Macronodular Cirrhosis Research Articles

Application of Indocyanine Green Fluorescence as an Adjuvant to Laparoscopic Ultrasound in Minimally Invasive Liver Resection.

Background: Indocyanine green (ICG) fluorescence imaging has been extensively used in a variety of applications in visceral surgery. In minimally invasive liver resections, the detection of small superficial hepatic lesions using an intravenous injection of ICG before surgery represents a promising application. Methods: We analyzed 18 consecutive patients who underwent laparoscopic liver resection for superficial malignant tumors, namely 11 patients with hepatocellular carcinoma (HCC), 5 patients with colorectal liver metastases (CRLM), 1 patient with intrahepatic cholangiocarcinoma (ICC), and 1 patient with thyroid cancer metastasis, using ICG fluorescence as an adjuvant tool to intraoperative laparoscopic ultrasound (LUS). Results: An optimal ICG 15-minute clearance retention rate (R15 < 10%) and ICG plasma disappearance rate (<18%/minute) were present in 11 patients (61.1%) and in 14 patients (77.7%), respectively. Liver tumors were 29 in total, including 14 HCCs (48.3%), 13 CRLMs (44.8%), 1 ICC (3.4%), and 1 thyroid cancer metastasis (3.4%). Twenty-nine tumors (100%) were correctly visualized with ICG/fluorescence, as compared with 21 tumors identified with LUS (72.4%). After complete liver mobilization, ICG staining allowed to identify more superficial lesions (early HCC and small CRLM) in posterolateral segments (Segments 6 and 7) as compared with LUS (14 versus 10 lesions). In addition, in segments usually treated laparoscopically (e.g., left lateral segments), ICG was superior to LUS (10 versus 6 lesions) to identify superficial early HCC in patients with macronodular cirrhosis. Conclusions: ICG visual feedback might substitute the tactile feedback of the hand and might in some cases act as a "booster" of LUS for superficial hepatic lesions.

Laparoscopic Subtotal Cholecystectomy for Gangrenous Cholecystitis in a Liver Cirrhosis Patient: A Case Report

Introduction: Subtotal cholecystectomy should be considered when structures of calot can not be identified or critical view of safety can not be achieved. Here, we present a case of laparoscopic subtotal fenestrating cholecystectomy for gangrenous cholecystitis in a liver cirrhosis patients. Case report: A 64 year-old male came to emergency room after suffering from RUQ pain for 4 days. Underlying medical conditions included hypertension, diabetes, and alcoholic liver cirrhosis with BMI of 22.5. Initial laboratory results were as following: WBC count of 12670/ul, platelet count of 90000/ul, C-reactive protein of 20.35 mg/dL, AST/ALT of 58/52 IU/L, Total bilirubin/Direct bilirubin of 3.88/2.37 mg/dL. Computed tomography showed gangrenous cholecystitis with cystic duct stones and liver cirrhosis with splenomegaly. The patient underwent laparoscopic cholecystectomy using conventional four port approach. Upon entering the peritoneum, severe adhesion around the gallbladder and macronodular cirrhosis were noted. Due to severe adhesion and collateral vessels, calot dissection was not possible. After identifying the cystic duct and retrieving the stones, cystic duct stump was sutured internally with 4-0 vicryl and laparoscopic subtotal cholecystectomy was completed after inserting a drain. Total operation time was 210 minutes with blood loss of 100cc. Patient was discharged on postoperative day #10 after conservative care for ascites. Conclusion: Subtotal cholecystectomy is an important tool for hepatobiliary surgeons facing complex intra operative situations with high risk of postoperative complications. Figures: A, B) preoperative CT, C) postoperative 1 month CT, D) Dissection of gallbladder, E) Identification of cystic duct, F) Cystic duct stump internally sutured

Deaf Beethoven’s «swan song»

Illnesses of the great German composer Ludwig van Beethoven are still being the subject of discussions. The composer’s biographers focused more on the problems related to his hearing disorders than on complaints of disturbing abdominal pain. While analyzing the history of Beethoven’s illness, the symptoms of intestinal disease, such as recurring pain (colic) and diarrhea, accompanied by a worsening of the general condition, attract attention. These symptoms were noted when he was 24. One of the doctors designated the composer’s intestinal disease as hemorrhagic colitis. In 1812 — 1820, anorexia, signs of dehydration accompanied this clinical picture. Abdominal pain became colicky, painful — the composer started abusing alcohol to escape from this pain. In 1821, Beethoven had jaundice, abdominal pain, and vomiting, which recurred after a few months. At the age of 28, deafness started to develop, accompanied by ringing in the ears; at the age of 44, he completely lost his hearing. Mentally exhausted, he kept on drinking. In 1822, severe headaches, problems with the digestive organs appeared. In 1825, Beethoven was re‑diagnosed with jaundice, which was accompanied by mental disorders, pyoderma, nosebleeds, and repeated hemoptysis. In 1826, Beethoven got pneumonia because of supercooling; jaundice with hepatomegaly appeared, the legs swelled, and his stomach increased due to ascites. Beethoven went through several punctures from the abdominal cavity without any effect. His body was covered with ulcers and scabs, the symptoms only continued to grow. Beethoven’s body struggled with death for more than three months, but on March 26, 1827, the composer passed away. Beethoven’s body was repeatedly autopsied. Post‑mortem autopsy reported macronodular liver cirrhosis, portal hypertension and splenomegaly (spleen’s size was 3 time s bigger than norm), gallstone disease, and chronic pancreatitis. An autopsy doctor described his pancreas as «shrunken and fibrous», with a very thin and narrowed exocrine duct. The original Beethoven post‑mortem autopsy report, written in Latin, was found at the Vienna Pathologic‑Anatomical Museum in 1970.

Supersonic shear-wave elastography and APRI for the detection and staging of liver disease in pediatric cystic fibrosis

BackgroundCurrent diagnostic methods for the diagnosis of Cystic fibrosis (CF)-associated liver disease (CFLD) are non-specific and assessment of disease progression is difficult prior to the advent of advanced disease with portal hypertension. This study investigated the potential of Supersonic shear-wave elastography (SSWE) to non-invasively detect CFLD and assess hepatic fibrosis severity in children with CF. Methods125 children were enrolled in this study including CFLD (n = 55), CF patients with no evidence of liver disease (CFnoLD = 41) and controls (n = 29). CFLD was diagnosed using clinical, biochemical and imaging best-practice guidelines. Advanced CFLD was established by the presence of portal hypertension and/or macronodular cirrhosis on ultrasound. Liver stiffness measurements (LSM) were acquired using SSWE and diagnostic performance for CFLD detection was evaluated alone or combined with aspartate aminotransferase-to-platelet ratio index (APRI). ResultsLSM was significantly higher in CFLD (8.1 kPa, IQR = 6.7–11.9) versus CFnoLD (6.2 kPa, IQR = 5.6–7.0; P < 0.0001) and Controls (5.3 kPa, IQR = 4.9–5.8; P < 0.0001). LSM was also increased in CFnoLD versus Controls (P = 0.0192). Receiver Operating Characteristic (ROC) curve analysis demonstrated good diagnostic accuracy for LSM in detecting CFLD using a cut-off = 6.85 kPa with an AUC = 0.79 (Sensitivity = 75%, Specificity = 71%, P < 0.0001). APRI also discriminated CFLD (AUC = 0.74, P = 0.004). Classification and regression tree modelling combining LSM + APRI showed 14.8 times greater odds of accurately predicting CFLD (AUC = 0.84). The diagnostic accuracy of SSWE for discriminating advanced disease was excellent with a cut-off = 9.05 kPa (AUC = 0.95; P < 0.0001). ConclusionsSSWE-determined LSM shows good diagnostic accuracy in detecting CFLD in children, which was improved when combined with APRI. SSWE alone discriminates advanced CFLD.

Laparoscopic posterior sectionectomy for HCC

Background: We present the case of a 56-yo female with HCC on HCV cirrhosis. The lesion is located at the junction of segments 6 and 7. The patient is Child-Pugh A, MELD 8, AFP 6.6 ng/ml. Methods: The patient was placed in a partial left lateral decubitus. We used three 12mm and two 5 mm trocars. The optical trocar is placed on the mid-axillary line. Results: Abdominal cavity exploration confirmed macronodular cirrhosis. The lesion in the posterior sector was confirmed at intra-operative ultrasound. After cholecystectomy a tape was passed around the hepatic pedicle for the Pringle maneuver. The right posterior pedicle was dissected and clamped extraparenchymally in order to define the transection line which was marked with monopolar cautery and Thunderbeat. The liver parenchyma was partially opened at the level of right posterior pedicle in order to facilitate its control and division using a linear stapler. The parenchymal transection was pursued along the right hepatic vein with CUSA and Thunderbeat. Hemostasis and biliostasis was achieved with Hem-o-loks. Intermittent hepatic pedicle clamping was used for 105 minutes. Blood loss were 200 cc, no intra-operative blood transfusion were needed. Conclusion: Pathological report showed a well differentiated HCC with a R0 resection.Post-operative course was marked by transient ascetic decompensation. Patient is alive without signs of recurrence 12 months after surgery.

New nomogram predicts the recurrence of hepatocellular carcinoma in patients with negative preoperative serum AFP subjected to curative resection.

There is currently no established model for predicting the recurrence of hepatocellular carcinoma (HCC) in patients with negative alpha-fetoprotein (AFP) after curative resection. Therefore, the objective of this study was to establish a nomogram to identify the risk of recurrence in AFP-negative (<or = 20 ng/mL) patients with HCC. A retrospective study was conducted to establish the recurrence-free survival (RFS) nomogram in a training cohort of 326 AFP-negative HCC patients. The results were validated on a well-matched validation cohort in the literature. Macrovascular tumour invasion (P = 0.018, HR = 1.642), macronodular cirrhosis (P < 0.001, HR = 2.128), tumor size (P = 0.004, HR = 1.691), and γ-glutamyl transferase (P = 0.039, HR = 1.496) were found to be independent risk factors for RFS in the training cohort, and all these factors were included in the nomogram. The C-index for RFS in the nomogram was 0.661, which was higher than that of the BCLC system (0.551), the CLIP score (0.537), and the prediction model of Ju (0.618). The high consistency between the nomogram prediction and actual observation was further demonstrated by the calibration curve. In the subsequent study, the better net benefit and higher threshold probability of the nomogram were determined by decision curve analysis, and these advantages were confirmed in the validation cohort. The present RFS nomogram for AFP-negative HCC patients after curative resection provides an accurate and reliable prognostic model to facilitate recurrence surveillance. Once AFP-negative patients are predicted to have a high recurrence score, additional high-end imaging examinations, such as MRI or CT exams, should be considered, and the interval time of regular folow-up should be reduced.

Introduction of Fusion Imaging and Contrast Enhanced Ultrasound (CEUS): The Impact on a Liver Ablation Service

Percutaneous ablative therapies for primary and secondary focal liver tumours are becoming increasingly utilised as an alternative to surgical treatment or palliative therapies such as trans-arterial chemo-embolisation (TACE) and systemic chemotherapy. This is in part due to improving thermal ablative technologies and novel techniques such as Irreversible Electroporation (IRE). These radiologically guided procedures are only possible with confident and precise on-table imaging during the procedure, often in challenging background livers, such as in macro-nodular cirrhosis. Contrast enhanced ultrasound (CEUS) and fusion ultrasound, often used in combination, allows confident peri-operative visualisation of lesions not previously deemed suitable for percutaneous therapy, and is significantly increasing the numbers of patients receiving potentially curative treatment. Every patient referred for radiologically guided ablation of a focal liver lesion within a twelve month period was included in a retrospective analysis, looking at type of ablation and where advanced ultrasound techniques were used and the value they brought to the procedure. In 2016, 44 patients underwent ultrasound guided percutaneous ablative therapy on focal liver tumours (35 were MW, 9 were IRE). Advanced ultrasound techniques were incorporated into 66% (29/44) of all cases. On 16 occasions the ablations were performed under CEUS guidance either pre- or peri-operatively, a further 13 under CEUS/fusion guidance pre- or peri-operatively and one ablation was only possible using needle tracking and an off-axis approach. In our centre, CEUS and fusion has become an integral part of liver treatment, broadening the application of ablative therapies in liver cancer.

Ankle metastasis as a sign of intrahepatic cholangiocellular carcinoma.

A 51-year-old man presented with a 1-month history of right ankle pain and swelling that gradually increased (Panel A). There was no history of associated abdominal symptoms. X-ray examination showed an osteolytic lesion of the calcaneus and talus measuring 6.6 cm × 6 cm × 4 cm (Panel B). An abdominal CT scan revealed macronodular liver cirrhosis with a hypovascular lesion measuring 8.3 cm × 7.3 cm involving the 5th and 6th liver segment suspicious of a primary liver malignancy. A positron emission tomography (PET) scan showed pathologic flourodeoxyglucose (FDG) uptake in the right liver lobe, right talus, talocalcaneal joint and calcaneus (Panel C). A right hepatectomy and simultaneous foot amputation was indicated. Intraoperatively, a liver cirrhosis and a stage 4 liver tumor was found which was infiltrating vascular structures in the hepatoduodenal ligament and therefore was inoperable (Panel D). A liver biopsy was performed and the planned amputation of the foot was not carried out. Pathohistologic analysis confirmed an intrahepatic cholangiocarcinoma.

Hepatotoxicity after Sevoflurane Exposure in a Patient with Chronic Hepatitis C: A Case Report

Sevoflurane is considered a safe inhaled anesthetic of choice in patients with liver disease. Compared to other halogenated inhaled anesthetics, Sevoflurane is reported to lessen the severity of decreased hepatic blood flow and undergoes a different mechanism of hepatic metabolism. In patients with preexisting liver disease, there is potential for low-flow Sevoflurane to induce acute liver damage through other mechanisms. Limited data exists to guide clinical decision-making when quantifying the severity of cirrhosis in patients with hepatitis C and its relationship to anesthesia choice. Previous studies have found that exposure to general anesthesia during abdominal surgery may increase the risk of hepatorenal failure. This study has raised a concern that anesthetics may interfere with various hepatic functions secondary to viral infection. The generation of abnormal liver enzymes and hypercoagulation has provided further exploration for such toxicity. A 53-year-old African American man, with a significant past medical history of controlled hypertension and chronic, uncontrolled Hepatitis C infection, and abdominal trauma in 1983, presented to the community hospital with abdominal discomfort with a 10 x 8 cm ventral hernia. The patient had an underlying hepatitis C infection, but was asymptomatic upon interview. Patient was subsequently scheduled for elective hernia repair for lysis of adhesions, component separation, and mesh placement. General anesthesia, which included low doses of fentanyl, propofol, rocuronium, and ketamine were maintained with sevoflurane, all of which lasted 4 hours. The patient remained hemodynamically stable throughout the procedure. Postoperatively, he showed signs of hemodynamic instability, suggestive of DIC and acute renal failure. Patient expired soon after, and autopsy revealed macronodular cirrhosis with dilated venous collaterals, pulmonary edema, and cardiomyopathy. This report demonstrates a clinical impact and further evaluation in current patient management. It creates awareness and demonstrates the necessity to evaluate patients with any severe disease and its contraindications to proposed treatment plans. Knowledge of anesthetic induced toxicities and comorbidities has been illustrated, as in the case with sevoflurane and chronic Hepatitis C. Although more studies are needed, physicians should determine the risks and benefits in such patients into operative procedures, as well as management strategies to prevent any possible mortality.

Valor del FibroScan® en el seguimiento de los pacientes con infección crónica por virus B sin indicación de tratamiento

Transient elastography (TE) is a noninvasive method of assessing hepatic fibrosis in a quick, simple and reproducible manner. FibroScan is the best-known elastography apparatus and can assess a tissue volume 100 times greater than hepatic biopsy. Given that it lacks complications, TE can be repeated in the follow-up visit, thereby providing evolutionary information. One of its limitations, however, is its failure rate (4.5% of examinations), mainly in obese patients. TE has certain characteristics in chronic hepatitis B (HBV) infection. Transaminase levels and necroinflammation increase in reactivations, with hepatic stiffness increasing by 1.2 to 4.4 times. The second characteristic is related to macronodular cirrhosis caused by HBV, with less fibrous tissue compared with that produced by hepatitis C. Therefore, the cutoff values are smaller for hepatitis B than for hepatitis C.FibroScan helps categorize patients with chronic HBV infection into 4 fibrosis groups (approximate mean values and adding 1–2 more points with high transaminase levels): not significant (<6kPa), grey area (6–9kPa), significant (>9kPa) and cirrhosis (>12kPa). Thus, Fibroscan contributes to the treatment decision, and its repeated use during treatment enables us to verify that fibrosis has not progressed. In cases with no indication for treatment (chronic hepatitis with no criteria, inactive carrier state, immune-tolerant), the periodic reapplication of TE helps determine whether the inactivity continues or not. If the results are compatible with cirrhosis, hepatocarcinoma surveillance should be started.

Incidence and risk factors for surveillance failure in patients with regular hepatocellular carcinoma surveillance.

Initial presentation of hepatocellular carcinoma (HCC) at an advanced stage in patients under a regular surveillance program is a devastating problem. We assessed the prevalence and factors associated with this surveillance failure. A total of 304 HCC patients who received regular surveillance were retrospectively reviewed. Surveillance failure was defined when the tumor was diagnosed at beyond the Milan criteria. Surveillance failure rate was 5.9%. Macronodular cirrhosis (MC), ultrasonography-only surveillance (US-S) and infiltrative tumor type were independent factors associated with surveillance failure. The surveillance failure rate was higher in patients with MC (10.3 vs. 3.2%, p=0.022), US-S (14.6 vs. 4.3%, p=0.013) and when the tumor was infiltrative type (57.1 vs. 2.1%, p<0.001). Based on the two baseline factors (MC and US-S), the surveillance failure rates were 35.7, 6.8, 5.9 and 2.6% for MC(+)/US-S(+), MC(+)/US-S(-), MC(-)/US-S(+) and MC(-)/US-S(-), respectively (p<0.001). The HCC surveillance failure was not rare in clinical practice. These data suggest that special attention for surveillance failure might be needed for patients with MC who receive US-S.

PTU-116 Transplantation for ALD: Lessons from the Explant

IntroductionAlcoholic liver disease (ALD) remains one of the commonest indications for liver transplantation in Europe. The histological features of ALD vary, depending on extent and stage of injury, No features...

Planning Ultrasound for Percutaneous Radiofrequency Ablation to Treat Small (≤ 3 cm) Hepatocellular Carcinomas Detected on CT or MRI: A Multicenter Prospective Study to Assess Factors Affecting Ultrasound Visibility

Brief Description of the Purpose of the StudyThe purpose of this study was to assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on CT or MRI.MethodsThe patients referred for planning US for percutaneous radiofrequency ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. HCCs which were not visible on planning US were compared with visible HCCs with respect to tumor size, the distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha-fetoprotein level, body mass index, previous treatments for HCC, previous chemoembolizations for HCC, institutions, and experience of radiologists.Main ResultsAmong 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, the distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each p < 0.05).Importance of the ConclusionsSmaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of non-visualized tumors on planning US. Brief Description of the Purpose of the StudyThe purpose of this study was to assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on CT or MRI. The purpose of this study was to assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on CT or MRI. MethodsThe patients referred for planning US for percutaneous radiofrequency ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. HCCs which were not visible on planning US were compared with visible HCCs with respect to tumor size, the distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha-fetoprotein level, body mass index, previous treatments for HCC, previous chemoembolizations for HCC, institutions, and experience of radiologists. The patients referred for planning US for percutaneous radiofrequency ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. HCCs which were not visible on planning US were compared with visible HCCs with respect to tumor size, the distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha-fetoprotein level, body mass index, previous treatments for HCC, previous chemoembolizations for HCC, institutions, and experience of radiologists. Main ResultsAmong 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, the distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each p < 0.05). Among 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, the distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each p < 0.05). Importance of the ConclusionsSmaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of non-visualized tumors on planning US. Smaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of non-visualized tumors on planning US.

Duplex Sonographic Evaluation of Hepatic Vasculature in Cirrhosis

Background: Cirrhosis of liver in an ancient illness, known to the mankind since antiquity. Alcohol consumption is the most important cause of micronodular cirrhosis and chronic hepatitis is the most frequent cause of macronodular cirrhosis. The objective of this study was to assess the morphological changes and flow haemodynamics in portal vein, hepatic vein and hepatic artery using various Doppler parameters. Methods: The study was done on prospective basis in 35 patients with clinical diagnosis of cirrhosis and these patients were subjected to ultrasonography of the abdomen for the assessment of morphological changes and flow haemodynamics in hepatic vasculature. Results: Portal venous blood flow becomes reversed with advanced portal hypertension, veno-occlusive disease and portosystemic shunts. Reduced portal blood flow velocity was observed in majority of the patients and was found to be lower in patients with history of variceal haemorrhage. Hepatic artery resistive index was found to be significantly higher in patients with dilated coronary veins as compared to those with normal non-dilated veins. Dilated paraumbilical vein was the most consistently observed collateral followed by dilated coronary veins. Abnormal hepatic vein flow profiles are seen in patients with cirrhosis, with decreased amplitude of phasic occilation pattern being the most frequently observed abnormality. Conclusion: Although many factors may affect the accuracy of volume flow and velocity measurements and the flow profile of the liver vasculature may change in different situations, Doppler ultrasound is useful in the assessment of the patient with cirrhosis and portal hypertension. Nepal Journal of Medical Sciences | Volume 02 | Number 01 | Jan-Jun 2013 | Page 13-19 DOI: http://dx.doi.org/10.3126/njms.v2i1.7645

Hepatectomy for hepatocellular carcinoma patients with macronodular cirrhosis

Patients with hepatocellular carcinoma (HCC) presenting with nonmicronodular or micronodular cirrhosis are usually treated by hepatectomy. The value of resection for patients with hepatitis B virus-related macronodular cirrhosis, however, remains unknown because of potentially fatal complications of this procedure. Clinicopathological data were analyzed for 85 resected HCC patients with hepatitis B virus-related macronodular cirrhosis. An additional 255 patients with nonmicronodular and micronodular cirrhosis were randomly selected during the same period as the control group. Compared with nonmicronodular and micronodular cirrhosis patients, macronodular cirrhotic patients exhibited elevated alanine aminotransferase, aspartate aminotransferase, and γ-glutamyltransferase levels, higher Child-Pugh classification, higher indocyanine green retention rate at 15 min (ICG R15), and more number of total complications. No significant differences were observed between the two groups with regard to major complications, mortality, overall survival, and recurrence-free survival. The morbidity rate was relatively low in patients exhibiting low ICG R15 (<10%). Cox analysis identified small tumors (≤ 5 cm) and radical resection as independent prognostic factors that could predict long-term overall survival. Radical resection can result in high recurrence-free survival in macronodular cirrhotic patients. Resection is safe for macronodular cirrhotic HCC patients, and radical resection provides a positive outcome. Small-sized patients are good candidates for hepatectomy. Macronodular cirrhosis should not rule out hepatectomy in patients with low ICG R15.

Planning Ultrasound for Percutaneous Radiofrequency Ablation to Treat Small (≤ 3 cm) Hepatocellular Carcinomas Detected on Computed Tomography or Magnetic Resonance Imaging: A Multicenter Prospective Study to Assess Factors Affecting Ultrasound Visibility

PurposeTo assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency (RF) ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on computed tomography (CT) or magnetic resonance (MR) imaging. Materials and MethodsPatients referred for planning US for percutaneous RF ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. The study enrolled 898 patients (684 men and 214 women, age range 32–86 years). HCCs that were invisible on planning US were compared with visible HCCs with respect to tumor size, distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha fetoprotein (AFP) level, body mass index (BMI), previous treatments for HCC, previous chemoembolization treatments for HCC, institutions, and experience of radiologists. ResultsAmong 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each P < .05). ConclusionsSmaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of invisible tumors on planning US.

Are irreversible morpholocical signs of portal hypertension in neurological form of Wilson’s disease associated with treatment delay? A pilot study

Aim of this study was to evaluate the rate of morphological liver and spleen abnormalities in patients with neurological clinical presentation of Wilson's disease (WD). Fourteen patients with neurological presentation of WD divided into group A (5 patients who initiated chelating therapy <24 months from the first symptoms) and group B (9 patients whose therapy started ≥24 months after the initial symptoms) underwent abdominal MRI examination. Abnormal findings on abdominal MRI were present in 28% of patients with neurological form of WD. Significant hepatosplenomegaly was present in none of the patients from group A and in 4 (44%) patients from group B. In addition, macronodular liver cirrhosis and peritoneal effusion were evident in two and one patient from group B, respectively, and in none of the patients from group A. Our results suggest that severe portal hypertension and liver damage in patients with neurological presentation of WD might be reversible or do not even develop if chelating treatment is initiated <2 years after the onset of symptoms.

Routine Upper Gastrointestinal Imaging Is Superior to Clinical Signs for Detecting Gastrojejunal Leak after Laparoscopic Roux-en-Y Gastric Bypass

There are myriad symptoms and signs of gastrojejunal leak; prompt recognition is essential. Many surgeons use clinical predictors to guide selective use of upper gastrointestinal imaging (UGI). The appropriate practice remains undefined. A review of patients who underwent primary laparoscopic Roux-en-Y gastric bypass between January 2002 and December 2008 was conducted. All underwent routine UGI studies on postoperative day 1. Actual gastrojejunal leak within 7 days of surgery (actual leak [AL], radiologic leaks), operative reports, patient charts, and postoperative vital signs were retrospectively reviewed. There were 2,099 operations. Eight ALs (0.43%) occurred without associated mortality. UGI was positive in 7 AL patients and falsely positive in 6 patients. The AL patients underwent laparoscopy on postoperative days 1 and 3 (n = 5 and n = 1, respectively), laparotomy on postoperative day 3 (n = 1), and peritoneal drainage (n = 1). False-positive UGIs prompted laparoscopy (n = 3) and close observation (n = 3). Pulse was 100 to 120 beats per minute in 2 patients and fever (>38.5°C) was present in 0 AL patients. AL patients had osteogenesis imperfecta (n = 1), macronodular cirrhosis (n = 1), positive bubble test (n = 3), and concomitant splenectomy (n = 1). No jejunojejunostomy leaks were identified. Routine UGI after laparoscopic Roux-en-Y gastric bypass has greater sensitivity than clinical signs for detecting gastrojejunal leak. Delay in the diagnosis of leakage can impact mortality, and this suggests that indications for routine UGI might still exist. Tachycardia is not a reliable early marker of leak. There might be risk factors for leak in addition to vital signs, including patient medical history or intraoperative events, which should prompt routine UGI on postoperative day 1.

A Novel Canine Model of Portal Vein Stenosis Plus Thioacetamide Administration-Induced Cirrhotic Portal Hypertension With Hypersplenism

Current large animal models that could closely resemble the typical features of cirrhotic portal hypertension in human have not been well established. Thus, we aimed to develop and describe a reliable and reproducible canine cirrhosis model of portal hypertension. A total of 30 mongrel dogs were randomly divided into four groups: 1 (control; n = 5), 2 (portal vein stenosis [PVS]; n = 5], 3 (thioacetamide [TAA]; n = 5), and 4 (PVS plus TAA; n = 15). After 4-months modeling period, liver and spleen CT perfusion, abdominal CT scans, portal hemodynamics, gastroscopy, hepatic function, blood routine, the bone marrow, liver, and spleen histology were studied. The animals in group 2 (PVS) developed extrahepatic portosystemic collateral circulation, particularly esophageal varices, without hepatic cirrhosis and portal hypertension. Animals from group 3 (TAA) presented mild cirrhosis and portal hypertension without significant symptoms of esophageal varices and hypersplenism. In contrast, animals from group 4 (PVS + TAA) showed well-developed micronodular and macronodular cirrhosis, associated with significant portal hypertension and hypersplenism. The combination of PVS and TAA represents a novel, reliable, and reproducible canine cirrhosis model of portal hypertension, which is associated with the typical characteristics of portal hypertension, including hypersplenism.

Outcomes of patients with hepatocellular carcinoma referred for percutaneous radiofrequency ablation at a tertiary center: Analysis focused on the feasibility with the use of ultrasonography guidance

Purpose This study aimed to assess the feasibility of performing ultrasonography (US)-guided percutaneous radiofrequency (RF) ablation on patients with hepatocellular carcinoma (HCC) and identify causes of procedure infeasibility and its predisposing conditions. Materials and methods A total of 109 consecutive patients (male:female = 86:23; mean 59.9 years) with 136 HCCs (mean 1.8 cm) who had been referred for planning US were analyzed. We evaluated overall procedure feasibility as well as specific factors relating to feasibility, including inability to visualize the tumor with US and factors relating to safety of the procedure. Results The use of percutaneous RF ablation was concluded as infeasible for 45 tumors (33.1%). Reasons for infeasibility included tumor invisibility ( n = 32), a high risk of collateral thermal injury ( n = 5), absence of a safe electrode path ( n = 5) and a combination of factors ( n = 3). Among 136 tumors, 36(26.5%) were invisible due to isoechogenicity ( n = 16), indiscrimination from surrounding cirrhotic nodules ( n = 10) or an unfavorable location ( n = 10). Tumor invisibility was significantly attributed to a small tumor size ( P < 0.001, risk ratio = 0.823) and the presence of macronodular cirrhosis ( P = 0.006, risk ratio = 4.117). Seven patients with invisible tumors were treated with RF ablation after follow-up ( n = 4) or with use of adjacent structures as landmarks ( n = 3). Ultimately, 65 of 109 patients were treated with percutaneous RF ablation. Conclusions US-guided percutaneous RF ablation for HCC was feasible in about two-thirds of candidates. Infeasibility was mostly due to inability to visualize the tumor with US, especially for patients with smaller tumor and macronodular cirrhosis.