Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery.

OBJECTIVE: The study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop. MATERIALS AND METHODS: Eleven consecutive patients (age range, 2-79 years; eight men and three women) who underwent portal stenting between April 2009 and December 2015 were included in the study. Preoperative medical history and the postoperative clinical course were reviewed. Characteristics of portal occlusion and details of procedures were also investigated. Technical success, treatment efficacy (defined as disappearance of jejunal varix on follow-up CT), and clinical success were analyzed. Primary stent patency rate was plotted using the Kaplan-Meier method. RESULTS: All patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Variceal bleeding occurred at 27 months (4 to 72 months) and portal stenting was performed at 37 months (4 to 121 months), on average, postoperatively. Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of 9 months. Neither procedure-related complication nor mortality occurred. CONCLUSION: Interventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.

Early Stage Hepatocellular Carcinomas Not Feasible for Ultrasound-Guided Radiofrequency Ablation: Comparison of Transarterial Chemoembolization Alone and Combined Therapy with Transarterial Chemoembolization and Radiofrequency Ablation.

PURPOSE: To report the results of combined therapy with transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for early stage hepatocellular carcinoma (HCC) considered infeasible for ultrasound (US)-guided RFA in comparison with those of TACE monotherapy. METHODS: From January 2007 through December 2010, 91 patients with early or very early stage HCC infeasible for US-guided RFA received either TACE alone (TACE group; n = 54) or TACE immediately followed by RFA (TACE-RFA group; n = 37) as a first-line treatment. 1-month tumor response, time to progression (TTP), and overall survival (OS) rates were calculated. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: TACE-RFA group showed a better 1-month tumor response than TACE group (P < .001). The mean TTP was 29.7 ± 3.4 months (95 % confidence intervals [CIs] 23.0-36.5) in TACE group and 34.9 ± 2.8 months (95% CIs 29.4-40.4) in TACE-RFA group. TACE-RFA group had a significantly longer TTP (P = .014). Cumulative 1-, 2-, and 3-year OS rates in the TACE and TACE-RFA groups were 91, 79, and 71% and 100, 97, and 93%, respectively (P = .008). Initial treatment of TACE was found to be the only significant risk factor for tumor progression and OS in multivariate analysis. CONCLUSION: TACE-RFA combination therapy appears superior to TACE monotherapy in terms of 1-month tumor response, TTP, and OS when performed for early stage HCC infeasible for US-guided RFA.

Efficacy of RECIST and mRECIST criteria as prognostic factors in patients undergoing repeated iodized oil chemoembolization of intermediate stage hepatocellular carcinoma.

BACKGROUND: Given that transarterial chemoembolization (TACE) is usually a repeated procedure for treatment of hepatocellular carcinoma (HCC), repeated radiologic response assessments rather than a single time point assessment may have different clinical implications through the repeated course of TACE. PURPOSE: To evaluate the efficacy of RECIST and mRECIST criteria as a survival predictor across early time points after repeated TACE of HCC. MATERIAL AND METHODS: Ninety-eight patients with intermediate stage HCC received repeated iodized oil TACE. Treatment response was assessed according to RECIST and mRECIST criteria at 1, 3, and 6 months after initial TACE. Cox proportional model was used for survival analysis and the predicting power of each time point response was evaluated with C-statistics and time-dependent area under the receiver operating characteristic curve (AUC). Inter-method agreement was assessed with the κ coefficient. RESULTS: mRECIST was not applicable in 15 patients because of patchy uptake of iodized oil after TACE. On multivariate analysis, responders at 6 months by RECIST, responders at 3 months, and 6 months by mRECIST showed better survival than non-responders (P < 0.05). Predicting power of response criteria improved over time and mRECIST at 6 months showed the best performance. The degree of agreements was poor or fair between RECIST and mRECIST. CONCLUSION: mRECIST predicted long-term survival as early as 3 months after TACE of intermediate stage HCC. The predicting power of the uni-dimensional response criteria tended to be stronger over time.

Transarterial chemoembolization as first-line therapy for hepatocellular carcinomas infeasible for ultrasound-guided radiofrequency ablation: a retrospective cohort study of 116 patients.

BACKGROUND: Ultrasound (US)-guided radiofrequency ablation (RFA) is frequently infeasible even for very early or early stage hepatocellular carcinoma (HCC) due to various reasons such as inconspicuous tumors or absence of a safe electrode path and the infeasibility rate is reportedly as high as 45%. In such cases, transarterial chemoembolization (TACE) is a commonly practiced alternative. PURPOSE: To analyze long-term outcomes including tumor progression patterns and factors contributing to survival of patients who received TACE as the first line of therapy for very early or early stage HCC infeasible for US-guided RFA. MATERIAL AND METHODS: From October 2006 through October 2009, 116 patients with very early or early stage HCCs underwent the first-line therapy TACE after their tumors were deemed infeasible for RFA. Long-term survival rates were calculated and prognostic factors were assessed by univariate and multivariate analyses. The patterns and rates of tumor progression or recurrence were also evaluated. RESULTS: The 1, 3, and 5-year survival rates of the whole cohort were 94.7%, 68.4%, and 47.2% with a mean overall survival of 53.1 months (95% CI: 48.2-58.0). Preserved liver function with Child-Pugh class A was the only independent factor associated with longer survival. The most common first tumor progression pattern was intrahepatic distant recurrence. The cumulative rates of local tumor progression and intrahepatic distant recurrence at 1, 3, and 5 years were 33% and 22%, 52% and 49%, and 73% and 75%, respectively. CONCLUSION: TACE is a viable first-line treatment of HCC infeasible for RFA, especially when liver function was preserved.

Evolution of portal vein tumor thromboses in patients with hepatocellular carcinoma: CT findings and transition of serum tumor markers.

We investigated the patterns of evolution of portal vein tumor thromboses (PVTTs) and the changes in serum tumor marker levels in untreated hepatocellular carcinomas. The mean time required for the subsegmental or lower-order branch PVTTs and the segmental PVTTs to reach the large portal vein was 120 and 101 days, respectively. The mean values of the serum alpha-fetoprotein levels markedly increased after the appearance of PVTTs from 1858.7 ng/ml to 6795.2 ng/ml.

Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis?

GOALS: To evaluate the safety, efficacy, and long-term outcome of percutaneous cholecystostomy without additional cholecystectomy as a definitive treatment for acute acalculous cholecystitis (AAC). BACKGROUND: AAC mainly occurs in seriously ill patients, and for those considered to be at high-risk for cholecystectomy, immediate percutaneous cholecystostomy can be a simple alternative interim treatment. However, no consensus has been reached on the issue of additional cholecystectomy. STUDY: The medical records of 57 patients that underwent percutaneous cholecystostomy for AAC at a single institution between 1995 and 2010 were retrospectively analyzed. RESULTS: Percutaneous cholecystostomy was technically successful in all patients, and no major complications relating to the procedure were encountered. Symptoms resolved within 4 days in 53 of the 57 (93%) patients. The in-hospital mortality rate was 21% (11/57) and elective cholecystectomy was performed in 18/57 (31%). Twenty-eight patients were managed non-operatively and cholecystostomy tubes were subsequently removed. These 28 patients were follow-up over a median 32 months and recurrent cholecystitis occurred in 2 (7%). CONCLUSION: Percutaneous cholecystostomy is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or an underlying comorbidity. After patients with AAC have recovered from percutaneous cholecystostomy, further treatment such as cholecystectomy might not be needed.

Heavily calcified occlusive lesions of the iliac artery: long-term patency and CT findings after stent placement.

PURPOSE: To evaluate the influence of heavy calcification on iliac arterial stent expansion and patency and to define the spatial relationship between the stent and heavy calcifications on computed tomography (CT). MATERIALS AND METHODS: Thirteen patients (11 men, two women; mean age, 66.5 y) with 14 heavily calcified iliac arteries received primary stent treatment between 1998 and 2008. Anatomic success was defined by less than 30% residual stenosis on final follow-up CT angiography. Hemodynamic success was defined as an increase in the ankle-brachial index (ABI) of at least 0.15 versus baseline. Clinical success was defined by achievement of clinical improvement of at least one clinical category. Stent patency; anatomic, hemodynamic, and clinical success rate; morphology of heavy calcifications; calcium score; and stent geometry were evaluated. RESULTS: Stents were successfully inserted in all cases. During a mean follow-up of 33.6 months (range, 8-55 mo), the stent-implanted iliac arteries remained anatomically patent in all patients on final follow-up. The anatomic, hemodynamic, and clinical success rates were 28.6%, 60%, and 78.6%, respectively. Mean ABIs were 0.68 ± 0.22 before the procedure and 0.91 ± 0.23 after the procedure (P = .021). Mean luminal stenosis measurements were 77.9% before the procedure and 47.9% after the procedure (P = .008). CONCLUSIONS: Iliac stents in heavily calcified lesions showed hemodynamically significant residual stenosis in a considerable number of cases. However, stent patency was not affected even with incomplete expansion of the stent.

Ischemic liver injuries after hepatic artery embolization in patients with delayed postoperative hemorrhage following hepatobiliary pancreatic surgery.

BACKGROUND: Many collateral pathways to the liver are dissected during hepatobiliary pancreatic surgery and, if the arterial bleeding is massive and a hematoma becomes larger, the adjacent portal vein can be compressed with impairment of the portal venous flow. PURPOSE: To evaluate the frequency and severity of ischemic liver injuries after hepatic artery embolization in patients with delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery. MATERIAL AND METHODS: Eighteen patients undergoing proper or common hepatic artery embolization for delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery achieved hemostasis. To evaluate the frequency and severity of ischemic liver injuries, the liver enzyme levels and CT findings before and after hepatic artery embolization were retrospectively compared and the clinical outcomes after hepatic artery embolization were analyzed. Angiographic findings were also analyzed to reveal any association with development of ischemic liver injuries after hepatic artery embolization. RESULTS: Ischemic liver injuries were observed in 15 (83%) of 18 patients undergoing hepatic artery embolization for postoperative hemorrhage. Injuries included hepatic infarction combined with abscess in one (5%) patient, hepatic infarction in 12 (67%) patients, and transient hepatic ischemia/dysfunction in two (11%). As for the extent of hepatic infarction, lobar infarction developed in two patients and subsegmental infarction in 11. One patient with right hepatic lobar infarction died of hepatic failure 11 days after hepatic artery embolization. In the other 14 patients with ischemic liver injuries, the elevated liver enzymes returned to baseline levels within two weeks. All of the four patients with portal vein stenosis, four patients with no hepatic arterial flow on post-embolization angiogram, and one patient with both had hepatic infarction after hepatic artery embolization. No ischemic liver injuries developed after hepatic artery embolization in three patients with no portal vein stenosis and bilobar hepatic arterial flow via the left hepatic artery aberrantly arising from the left gastric artery or from the common hepatic artery. CONCLUSION: Ischemic liver injuries can develop in most patients undergoing hepatic artery embolization for postoperative arterial hemorrhage after hepatobiliary pancreatic surgery; hepatic infarction appears to be the most frequent type of ischemic liver injury. Hepatic artery embolization for postoperative arterial hemorrhage after hepatobiliary pancreatic surgery may carry a great risk of ischemic liver injury if a patient has portal vein stenosis or no aberrant hepatic artery.

Are endoscopic or percutaneous biliary drainage effective for obstructive jaundice caused by hepatocellular carcinoma?

OBJECTIVES: The prognosis of patients with obstructive jaundice caused by hepatocellular carcinoma (HCC) has been reported to be poor. The aims of this study were to determine whether effective biliary drainage in patients with obstructive jaundice caused by HCC can affect clinical outcome and to identify those factors that affect effective biliary drainage and clinical outcome. METHODS: The clinical records of 68 patients with obstructive jaundice caused by HCC who underwent endoscopic or percutaneous transhepatic biliary drainage from 1 January 2004 to 31 December 2008 were analyzed. Effective biliary drainage was defined as a decrease in total bilirubin level of more than 30% of the preprocedural value within 4 weeks. RESULTS: (i) Effective biliary drainage was achieved in 51.5% of the patients who underwent a biliary drainage procedure. The independent risk factors for ineffective biliary drainage were total bilirubin more than 13 mg/dl and Child-Turcotte-Pugh class C. (ii) Patients with effective biliary drainage showed a significant improvement of Child-Turcotte-Pugh class and received additional treatment for HCC. (iii) The mean survival times of patients who received effective or ineffective biliary drainage were 247 and 44 days, respectively. (iv) The independent risk factors of mortality were an age of more than 63 years, ineffective biliary drainage, and no following treatment for HCC. CONCLUSION: When effective biliary drainage was achieved after an appropriate biliary drainage procedure in patients with obstructive jaundice caused by HCC, survival improved.

Ethanol embolotherapy of hand arteriovenous malformations.

PURPOSE: Ethanol embolotherapy is one of the established methods in the treatment of extremity arteriovenous malformations (AVMs). The purpose of this study was to report the application of this method to hand AVMs and to assess retrospectively the therapeutic outcomes and complications. PATIENTS AND METHODS: From December 1998 to March 2009, we treated 31 patients with hand AVMs (16 women, 15 men, age range, 5-51 years; mean age, 27 years). With the patients under general anesthesia, they underwent staged ethanol embolotherapy (range, 1-11 sessions; mean, 2.8 sessions) by direct puncture and or intra-arterial approach. Therapeutic outcomes were evaluated by clinical responses of symptoms and signs, as well as the degree of devascularization on angiography. We also divided the patients into three groups according to the extent of involvement: a group involving fingers (n = 14), a group involving fingers and parts of the palm (n = 9), and a group involving parts of the palm (n = 8) and compared the therapeutic outcomes and complications among groups. RESULTS: One patient (3%) was cured, 22 patients (73%) showed improvement, and 7 patients (23%) showed no change or aggravation after the treatment. One patient was lost to follow-up. Nineteen patients (61%) had one or more complications, including skin necrosis in 14 patients (45%), bullae in 7 patients (23%), joint stiffness or contracture in 6 patients (19%), and transient nerve palsy in 4 patients (13%). All of the complications were resolved completely after 1 to 8 months' (average, 3.4 months) follow-up, except in 2 patients who underwent amputation. According to the location of AVMs, rates of therapeutic benefit and complications were 93% and 64% in the group involving fingers, 38% and 78% in the group involving fingers and the palm, and 88% and 38% in the group involving the palm, respectively. CONCLUSION: Ethanol embolotherapy of hand AVMs improves symptoms in a certain percentage of patients with a relatively high risk of complications. According to the extent of AVMs, there was a trend toward a higher complication rate in treatment of AVMs involving fingers and a lower rate of therapeutic benefit in AVMs involving both the fingers and the palm.

Percutaneous transluminal angioplasty of renal artery fibromuscular dysplasia: mid-term results.

OBJECTIVE: To evaluate mid-term imaging, clinical follow-up, and restenosis rates from patients that had undergone percutaneous transluminal renal artery angioplasty (PTRA) for symptomatic renal artery fibromuscular dysplasia (FMD). MATERIALS AND METHODS: Between March 1999 and July 2006, 16 consecutive renal artery FMD patients underwent PTRA for poorly controlled hypertension. The patients were enrolled into this retrospective study after receiving 19 primary and four secondary PTRAs in 19 renal artery segments. Follow-up monitoring of blood pressure, use of antihypertensive medication, and the serum creatinine level after PTRA were assessed at 1, 3, 6, 9, 12 months, and each following year. The degree of restenosis was evaluated with computed tomographic angiography (CTA) after PTRA at 6, 12 months, and every year if possible. Technical and clinical success rates for the treatment of FMD, and restenosis rates for the renal artery were evaluated. RESULTS: The technical success rate for primary PTRA was 79% (15/19) and the complication rate was 16% (3/19). Hypertension improved in 80% (12/15) of the patients after four weeks follow-up, and was finally cured or improved in 93% (14/15) during the mean follow-up period of 23.6 months. There was a cumulative 22% (4/18) restenosis rate during the follow-up period. All of the patients were treated with a second PTRA without complications and all of the patients were cured of hypertension after the second PTRA. CONCLUSION: Percutaneous transluminal renal artery angioplasty for clinically symptomatic renal FMD is technically and clinically successful and safe to perform. For all patients with restenosis, there was a good response after undergoing a second PTRA.

Diaphragmatic weakness after transcatheter arterial chemoembolization of inferior phrenic artery for treatment of hepatocellular carcinoma.

PURPOSE: To prospectively assess the diaphragmatic anatomic and functional consequences of transcatheter arterial chemoembolization (TACE) of the inferior phrenic artery in patients with hepatocellular carcinoma. MATERIALS AND METHODS: Informed consent and institutional review board approval were obtained. Fifteen patients (13 men, two women; mean age, 52 years; age range, 22-61 years) who underwent TACE of the inferior phrenic artery for treatment of hepatocellular carcinoma were enrolled. The right inferior phrenic artery was embolized in 14 patients, and the left inferior phrenic artery was embolized in one patient. Chest radiography, fluoroscopy, computed tomography (CT), and pulmonary function tests were performed before and after TACE of the inferior phrenic artery. The post-TACE examinations were performed 2-3 months after TACE, and the results were compared with those of the pre-TACE examinations. A paired t test or the Wilcoxon signed rank test was used for statistical analyses. RESULTS: At chest radiography and fluoroscopy, six of 15 patients (40%) had both elevation and movement abnormality of the ipsilateral hemidiaphragm after TACE of the inferior phrenic artery. The mean (+/- standard deviation) diaphragmatic thickness on CT scans changed from 9.11 mm +/- 3.02 to 7.67 mm +/- 2.27 after TACE (P = .048). The mean vital capacity also was significantly decreased after TACE, from 91.87% +/- 18.52 to 82.27% +/- 16.94 of the predicted value (P = .006). The decreases in diaphragmatic thickness and vital capacity were most pronounced in the patients with abnormal findings at chest radiography and fluoroscopy. CONCLUSION: After TACE of the inferior phrenic artery, a substantial portion of patients showed functional and anatomic evidence of diaphragmatic weakness.

Subintimal angioplasty in the treatment of chronic lower limb ischemia.

OBJECTIVE: To present our experience with subintimal angioplasty (SA) for treatment of chronic lower limb ischemia (CLLI) and to assess its effectiveness and durability. MATERIALS AND METHODS: From April 2003 through June 2005, we treated 40 limbs in 36 patients with CLLI by SA. Balloons with or without secondary stent placement appropriate in size to the occluded arteries were used for SA of all lesions, except for iliac lesions where primary stent placement was done. The patients were followed for 1-23 months by clinical examination and color Doppler ultrasound and/or CT angiography. Technical results and outcomes were retrospectively evaluated. The presence of a steep learning curve for performance of SA was also evaluated. Primary and secondary patencies were determined using Kaplan-Meier analysis. RESULTS: Technical success was achieved in 32 (80%) of 40 limbs. There was no statistical difference between technical success rates of 75% (18/24) during the first year and 88% (14/16) thereafter. There were four complications (10%) in 40 procedures; two arterial perforations, one pseudoaneurysm at the puncture site, and one delayed hematoma at the SA site. Excluding initial technical failures, the primary patency rates at six and 12 months were 68% and 55%, respectively. Secondary patency rates at six and 12 months were 73% and 59%, respectively. CONCLUSION: Subintimal angioplasty can be accomplished with a high technical success rate. It should be attempted in patients with CLLI as an alternative to more extended surgery, or when surgical treatment is not recommended due to comorbidity or an unfavorable disease pattern.

The balloon dilatation and large profile catheter maintenance method for the management of the bile duct stricture following liver transplantation.

OBJECTIVE: We wanted to evaluate the therapeutic efficacy of the percutaneous balloon dilatation and large profile catheter maintenance method for the management of patients with anastomotic biliary strictures following liver transplant. MATERIALS AND METHODS: From May 1999 to June 2003, 12 patients with symptomatic benign biliary stricture complicated by liver transplantation were treated with the percutaneous balloon dilatation and large profile catheter maintenance method (1-6 months). The patients were eight males and four females, and their ages ranged from 20 to 62 years (mean age: 44 years). Ten patients underwent living donor liver transplantation and two underwent cadaveric liver transplantation. Postoperative biliary strictures occurred from two to 21 months (mean age: 18 months) after liver transplantation. RESULTS: The initial technical success rate was 92%. Patency of the bile duct was preserved for eight to 40 months (mean period: 19 months) in 10 of 12 (84%) patients. When reviewing two patients (17%), secondary balloon dilatations were needed for treating the delayed recurrence of biliary stricture. In one patient, no recurrent stenosis was seen during the further 10 months follow-up after secondary balloon dilatation. Another patient did not response to secondary balloon dilatation, and he was treated by surgery. Eleven of 12 patients (92%) showed good biliary patency for 8-40 months (mean period: 19 months) of follow-up. CONCLUSION: The percutaneous balloon dilatation and large profile catheter maintenance method is an effective therapeutic alternative for the treatment of most biliary strictures that complicate liver transplantation. It has a high success rate and it should be considered before surgery.

Stent placement for chronic iliac arterial occlusive disease: the results of 10 years experience in a single institution.

OBJECTIVE: We wanted to retrospectively evaluate the long-term therapeutic results of iliac arterial stent placement that was done in a single institution for 10 years. MATERIALS AND METHODS: From May 1994 to April 2004, 206 patients who underwent iliac arterial stent placement (mean age; 64+/-8.8) were followed up for evaluating the long term stent patency. Combined or subsequent bypass surgery was performed in 72 patients. The follow up period ranged from one month to 120 months (mean; 31+/-25.2 months). The factors that were analyzed for their effect on the patency of stents were age, the stent type and diameter, the lesion site, lesion shape, lesion length, the Society of Cardiovascular and Interventional Radiology criteria, the total run off scores, the Fontaine stage and the cardiovascular risk factors (diabetes mellitus, hypertension and smoking). Follow-up included angiography and/or CT angiography, color Doppler sonography and clinical evaluation with the ankle-brachial index. RESULTS: Two hundred and eighty-four stents were placed in 249 limbs of 203 patients. The technical success rate was 98% (203/206). The primary patency rates of the stents at 3, 5, 7 and 10 year were 87%, 83%, 61% and 49%, respectively. One hundred seventy-seven patients maintained the primary stent patency until the final follow up and 26 patients showed stenosis or obstruction during the follow up. Secondary intervention was performed in thirteen patients. Lesions in the external iliac artery (EIA) or lesions in both the common iliac artery (CIA) and EIA were a poor prognostic factor for stent patency. The run off score and stent diameter also showed statistically significant influence on stent patency. The overall complication rate was 6%. CONCLUSION: Iliac arterial stent placement is a safe treatment with favorable long term patency. Lesions in the EIA or lesions in both the EIA and CIA, poor run off vessels and a stent having the same or a larger diameter than 10 mm were the poor prognostic factors for long term stent patency.

Use of double-occlusion balloon catheter: preoperative portal vein embolization for induction of future remnant liver hypertrophy.

PURPOSE: To evaluate the efficacy and safety of using double-occlusion balloon catheters in preoperative portal vein embolization (PVE) to induce future remnant liver hypertrophy. MATERIALS AND METHODS: PVE was achieved with gelatin sponges by using double-occlusion balloon catheter in seventeen patients with hepatobiliary malignant tumors. The ipsilateral approach was used in thirteen patients and the contralateral approach in four patients due to large size of tumor in the right hepatic lobe. Surgery was performed in 15 patients, 14-27 days (mean, 21.9 days) after PVE. Computed tomographic liver volumetric studies were performed before embolization and before surgery. The changes in aspartate aminotransferase (AST), alanine aminotransferase (ALT), prothrombin time (PT), and total bilirubin levels before and after the PVE were evaluated. Complications were evaluated after PVE. RESULTS: PVE using double-occlusion balloon catheter was successful in all cases, irrespective of approach technique. The future remnant liver (FRL) volumes were 251-920 cm3 (mean, 437 cm3) before PVE and 281-1042 cm3 (mean, 555 cm3) after PVE. The mean increase in the volume of the FRL was 28.6%; this represented 37% of the preresection volume of the liver. Clinical and biologic tolerance of PVE was mandatory. There were no complications. CONCLUSIONS: PVE using the double-occlusion balloon catheter is safe and well-tolerated and can be performed technically with ease. This hypertrophy allows hepatectomy to be performed safely when the FRL volume is initially insufficient in patients with hepatobiliary tumors.

Selective intra-arterial calcium stimulation with hepatic venous sampling for preoperative localization of insulinomas.

OBJECTIVE: To determine the value of selective intra-arterial calcium stimulation with hepatic venous sampling using serum insulin and C-peptide gradients for the preoperative localization of insulinomas. MATERIALS AND METHODS: Seven consecutive patients (three men and four women aged 15-77 (mean, 42.7) years) with hypoglycemia underwent selective intra-arterial calcium stimulation in conjunction with hepatic venous sampling. Insulin gradients were calculated by an individual blinded to all other preoperative imaging studies and operative findings. In all patients except one, C-peptide gradients were also analyzed. The results were compared with the preoperative findings of ultrasonography, computed tomography, arteriography and endoscopic ultrasonography, as well as with the intraoperative findings of ultrasonography and palpation at surgery. RESULTS: Eight insulinomas (mean diameter, 12.5 mm) were diagnosed after surgery. In six patients, the calcium stimulation test with insulin gradients allowed accurate localization of the pathologic source of insulin secretion. Both C-peptide and insulin gradients substantially increased diagnostic accuracy. In one patient, C-peptide gradients were more helpful than insulin gradients for tumor localization. CONCLUSION: Selective intra-arterial calcium stimulation with hepatic venous sampling is a highly accurate and safe method for the preoperative localization of insulinomas. Additional C-peptide gradients seem to be helpful in assessing tumor location, but further study is needed.