Personnel dose reduction in 90Y microspheres liver-directed radioembolization: from interventional radiology suite to patient ward.

OBJECTIVE: To describe a method to reduce the external radiation exposure emitted from the patient after liver-directed radioembolization using 90Y glass microspheres, to quantitatively estimate the occupational dose of medical personnel providing patient care to the patient radioembolized with the use of the method and to discuss radiation exposure to patients who are adjacent if the patient radioembolized needs hospitalization. METHODS: A lead-lined blanket of lead equivalence of 0.5 mm was used to cover the patient abdomen immediately after the 90Y radioembolization procedure, in order to reduce the radiation emitted from the patient. The interventional radiologist used a rod-type puncture site compressor for haemostasis to avoid direct contact with possible residual radioactivity at the puncture site. Dose rates were measured at the interventional radiologist chest and hand positions during puncture site pressing for haemostasis with and without the use of the blanket. The measurement results were applied to estimate the occupational dose of colleagues performing patient care to the patient radioembolized. The exposure to patients adjacent in the ward was estimated if the patient radioembolized was hospitalized. RESULTS: The radiation exposures measured at the radiologist chest and hand positions have been significantly reduced with the lead-lined blanket in place. The radiologist, performing puncture site pressing at the end of radioembolization procedure, would receive an average hand dose of 1.95 µSv and body dose under his own lead apron of 0.30 µSv for an average 90Y microsphere radioactivity of 2.54 GBq. Other medical personnel, nurses and porters, would receive occupational doses corresponding to an hour of background radiation. If the patient radioembolized using 90Y needs hospitalization in a common ward, using the lead-lined blanket to cover the abdomen of the patient and keeping a distance of 2 m from the patient who is adjacent would reduce the exposure by 0.42% of dose limit for the general public. CONCLUSION: By placing a lead-lined blanket on the patient abdominal region after 90Y radioembolization, hospital staff receive minimal radiation exposure in order to comply with the radiation protection "as low as reasonably achievable" principle. There will be no increase in radiation level in ward if the patient radioembolized using 90Y needs to be hospitalized. Therefore, the patient radioembolized can be accommodated alternatively at a corner bed of a common ward if an isolation room with private toilet facility is not available. Advances in knowledge: To reduce exposure to personnel providing patient care to patients radioembolized using 90Y.

Conservative management of placenta praevia with accreta.

It has been advocated that placenta accreta/percreta should be managed conservatively to avoid massive pelvic bleeding and preserve fertility. Diagnosis of this condition with high-resolution imaging investigations performed during the antenatal period facilitates discussion of management plans with other clinical disciplines (eg interventional radiologists), the patient, and her family. Three cases of placenta praevia with accreta are presented. The three cases were managed by leaving the placenta in-utero after caesarean section, using uterine arterial embolisation to control postpartum haemorrhage only when needed. In all these cases, we succeeded in conserving the uterus without major complications. With improved imaging techniques, accurate antenatal diagnosis of placenta praevia with accreta is now possible. This new approach to conservative management can be considered in order to not only conserve the uterus but also to avoid uncontrolled pelvic haemorrhaging.

Efficacy and complications in peripherally inserted central catheter insertion: a study using 4-Fr non-valved catheters and a single infusate.

The purpose of this prospective study was to evaluate the efficacy and complications associated with the use of 4-Fr single-lumen non-valved peripherally inserted central venous catheters (PICC) for the infusion of long-term antibiotics. Forty-four non-valved PICC were inserted using micropuncture technique by interventional radiologists. Six patients were lost to unrelated death or follow up. The remaining 38 patients (24 men and 14 women; mean age 54.79 years) were analysed. Catheters were placed under ultrasound guidance using micropuncture technique and subsequently advanced over guidewire through peel-away sheath under fluoroscopic guidance. Doppler ultrasound was used before PICC removal in order to detect possible complications. All non-valved PICC were flushed with 5 ml of heparinized saline before and after each antibiotic infusion. Efficacy was evaluated and analysed on the average duration of catheter patency and whether any complication was present. Procedural success rate was 100% in our patient population. Seven patients had complications necessitating early PICC removal with the average patency duration of 44 days (95% confidence interval 7.79-80.21 days), whereas an average indwelling patency duration of the remaining 31 patients with no complication was 30.58 days (95% confidence interval 25.74-35.43 days). Total complication rate was calculated to be 5.58 incidences per 1000 catheter days. Complication rate associated with the placement and use of 4-Fr non-valved PICC for antibiotic therapy was observed to be low when compared with other studies using valved and non-valved PICC for various infusates.

Percutaneous retrieval of a chronic foreign body with both intravascular and extravascular components.

Removal of unwanted intravascular foreign body is a useful but infrequent procedure carried out by interventional radiologists. We study a patient who had a long guidewire left in her body following central venous catheter placement by a surgeon. The guidewire was later found in situ, with both intravascular and extravascular components in continuity. We successfully removed the guidewire without causing any complications. Standard interventional techniques, Amplatz gooseneck snare (Microvena, White Bear Lake, MN, USA) and 6-Fr Multipurpose catheter were used.

Improved operative and survival outcomes of surgical treatment for hilar cholangiocarcinoma.

BACKGROUND: The aim of the present study was to assess whether an aggressive surgical approach in the management of patients with hilar cholangiocarcinoma was associated with improved operative and survival outcomes. METHODS: Eighty-two patients with hilar cholangiocarcinoma treated between 1989 and 1998 (period 1), and 60 patients treated between 1999 and 2004 (period 2), were evaluated. Modifications to management in period 2 primarily included percutaneous biliary drainage instead of endoscopic drainage for relief of obstructive jaundice, preoperative right portal vein embolization before right-sided hepatectomy, routine total caudate lobectomy and radical lymphadenectomy during surgical resection of the tumour. RESULTS: The surgical resection rate was significantly higher in period 2 than in period 1 (45 versus 16 per cent; P < 0.001). All patients in period 2 underwent major hepatectomy with concomitant caudate lobectomy. The operative morbidity and hospital mortality rates decreased significantly in period 2 compared with period 1, with significantly better survival outcomes. In multivariate analysis, resection of the tumour in period 2 and operative blood loss of 1.5 litres or less were the significant independent factors associated with improved survival. CONCLUSION: An aggressive surgical approach was associated with improved operative and survival outcomes for patients with hilar cholangiocarcinoma.

Efficacy and safety of radiofrequency ablation for perivascular hepatocellular carcinoma without hepatic inflow occlusion.

BACKGROUND: The role of radiofrequency ablation (RFA) for perivascular (up to 5 mm from the major intrahepatic portal vein or hepatic vein branches) hepatocellular carcinoma (HCC) is unclear because of possible incomplete tumour ablation and potential vascular damage. This study aimed to evaluate the safety and efficacy of RFA for perivascular HCC without hepatic inflow occlusion. METHODS: Between May 2001 and November 2003, RFA using an internally cooled electrode was performed on 52 patients with perivascular HCC (group 1) through open (n = 39), percutaneous (n = 9), laparoscopic (n = 2) and thoracoscopic (n = 2) approaches. Hepatic inflow occlusion was not applied during the ablation procedure. The perioperative and postoperative outcomes were compared with those of 90 patients with non-perivascular HCC (group 2) treated by RFA during the same period. RESULTS: The morbidity rate was similar between groups 1 and 2 (25 versus 28 per cent; P = 0.844). One patient in group 1 (2 per cent) and two in group 2 (2 per cent) had developed thrombosis of major intrahepatic blood vessels on follow-up computed tomography scan. There were no significant differences between groups 1 and 2 in mortality rate (2 versus 0 per cent; P = 0.366), complete ablation rate for small HCC (92 versus 98 per cent; P = 0.197), local recurrence rate (11 versus 9 per cent; P = 0.762) and overall survival (1-year: 86 versus 87 per cent; 2-year: 75 versus 75 per cent; P = 0.741). CONCLUSION: RFA without hepatic inflow occlusion is a safe and effective treatment for perivascular HCC.

Portal vein embolisation prior to extended right-sided hepatic resection.

OBJECTIVES: To determine whether preoperative portal vein embolisation improves the operative outcome of patients undergoing extended right-sided hepatic resection for hepatobiliary malignancy. DESIGN: Prospective non-randomised study. SETTING: University teaching hospital, Hong Kong. PATIENTS: Ninety-two patients underwent extended right-sided hepatic resection for hepatobiliary malignancy during a 45-month period (January 2000 to September 2003). Among them, 15 (16%) underwent portal vein embolisation via a percutaneous ipsilateral approach (n=9) or through the ileocolic vein with a mini-laparotomy (n=6). The remaining 77 (84%) patients underwent hepatic resection without portal vein embolisation. MAIN OUTCOME MEASURES: Operative morbidity and mortality. RESULTS: Patients undergoing portal vein embolisation were older (69 years vs 55 years; P=0.009), and had significantly worse preoperative renal function (creatinine, 96 micromol/L vs 86 micromol/L; P=0.039) and liver function (bilirubin, 23 micromol/L vs 12 micromol/L; P<0.001). Portal vein embolisation resulted in an increase in the future liver remnant of 9% (interquartile range, 7-13%) of the estimated standard liver volume. The operating time for patients receiving portal vein embolisation was significantly longer (medium, 660 min vs 420 min; P<0.001) with more complicated surgery performed in terms of concomitant caudate lobectomy and hepaticojejunostomy. There was no hospital mortality in patients who underwent portal vein embolisation whereas five without the treatment died (P=0.587). The operative morbidity of patients who underwent portal vein embolisation and those who did not was 20% and 30%, respectively (P=0.543). CONCLUSIONS: In older patients who have worse preoperative liver and renal functions, portal vein embolisation enhances the possibility to perform extended right-sided hepatic resection for hepatobiliary malignancies with potentially lower operative mortality and morbidity.

Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography.

BACKGROUND: Occult biliary stones escape detection on conventional investigations, and clinico-biochemical systems proposed for predicting biliary pancreatitis has low predictive values. AIM: To evaluate the accuracy of clinico-biochemical parameters for prediction of biliary pancreatitis in patients undergoing endoscopic ultrasonography. METHODS: Early endoscopic ultrasonography was performed on 139 patients presenting with acute pancreatitis within 24 h of admission. The aetiologies of all patients were determined after complete evaluations, and clinico-biochemical characteristics of patients with a biliary cause (biliary group) and non-biliary causes (non-biliary group) were compared. RESULTS: Biliary pancreatitis was diagnosed in 107 patients and 32 patients had non-biliary causes. The biliary group belonged to a significantly older age group, had a female predominance, significantly more derangement of liver function and a higher incidence of severe attack of acute pancreatitis. On multivariate analysis, female sex, age >58 years and serum alanine aminotransferase >150 U/L were independent predictive factors for biliary cause of acute pancreatitis. Using these three factors for prediction of biliary cause, the sensitivity was 93% and overall accuracy was 85%. CONCLUSION: Clinico-biochemical prediction for biliary cause of acute pancreatitis improves in the era of endoscopic ultrasonography with a higher sensitivity and overall accuracy. In centres where endoscopic ultrasonography is inaccessible or local expertise is unavailable, clinico-biochemical prediction of biliary cause of acute pancreatitis may provide a useful alternative in the initial management of this group of patients.

Multiple brain abscesses in a patient with bilateral pulmonary arteriovenous malformations and immunoglobulin deficiency.

A 34 year old Chinese man presented with grand mal seizures complicating multiple brain abscesses caused by mixed oral flora. Because of persistent hypoxaemia contrast spiral thoracic computed tomography was done, which revealed bilateral pulmonary arteriovenous malformations (PAVMs). Concomitant IgA and IgG subclass deficiency was also found. The combination of these two conditions appears to have predisposed this patient to presumably paradoxical septic embolism. The patient's cerebral condition responded to postoperative antibiotic treatment and he eventually received selective coil embolisation of right lower lobe PAVMs, which relieved his hypoxaemia and dyspnoea.

Factors predictive of 5-year survival after transarterial chemoembolization for inoperable hepatocellular carcinoma.

BACKGROUND: Transarterial chemoembolization (TACE) is widely used for unresectable hepatocellular carcinoma (HCC), but the long-term survival benefit remains unclear. METHODS: Pretreatment variables were analysed for factors predictive of actual 5-year survival from a prospective database of patients with inoperable HCC treated by TACE between 1989 and 1996. RESULTS: Complete 5-year follow-up (median 91 months) was obtained for 320 patients who underwent a median of 4 (range 1-41) TACEs. Median tumour size was 9 (range 1-28) cm. There were 25 5-year survivors (8 per cent), including eight with tumours larger than 10 cm in diameter and three with portal vein branch involvement. On univariate analysis, female gender (P = 0.037), absence of ascites (P = 0.028), platelet count below 150 x10(9) per litre (P = 0.011), albumin concentration greater than 35 g/l (P = 0.04), alpha-fetoprotein level below 1000 ng/ml (P = 0.007), unilobar tumour (P = 0.027), fewer than three tumours (P = 0.015), absence of venous invasion (P = 0.011), and tumour diameter less than 8 cm (P = 0.021) were significant predictors of 5-year survival. Albumin concentration greater than 35 g/l (P = 0.011), unilobar tumour (P = 0.012) and alpha-fetoprotein level below 1000 ng/ml (P = 0.014) were independent prognostic factors on multivariate analysis. CONCLUSION: Five-year survival is possible with TACE for inoperable HCC, even in some patients with advanced tumours. Unilobar tumours, alpha-fetoprotein level below 1000 ng/ml and albumin concentration greater than 35 g/l were factors predictive of 5-year survival.

Surgical complications and outcome of pediatric liver transplantation in Hong Kong.

PURPOSE: The aim of this study was to analyze the early and late results of pediatric liver transplantation, with particular reference to complications that required surgical or radiologic intervention. METHODS: The records and code sheets of children who underwent liver transplantation in the authors' institution between September 1993 and December 2001 were reviewed. RESULTS: Twenty-nine children (16 boys and 13 girls) underwent 31 liver transplantations (23 living donor, 8 cadaveric donor) during the study period. The ages of the children ranged from 4 months to 132 months (median, 16 months). Eighteen children had complications that required surgical or radiologic interventional procedures. Complications included, among others, hepatic vein thrombosis (n = 1, 3%), hepatic vein stenosis (n = 2, 7%), portal vein thrombosis (n = 2, 7%), biliary stricture (n = 3, 10%), bile leakage (n = 2, 7%), hepatic artery pseudoaneurysm (n = 1, 3%), jejuno-jejunostomy leakage (n = 1, 3%), graft hepatitis (n = 1, 3%), and posttransplant lymphoproliferative disorder (n = 2, 7%). In addition, 6 children (21%) suffered from intraabdominal bleeding from a variety of causes. After appropriate interventions, at a median follow-up of 38 months (range, 1 to 96 months), patient and graft survival rates were 79% and 74%, respectively. The retransplantation rate was only 7%. There was no incidence of hepatic artery thrombosis. All living donors remain alive and well. CONCLUSIONS: Complications are inevitable in pediatric liver transplantation. However, with timely recognition and active intervention, a good outcome can be achieved.

Ten-year experience with liver transplantation at Queen Mary Hospital: retrospective study.

OBJECTIVE: To report the experience with liver transplantation at the Queen Mary Hospital from 1991 to 2000. DESIGN: Retrospective study. SETTING: Liver transplant centre of a University teaching hospital, Hong Kong. PATIENTS: One hundred and forty-eight patients (127 adults and 21 children) who underwent a total of 155 liver transplants using 75 cadaver grafts (full-size, 67; reduced-size, 5; split, 3) and 80 living donor grafts (left lateral segment, 15; left lobe, 6; right lobe, 59) from October 1991 to December 2000 were reviewed. MAIN OUTCOME MEASURES: Graft and patient survival rate. RESULTS: The most common disease indications for liver transplantation were chronic hepatitis B-related liver disease (n=74) in adults and biliary atresia (n=14) in children. Eighteen patients had hepatocellular carcinoma. Forty-eight (31%) liver transplants (three ABO-incompatible) were performed in high-urgency situations for patients requiring intensive care. The proportion of living donor liver transplants was 47.7% in adults and 73.9% in children. The overall 1-year and 5-year patient survival rates were 82% and 77%, respectively. The survival of high-risk recipients, such as those with fulminant hepatic failure (80%), chronic hepatitis B (81%), or hepatocellular carcinoma (94%), was not inferior to that of other patients. CONCLUSION: Over the last decade, the promotion of (cadaver) organ donation through public education coupled with innovative techniques in living donor liver transplantation have enabled a liver transplantation programme to be established in Hong Kong with gratifying results.

Management of spontaneous rupture of hepatocellular carcinoma: single-center experience.

PURPOSE: To report the management of patients with spontaneous rupture of hepatocellular carcinoma (HCC) in a single center over a 10-year period and to evaluate a two-stage therapeutic approach. PATIENTS AND METHODS: A retrospective study was performed on all 1,716 patients with HCC who presented from 1989 to 1998. The two-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, hemostasis by transarterial embolization (TAE) or surgical means, followed by second-stage hepatic resection or transarterial oily chemoembolization (TOCE). Results of definitive treatment were compared with patients with no history of rupture during the same study period. RESULTS: During the study period, 154 patients (9%) had spontaneous HCC rupture. Initial intervention to control bleeding included TAE in 42 patients, surgical hemostasis in 35 patients, and conservative management only in 53 patients. The 30-day mortality rate was 38%. Independent factors on presentation affecting 30-day mortality were shock on admission, hemoglobin, serum total bilirubin, and known diagnosis of inoperable tumor. After initial stabilization and clinical evaluation, 33 patients underwent hepatic resection and 30 patients received TOCE. Median survival of the hepatectomy patients was 25.7 months; that of the TOCE patients was 9.7 months. Compared with patients with no rupture, survival after hepatectomy (25.7 months v 49.2 months, P =.003) was inferior but still substantially long, whereas survival after TOCE was comparable (9.7 months v 8.7 months, P =.904). CONCLUSION: Early mortality of spontaneous rupture of HCC was dependent on prerupture disease state, liver function, and severity of bleeding. Although it was a catastrophic presentation, prolonged survival could be achieved in selected patients with second-stage hepatic resection or TOCE.

Microvessel density, vascular endothelial growth factor and its receptors Flt-1 and Flk-1/KDR in hepatocellular carcinoma.

Assessment of angiogenesis may yield important information for an effective antiangiogenic treatment for hepatocellular carcinoma (HCC) because HCC is characteristically hypervascular We examined the relationship of microvessel density (MVD), vascular endothelial growth factor (VEGF), and VEGF receptors Flt-1 and Flk-1/KDR in 50 patients with HCC and in 3 hepatoma cell lines. VEGF messenger RNA (mRNA) was overexpressed in 26 tumors (52%), and the 3 VEGF isoforms (121, 165, and 189) were present in high frequencies. Flt-1 mRNA was overexpressed in 34 tumors (68%), with levels significantly increased in HCCs compared with the nontumorous livers. Tumor Flt-1 mRNA significantly correlated with tumor VEGF mRNA levels. Within the group of tumors 8.5 cm or less in diameter, tumors with intrahepatic metastasis in the form of tumor microsatellite formation had significantly higher VEGF mRNA levels. MVD assessed by immunohistochemical analysis with CD34 antibody was inversely related to tumor size. Angiogenesis as assessed by MVD and tumor VEGF expression seems to have a more important role in tumor growth and intrahepatic metastasis in smaller HCCs. The differential up-regulation of Flt-1 suggests that it may have an important role in angiogenesis in HCC.

Intraosseous venous drainage anomaly of the tibia treated with imaging-guided sclerotherapy.

A 23-year-old man presented with a pre-tibial soft tissue mass. Magnetic resonance images demonstrated the subcutaneous, intracortical and intramedullary components of an intraosseous venous drainage anomaly, which was confirmed by direct venography. Sclerotherapy using absolute alcohol was subsequently performed under imaging guidance with complete resolution of the subcutaneous component of the lesion.