[Management and treatment of liver injuries after blunt abdominal trauma]. / Management und Versorgung von Leberverletzungen nach stumpfem Bauchtrauma.

The liver is involved in about 20% of cases of blunt abdominal trauma. The management of liver trauma has changed significantly in the past three decades towards conservative treatment. Up to 80% of all liver trauma patients can now be successfully treated by nonoperative management. Decisive for this is the adequate screening and assessment of the patient and the injury pattern as well as the provision of the appropriate infrastructure. Hemodynamically unstable patients require immediate exploratory surgery. In hemodynamically stable patients, a contrast-enhanced computed tomography (CT) should be performed. If active bleeding is detected angiographic imaging and embolization should be performed to stop the bleeding. Even after initially successful conservative management of liver trauma, subsequent complications can occur that make surgical inpatient treatment necessary.

Introduction of laparoscopic nephrectomy for autosomal dominant polycystic kidney disease as the standard procedure.

PURPOSE: Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary disorder and accounts for 5-10% of all cases of kidney failure. 50% of ADPKD patients reach kidney failure by the age of 58 years requiring dialysis or transplantation. Nephrectomy is performed in up to 20% of patients due to compressive symptoms, renal-related complications or in preparation for kidney transplantation. However, due to the large kidney size in ADPKD, nephrectomy can come with a considerable burden. Here we evaluate our institution's experience of laparoscopic nephrectomy (LN) as an alternative to open nephrectomy (ON) for ADPKD patients. MATERIALS AND METHODS: We report the results of the first 12 consecutive LN for ADPKD from August 2020 to August 2021 in our institution. These results were compared with the 12 most recent performed ON for ADPKD at the same institution (09/2017 to 07/2020). Intra- and postoperative parameters were collected and analyzed. Health related quality of life (HRQoL) was assessed using the SF36 questionnaire. RESULTS: Age, sex, and median preoperative kidney volumes were not significantly different between the two analyzed groups. Intraoperative estimated blood loss was significantly less in the laparoscopic group (33 ml (0-200 ml)) in comparison to the open group (186 ml (0-800 ml)) and postoperative need for blood transfusion was significantly reduced in the laparoscopic group (p = 0.0462). Operative time was significantly longer if LN was performed (158 min (85-227 min)) compared to the open procedure (107 min (56-174 min)) (p = 0.0079). In both groups one postoperative complication Clavien Dindo ≥ 3 occurred with the need of revision surgery. SF36 HRQol questionnaire revealed excellent postoperative quality of life after LN. CONCLUSION: LN in ADPKD patients is a safe and effective operative procedure independent of kidney size with excellent postoperative outcomes and benefits of minimally invasive surgery. Compared with the open procedure patients profit from significantly less need for transfusion with comparable postoperative complication rates. However significant longer operation times need to be taken in account.

[Management of bile duct injuries]. / Management von Gallengangsverletzungen.

Bile duct injuries can occur after abdominal trauma, postoperatively after cholecystectomy, liver resection or liver transplantation and also as a complication of endoscopic retrograde cholangiopancreatography (ERCP). The clinical appearance of bile duct injuries is highly variable and depends primarily on the underlying cause. In addition to the high perioperative morbidity, following successful initial complication management, bile duct injuries can lead to significant long-term complications. The treatment requires close interdisciplinary cooperation between surgery, interventional gastroenterology and interventional radiology. The treatment of bile duct injuries depends primarily on the time of diagnosis (intraoperative/postoperative) as well as the extent of the injury and is discussed in this review.

[Image-guided, minimally invasive surgery and other local therapeutic procedures for primary liver tumors]. / Bildgestützte minimal-invasive Chirurgie und andere lokaltherapeutische Verfahren bei primären Lebertumoren.

BACKGROUND: The incidence of primary liver tumors is rising. Modern minimally invasive, image-guided procedures offer a potentially curative therapy option. OBJECTIVE: The aim of this study was to evaluate the multitude of image-guided minimally invasive procedures concerning their evidence-based effect on local tumor control and overall survival. MATERIAL AND METHODS: A systematic search of MEDLINE focused on hepatocellular cancer, minimally invasive treatment, local ablative therapy, therapeutic stratification and comparative studies was performed. RESULTS: The level of evidence varied greatly depending on the procedure used. The highest quality evidence including prospective randomized studies was found for radiofrequency ablation (RFA) of hepatocellular cancer. The RFA is superior with respect to local tumor control and overall survival in comparison to other ablative procedures. Prospective randomized studies comparing surgery and RFA showed diverging and contradictory results. Microwave ablation and robotic stereotactic irradiation showed sufficient potential in retrospective studies in comparison to RFA and surgery in order to confirm the techniques in randomized studies. There is only anecdotal evidence concerning high intensity focused ultrasound (HIFU) and irreversible electroporation. Percutaneous ethanol injection (PEI), cryoablation and laser-induced thermal therapy (LITT) were inferior techniques to RFA in most studies. CONCLUSION: Minimally invasive resection and local ablative therapies based on structured imaging and image reporting can improve the prognosis of patients with hepatocellular cancer even in patients that exceed the BCLC 0/A stage.

Correlation Between the Transplant Evaluation Rating Scale (TERS) and Medical Outcomes in Living-Donor Kidney Transplant Recipients: A Retrospective Analysis.

BACKGROUND: Pretransplant psychosocial evaluation of living-donor kidney transplantation (LDKT) candidates identifies recipients with potentially inferior posttransplant outcomes. Rating instruments, based on semi-standardized interviews, help to improve and standardize psychosocial evaluation. The goal of this study was to retrospectively investigate the correlation between the Transplant Evaluation Rating Scale (TERS) and transplant outcome in LDKT recipients. METHODS: TERS scores were retrospectively generated by 2 raters based on comprehensive interviews of 146 LDKT recipients conducted by mental health professionals (interrater reliability, 0.8-0.9). All patients were eligible for transplantation according to pretransplant psychosocial evaluation. Patients were classified into 2 groups according to their TERS scores, in either two thirds excellent risk (TERS <29) and one third at least moderate risk (TERS ≥29) candidates. Analyzed medical parameters were change in estimated glomerular filtration rate and acute rejection (AR) episodes within the first year posttransplant. In addition, a subgroup of 65 patients was tested for de novo donor-specific HLA antibodies (DSA) posttransplant. RESULTS: There was no significant difference between the excellent (n = 97) and at least moderate (n = 49) risk candidates according to TERS in terms of organ function (estimated glomerular filtration rate decline >25%: 17 of 97 vs 11 of 49; P = .51) and episodes of AR (19 of 97 vs 15 of 49; P = .15). Patients developing de novo DSA (n = 18 [28%]) did not have higher pretransplant TERS scores (DSA positive, 11 of 42 vs 7 of 23; P = .78). CONCLUSIONS: Classifying LDKT recipients according to TERS score did not predict medical outcome at 1 year posttransplant or the occurrence of de novo DSA.

Prospective Analyses of Circulating B Cell Subsets in ABO-Compatible and ABO-Incompatible Kidney Transplant Recipients.

Immunosuppressive strategies applied in renal transplantation traditionally focus on T cell inhibition. B cells were mainly examined in the context of antibody-mediated rejection, whereas the impact of antibody-independent B cell functions has only recently entered the field of transplantation. Similar to T cells, distinct B cell subsets can enhance or inhibit immune responses. In this study, we prospectively analyzed the evolution of B cell subsets in the peripheral blood of AB0-compatible (n = 27) and AB0-incompatible (n = 10) renal transplant recipients. Activated B cells were transiently decreased and plasmablasts were permanently decreased in patients without signs of rejection throughout the first year. In patients with histologically confirmed renal allograft rejection, activated B cells and plasmablasts were significantly elevated on day 365. Rituximab treatment in AB0-incompatible patients resulted in long-lasting B cell depletion and in a naïve phenotype of repopulating B cells 1 year following transplantation. Acute allograft rejection was correlated with an increase of activated B cells and plasmablasts and with a significant reduction of regulatory B cell subsets. Our study demonstrates the remarkable effects of standard immunosuppression on circulating B cell subsets. Furthermore, the B cell compartment was significantly altered in rejecting patients. A specific targeting of deleterious B cell subsets could be of clinical benefit in renal transplantation.

Bile duct carcinoma recurrence in the papillary region in a long-term survivor of hilar cholangiocarcinoma: a case report.

BACKGROUND: Because of its high rate of early recurrence and its poor prognosis, long-term survival after cholangiocarcinoma is rare; therefore, only limited information on patients surviving more than 5 years after surgical therapy is available. CASE PRESENTATION: We report the case of a 57-year-old white man who developed a distal bile duct carcinoma 9 years after curative surgical therapy of intrahepatic cholangiocarcinoma. He had undergone a right lobe hemihepatectomy 11 years ago. Nine years later, he was diagnosed with a distal bile duct carcinoma and a duodenopancreatectomy was performed. On histologic examination both carcinomas revealed a tubular and papillary growth pattern with cancer-free resection margins and for both carcinomas there were no signs of lymphatic infiltration or metastatic spreading. Targeted next-generation sequencing showed an identical activating mutation pattern in both carcinomas. CONCLUSIONS: Late recurrence of cholangiocarcinoma, even anatomically distant to the primary, in long-time survivors is possible and could be caused by a distinct tumor biology. A better understanding of the individual tumor biology could help hepatologists as well as hepatobiliary and pancreatic surgeons in their daily treatment of these patients.

Postoperative Continuous Infusion of Local Anesthesia in Hand-Assisted Retroperitoneoscopic Living Donor Nephrectomy.

INTRODUCTION: Postoperative pain management in living kidney donor nephrectomy plays a key role in donor comfort and is important for the further acceptance of living kidney donation in times of organ shortage. Standard pain treatment (SPT) based on opioids is limited due to related side effects. Continuous infusion of local anesthesia (CILA) into the operative field is a promising alternative. The aim of this study was to evaluate whether CILA could reduce the dose of opioids in living kidney donors operated with hand-assisted retroperitoneoscopic donor nephrectomy (HARP). METHODS: An observational study on 30 living donors was performed. The primary outcome was the difference of morphine equivalents (MEQ) administered between CILA and SPT. RESULTS: On day 0 and 1, living donors with CILA received significant less MEQ compared to the SPT group, although on day 1 this effect was not statistically significant (day 0: 6.3 mg, interquartile range [IR] 4.2-11.2 vs 16.8 mg, IR 10.5-22.1, P = .009; day 1: 5.25 mg, IR 2.1-13.3 vs 13.3 mg, IR 6.7-23.8, P = .150). On days 2 and 3 there was no difference (day 2: 13.3 mg, IR 0.0-20.0 vs 13.3 mg, IR 6.7-13.3, P = .708; day 3: 13.3 mg, IR 0.0-26.7 vs 13.3 mg, IR 6.7-20, P = .825). Overall (days 0 to3) MEQ was also less for CILA without reaching statistical significance (39.6 mg, IR 10.9-70.5 vs 59.6 mg, IR 42.4-72.9, P = .187). CONCLUSIONS: CILA seems to be an effective instrument for donor pain management in the first 24 hours after HARP. Its effect abates by 48 hours after surgery, especially if highly potent nonopioids are given.

Prognosis after "high urgent" kidney transplantation might be determined by control of preexisting septic condition.

INTRODUCTION: Dialysis is the standard bridging method for patients with end-stage renal disease. In rare cases, dialysis is impossible and immediate kidney transplantation (KT) is the only option for survival. Most allocation organizations offer an immediate allocation procedure (high urgency [HU]), which focuses on immediate allocation at the cost of immunologic matching. The impossibility of dialysis is mainly caused by multiple systemic thromboses and blood stream infections. This situation creates an ethical dilemma: Accepting the HU-KT allocation potentially saves the patient's life albeit with negatively effects on the expected patient and organ survivals. In times of organ shortage, more information is needed regarding this difficult decision; the published literature is limited to 4 papers. METHODS: We performed a retrospective analysis of patients who were transplanted by HU allocation in our center between January 1989 and October 2010. RESULTS: Of 1040 KT, 10 (0.96%) were performed in HU condition. Mean follow-up time was 37 months. The main reason for HU-KT was exhaustion of vascular access in combination with a bloodstream infection. All recipients showed severe preoperative comorbidities. Patient survival was 90% at 1, 80% at 3, and 60% at 5 years. There was 1 graft loss owing to chronic rejection. CONCLUSION: When kidney transplantation is performed as an HU procedure, it is associated with a greater morbidity and mortality compared with elective cases. Bloodstream infections that existed before transplantation contributed considerably to mortality.

Lymph node size and metastatic infiltration in adenocarcinoma of the pancreatic head.

BACKGROUND: Preoperative lymph node staging of pancreatic cancer by CT relies on the premise that malignant lymph nodes are larger than benign nodes. In imaging procedures lymph nodes >1 cm in size are regarded as metastatic nodes. The extend of lymphadenectomy and potential application of neoadjuvant therapy regimens could be dependent on this evaluation. PATIENTS AND METHODS: In a morphometric study regional lymph nodes from 52 patients with pancreatic cancer were analyzed. The lymph nodes were counted, the largest diameter of each node was measured, and each node was analyzed for metastatic involvement by histopathological examination. The frequency of metastatic involvement was calculated and correlated with lymph node size. RESULTS: A total of 636 lymph nodes were present in the 52 specimens examined for this study (12.2 lymph nodes per patient). Eleven patients had a pN0 status, whereas 41 patients had lymph nodes that were positive for cancer. Five-hundred-twenty (82%) lymph nodes were tumor-free, while 116 (18%) showed metastatic involvement on histopathologic examination. The mean (±SD) diameter of the nonmetastatic nodes was 4.3 mm, whereas infiltrated nodes had a diameter of 5.7 mm (p = 0.001). Seventy-eight (67%) of the infiltrated lymph nodes and 433 (83%) of the nonmetastatic nodes were ≤5 mm in diameter. Of 11 pN0 patients, 5 (45%) patients had at least one lymph node ≥10 mm, in contrast only 12 (29%) out of 41 pN1 patients had one lymph node ≥10 mm. CONCLUSION: Lymph node size is not a reliable parameter for the evaluation of metastatic involvement in patients with pancreatic cancer.

Electro-physiological parameters of hepatic radiofrequency ablation--a comparison of an in vitro versus an in vivo porcine liver model.

BACKGROUND: Radiofrequency ablation (RFA) is an inherent part of curative treatment within a multimodal therapy concept of malignant liver tumors. The biggest problem is the high rate of local recurrences in tumors with a diameter of more than 3 cm because of the high variability and poor reproducibility of the zone of ablation. No imaging modality facilitates monitoring during neither intraoperativ nor percutaneous RFA. This experimental study describes and compares an in vitro and in vivo porcine model by its electro-physiological parameters with the aim of monitoring RFA procedures. MATERIALS AND METHODS: RFA was performed in a perfused in vitro porcine (one RFA per liver) and in vivo porcine model (24 animals) with three different RFA systems (Rita XL 5 cm, Rita XLi 7 cm, LeVeen 5 cm). In the in vivo model, percutaneous placement of the RFA device was guided by native and contrast-enhanced CT scan. The electro-physical parameters during RFA were online (in real time) recorded by a dedicated software. After the RFA, the livers were explanted, sliced, and measured according to the consensus technique. RESULTS: The delivered energy was in vivo versus in vitro: Rita XL 238 +/- 135 kJ versus 135 +/- 53 kJ (p = 0.247); Rita XLi 711 +/- 180 kJ versus 159 +/- 54 (p = 0.016) and with LeVeen 212 +/- 71 kJ (in vivo). The LeVeen system was inconsistent in the in vitro model. This correlates to an energy consumption per ml of necrosis in vivo versus in vitro Rita XL of 8 +/- 3 kJ/ml versus 6.4 +/- 3.9 kJ/ml (p = 0.537), Rita XLi of 10 +/- 6 kJ/ml versus 1.8 +/- 0.2 kJ/ml (p = 0.016), and LeVeen of 14.0 +/- 12 kJ/ml (in vivo). The volume of ablation was in vivo versus in vitro Rita XL 30 +/- 10 ml versus 26 +/- 17 ml (p = 0.329), Rita XLi 90 +/- 58 ml versus 88 +/- 21 ml (p = 0.905), and LeVeen 22 +/- 11 ml versus 50 +/- 12 ml (p = 0.04). The impedance during RFA were in vivo versus in vitro Rita XL 39 +/- 4 Omega versus 50 +/- 14 Omega (p < 0.247), Rita XLi 33 +/- 5 Omega versus 61 +/- 16 Omega (p = 0.016) and LeVeen 31 +/- 2 Omega (in vivo). CONCLUSION: The volume of ablation showed analogue data in vivo and in vitro. The delivered energy and energy consumption was in vivo up to five times (Rita XLi) higher than in vitro and the impedance in vivo was always lower than in vitro. These differences observed between in vivo and in vitro were more pronounced than previously described. Thus the use of an in vitro model for research of the RFA technique must be challenged. The large deployment of the Rita XLi was a problem for percutaneous positioning of the device without direct contact to liver surface or major vessels in 80-kg pigs and to a lesser extent in in vitro liver originating from 130- to 140-kg pigs. Modern RFA systems which generate large volume of tissue necrosis can therefore only be adequately tested in a porcine model with a liver weight of at least 1.5-2 kg. Alternatively, a bovine liver model (with a liver weight up to 10 kg) should be developed in the future.

Competition between native liver and graft in auxiliary liver transplantation in a rat model.

The competition between the native and the grafted liver in heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA) was investigated in a rat model. The experimental groups were: HALT with flow-regulated PVA and 70% resection of a native liver and graft (n = 32; group I) versus 70% liver resection (n = 32; group II). After HALT, the weight of the native liver increased until the sixth postoperative week (431% +/- 55% of the intraoperative weight), whereas, the graft weight was only 76% +/- 31% of the intraoperative weight at this time. In group II, liver weight increased continuously to 529% +/- 30% of the intraoperative weight after 6 weeks. On postoperative day 2, there was significantly increased proliferative hepatocellular activity in all groups. This was highest in the resected livers of group II, followed by the native livers of group I, and the grafts of group I (301 +/- 126 vs 262 +/- 97 vs 216 +/- 31 Ki-67-positive hepatocytes/10 visual fields). However, the differences between the groups were not significant. With regard to hepatocellular apoptosis, the livers were similar among all groups and at all time points, M30-positive hepatocyte counts were

[Percutaneous, laparoscopic and open surgical radiofrequency ablation of malignant liver lesions]. / Interventionelle, laparoskopische und offen operative Radiofrequenztherapie maligner Leberläsionen.

The growing clinical impact of radiofrequency ablation of liver lesions is reflected by a rapidly increasing number of published papers. Experimental work focuses on factors that reduce the variability of the ablation zone. The Pringle-maneuver plays a key role in this question from a surgeon's perspective. Large single center studies and a meta-analysis show a sharp rise in the rate of local recurrences for tumors larger 3 cm. An open surgical approach is significantly correlated to a low local recurrence rate. Bile duct lesions and intrahepatic abscesses are the most frequent complications. Intraductal bile duct cooling can prevent these complications. Three prospective randomized trials support the use of RFA for small hepatocellular carcinoma. The use of RFA in patients with multiple colorectal metastases is supported by single center studies showing a 3 year survival of > 35%. The favourable cost / benefit ratio will make RFA a part of future multimodal cancer therapy concepts.

[Primary cholangiocarcinoma in a case of Caroli's disease: case report and literature review]. / Primäres Cholangiokarzinom auf dem Boden einer Caroli-Erkrankung. Fallbericht und Literaturübersicht.

Caroli's disease is a liver disease with segmental cystic dilatation of the intrahepatic bile ducts. It belongs to the group of congenital ductal plate malformations. With an incidence of only 0.05% of all liver cases in the Liver Registry of the University of Cologne, it is a very rare disorder. Caroli's disease is usually combined with cholangitis and bile duct stones. Control of these infections and maintenance of biliary drainage are the main therapeutic aims. The development of intra epithelial neoplasia and invasive carcinoma are rare complications. We report a case of Caroli's disease with the development of cholangiocarcinoma and review the literature.

Successful renal transplantation in a child with thrombosis of the inferior vena cava and both iliac veins.

An 8-year-old girl who was born premature in the 24th gestational week suffered a septic venous thrombosis due to an indwelling central line during the early perinatal period. As a result the inferior vena cava including the intrahepatic segment and both iliac veins was obliterated. The right kidney was primarily dysplastic, and the left kidney developed a partial infarction. Renal function was compensated until the age of 6 years. Magnetic resonance angiography at that time showed a collateral system via the azygos vein. The venous pressure and its variation with breathing as measured invasively showed normal values. During pretransplant initiation of immunosuppressive therapy, the child developed cerebral convulsions after the third dose of cyclosporine. Therefore we utilized a regimen of rapamycin, mycophenolate mofetil, and steroids. The transplantation was performed using a living donor graft from the child's mother. The relatively long vein from the left kidney was used for anastomosis with a large presacral collateral vein. Twelve months after transplantation the kidney function is stable with a serum creatinine of 0.5 mg/dL. The recipient thrombosis of the caval and iliac veins is not a principal contraindication for successful renal transplantation. MR angiography and invasive pressure measurements facilitated evaluation of the collateral venous system. The living donation setting allowed the initiation of an immunosuppressive regimen that was tailored to the concomitant diseases of the child.

Portal hyperperfusion causes disturbance of microcirculation and increased rate of hepatocellular apoptosis: investigations in heterotopic rat liver transplantation with portal vein arterialization.

Clinical results of portal vein arterialization (PVA) in liver transplantation are controversial. One reason for this is the lack of a standardized flow regulation. Our experiments in rats compared PVA with blood-flow regulation to PVA with hyperperfusion in heterotopic auxiliary liver transplantation (HALT). In group I (n = 19), the graft's portal vein was completely arterialized via the right renal artery in-stent technique, using a 0.3-mm stent, leading to a physiological average portal blood flow. In group II (n = 19), a 0.5-mm stent was used. In group II, the average portal blood flow after reperfusion was significantly elevated (group II: 6.4 +/- 1.5; group I: 1.7 +/- 0.4 mL/min/g of liver weight; P < .001). The sinusoidal diameter after reperfusion was significantly greater in group II (9.8 +/- 0.5 microm) than in group I (5.5 +/- 0.2 microm; P < .001). Red blood cell velocity in the dilated sinusoids was significantly lower in group II (171 +/- 18 microm/s) than in group I (252 +/- 13 microm/s). Stasis of erythrocytes occurred; consequently, the functional sinusoidal density was significantly reduced in group II (38 +/- 7%) compared with group I (50 +/- 3%; P < .01). Two hours after reperfusion of the portal vein, the number of apoptotic hepatocytes was significantly higher in group II than in group I (I: 0 +/- 0 vs II: 7 +/- 9 M30-positive hepatocytes/10 high-power fields). The 6-week survival rate was 9 of 11 in both groups. In group II, 6 of 9 grafts showed massive hepatocellular necroses after 6 weeks, whereas in group I, only 1 of 9 presented a slight hepatocellular necrosis. Finally, our results demonstrate negative effects of portal hyperperfusion in transplanted livers, which are correctable by adequate flow regulation.

Supraventricular tachyarrhythmia as early indicator of a complicated course after esophagectomy.

In a group of 89 consecutive patients with a standardized operative procedure, the incidence of supraventricular tachyarrhythmia (SVT), predisposing risk factors (preoperative and intraoperative factors and parameters of intensive care strategy) and therapeutic strategies were evaluated. Operative treatment consisted of transthoracic esophagectomy, gastric interposition and intrathoracic anastomosis. Overall hospital mortality was 6.7%. In 32 (37%) patients a new onset SVT occurred. Age and elevated body temperature were the only significant risk factor for SVT in the multivariate analysis, their odds ratios being 1.3 for each year above 58 and 5.6 for each degree above 37.8 degrees C, respectively. Secondary risk factors were history of hypertension and use of epinephrine, the corresponding odds ratios being 6.6 and 10.2. Digitalis (2/32) and calcium-antagonists (2/9) were unsatisfactory, while beta-blockers (13/20) and amiodarone (12/12) were efficient therapeutic agents. Incidence of SVT was significantly correlated with the development of postoperative septic complications.

Successful use of sirolimus in a patient with bulky ovarian metastasis of hepatocellular carcinoma after liver transplantation.

This 44-year-old woman developed multifocal hepatocellular carcinoma (HCC) within hepatitis B-induced liver cirrhosis. At the time of listing for transplantation the HCC had progressed beyond the Milan criteria. Due to her young age, high grade of histological differentiation according to biopsy, and lack of therapeutic alternatives, she was listed for transplantation. She received an organ from the Eurotransplant marginal liver list. Immunosuppression was reduced to tacrolimus monotherapy within 4 months. Five months after transplantation bilateral bulky ovarian metastases were seen on computed tomography (CT) scan. A bilateral salphingo-oophorectomy was performed and immunosuppression switched to sirolimus monotherapy. Fourteen months after this procedure and 19 months after transplantation, the patient is asymptomatic with stable liver function. She is free of recurrence as judged by CT scan, bone scan, and alpha-fetoprotein. In conclusion, radical surgical treatment and immunosuppression using sirolimus may achieve tumor-free survival in selected patients with advanced or recurrent HCC.

Experimental bile duct protection by intraductal cooling during radiofrequency ablation.

BACKGROUND: The use of radiofrequency ablation (RFA) for liver tumours is limited by the proximity of large bile ducts to the targeted lesion. The aim of this randomized study was to evaluate intraductal cooling as a mean of protecting the bile ducts during RFA. METHODS: Twelve pigs underwent RFA adjacent to the right bile duct. After placement of an intraductal cooling catheter and a RFA probe, pigs were randomized to cooling or no cooling. Intraductal temperature was measured in all animals. The bile ducts were assessed by magnetic resonance imaging (MRI) and cholangiography 1 and 28 days after the procedure. RESULTS: Intraductal cooling abolished the increase of intraductal temperature seen in the absence of cooling. Concurrent cholangiography and MRI showed a biliary lesion in one of six pigs subjected to intraductal cooling and in five of six without cooling (P = 0.040). The biliary injuries were barely visible by MRI on day 1 but were clearly visible on day 28. CONCLUSION: Intraductal cooling can prevent biliary injury induced by RFA. The exact parameters for intraductal cooling require further investigation to establish the best compromise between bile duct protection and complete ablation of surrounding tissue.