In patients with hepatocellular carcinoma (HCC), recurrences in the distant liver often are observed after curative treatment. Microwave coagulation therapy (MCT) and radiofrequency ablation (RFA) have been developed as less invasive alternatives than surgical resection for small HCCs. In the current study, risk factors for distant recurrence of HCC were analyzed in patients in whom complete coagulation was achieved.Ninety-two patients with HCCs < 3 cm in greatest dimension were treated by MCT or RFA percutaneously or laparoscopically. Eighty-four patients in whom complete coagulation was achieved without recurrence in the same subsegment as the primary nodule were included in this study. Distant recurrences were observed in 22 patients. Fifteen possible risk factors for a distant recurrence were analyzed.When comparing the patients with a recurrence of HCC nodules in the remnant liver to those without recurrence, the authors observed a statistically significant difference only in serum alpha-fetoprotein. The distant recurrence-free survival was analyzed by the Kaplan-Meier method. A statistically significant difference was observed in hepatitis C virus (HCV) infection as an etiopathic agent of underlying liver diseases (P < 0.005) and in the number of the primary HCC nodules (P < 0.05, log-rank test). A multivariate stepwise Cox hazard model revealed that HCV infection and the number of primary HCC nodules were statistically independent risk factors.Patients who had more than two HCC nodules accompanied by HCV infection had a high incidence of recurrence of HCC in the remnant liver, even when coagulation by microwave or ablation by radiofrequency was complete.
An 85-year-old woman was admitted with massive upper gastrointestinal hemorrhage. She had a history of small upper gastrointestinal bleeding on 11 days before admission. On admission, physical examination revealed a pulsatile abdominal mass and her hematocrit was 16.8 per cent. An emergency endoscopic examination revealed no bleeding source in the esophagus and stomach but bleeding from pulsatile submucosal elevation at the third portion of the duodenum. A CT scan demonstrated a 6-cm abdominal aortic aneurysm. Emergency laparotomy revealed an abdominal aortic aneurysm with aortoduodenal fistula at the level of third portion. The fistula was taken down and closed, and the aneurysm was replaced by a graft. Histology of the resected aorta showed the features of atherosclerotic aneurysm with fibrin plug at the fistula. No complication including infection and rebleeding occurred, and endoscopy at 14 days after surgery revealed improvement of the duodenal fistula. Aortoduodenal fistula is rare but invariably fatal without precise diagnosis and prompt surgical treatment. The presence of antecedent nonexsanguinating hemorrhage before hypovolemic shock, socalled“herald bleed”is present in two-thirds of the patients, making it important to establish diagnosis before fatal exsanguination. Physician should consider the diagnosis of aortoduodenal fistula in patients with even mild upper gastrointestinal bleeding of uncertain etiology and abdominal pulsatile mass.
