Clinical course of abdominal aortic aneurysms in Behçet disease: a retrospective analysis.

Arterial aneurysms are rare manifestations of Behçet Disease (BD) with high morbidity and mortality. This study aimed to investigate the clinical course of BD patients with abdominal aortic aneurysms (AAA). We retrospectively searched charts of BD patients, followed up between 1988 and 2011, to identify those with AAA with at least 6-month clinical and radiological follow-up data. Chart review revealed 12 patients (11 males) with AAA amongst 1224 patients; follow-up data from 11 patients were available. The most common symptoms were lower back and abdominal pain. The only pre-treatment complication was a spontaneous rupture. All but one patient received corticosteroid and cyclophosphamide pulses for the induction, and corticosteroid and azathioprine for the maintenance treatment; one patient received only the maintenance treatment. Two patients had surgical graft interposition, without postoperative complications. Seven patients had endovascular stenting; five of them (71.4%) showed radiological regression after 32.5 (13.4-53.8) months, while four (57%) had clinical improvement after 11.8 (0.2-29.4) months. However, one non-responsive patient developed stent infection and exsanguinated during percutaneous drainage, and one patient developed femoral artery pseudo-aneurysm at the catheter insertion site. Another patient developed a new aneurysm under the maintenance treatment. Medical treatment alone yielded radiological regression in one of two patients. Current immunosuppressive, surgical or endovascular approaches can provide clinical and radiological improvements lately in BD patients with AAA. Furthermore, complication rates seem to be high with interventional approaches. These findings suggest an unmet need for safer alternative treatments.

Preoperative adrenal artery embolization followed by surgical excision of giant hypervascular adrenal masses: report of three cases.

BACKGROUND: Transcatheter arterial embolization (TAE) is an effective minimally invasive adjunct to surgery for the management and/or palliation of adrenal tumors. METHODS: In this case study, we reported three patients who underwent preoperative TAE before adrenalectomy for large hypervascular adrenal tumors. All patients underwent preoperative embolization 24 h before the operation and were then followed up at the intensive care unit surgery. RESULTS: The largest diameter of the adrenal lesions ranged between 8 and 17 cm. Hypertensive attack occurred in one patient with pheochromocytoma during embolization. No other complications associated with the procedure was noted. The adrenal tumors were totally excised in all patients. The major intraoperative findings associated with preoperative embolization were marked reduction in hypervascularity and the decrease in the size of collateral vessels. No major hemorrhage necessitating blood transfusion were noted during surgery. CONCLUSIONS: Preoperative embolization of large hypervascular adrenal masses could reduce perioperative blood loss by reducing tumor vascularity.

Superselective Transarterial Chemoembolization as an Alternative to Surgery in Symptomatic/Enlarging Liver Hemangiomas.

BACKGROUND: Transarterial embolization of liver hemangiomas has not been considered to be consistently effective. METHODS: The charts of 25 patients who underwent superselective transarterial chemoembolization with the bleomycin-lipiodol emulsion were evaluated retrospectively. RESULTS: Twenty-two patients had abdominal pain; asymptomatic/vaguely symptomatic enlargement was the treatment indication in three patients. A single session was conducted in 17 patients, two sessions in 7 and three sessions in one. After the first session, lesion volume decreased by median (range) 51% (10-92%) from median (range) 634 (226-8435) to 372(28-4710) cm3 (p < 0.01), after a median period of 4 months (range 2-8). A second session was performed in eight patients (median (range) initial volume 1276 (441-8435) cm3) with persistent complaints and/or large lesions receiving feeders from both right and left hepatic arteries (staged treatment). Median (range) lesion size decreased further from 806 (245-4710) to 464 (159-2150) cm3 (p < 0.01). Three patients experienced a postembolization syndrome that persisted after the first week. Seventeen of the 22 symptomatic patients (77%) reported resolution or marked amelioration of complaints. Regrowth after initial regression was not observed during median (range) 14 (8-39) months of follow-up (n:18). CONCLUSION: Transarterial chemoembolization with the bleomycin-lipiodol emulsion is a potential alternative to surgery for symptomatic/enlarging liver hemangiomas. Volume reduction is universal, and symptom control is satisfactory. Centrally located and very large (>1000 cm3) lesions may require two sessions.

Influence of Early Versus Delayed Hepatic Artery Perfusion Scan on 90Y Selective Internal Radiation Therapy Planning.

Purpose: This study evaluated the effect of an increase in the time interval between hepatic intra-arterial injection of 99mTc-macroaggregated albumin (MAA) and hepatic artery perfusion scintigraphy (HAPS) on the lung shunt fraction (LSF) and perfused volume (PV) calculations in the treatment planning of selective internal radiation therapy (SIRT). Methods: The authors enrolled 51 HAPS sessions from 40 patients diagnosed with primary or metastatic liver malignancy. All patients underwent scan at the first and fourth hour after hepatic arterial injection of 99mTc-MAA. Based on single-photon emission computed tomography images, LSF values were measured from each patient's first and fourth hour images. PV1 and PV4 were also calculated based on three-dimensional images using 5% and 10% cutoff threshold values and compared with each other. Results: The authors found that the median of LSF4 was statistically significantly higher than LSF1 (3.05 vs. 4.14, p ≤ 0.01). There was no statistically significant difference between PV1 and PV4 on the 10% (p = 0.72) thresholds. Conclusions: LSF values can be overestimated in case of delayed HAPS, potentially leading to treatment cancellation due to incorrectly high results in patients who could benefit from SIRT. Threshold-based PV values do not significantly change over time; nevertheless, keeping the short interval time would be safer.

Left Adrenal Venous Drainage into the Inferior Vena Cava in a Pheochromocytoma Patient with Ectopic Pelvic Kidney.

In this report, we describe a very rare variant adrenal venous anatomy in a left-sided pheochromocytoma case with left adrenal vein draining into the inferior vena cava (IVC). A 66-year-old female with an incidentally discovered left adrenal mass was referred to our clinic for further diagnostic work up. She had hypertension for the past three years. Abdominal magnetic resonance imaging which has been performed for essential thrombocytopenia revealed a left adrenal mass. She was diagnosed as pheochromocytoma by further laboratory workup. Pre-operative imaging with computed tomography (CT) angiography showed that left kidney was ectopically localized in pelvis, and left adrenal vein was draining directly into the IVC. A laparoscopic transabdominal left adrenalectomy was performed. Final pathology result was consistent for pheochromocytoma. Variant adrenal venous anatomy is rare. There are only few case reports on patients with left adrenal vein draining into the IVC. Although there are handful of autopsy studies, these studies were performed on normal adrenal glands. The number of clinical reports on variant adrenal venous anatomy is limited. Clinical studies revealed that most commonly seen variant adrenal venous anatomy was number based and were associated with larger tumor size and pheochromocytoma. Pre-operative CT imaging could be used to improve the identification of venous anatomy. In this report, we present a very rare case of an adult patient with left ectopic kidney who had undergone laparoscopic adrenalectomy for left adrenal pheochromocytoma and had left adrenal vein draining into the IVC. To the best of our knowledge, it is a first in the literature. Pre-operative CT imaging identified the variant adrenal venous anatomy in this patient.

Is the Y90-radioembolization treatment effective on the intermediate-advanced stage of hepatocellular carcinoma and what is the albumin-bilirubin score's prediction factor for survival?

Background and Aim: Radioembolization (RE) is a one of the palliative treatments that have been used to down stage and/or increase the survival time in intermediate-advanced stages of HCC. We aimed to evaluate the clinical impact of RE and the clinical use of the albumin-bilirubin (ALBI) score as a predictor for survival in HCC patients. Materials and Methods: Fifty-nine unresectable hepatocellular carcinoma (HCC) patients were enrolled. RE was performed in 28 of them (group 1) and 31 patients were followed up in the natural course (NC) (group 2). Patients were classified according to the Child-Pugh score (only cirrhotic patients), Barcelona clinic liver cancer (BCLC) staging, and ALBI scores were also calculated. Results: All patients in Group 1 were cirrhotic and their BCLC stages were as follows: 60.7% stage B and 39.3% stage C. In Group 2, 83.9% of patients were cirrhotic and their BCLC stages were as follows: 9.7% stage B, 51.6% stage C, and 38.7% stage D. Mortality rates were 82% and 100% in Groups 1 and 2, respectively. The median overall survival (OS) was 13.5 months (95% CI: 10.4-16.6 months) and 4.5 months (95% CI: 3.5-5.5 months) in Groups 1 and 2, respectively (p=0.000). When RE was applied to patients with ALBI Grade 1 and 2, the median OS was statistically higher than in the NC group, respectively (p<0.001, p<0.001). Conclusion: RE is an effective treatment method at the advanced stages of HCC. The ALBI score is a more useful and practical than the other prognostic tools.

Cell-free methylation of RASSF1 and CDKN2AIP genes in the diagnosis of hepatocellular carcinoma associated with hepatitis B virus cirrhosis.

Background and Aim: Chronic hepatitis B virus (HBV) infection is a major cause of hepatocellular carcinoma (HCC). Circulating cell-free DNA (cfDNA) methylation of tumor suppressor genes are emerging potential biomarkers in HCC. We aimed to evaluate the cfDNA methylation status of RASSF1 and CDKN2AIP genes in patients with liver cirrhosis (LC) with or without HCC caused by HBV. Materials and Methods: A total of 47 patients with HBV cirrhosis were included in the study. Patients were divided into two groups: HCC and LC (HCC+LC, n=22) and HBV cirrhosis only (LC, n=25). cfDNA was isolated from the plasma samples of the patients. Methylation analysis was performed for RASSF1 and CDKN2AIP genes. Results: Mean methylation percentage of CDKN2AIP gene was 0.001±0.004% in the HCC+LC group and 0.008±0.004 % in the LC only group. The mean methylation percentage of RASSF1 gene was 5.1±16.1% in the HCC+LC group and 9.7±25.9% in the LC only group. The methylation rate of CDKN2AIP was significantly lower in the HCC+LC group (p=0.027). A positive correlation was found with the absence of cfDNA methylation of CDKN2AIP gene in the presence of HCC (R=0.667, p=0.018). Conclusion: cfDNA methylation of CDKN2AIP and RASSF1 genes may provide important diagnostic information regarding the development of HCC in the setting of HBV cirrhosis.

Incomplete or inappropriate endoscopic and radiologic interventions as leading causes of cholangitis.

BACKGROUND: Iatrogenic factors persist as leading mechanisms of cholangitis at a referral center. METHODS: The records of 51 patients treated for cholangitis due to incomplete or inappropriate nonoperative biliary interventions between 2005-2016 were evaluated retrospectively. RESULTS: Twenty-nine patients were men; median (range) age was 60 (30-90). An incomplete or inappropriate ERCP and percutaneous transhepatic biliary drainage (PTBD) had been performed in 45 and 6 patients respectively. Inappropriate endoscopic stenting for hilar obstruction (perihilar cholangiocarcinoma: 22 and gallbladder carcinoma:3) was the most common scenario (n: 25, 49%). Twenty other patients had undergone an ERCP with incomplete (n: 12) or no (n:8) drainage. The errors in the PTBD group were passage of the catheter to the duodenum in patients with hilar obstruction (n: 4) and incomplete drainage in patients with perihilar cholangiocarcinoma (n: 2). Two patients (4%) died of infection. The surgery of 6 operable tumor patients was delayed for median (range) 5 (1-7) months. CONCLUSIONS: Incomplete or inappropriate nonoperative biliary interventions put patients' lives at risk and delay radical treatments.

Dramatic response to albendazole in transplantation candidates with unresectable hepatic alveolar hydatid disease.

Long-term albendazole treatment should be given to all patients with unresectable hepatic alveolar echinococcosis as dramatic regression is possible in 15%-20%. It may be prudent to prepare a living donor for possible salvage transplant in case of a severe complication. Preemptive transplantation in mildly symptomatic patients should be discouraged.

Spontaneous regression of liver hemangiomas: a single-institution analysis of 46 patients.

OBJECTIVE: The aim of this study was to determine the nature of spontaneous regression of liver hemangiomas. PATIENTS AND METHODS: The records of the liver hemangioma patients who attended the out-patient clinic between 1988 and 2018 were evaluated. The data of the 716 adult patients who were followed for at least 3 years with cross-sectional imaging were analyzed. RESULTS: Spontaneous regression was documented in 46 patients (6.4%). Twenty-eight patients had a single hemangioma (61%), eight (17%) had two hemangiomas; the other 10 patients had 3-6 hemangiomas. Of the 87 lesions in 46 patients, 69 actually regressed during the study. Twelve patients with more than one lesion exhibited discordant courses - one of the hemangiomas of a patient with multiple lesions regressed, whereas the other enlarged or remained stable. Eleven of the regressed hemangiomas exhibited enlargement first, followed by spontaneous regression. Fourteen (20%) of the regressed hemangiomas acquired atypical characteristics that would have suggested a malignancy had the original films been unavailable. CONCLUSION: Spontaneous regression of liver hemangiomas is an underrecognized phenomenon. Enlargement should not be a straightforward indication for intervention because it may be followed by regression. A regressed hemangioma should be considered in the differential diagnosis of liver lesions suspicious for malignancy.

Malignant Tumors Misdiagnosed as Liver Hemangiomas.

Background and Aim: To derive lessons from the data of patients who were followed for various periods with the misdiagnosis of liver hemangioma and eventually found to have a malignancy. Material and Methods: The records of 23 patients treated between 2003 and 2018 were analyzed retrospectively. Results: Twelve patients were men and 11 were women; median (range) age was 55 (35-80). The principal diagnostic modality for the initial diagnosis was ultrasonography (n:8), magnetic resonance imaging (MRI) (n:13), and computed tomography (CT) (n:2). At our institution, MRI was performed in 16 patients; the diagnosis was made with the available MRI and CT studies in five and two patients, respectively. In other words, the ultrasonography interpretations were not confirmed on MRI; in others, the MRI or CT examinations were of low quality or they had not been interpreted properly. Fifteen patients underwent surgery; the other patients received chemotherapy (n:6) or chemoembolization (n:2). The misdiagnosis caused a median (range) 10 (0-96) months delay in treatment. The final diagnoses were hepatocellular carcinoma in 12 patients, cholangiocarcinoma in four patients, metastatic mesenchymal tumor, metastasis of colon cancer, metastatic neuroendocrine carcinoma, sarcomatoid hepatocellular carcinoma, angiosarcoma, thoracic wall tumor, and metastatic tumor of unknown primary in one patient each. Conclusions: High-quality MRI with proper interpretation and judicious follow up are vital for the accurate differential diagnosis of liver lesions.

Complementary Roles of Cadaveric and Living Donor Liver Transplantation in Acute Liver Failure.

BACKGROUND: Living donor liver transplantation may complement cadaveric transplantation in acute liver failure (ALF) patients. METHODS: Between 2008 and 2017, 89 patients were treated for ALF; 15 patients (17%) recovered with intensive care treatment; 31 (35%) died without transplant. The records of the remaining 43 patients (median (range) age: 14 (1-62)) who underwent transplantation were evaluated. RESULTS: The etiologic factors were toxic agents (10; mushrooms: 8; herbs: 2), hepatitis viruses (7; A: 1; B: 6), Wilson's disease (7), autoimmune hepatitis (4), and Budd-Chiari syndrome (2); 13 cases were idiopathic. Cadaveric organs (whole, split, reduced) were transplanted to 32 patients; 11 patients underwent living donor transplantation. One patient (2%) died of septic shock on the second postoperative day. Bacterial infection was the most common early (< 3 months) complication in the remaining patients (31/42; 74%), followed by delirium (5/42; 12%) and acute rejection requiring steroid pulse (5/42; 12%). Seven other patients died during median (range) follow-up of 94 (14-142) months: various infections (5), leukemia (1), and acute myocardial infarction (1). The 1-, 5-, and 10-year survival rates were 100%, 96%, and 92% in children and 94%, 82%, and 65% in adults respectively. CONCLUSIONS: Cadaveric organ sharing and transplantation from living donors when appropriate yield a high survival rate, despite high early morbidity, in ALF patients whose conditions deteriorate despite intensive care treatment. Efforts to eliminate preventable causes of acute liver failure will lead to more efficient use of health care resources.

Steroid-induced reconstitution of the biliary tree ravaged by IgG4-related disease.

The steroid-induced, rapid healing of the biliary tree ravaged by IgG4-related disease shows that the point of irreversibility remains to be defined.

Y90 selective internal radiation therapy and peptide receptor radionuclide therapy for the treatment of metastatic neuroendocrine tumors: combination or not?

BACKGROUND: Peptide receptor radionuclide therapy and selective internal radiation therapy are effective radionuclide therapy modalities for unresectable metastatic neuroendocrine tumor patients that cannot be controlled with somatostatin analogs. The present study is intended to evaluate the therapeutic efficacy and toxicity of the combined therapy of selective internal radiation therapy and peptide receptor radionuclide therapy and stand-alone selective internal radiation therapy in patients with neuroendocrine tumor, a liver-dominant disease. METHODS: This cohort consists of 27 patients with metastatic neuroendocrine tumor and liver-dominant disease. They were grouped as the patients who were treated with selective internal radiation therapy for unresectable liver metastasis (n = 15) and the patients who received a combination of selective internal radiation therapy and peptide receptor radionuclide therapy (n = 12) for hepatic and extrahepatic metastasis. Treatment efficacy and treatment-associated toxicity were retrospectively assessed in both groups. RESULTS: The objective treatment response and stable disease were found in 13 patients (86.6%) in the selective internal radiation therapy group and eight patients (66.6%) in the selective internal radiation therapy + peptide receptor radionuclide therapy group. The median overall survival rate was found to be 34.9 months, in the selective internal radiation therapy group and 67.5 months in the selective internal radiation therapy + peptide receptor radionuclide therapy group (P = 0.217). The median progression-free survival data was not reached, and the mean values of progression-free survival were 53.1 ± 9.9 months in the selective internal radiation therapy group, and 27.2 ± 5.9 months in the selective internal radiation therapy + peptide receptor radionuclide therapy group (P = 0.561). Temporary lymphopenia was the most common side effect. Grade 1-2 hepatotoxicity was observed to be 6.6% in the selective internal radiation therapy group, while it was not observed in selective internal radiation therapy + peptide receptor radionuclide therapy group. CONCLUSIONS: In the neuroendocrine tumors with liver-dominant metastatic disease, personalized selective internal radiation therapy and peptide receptor radionuclide therapy and their combinations result in increased survival rates. Selective internal radiation therapy alone could be an effective treatment in patients with liver-limited and -dominant disease.

Primary retroperitoneal hydatid disease mimicking retroperitoneal malignant tumor.

BACKGROUND: Hydatid disease (HD) is endemic in many parts of the world. It may develop in almost any part of the body; the liver is the organ most frequently involved. HD in an unusual location may make differential diagnosis difficult. Isolated retroperitoneal HD is extremely rare. CASE REPORT: We report herein a case of retroperitoneal HD mimicking retroperitoneal malignant tumor. CONCLUSIONS: HD should be considered in the differential diagnosis of all cystic masses in all anatomic locations, especially in regions of the world where the disease is endemic.

Current state and clinical outcome in Turkish patients with hepatocellular carcinoma.

AIM: To investigate clinical, etiological, and prognostic features in patients with hepatocellular carcinoma. METHODS: Patients with hepatocellular carcinoma who were followed-up from 2001 to 2011 were included in the study. The diagnosis was established by histopathological and/or radiological criteria. We retrospectively reviewed clinical and laboratory data, etiology of primary liver disease, imaging characteristics and treatments. Child-Pugh and Barcelona Clinic Liver Cancer stage was determined at initial diagnosis. Kaplan-Meier survival analysis was done to find out treatment effect on survival. Risk factors for vascular invasion and overall survival were investigated by multivariate Cox regression analyses. RESULTS: Five hundred and forty-five patients with hepatocellular carcinoma were included in the study. Viral hepatitis was prevalent and 68 patients either had normal liver or were non-cirrhotic. Overall median survival was 16 (13-19) mo. Presence of extrahepatic metastasis was associated with larger tumor size (OR = 3.19, 95%CI: 1.14-10.6). Independent predictor variables of vascular invasion were AFP (OR = 2.95, 95%CI: 1.38-6.31), total tumor diameter (OR = 3.14, 95%CI: 1.01-9.77), and hepatitis B infection (OR = 5.37, 95%CI: 1.23-23.39). Liver functional reserve, tumor size/extension, AFP level and primary treatment modality were independent predictors of overall survival. Transarterial chemoembolization (HR = 0.38, 95%CI: 0.28-0.51) and radioembolization (HR = 0.36, 95%CI: 0.18-0.74) provided a comparable survival benefit in the real life setting. Surgical treatments as resection and transplantation were found to be associated with the best survival compared with loco-regional treatments (log-rank, P < 0.001). CONCLUSION: Baseline liver function, oncologic features including AFP level and primary treatment modality determines overall survival in patients with hepatocellular carcinoma.

The Results of Ultrasonography-Guided Percutaneous Radiofrequency Ablation in Hyperparathyroid Patients in Whom Surgery Is Not Feasible.

BACKGROUND: The aim of the study was to evaluate the results of ultrasonography (US)-guided percutaneous radiofrequency ablation (RFA) in hyperparathyroid patients who refused surgery or had high surgical risks. PATIENTS AND METHODS: Five patients with hyperparathyroidism (HPT) underwent US-guided RFA for a single hyperfunctioning parathyroid lesion. Post-ablation serum calcium and parathormone (PTH) assays were performed. All patients underwent imaging studies 6 months after the ablation to visualize the post-ablation change in the size of the treated parathyroid lesions. RESULTS: All patients were normocalcemic on the post-ablation 1st day and 6th month. The post-ablation PTH levels were normal in three patients but remained elevated in two patients. The size of the parathyroid lesion was ≥30 mm in the two patients with elevated PTH, whereas the lesion was smaller than 30 mm in those with normal post-ablation PTH values. CONCLUSION: Although this is a limited case series, it demonstrates the potential feasibility of RFA for HPT. Benefits were achieved particularly in patients with small parathyroid lesions.

Hepatic atrophy-hypertrophy complex due to Echinococcus granulosus.

Obstruction of a major hepatic vein, or major portal vein, or biliary tree branch causes atrophy of the related hepatic region, and frequently, hypertrophy in the remaining liver-the atrophy-hypertrophy complex (AHC). Whether hydatid cysts can cause AHC is controversial. The records of 370 patients who underwent surgery for hepatic hydatid disease between August 1993 and July 2002 were evaluated retrospectively. Excluding six patients with previous interventions on the liver, AHC had been recorded in the operative notes of 16 patients (4.4%); for all patients, a cyst located in the right hemiliver had caused atrophy of the right hemiliver and compensatory hypertrophy of the left hemiliver. The computed tomography images of seven patients were suitable for volumetric analysis. The median (range) right and left hemiliver volumes were 334 (0-686) ml and 1084 (663-1339) ml, respectively. The median (range) cyst volume was 392 (70-1363) ml. AHC due to Echinococcus granulosus was confirmed by objective volumetric analysis. The presence of AHC should alert the surgeon to two implications. First, pericystectomy may be hazardous due to association with major vascular and biliary structures. Second, in patients with AHC, the hepatoduodenal ligament rotates around its axis; this should be considered to avoid vascular injury if a common bile duct exploration is to be performed.

Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention.

AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 13 x 10(3)+/-1 x 10(3) microg/L, P < 0.05 for 24 h after PC; 13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 8.3 x 10(3)+/-1.2 x 10(3) microg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2+/-18.5 mg/L vs 27.3+/-10.4 mg/L, P < 0.05 for 24 h after PC; 51.2+/-18.5 mg/L vs 5.4+/-1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38+/-0.35 centigrade vs 37.3+/-0.32 centigrade, P < 0.05 for 24 h after PC; 38+/-0.35 centigrade vs 36.9+/-0.15 centigrade, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutaneous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

An asymptomatic huge hepatocellular carcinoma with intra-atrial tumor thrombus in a patient with chronic hepatitis B viral infection.

Hepatocellular carcinoma is the most important complication of cirrhosis. All types of cirrhosis predispose to hepatocellular carcinoma, but 10 to 20% of cases may develop in patients without cirrhosis. Here, we present an asymptomatic precirrhotic patient with hepatocellular carcinoma and intra-atrial tumor thrombus.