Background and Aim: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly used to treat severe complications of portal hypertension, while its efficacy in treating acute variceal bleeding caused by different etiology of liver cirrhosis has not yet being evaluated. This study aims to evaluate whether different etiology of liver cirrhosis may influence the outcome of TIPS treatment for acute variceal bleeding.
Materials and Methods: A total of 74 patients with acute variceal bleeding receiving TIPS treatment from March 2004 to December 2006 were enrolled for the analysis. They were divided into four groups: HBV-related (Group Ⅰ, n=22), HCV-related (Group Ⅱ, n=25) and Alcohol-related (Group Ⅲ, n=19) as well as Others (Group Ⅳ, n=8). The hepatic venous pressure gradient (HVPG) was measured before (pre-TIPS) and after (post-TIPS) the procedure and immediate stop bleeding was assessed. Survival curves were constructed by the Kaplan-Meier method, and compared by log-rank test.
Results: Survival for the whole patient group after TIPS was short with a mean of 9.6±14.5 months and with a median survival time of 3.0 months. Patient group Ⅳ(Others) had the best outcome with a median survival time of 24 months after TIPS (overall P＜0.05), while alcohol liver cirrhosis patients (Group Ⅲ) had the worst outcome after TIPS with a median survival time of 2.0 months. HCC patients receiving the TIPS therapy for acute variceal bleeding survived shorter than those without HCC (P=0.008, log-rank test).
Conclusions: Different etiology of liver cirrhosis may influence the outcome of TIPS treatment for acute variceal bleeding. Despite its apparent efficacy for emergent conditions, TIPS procedure should be limited to salvage therapy as a transition to liver transplantation.
Abstract Background: The aims of the study were to compare (i) the effects of transcatheter arterial embolization on initial hemostasis and the control of rebleeding in the treatment of hemorrhage due to hepatic artery injury; and (ii) the outcomes of embolization by different locations. Methods: Subjects were 32 patients with suspected hepatic artery injury who were transferred to Chi‐Mei Foundation Medical Center for hepatic angiography and embolization. The causes of arterial injury included liver trauma ( n = 15) and iatrogenic injury ( n = 17). The sites of embolization were classified into four groups: group 1 ( n = 8) was classified as ‘combined outlet, target and inlet control’ with embolization of the vascular lesion (target) and hepatic artery distal (outlet) and proximal (inlet) to the vascular lesion simultaneously; group 2 ( n = 11) as ‘combined target and inlet control’; group 3 ( n = 8) as ‘combined outlet and inlet control’; group 4 ( n = 5) as ‘inlet control’ only. Results: Successful initial hemostasis was achieved in 30 of the 32 patients (93.8%), with two failures, both of which were caused by liver injury and occurred in subjects in group 4. Rebleeding was seen in three patients who had successful initial hemostasis: two of them in group 4 (66.7%) and one in group 1 (12.5%). All rebleedings were successfully managed by repeat embolization. Abscess formation was found in two group 1 patients, and both were successfully managed by percutaneous drainage. Conclusions: Transcatheter arterial embolization is an effective method for hemostasis in hepatic artery hemorrhage for both patients with liver trauma and patients with iatrogenic injuries to the hepatic artery. Based on this experience, embolization of the vascular lesion and/or the arterial lumen distal to the vascular lesion combined with inlet control is recommended for preventing recurrent hemorrhage, but studies with larger sample sizes will be required to validate this conclusion.
Laceration of the colonic serosa or mesocolon complicated by colonoscopy is rare but probably overlooked. Certain clinical and historical features may suggest the diagnosis. A case of 59-year-old woman, after colonoscopic examination was done and persistent abdominal pain with drop in hemoglobin level and blood pressure accompanied with transvaginal ultrasonography detected pelvic fluid, which led to the diagnosis of intraabdominal hemorrhage. The abdominal computed tomography depicted the bleeding focus. The exploratory laparotomy confirmed the sigmoid serosal lacerations with hemoperitoneum. The postoperative course was uneventful. The incidence, manifestations, diagnosis and managements of this complication were discussed. The possibility of serosal laceration, a fatal complication of colonoscopy, should be kept in mind.
Aneurysm of the hepatic artery can rupture into biliary system and cause hemobilia that may be lethal. We here report a case of massive hemobilia caused by a secular aneurysm of the right hepatic artery that was successfully treated by transarterial embolization. In order to prevent recurrence of the aneurysm, we not only embolized completely the chamber of aneurysm but also the hepatic arterial lumen around and proximal to the orifice of the aneurysm simultaneously.
Abstract Background: Up-regulation of Wnt-1 protein has been reported in hepatitis B virus (HBV)–related and hepatitis C virus (HCV)–related hepatocellular carcinoma (HCC) tissues and cell lines. It is known to play a fundamental role in signaling cancer progression, whereas its prognostic role in HCC remains unexplored. Methods: As a prognostic biomarker, this study analyzed Wnt-1 protein expression in 63 histology-verified HCC patients receiving curative resection. In each paired tumor and nontumor specimen, Wnt-1 levels were semiquantitatively measured by Western blotting and expressed by tumor/nontumor ratio. The data were further correlated with quantitative real-time PCR as well as with β-catenin and E-cadherin expression by immunohistochemistry. Cumulative tumor recurrence-free survival curves were constructed using the Kaplan-Meier method and compared by the log-rank test. Results: The results showed that 26 (group I) and 37 (group II) HCC patients had an expression ratio of Wnt-1 ≥1.5 and <1.5, respectively. The amount of Wnt-1 estimated by tumor/nontumor ratio correlated with the results by quantitative real-time PCR. High tumor Wnt-1 expression correlated with enhanced nuclear β-catenin accumulation, diminished membranous E-cadherin expression, and increased tumor recurrence after curative tumor resection. Conclusions: These results suggest that Wnt-1 may be used as a predisposing risk factor for HCC recurrence. The use of tumor Wnt-1 as prognostic biomarker may identify patients with HBV- and/or HCV-related HCC patients with a high risk of tumor recurrence who may then benefit from further intensive therapy after surgery. (Cancer Epidemiol Biomarkers Prev 2009;18(5):1562–9)
In chronic hepatitis C, the change of perihepatic lymph nodal size after antiviral therapy could be a marker of virologic response. Whether the on-treatment nodal manifestations predict virologic responses is unknown.Patients (n=88) with biopsy-proven chronic hepatitis C received standard doses of bi-therapy for 24 weeks; sequential changes of the perihepatic lymph nodes were evaluated prospectively by ultrasound. Pretreatment and on-treatment factors were analyzed and correlated with sustained virologic response, focusing on early on-treatment nodal changes (12 weeks).Perihepatic lymph nodes were prevalent in 75% of the patients; 72 patients (81.8%) achieved sustained viral response. Before treatment, no factor was significantly associated with the nodal prevalence or size. The pretreatment nodal width (mean 5.3 vs. 3.6 mm; P=0.023) and the on-treatment nodal manifestations including a reduction in nodal width at 12 weeks of antiviral treatment (median; 1.05 vs. 0 mm, P=0.029) and a reduction of nodal volume at the end of treatment (24 weeks; median 0.62 vs. -0.01 ml, P=0.015) were significantly correlated with the sustained virologic response. A reduction of nodal width greater than 2.5 mm at 12 weeks always predicts sustained virologic response (100 vs. 77%; P=0.019).Results confirm the high prevalence of perihepatic lymphadenopathy in patients with chronic hepatitis C. The use of the nodal width measurement in routine ultrasound follow-up may be a simpler early predictor of sustained virologic response during standard bi-therapy.
In this study, a high-sensitivity colorimetric membrane array method was used to detect circulating tumor cells (CTC) in the peripheral blood of colorectal cancer (CRC) patients with normal perioperative serum carcinoembryonic antigen (CEA) levels. This membrane array method was evaluated as a potential diagnostic and postoperative surveillance tool.Membrane arrays consisting of a panel of mRNA markers that include human telomerase reverse transcriptase, cytokeratin-19, cytokeratin-20, and CEA mRNA were used to detect CTCs in the peripheral blood of 157 postoperative CRC patients with normal perioperative serum CEA levels and in 80 healthy individuals. Digoxigenin-labeled cDNA were amplified by reverse transcription-PCR from the peripheral blood samples, which were then hybridized to the membrane array. The sensitivity, specificity, and accuracy of membrane arrays for the detection of CTCs were then calculated.Using the four markers in combination, expression of any three markers or all the four markers in this panel was significantly correlated with the clinicopathologic characteristics, including depth of tumor invasion, lymph node metastasis, tumor-node-metastasis stage, and postoperative relapse (all P < 0.05). The interval between the detection of all four positive molecular markers and subsequent elevated CEA ranged from 3 to 8 months (median 6 months). The expression of all four mRNA markers was an independent predictor for postoperative relapse. CRC patients with all four mRNA markers expression showed a significantly poorer survival rate than those with less than four positive markers.The constructed membrane array method was helpful in the early prediction of postoperative relapse in CRC patients with normal perioperative serum CEA levels.
Two alternative surgical techniques for elective laparoscopic cholecystectomy (LC), low-pressure insufflation of the peritoneal cavity and abdominal wall lifting (AWL), have been developed over time to minimize the disadvantages associated with CO2-elicited pneumoperitoneum. To the best of our knowledge, the 2 methods have seldom been compared as regards their relative advantages and disadvantages.Eighty patients scheduled for elective LC were randomized into either a low-pressure (8 mmHg) CO2 insufflation method (LPLC) group, or a gasless technique using a subcutaneous abdominal wall lifting device (GLC group). The duration of the surgical procedure, the surgical results including level of postoperative pain, and perioperative cardiopulmonary function changes experienced by the members of both groups were compared.Laparoscopic surgery was completed for all but 1 patient from each group due to an inadequate surgical-site exposure. There was no mortality for study participants, and no major complications were noted for members of either group. The LPLC group evidenced a shorter surgical duration as compared to the GLC group (77 +/- 28 minutes vs. 98 +/- 27 minutes, respectively; p < 0.01) and a lower incidence of postoperative shoulder pain (2/38 vs. 8/39, respectively; p < 0.05), although significant differences in intraoperative pulmonary function were noted (an increased PaCO2, Pet CO2 and peak-airway pressure and decreased arterial blood pH; p < 0.01) for the LPLC group compared to the GLC group.Both alternative methods for this type of surgery appeared feasible and safe for LC. Low-pressure CO2 pneumoperitoneum had a shorter surgical duration and less postoperative shoulder pain compared to the GLC technique, but did not feature any other advantage over the AWL technique with regard to impact on cardiopulmonary function.
Liver abscess after hepatic artery embolization is a rare but serious complication associated with significant morbidity and mortality. Here we report a 52-year-old case of chronic hepatitis B, liver cirrhosis and diabetes mellitus (DM) type 2 with a large gas forming liver abscess (11.4 cm) developed after transarterial chemoembolization (TACE) treatment for a large hepatocellular carcinoma (HCC). The condition responded well to four weeks of antibiotics treatment plus percutaneous drainage with continuous abscess regression after treatment. Infection of the necrotic tumor seems to be the cause of abscess formation in this case. We suggest that for patient with large tumor size, multiple risk factors such as DM, liver cirrhosis, associated biliary disease and old age; post TACE abscess formation should be highly aware of, investigated early and treated promptly. Prophylaxis antibiotics may also be considered.
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