Survival benefit of radioembolization for inoperable hepatocellular carcinoma using yttrium-90 microspheres.

BACKGROUND AND AIM: Transarterial radioembolization with yttrium-90 microspheres is one treatment option for inoperable hepatocellular carcinoma. We compared the survival in a cohort of patients receiving radioembolization or no radioembolization. METHODS: The data of 46 patients referred for radioembolization was retrospectively reviewed. The patient, tumor characteristics, and the survival were compared in the two groups. The independent predictors for survival were studied with multivariate analysis. The side-effects and the complication of radioembolization-induced liver disease was recorded. RESULTS: Thirty patients received radioembolization; 16 patients did not. The two groups did not differ in the mean age, Child-Pugh classes, Barcelona Clinic of Liver Cancer (BCLC) stages, tumor types, sum of diameter of the two biggest tumors, and extent of portal vein invasion. Those with BCLC stage C tumor, with portal vein thrombus, or with less than three nodules had significantly longer survival after radioembolization. There was a trend of longer survival in patients with Child-Pugh A liver function, or with BCLC stage B tumor after radioembolization. The median survival was more than 31.9 months, 14.5 months, and 5.2 months in patients with BCLC stage A, B, and C tumors. The independent predictors for longer survival were Child-Pugh class, tumor diameter sum, BCLC stage, and receiving radioembolization. Grade 2 irradiation-induced gastritis occurred in three patients (10%). Radioembolization-induced liver disease occurred in four patients (13%). CONCLUSIONS: Radioembolization may prolong survival for patients with inoperable hepatocellular carcinoma. Radioembolization-induced liver disease occurred and should be further studied.

Endovascular management of aortoduodenal fistula arising from recurrent mycotic aneurysm in an aortic stump.

BACKGROUND: We present a case of successful endovascular exclusion of an aortoduodenal fistula using an endovascular graft iliac plug. This treatment modality of aortoduodenal fistula arising from a recurrent mycotic aortic aneurysm stump has not yet been described in the literature. CASE REPORT: An 80-year-old man underwent emergency repair of a ruptured infrarenal mycotic aortic aneurysm with an axillobifemoral vascular bypass. Four months after the operation, a pseudoaneurysm arising from the aortic stump invaded the third part of the duodenum, forming an aortoduodenal fistula. An endovascular graft iliac plug and a chimney stent were used to achieve endovascular exclusion of the aortoduodenal fistula. CONCLUSION: The management of aortoduodenal fistula arising from recurrent mycotic aortic aneurysm stump with an endovascular graft iliac plug is successful, especially in patients with a previous history of abdominal aortic surgeries. This procedure reduces the mortality and morbidity associated with open surgery. Further validation with a greater number of cases and longer follow-up times would be required to prove that this is a viable definitive treatment modality.

Endovascular Management of Isolated Spontaneous Superior Mesenteric Artery Dissecting Aneurysm.

OBJECTIVES: The aim is to present the technique of successful management of a superior mesenteric artery (SMA) dissecting aneurysm by a purely endovascular approach. METHODS: This was a single centre case report. RESULTS: Isolated spontaneous SMA dissecting aneurysm is rare, and previously was usually treated by an open or hybrid approach. This is a single centre case report of the successful management of a SMA dissecting aneurysm by a purely endovascular approach. CONCLUSIONS: A pure endovascular approach is feasible and effective in the management of isolated SMA dissecting aneurysm, which is a rare but life threatening condition.

Hong Kong Consensus Statements for the Management of Unresectable Hepatocellular Carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is highly prevalent in Hong Kong due to the high prevalence of chronic hepatitis B infection. Liver cancer is the fourth most common cancer and the third most common cause of cancer death. Due to the high case load, there is a high level of local expertise in treating HCC, and the full spectrum of treatment modalities is available. This document summarizes how these modalities should be used based on the latest evidence. SUMMARY: In 2 meetings held in early 2017, a multidisciplinary group of Hong Kong clinicians, including liver surgeons, interventional radiologists, clinical oncologists, and medical oncologists, met to update local consensus statements for management of HCC. These statements are based on the latest evidence and give detailed guidance on how to deploy these modalities, in particular for cases of HCC which are not suited to surgical resection. KEY MESSAGES: These statements give detailed information on how to decide if a patient is a candidate for resection, methods to improve candidacy for resection, and guidance for use of various nonsurgical interventions to manage patients ineligible for resection.

A veno-caliceal fistula related to ureteric stricture in a kidney allograft masquerading as renal failure.

We report an unusual case of veno-caliceal fistula that developed because of high ureteric pressure caused by graft ureteric stricture after kidney transplantation in a 60-year-old patient. We further confirmed its presence with radiological images. Recirculation of creatinine and other uremic toxins resulted in a biochemical picture of renal failure in the presence of normal kidney function, confirmed by normal scintigraphy findings. Drainage of the pelvi-caliceal system could not be assessed accurately by means of diuretic renogram using technetium-99m diethylenetriaminepentaacetic acid with frusemide because of the rapid clearance of tracer activity from the system in the presence of a veno-caliceal fistula. The patient's renal function improved rapidly after interrupting urine recirculation by using percutaneous drainage, confirming "pseudo renal failure" as the cause of his persistently increased serum creatinine concentration. The ureter was re-implanted later, and the veno-caliceal fistula was not seen in the nephrostogram after the operation. He remains well with stable renal function at 3 years' follow-up. Clinicians should exercise judgment when evaluating patients with allograft dysfunction, especially when the investigation and clinical findings show contradicting results.

Combined endovascular and open treatment for infected pseudoaneurysm of the thoracic aortic arch.

Infected pseudoaneurysm of the aortic arch is a rare but life-threatening condition. The conventional treatment involves cardiopulmonary bypass, prolonged vascular clamping, and an extensive bypass procedure. We report a case of infected pseudoaneurysm involving the aortic arch. The patient underwent debranching of the supra-aortic arteries and bypass surgery, followed by stent grafting the next day. The patient had good recovery, and the 1-year follow-up computed tomography scan showed resolution of the infected pseudoaneurysm.

Liver resection for intrahepatic stones.

HYPOTHESIS: Long-term outcome is good for a selected group of patients with hepatolithiasis treated with liver resection. Liver resection should also be offered to patients with complex hepatolithiasis such as bilateral stones or those with strictures. DESIGN: Retrospective study. SETTING: Regional hospital. PATIENTS: A total of 174 patients with hepatolithiasis (201 procedures) treated between January 1, 1989, and September 30, 2003. INTERVENTIONS: Liver resection (52 procedures) or removal of stones primarily by percutaneous choledochoscopy (149 procedures). MAIN OUTCOME MEASURE: Recurrence of cholangitis. RESULTS: Most patients in the liver resection group had stones localized to the left side. The overall success rate in this group was 98.0% (49 of 50 patients, excluding 2 patients found to have cholangiocarcinoma). The chance of biliary sepsis at 5 years after resection was 13.3%. The overall success rate of stone removal primarily by percutaneous choledochoscopy was 70.5%. The bilaterality of stones, the presence of stricture, and the presence of atrophy were found to be significant risk factors for a poor long-term outcome after stone removal alone. The chance of biliary sepsis at 5 years was 26.4% and 43.2% for those without and with stricture, respectively. CONCLUSIONS: The long-term outcome after liver resection for hepatolithiasis was excellent for a selected group of patients. Poor outcomes were recorded for patients whose intrahepatic stones were removed primarily by percutaneous choledochoscopy, especially those with strictures. The indication for liver resection for hepatolithiasis should be extended to patients with strictures and those with bilateral stones. A combination of different treatment modalities is necessary to improve the outcome of these patients.

Percutaneous drainage and necrosectomy in the management of pancreatic necrosis.

BACKGROUND: The degree of necrosis and presence of infection are the crucial determinants of the outcome in patients with pancreatic necrosis. In patients with sterile necrosis, the necrotic material can persist and subsequently results in sepsis. Some of these patients will ultimately require an operation to remove the necrotic material. Percutaneous necrosectomy has been introduced to remove this residual debris in a minimally invasive way. METHODS: We retrospectively reviewed all patients with pancreatic necrosis who had percutaneous drainage (PCD) performed. Percutaneous pancreatic necrosectomy (PCPN) was done for those patients whose necrotic cavity failed to resolve. RESULTS: Percutaneous drainage was performed in eight patients, four with evidence of infection by the positive culture in the aspirate. In three of them, the necrotic cavity completely resolved after drainage. Percutaneous necrosectomy was performed in another three patients through the tract placed by the radiologist and another one through a sinus tract after an operation. The necrotic cavity in three of them completely resolved after percutaneous necrosectomy. CONCLUSION: Those patients who had 'organized necrosis' after the acute episode of pancreatitis could receive benefit from percutaneous necrosectomy. The persistent symptoms could be alleviated after the removal of the residual necrotic material. It could also be useful after an open surgery to remove any residual devitalized tissue.

Hemodialysis catheter insertion using transrenal approach.

We report a patient suffering from end-stage renal disease (ESRD) because of lupus nephritis presented with exhausted vascular access after multiple arteriovenous grafts creation and hemodialysis catheters insertion. A rare percutaneous transrenal approach was finally used for the insertion of dialysis catheter. After 2 years, this hemodialysis catheter was complicated by blockage but was successfully replaced by a new catheter via the same site. Our report shows that the transrenal route of hemodialysis catheter insertion can provide a glimpse of hope for those ESRD patients with exhausted vascular access.

Hong Kong consensus recommendations on the management of hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is particularly prevalent in Hong Kong because of the high prevalence of chronic hepatitis B (CHB) infection; HCC is the fourth commonest cancer in men and the seventh commonest in women, and it is the third leading cause of cancer death in Hong Kong. The full spectrum of treatment modalities for HCC is available locally; however, there is currently no local consensus document detailing how these modalities should be used. SUMMARY: In a series of meetings held between May and October 2013, a multidisciplinary group of Hong Kong clinicians - liver surgeons, medical oncologists, clinical oncologists, hepatologists, and interventional radiologists - convened to formulate local recommendations on HCC management. These recommendations consolidate the most current evidence pertaining to HCC treatment modalities, together with the latest thinking of practicing clinicians engaged in HCC management, and give detailed guidance on how to deploy these modalities effectively for patients in various disease stages. KEY MESSAGES: Distinct from other regional guidelines, these recommendations provide guidance on the use of antiviral therapy to reduce the incidence of HCC in CHB patients with cirrhosis and to reduce recurrence of CHB-related HCC.

Surgical management of pancreatic necrosis: towards lesser and later.

BACKGROUND/PURPOSE: Our aim was to determine the overall success rate and survival rate with respect to the timing of intervention in the management of pancreatic necrosis. The use of minimally invasive pancreatic necrosectomy was also examined. METHODS: This was a retrospective study carried out in a tertiary referral hospital. The subjects were all patients who suffered from acute pancreatic necrosis with emergency interventions from January 2001 to December 2007. For outcome measures, special emphasis was placed on the overall success rate and survival rate with respect to the timing of intervention. The success rate of percutaneous pancreatic necrosectomy (PCPN) was examined. RESULTS: A total of 26 patients with pancreatic necrosis were studied. The overall mortality rate was 26.9% and the rate was significantly higher in those patients who had earlier intervention (before 6 weeks). Eleven patients had PCPN. There were 2 failures due to PCPN in the early phase; 2 had partial success, while the procedure was completely successful to remove all the necrotic tissues in the other 7 patients. CONCLUSIONS: With a multidisciplinary approach, particularly with sophisticated intensive care, most patients with pancreatic necrosis can survive the initial phase. Open surgery should be limited to simple drainage and laparostomy to relieve the abdominal tension. Active intervention preferably should be delayed until the necrosis has become walled off, when a variety of minimally invasive maneuvers, notably percutaneous necrosectomy, can be offered to remove the debris. The surgical management of pancreatic necrosis should change towards a strategy of "lesser and later".

Difficult retrieval of a retrievable inferior vena cava filter placed in an inverted orientation.

The present report describes a technique of retrieving a retrievable inferior vena cava (IVC) filter placed in an inverted orientation that had attached to the IVC wall. The filter was removed with difficulty via a combined jugular and femoral venous approach.

Endovascular Treatment for Central Venous Stenosis due to Central Vein Catheterization for Hemodialysis.

Central venous stenosis is usually due to previous catheter insertion in the subclavian vein or internal jugular vein. These patients usually present with swelling of the arm bearing the arterio-venous fistula and adequate hemodialysis is not feasible. Endovascular treatment includes balloon angioplasty and stenting, but there is early recurrence of stenosis. Balloon angioplasty is the first treatment of choice. Stent may be used if there is elastic recoil after angioplasty or there is recurrence of stenosis within three months after angioplasty. Endovascular irradiation and stent graft do not prolong the patency. The results of newer technique, like drug eluting stent and cutting balloon, have to be evaluated.

Anatomy of the portal vein bifurcation: implication for transjugular intrahepatic portal systemic shunts.

PURPOSE: The relationship of the portal vein bifurcation to the liver capsule in Asians, which is an important landmark for transjugular intrahepatic portosystemic shunt, has not previously been described. METHODS: The anatomy of the portal vein bifurcation was studied in 70 adult Chinese cadavers; it was characterized as intrahepatic or extrahepatic. The length of the exposed portion of the right and left portal veins was measured when the bifurcation was extrahepatic. RESULTS: The portal vein bifurcation was intrahepatic in 37 cadavers (53%) and extrahepatic in 33 cadavers (47%). The mean length of the right and left extrahepatic portal veins was 0.96 cm and 0.85 cm respectively. Both were less than or equal to 2 cm in 94% of the cadavers with extrahepatic bifurcation. There was no correlation between the presence of cirrhosis and the location of the portal vein bifurcation (p = 1.0). There was no statistically significant difference in liver mass in cadavers with either extrahepatic or intrahepatic bifurcation (p = 0.40). CONCLUSIONS: These findings suggest that for transjugular intrahepatic portosystemic shunt placement, a portal vein puncture 2 cm from the bifurcation will be safe in most cases.

Percutaneous relief of tension pneumomediastinum in a child.

The purpose of this article was to describe the experience of relieving tension pneumomediastinum by a fluoroscopic-guided percutaneous method. We inserted a percutaneous drainage catheter with a Heimlich valve under fluoroscopic guidance to relieve the tension pneumomediastinum in a 2-year-old girl who suffered from dermatomyositis with lung involvement. This allowed immediate relief without the need for surgery. The procedure was repeated for relapsed tension pneumomediastinum. Good immediate results were achieved in each attempt. We conclude that percutaneous relief of pneumomediastinum under fluoroscopic guidance can be performed safely and rapidly in patients not fit for surgery.

Randomized controlled trial to compare the dose of adjuvant chemotherapy after curative resection of hepatocellular carcinoma.

BACKGROUND AND AIM: Adjuvant locoregional chemotherapy has been shown to be useful to prevent recurrence after curative resection of hepatocellular carcinoma (HCC) in some retrospective studies. Our aim was to compare the dose effect in the prevention of tumor recurrence. METHODS: A prospective randomized controlled trial was conducted in patients with curative resection of HCC; they were given either one intra-arterial dose of cisplatin/lipiodol, or received four doses, once every 3 months. The rates of recurrence, disease-free and overall survival were compared. RESULTS: During a median follow up of 818 days, 21 patients received one dose and 19 received four doses, with 10 (47.6%) and eight (42.1%) recurrences, respectively. The 1-year, 2-year and 3-year disease-free survival rates were 71%, 54% and 44% for the one-dose group and 74%, 60% and 40% for the four-dose group (P = 0.78). The respective overall survival rates were 85%, 74%, 55% and 84%, 71%, 40% (P = 0.64). The only prognostic factor was presence of vascular permeation. The side-effects were mild and tolerable. CONCLUSIONS: There is no significant difference in the survival rates between the two groups. Adjuvant chemotherapy may not be useful.