patients for a total of 10,841 catheter days. PICC-CLABSI occurred in 25 (5.2%) patients, with an infection rate of 2.31 per 1000 catheter days. PICC for chemotherapy (hazards ratio [HR] 11.421; 95% confidence interval (CI), 2.434-53.594; P = .019), double lumen catheter [HR 5.466; 95% CI, 1.257-23.773; P = .007], and PICC for antibiotic therapy [HR 2.854; 95% CI, 1.082-7.530; P = .019] were associated with PICC-CLABSI.PICC for chemotherapy or antibiotics, and number of catheter lumens are associated with increased risk of PICC-CLABSI in cancer patients. Careful assessment of these factors might help prevent PICC-CLABSI and improve cancer patients care.