A Review Of Mri Appearances Of Lipiodol In Conventional Tace (Ctace) Treated Hepatocellular Carcinomas.

Background: The global burden of patients affected by chronic liver disease (CLD) has shown a steady rise over the last few decades and is now considered the 11th most frequent cause of death globally. In addition, as the world population is facing increased obesity rates coupled with alcohol consumption, these rates are predicted to continue to rise. The Objective was to assess the appearance of Lipiodol retention upon different MRI sequences with a special focus on non-contrast sequences. Lipiodol Trans-arterial chemoembolization (TACE) has become the standard treatment for unresectable hepatocellular carcinoma (HCC) without vascular invasion. However, data regarding Lipiodol TACE imaging via MRI is limited and results are not familiar to radiologists for regular assessment of treatment response. Methods: After IRB and EC approval, we included all those patients who underwent TACE treatment with Lipiodol and chemotherapeutic agent; having both 4-6-week post-treatment CT and MRI imaging. This criterion was fulfilled by a total of 25 patients. Only lipiodol-containing areas within the lesion were noted for signal intensities on all MRI sequences and labelled as hyperintense, isointense, hypointense and mixed intensity. Data was entered and analyzed by SPSS v27. Frequencies and percentages were calculated for qualitative data. Results: The most sensitive sequence in detecting Lipiodol retention was Fat suppressed T1 imaging sequence, with low signal intensity seen on T1 weighted fat-suppressed sequences in up to 76% of lesions. While on non-fat suppressed T1 weighted images, 60% of Lipiodol retention areas appeared hyperintense. 52% of lesions showed a hypointense appearance on the T2 weighted sequence. A much more variable appearance was seen in Diffusion-weighted imaging sequences demanding cautious interpretation. MR patterns were clearer in patients having more than 50% lipiodol retention on CT and lesion size more than 2 cm. . Conclusion: While MRI is deemed as a reliable and most useful imaging modality for assessing HCC's following lipiodol TACE it requires cautious interpretation with knowledge of variable signal appearance seen on different imaging sequences.

Saving The Uterus; Our Experience In Uterine Artery Embolization For Acquired Uterine Vascular Abnormalities.

Background: Acquired uterine vascular abnormalities are a rare cause of potentially life threatening bleeding. These include uterine artery pseudoaneurysms (UAP)and acquired arteriovenous malformations. The objective of this study was to describe our experience with the diagnosis of acquired uterine vascular abnormalities and its treatment with uterine preservation. It was a retrospective cohort study. Methods: Eight patients were enrolled from the hospital database who presented to our Interventional Radiology department from April 2017 to March 2021 for uterine artery embolisation (UAE) with a history of iatrogenic/acquired uterine vascular abnormalities confirmed on imaging. These included two patients with uterine artery pseudoaneurysm (PA) concurrently with arteriovenous malformation (AVM), one with uterine artery PA and five having uterine AVMs. Embolisation agents used were histoacryl glue, lipiodol, PVA particles, and gelfoam slurry. Medical records, imaging studies, and telephonic contact with patients were assessed for patient presentation, intraprocedural details, and follow up to record treatment success. Statistical analysis was performed using descriptive statistics. Results: Bilateral UAE was performed in six patients, while two patients underwent unilateral UAE. Three of the patients presented with life-threatening bleeds requiring multiple transfusions. Clinical as well as angiographic success was achieved in all patients with immediate control of haemorrhage. No complications were observed during follow-up. Two of the patients were able to conceive normally within one year, though it resulted in a miscarriage. Conclusion: Acquired/iatrogenic uterine vascular abnormalities are a rare but important cause of life-threatening haemorrhage that can be expertly managed and successfully treated using UAE, which is rapid, safe, and minimally invasive, with the added advantage fertility preservation.

An audit of contrast extravasation in patients undergoing contrast enhanced CTs at radiology department in a tertiary care hospital in Pakistan.

OBJECTIVE: To audit the radiology department of a health facility, focusing on contrast extravasations management pre- and post-implementation of a standard protocol. METHODS: The audit was conducted at the Radiology Department of Shifa International Hospital, Islamabad, Pakistan and comprised reported computed tomography contrast extravasation incidents from January 2017 to December 2019 in the retrospective phase before the implementation of a standard protocol. Post-implementation, re-audit was done prospectively to assess compliance from January 2020 to May 2021. Overall score of >80% was chosen arbitrarily as a qualifying standard for adequate documentation. RESULTS: Of the 49 total cases, 26(53%) related to the first phase and 23(47%) to the second. In the first phase, 2(20%) of the 10 parameters cleared the cut-off mark; 'study performed' 25(96%) and 'limb assessment by technician' 26(100%). In the second phase, 2(20%) parameters failed to clear the cut-off mark; site of cannula/extravasation' 18(78.3%) and 'volume of contrast' 15(65%). CONCLUSIONS: Lack of early identification and appropriate management, especially in cases of large-volume extravasation, may result in significant morbidity.

Evaluating the use of coronary artery calcium scoring as a tool for coronary artery disease (CAD) risk stratification and its association with coronary stenosis and CAD risk factors: a single-centre, retrospective, cross-sectional study at a tertiary centre in Pakistan.

OBJECTIVE: Coronary artery disease (CAD) risk stratification plays a fundamental role in the early detection and optimal management of CAD. The aim of our study is to investigate the use of coronary artery calcium scoring (CACS) as a tool for CAD risk stratification through evaluation of its correlation with the degree of coronary stenosis and its association with conventional cardiovascular risk factors in asymptomatic patients. DESIGN: Single-centre, retrospective, cross-sectional study. SETTING: The study was conducted at a tertiary centre (Shifa International Hospital) in Islamabad, Pakistan, through review of medical records of patients who underwent coronary CT between the years 2016 and 2020. PARTICIPANTS: A total of 1014 patients were included in the study. The study population was analysed for presence of conventional risk factors (gender, age, diabetes, hypertension, body mass index, dyslipidaemia) and association with CACS (zero: n=534; minimal: 0 to ≤10, n=70; mild: >10 to ≤100, n=130; moderate: >100 to ≤400, n=118; and severe: >400, n=49). The association of CACS with the degree of coronary artery stenosis seen on CT scan (significant: ≥50% stenosis, n=216; non-significant: <50% stenosis, n=685) was also analysed. OUTCOME MEASURES: The main outcome was the association of coronary artery stenosis with CACS. The secondary outcome was the association of CACS with conventional CAD risk factors. RESULTS: A significant positive association was shown between CACS and coronary artery stenosis (zero vs minimal: OR 0.39, 95% CI 0.20 to 0.79, p=0.01; zero vs mild: OR 0.16, 95% CI 0.10 to 0.27, p<0.0001; zero vs moderate: OR 0.05, 95% CI 0.03 to 0.08, p<0.0001; zero vs severe: OR 0.02, 95% CI 0.01 to 0.050, p<0.0001). Age >45 (OR 1.03, 95% CI 1.01 to 1.05, p<0.0001), hypertension (OR 1.16, 95% CI 0.79 to 1.71, p=0.001) and diabetes (OR 1.33, 95% CI 0.88 to 1.99, p<0.0001) were associated with an increased risk of coronary artery stenosis. Moreover, plaques with higher calcium burden were found in the left anterior descending artery (mean CACS: 386.15±203.89), followed by right coronary (239.77±219.83) and left circumflex (175.56±153.54) arteries. CONCLUSION: The results indicate a strong positive association of CACS with coronary artery stenosis. CACS was also significantly associated with conventional CAD risk factors in this population.

Textbook outcome among voluntary donors undergoing major living donor hepatectomy.

PURPOSE: Textbook outcome (TO) is a composite measure of outcome and provides superior assessment of quality of care after surgery. TO after major living donor hepatectomy (MLDH) has not been assessed. The objective of this study was to determine the rate of TO and its associated factors, after MLDH. METHODS: This was a single center retrospective review of living liver donors who underwent MLDH between 2012 and 2021 (n = 1022). The rate of TO and its associated factors was determined. RESULTS: Among 1022 living donors (of whom 693 [67.8%] were males, median age 26 [range, 18-54] years), TO was achieved in 714 (69.9%) with no donor mortality. Majority of donors met the cutoffs for individual outcome measures: 908 (88.8%) for no major complications, 904 (88.5%) for ICU stay ≤ 2 days, 900 (88.1%) for hospital stay ≤ 10 days, 990 (96.9%) for no perioperative blood transfusion, 1004 (98.2%) for no 30-day re-admission, and 1014 (99.2%) for no post-hepatectomy liver failure. Early donation era (before streamlining of donor operative pathways) was associated with failure to achieve TO [OR 1.4, CI 1.1-1.9, P = 0.006]. TO was achieved in 506/755 (67%) donors in the early donation era versus 208/267 (77.9%) in the later period (P = 0.001). CONCLUSION: Despite zero mortality and low complication rate, TO was achieved in approximately 70% donors. TO was modifiable and improved with changes in donor operative pathway.

Living donor liver transplantation for advanced hepatocellular carcinoma including macrovascular invasion.

BACKGROUND: The indications for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) continue to evolve. The aim of this study was to report outcomes in patients who underwent living donor liver transplantation (LDLT) for HCC outside traditional criteria including macrovascular invasion (MVI). METHODS: We reviewed outcomes in patients who met the University of California San Francisco (UCSF) criteria (n = 159) and our center-specific criteria (UCSF+) (largest tumor diameter ≤ 10 cm, any tumor number, AFP ≤ 1000 ng/ml) (n = 58). We also assessed outcomes in patients with MVI (n = 27). RESULTS: The median follow was 28 (10.6-42.7) months. The 5 year overall survival and risk of recurrence (RR) in the UCSF and UCSF + group was 71% vs 69% (P = 0.7) and 13% vs 36% (P = 0.1) respectively. When patients with AFP > 600 ng/ml were excluded from the UCSF + group, RR was 27% (P = 0.3). Among patients with MVI who had downstaging (DS), 4/5(80%) in low-risk group (good response and AFP ≤ 100 ng/ml) and 2/10 (20%) in the high-risk group (poor response or AFP > 100 ng/ml) were alive at the last follow-up. When DS was not feasible, 3/3 (100%) in the low-risk group (AFP ≤ 100 ng/ml + Vp1-2 MVI) and 1/9 (9.1%) in the high-risk group (AFP > 100 or Vp3 MVI) were alive. The 5 year OS in the low-risk MVI group was 85% (P = 0.003). CONCLUSION: With inclusion of AFP, response to downstaging and degree of MVI, acceptable survival can be achieved with LDLT for HCC outside traditional criteria.

Risk Score Model for Liver Transplant Outcomes after Preoperative Locoregional Therapy for Hepatocellular Carcinoma.

PURPOSE: The role of preoperative locoregional therapy (LRT) for hepatocellular carcinoma (HCC) before liver transplantation (LT) remains unclear. Moreover, LRT in the setting of living donor liver transplantation (LDLT) merits further exploration. The objective of the current study was to determine risk factors for poor outcomes after LDLT in patients who received locoregional therapy (LRT). METHODS: We reviewed patients (n = 46) who underwent LDLT after LRT. Multivariate analysis was performed to determine independent predictors of recurrence-free survival (RFS). Risk scores were developed to define prognostic groups. RESULTS: Median tumor size was 3.7 (1.2-12) cm and tumor number was 1 (1-6). Macrovascular invasion was seen in 10/46 (21.7%) patients. There was a significant difference in 5-year RFS with > 3 tumor nodules (P = 0.005), tumors outside University of California San Francisco criteria (P = 0.03), bilobar disease (P = 0.002), AFP > 600 ng/ml (P = 0.006), and poor response to LRT (P = 0.007). On multivariate analysis, bilobar disease (HR = 2.9, P = 0.01), AFP > 600 ng/ml (HR = 2.3 P = 0.008), and poor response to LRT (HR = 2, P = 0.02) were predictors of 5-year RFS. The 5-year RFS in low risk (score = 0), intermediate risk (score = 1-3), and high risk (score = 4-7) groups was 86%, 76%, and 9% (P < 0.0001). There was no recurrence seen in 4/4 (100%) patients with macrovascular invasion in the low-intermediate risk group. The 5-year RFS in the low-intermediate risk group within and outside Milan criteria was 100% and 74% (P = 0.1). CONCLUSIONS: LDLT can provide excellent long-term RFS in patients after preoperative LRT in the low and intermediate risk groups.

Clinical Profile and Treatment of Hepatocellular Carcinoma: A Single-Center Experience.

Background Very few centers in Pakistan have all established treatments for hepatocellular carcinoma (HCC) available under one roof. With a dedicated hepato-pancreato-biliary surgery and liver transplant unit, we have gathered one of the largest data on HCC in our population. Aims The objective of the current study was to assess the clinical spectrum of HCC in Pakistani patients. Settings and Design This retrospective review of patients diagnosed with HCC was conducted between 2011 and 2016. Materials and Methods Patients were allocated to treatment groups based on the Barcelona clinic liver cancer (BCLC) staging algorithm and our local guidelines. The treatment options were grouped as curative (radiofrequency ablation [RFA], percutaneous ethanol injection [PEI], liver resection, and liver transplantation), palliative (transarterial chemoembolization [TACE]/sorafenib), and the best supportive care (BSC). Statistical Analysis Kaplan-Meier curves were used for the statistical analysis. Results The mean age was 57.9 ± 10.1 years (range: 18-90 years). The male-to-female ratio was (1,099/391) 2.8:1. Hepatitis B and hepatitis C were the most common underlying etiological factor in 1,350 of 1,490 (90.6%) patients. Macrovascular invasion (MVI) was seen in 492 of 1,490 (33%) patients. Out of the total, 191 (12.8%) additional patients were offered potentially curative treatments when compared with BCLC recommendations. The actuarial 5-year overall survival for patients who underwent liver transplant, RFA/PEI, TACE, sorafenib, and BSC was 87, 64, 18, 5, and 0%, respectively. Alpha fetoprotein cut-off of 400 ng/mL had a significant impact on survival irrespective of treatment received (41 vs. 11%, p < 0.0001). Conclusion MVI is the most frequent poor prognostic marker in our patients with HCC. Local treatment guidelines are effective in yielding comparable outcomes to BCLC.

Lung Biopsy in Coronavirus-19 Pneumonia: A Case Report and Review of Literature.

Pneumonia is one of the major manifestations of infection by the novel coronavirus (COVID-19) virus. CT scans are used as first line investigation in suspected cases. Biopsies are almost never done. The gross and microscopic pathology has been studied mostly on autopsy specimens in fatal cases. We present a case of a mildly symptomatic adult male, who was a chronic liver disease patient awaiting liver transplant. His lung biopsy was done for diagnosis of a lesion, suspected to be a fungal infection. He was tested for COVID-19 and was PCR-negative at the time. His biopsy showed patchy changes of viral pneumonia. One week later, he tested positive for COVID-19 on PCR. He became asymptomatic soon and the ground glass lung opacities cleared up within another week without any treatment in spite of having a serious comorbid condition.   Key Words: Viral pneumonia, COVID-19, Lung biopsy.

Liver transplantation for hepatocellular carcinoma: Improving eligibility without compromising outcomes.

BACKGROUND: In the context of liver transplantation for hepatocellular carcinoma (HCC), traditional transplant criteria appear restrictive. The objective of the current study was to determine risk factors for recurrence and improve transplant eligibility in patients with HCC. MATERIALS AND METHODS: This was a retrospective study of patients who underwent living donor liver transplant (LDLT) for HCC (n = 219). Largest tumor diameter, tumor number, AFP and neutrophil to lymphocyte ratio were assessed. Multivariate analysis was performed to develop risk scores. The new model was compared with seven previously published transplant criteria using receiver operator curves. RESULTS: Largest tumor size >3.7 cm [HR:2.6, P = 0.02], and AFP > 600 ng/ml [HR:4.7, P = 0.001] were independent predictors of recurrence. Patients with risk scores of 0, 1-3, 4-6 and 7-9 had recurrence rate of 5.9%, 12.5%, 25% and 58.4% respectively. When compared with Milan criteria, Metro ticket 2.0, AFP model and Samsung criteria; transplant eligibility increased by 31.5%, 22.9%, 8.7%, and 7% respectively. Recurrence rate with the current model was 16/199 (8%) (P < 0.0001) and was comparable with other transplant criteria (6.9-9.1%). On ROC analysis, only Milan criteria (AUC = 0.7, P = 0.001) and the current model (AUC = 0.66, P = 0.01) showed significance for recurrence. All patients with high risk scores within Milan criteria had recurred at 3 years (P = 0.03). CONCLUSIONS: Low AFP can be used to select patients for LDLT outside traditional criteria for HCC, with comparable recurrence rates.

Progression and Resolution of COVID-19 Pneumonia on Chest Radiograph.

OBJECTIVE: To evaluate the temporal changes on serial chest radiographs (CXRs)of hospitalised COVID-19 positive patients till their outcome(discharge/death); to determine the severity of CXR score and its correlation with clinical outcome (hospital stay, chest intubation and mortality). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Shifa International Hospital (SIH), Islamabad from March to June 2020. METHODOLOGY: After IRB approval, 112 patients were consecutively enrolled, having laboratory-confirmed SARS-CoV-2 and hospitalised in SIH. Patients' demographics and clinical data were retrieved from Radiology Information System (RIS). Chest radiographs (CXR) were retrieved from picture archive and communication system (PACS). CXR severity scoring was determined by three radiologists, and results were analysed. RESULTS: Lung opacities (98.2%), involvement of both lungs (96.4%), both peripheral and central region involvement (62.5%) and upper/mid/lower zone distribution (61.6%) were the most frequent findings. Males affected more than females with a mean age of 58.9 ± 13.1 years. Zonal involvement, density and extent of opacities peaked on 10-13th day of illness. In the last CXR, opacities showed decrease in extent as well as density, reduction in zonal involvement, and few having mixed interstitial thickening/fibrosis. One hundred and five out of 112 (93.8%) patients had residual radiographic abnormalities on discharge. CONCLUSION: Serial chest radiography can be used to monitor disease progression and temporal changes after initial HRCT. Patients who have CXR severity score of 4 or more at the time of admission, is a red flag for prolonged hospital stay and possible intubation. Severity of CXR findings peaked at 10-13 days. It is recommended to repeat CXRs every 3-4th day during hospital stay. Majority of the patients has residual radiographic abnormality on discharge. Key Words: COVID-19, Radiography, Thoracic, Pandemic, Chest X-ray.

Radiological Assistance In Managing Workflow In Medical And Surgical Indications At Shifa International Hospital In COVID-19 Pandemic.

BACKGROUND: Novel Corona Virus took the world by storm under the name of COVID-19, metamorphosing the whole health care structure and alienating what we the medical community considered normalcy. The sudden unexpected need for social distancing resulted in dire dependency on imaging for expert diagnosis and management. The purpose of the present study is to describe in-depth strategies that were taken by radiology department at our hospital as a part of a coordinated hospital system-wide response in managing workflow of patients presenting to our hospital for various medical and surgical semi-urgent/urgent indications requiring hospital admission. This article may assist and provide guidance for preparation and management for other radiology departments in the early stages or in dire need of providing services in a secure environment, especially in low-income countries such as ours, while maintaining the quality of radiological reports, dealing with increased workloads. It was a descriptive qualitative study, conducted at Shifa international hospital, Radiology Department, from 28 March to 5 June 2020. METHODS: After approval from IRB, a descriptive qualitative study was carried out, which included all patients regardless of age or gender who underwent radiological imaging including CT and radiograph chest, at our department from 28 March to 5 June, 2020. RESULTS: Overall, on a yearly basis, the number of CT scans decreased 30% (total), 53.4% (OPD), and 0.61% (IPD), respectively, in 2020 when compared with figures in 2019. However, no. of HRCTs performed were significantly increased compared to 2019, in same months 568 (0.09%), compared to 2020 where a majority of total CTs performed were HRCTs for COVID alone. CONCLUSION: The radiology department plays a central role in streamlining the patient inflow admitted for surgical or medical indications and thus needs to be prepared for patient surges and increased volumes, with large influxes of patients to the emergency department that will require diagnostic imaging and interventional services.

When to call it off: defining transplant candidacy limits in liver donor liver transplantation for hepatocellular carcinoma.

BACKGROUND: Living donor liver transplantation (LDLT) is an acceptable treatment option for hepatocellular carcinoma (HCC). Traditional transplant criteria aim at best utilization of donor organs with low risk of post transplant recurrence. In LDLT, long term recurrence free survival (RFS) of 50% is considered acceptable. The objective of the current study was to determine preoperative factors associated with high recurrence rates in LDLT. METHODS: Between April 2012 and December 2019, 898 LDLTs were performed at our center. Out of these, 242 were confirmed to have HCC on explant histopathology. We looked at preoperative factors associated with ≤ 50%RFS at 4 years. For survival analysis, Kaplan Meier curves were used and Cox regression analysis was used to identify independent predictors of recurrence. RESULTS: Median AFP was 14.4(0.7-11,326.7) ng/ml. Median tumor size was 2.8(range = 0.1-11) cm and tumor number was 2(range = 1-15). On multivariate analysis, AFP > 600 ng/ml [HR:6, CI: 1.9-18.4, P = 0.002] and microvascular invasion (MVI) [HR:5.8, CI: 2.5-13.4, P <  0.001] were independent predictors of 4 year RFS ≤ 50%. When AFP was > 600 ng/ml, MVI was seen in 88.9% tumors with poor grade and 75% of tumors outside University of California San Francisco criteria. Estimated 4 year RFS was 78% for the entire cohort. When AFP was < 600 ng/ml, 4 year RFS for well-moderate and poor grade tumors was 88 and 73%. With AFP > 600 ng/ml, RFS was 53% and 0 with well-moderate and poor grade tumors respectively (P <  0.001). CONCLUSION: Patients with AFP < 600 ng/ml have acceptable outcomes after LDLT. In patients with AFP > 600 ng/ml, a preoperative biopsy to rule out poor differentiation should be considered for patient selection.

Outcomes after Surgical Resection of Hilar Cholangiocarcinoma.

OBJECTIVE: To report long term outcomes after surgical resection of hilar cholangiocarcinoma (hCCA). STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Shifa International Hospital, Islamabad, Pakistan, from October 2011 to April 2018. METHODOLOGY: A prospective review of maintained database of patients who underwent surgical resection for hCCA was performed. A total of 24 patients were included. Outcome was assessed, based upon 90-day morbidity and mortality, 5-year recurrence-free survival (RFS) and overall survival (OS). RESULTS: Median age was 49 (23-73) years. Male to female ratio was 1.4:1. Median CA 19-9 level was 113 (2-1200) U/ml. Nine patients (37.5%) underwent right hepatectomy, six had right trisectionectomy (25%), three had central hepatectomy (12.5%) and left hepatectomy (12.5%) each, while three (12.5%) had other surgical procedures. In addition, two (8.3%) patients required portal vein resection and reconstruction. Median blood loss was 1350 (100-2000) ml. Median ICU stay was 4 (2-13) days, while hospital stay was 10 (6-32) days. Sixteen (66.7%) patients experienced at least one morbidity within 90 days, while 90-day mortality was 1/24 (4.1%). The overall recurrence rate was 6/18 (33.4%) and mortality was 9/18 (50%). The actuarial 5-year RFS was 60% and OS was 39%. CONCLUSION: hCCA remains a technically challenging surgical problem. Outcomes comparable to international standards can be achieved in experienced centres.

Living Donor Liver Transplantation for Hepatocellular Carcinoma: A Single-Center Experience from Pakistan.

BACKGROUND: Living donor liver transplantation (LDLT) is an established treatment for patients with cirrhosis and hepatocellular carcinoma (HCC) within Milan criteria. Acceptable outcomes have been demonstrated in patients fulfilling extended criteria. Here, we share our experience with LDLT for patients with HCC within and beyond Milan criteria, with emphasis on poor prognostic factors. METHODS: We retrospectively reviewed patients who underwent LDLT between 2012 and 2017 and had HCC proven on explant liver histopathology. A total of 117 patients were included. Patients who died early after transplant (in <30 days) were excluded. For outcomes, patients were divided into prognostic groups. These groups were based on (1) alpha fetoprotein >600, (2) poor differentiation, and (3) the presence of lymphovascular invasion. Recurrence-free survival (RFS) was determined using Kaplan-Meier curves. RESULTS: Median age was 53 (30-73) years. Median follow-up was 20.3 (1-63.2) months. Median model for end stage liver disease (MELD) score was 19 (9-34). Of a total of 117 patients, 74 (63.2%) patients met Milan criteria. Recurrence rate was 12/117 (10.3%). Actuarial 5-year RFS was 88% and 82% (P = 0.3) in patients within and outside Milan criteria. There was no difference in 3-year RFS in patients with 0, 1, or 2 poor prognostic factors within Milan criteria (92%, 87%, and 75%, respectively; P = 0.3). However, a significant difference in RFS was seen in patients outside Milan criteria (92%, 93%, and 53%; P = 0.03). CONCLUSIONS: Patients within Milan criteria have acceptable RFS even in the presence of poor prognostic factors. However, the presence of two or more poor prognostic variables significantly impacts RFS of patients outside Milan criteria.

Endovascular Aortic Repair for Thoracic Aortic Injuries.

Traumatic aortic injury (TAI) or aortic transection is the second most common cause of death after blunt trauma. The conventional management approach towards a thoracic aortic injury is open thoracotomy and surgical repair; however, there is a recent increase in the trend towards the use of endovascular approach in this regard, particularly in the developed countries. We here report the cases of two young healthy male patients presenting in emergency department with thoracic aortic injury, following a road traffic accident (RTA). Thoracic endovascular aortic repair (TEVAR) was planned for both patients, as open repair was risky owing to other systemic injuries. Aortic stent graft was deployed just below the origin of the left subclavian artery in one patient, while it partially covered the left subclavian in the other. End runs showed good position of the graft with perfusion of aortic branches and exclusion of flow to the transection. Both patients had an uneventful recovery with no episodes of cerebrovascular accident (CVA) or paraplegia. Our study gives an insight into the recent trends of endovascular aortic repair (EVAR) becoming the mainstay treatment for TAIs. As far as we know this is the first reported successful case series of thoracic endovascular stent graft deployment for blunt thoracic aortic trauma in Pakistan. We recommend education and further teaching of surgeons to acquire expertise in this novel approach.

Living Donor Liver Transplantation in South Asia: Single Center Experience on Intermediate-Term Outcomes.

BACKGROUND: There is paucity of data on intermediate-term post liver transplant outcomes from South Asia. The objective of this study was to determine survival outcomes in patients who underwent living donor liver transplantation (LDLT) in a busy liver transplant center in Pakistan. METHODS: This study was a review of patients who underwent LDLT between 2012 and 2016. A total of 321 patients were included in this study. Early (within 90 days) and late (>90 days) morbidity and mortality was assessed. Estimated 1- and 4-year survival was determined. RESULTS: Median age was 48 (18-73) years. Male to female ratio was 4.5:1. Out of total 346 complications, 184 (57.3%) patients developed 276 (79.7%) complications in early post-transplant period, whereas there were 70 (21.3%) late complications. Most common early complication was pleural effusion in 46 (16.6%) patients. Biliary complications were the most common late complication and were seen in 31/70 (44.2%) patients. Overall 21.4% patients had a biliary complication. The 3-month mortality was 14%. The estimated 1- and 4-year OS for a MELD cutoff of 30 was 84.5 versus 72 and 80 versus 57% (P = 0.01). There was no donor mortality. CONCLUSION: Acceptable intermediate-term post-transplant outcomes were achieved with LDLT. There is a need to improve outcomes in high-MELD patients.

Experience with Ambulatory Management of Pleural Pathologies Utilizing Small-Bore Indwelling Pleural Catheters.

Introduction Pleural effusion is the excess fluid that accumulates in the pleural space. Pneumothorax is the collection of free air in the pleural cavity, while empyema is the collection of pus in the pleural cavity. Such pleural pathologies pose a great challenge to patients and health care professionals alike. While multiple management options exist, the major portion of it is carried out in the inpatient setting. We sought to evaluate the ambulatory use of indwelling pleural catheters for pleural pathologies, including malignant pleural effusion, empyema, and primary spontaneous pneumothorax. Methods We conducted a prospective case series analysis of 15 patients with various pleural pathologies in which an indwelling pleural catheter was placed by interventional radiologists on an outpatient basis and subsequently followed-up in a pulmonary clinic. Results were analyzed on the basis of clinical, as well as radiological progress with parameters being complete, partial, or no resolution. We also obtained prospective data on the quality of life of these patients. Results Six out of seven patients with malignant pleural effusion reported clinical (complete or partial) resolution, while three reported radiological (complete or partial) resolution. Two of the three patients with nonmalignant pleural effusions reported complete clinical as well as radiological resolution. All three patients with empyema reported complete clinical resolution and partial radiological resolution, while both patients with primary spontaneous pneumothorax reported complete clinical and radiological resolution. Patients reported preserved or improved quality of life with the whole process managed on an outpatient basis. Conclusion We report a high rate of clinical and radiological resolution in various pleural pathologies in our study, which is first of its kind from this part of the world. It demonstrates the feasibility of ambulatory management of pleural pathologies with a multidisciplinary approach.

Spectrum of histopathological diagnosis in paediatric patients with liver disorders in Pakistan.

OBJECTIVE: To document spectrum of paediatric liver disorders confirmed on liver biopsy. METHODS: The retrospective review of patients was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of all children who underwent ultrasound-guided percutaneous liver biopsy between December 2008 and June 2015. Frequency of individual diagnosis was assessed and compared on gender basis. SPSS 16 was used for statistical analysis. RESULTS: There were medical records of 74 patients in the study with an overall median age of 6.9 years (interquartile range: 0.2-17.7 years). Metabolic 27(36.5%) and inflammatory 19(25.6%) disorders were the most common aetiologies. At presentation 29(39.1%) patients had cirrhosis; and 25(34%) children were <5 years of age. Metabolic disorders were the most common aetiology in children upto 10 years of age with 19(25.6%) patients. Above the age of 10 years, inflammatory disorders were more frequent and were seen in 10(13.5%). Based on gender, a trend towards significance was observed for metabolic disorders (p=0.08) and children who presented with cirrhosis (p= 0.07), but it was not statistically significant. CONCLUSIONS: Metabolic disorders were the most common cause of liver disorders. A number of children at presentation had underlying cirrhosis.

Assigning Treatment to HCC Patients for Transplantation: Utility of a New Decision-Making Tool.

BACKGROUND The Barcelona clinic liver cancer (BCLC) staging system is considered the standard of care for hepatocellular carcinoma (HCC) management. It has various limitations, including lack of second-line treatment options and combination therapy. We prospectively collected data on our HCC patients based on a new decision-making tool (NDT). The objective of this study was to determine the applicability of this tool and compare it with BCLC for treatment allocation, in particular with respect to liver transplantation. MATERIAL AND METHODS We retrospectively reviewed HCC patients who were managed based on an NDT that was developed in 2012. All patients whose treatment decision was based on this tool between 2012 and 2015 were included. Comparison was made with BCLC. Survival was compared for patients who underwent liver transplantation. RESULTS Based on the NDT, 406 (40.6%) patients were eligible for curative treatment versus only 22 (2.2%) patients based on BCLC. A total of 58 (5.8%) patients underwent liver transplant based on the NDT, while only 2 (0.2%) were transplantable based on BCLC. Estimated 3-year survival for transplanted patients based on the NDT was 73%. There were 41 (4.1%) stage C and 15 (1.5%) stage D BCLC patients who received transplant based on the NDT. Estimated 3-year survival for stage A, C, and D BCLC patients who received transplantation was 100%,72%, and 67%, respectively (P=0.6). CONCLUSIONS The NDT correctly identified a group of HCC patients for liver transplantation who would otherwise have received palliative treatment based on the BCLC algorithm.