Anthony Watkinson

TIPS for acute and chronic Budd-Chiari syndrome: a single-centre experience

BACKGROUND/AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is a technically challenging but feasible treatment for Budd-Chiari syndrome (BCS). However, information about the outcome, particularly in patients with liver failure, is scarce. We report our experience of TIPS for BCS. METHODS Fifteen patients with BCS underwent TIPS. Eight had hepatic failure and seven underwent TIPS for BCS uncontrolled by medical treatment. RESULTS Fourteen out of 15 had successful TIPS placement. Out of the eight hepatic failure patients, four died soon after TIPS: one liver rupture, one portal vein rupture, one liver failure and one pulmonary oedema. Another patient had a significant intrahepatic haematoma, which resolved with conservative management. TIPS was successfully placed in all of the seven patients with chronic BCS, in whom there was an average follow-up of 20 months. Ascites resolved and liver function improved in all. One patient died after 18 months from the original hepatic metastatic disease. Four patients have had evidence of TIPS dysfunction requiring three balloon dilatations and one restenting. No patient has required liver transplantation. CONCLUSIONS TIPS should be the first line treatment for BCS uncontrolled by medical therapy. However, mortality in BCS with hepatic failure is high and liver transplantation could be a better option.

Liver Transplantation in Cirrhotic Patients with Small Hepatocellular Carcinoma: An Analysis of Pre-Operative Imaging, Explant Histology and Prognostic Histologic Indicators

Background: In recent years, liver transplantation in patients with hepatocellular cancers and cirrhosis has been restricted to those with small cancers (<5 cm for solitary and <3 cm for multifocal HCC with <3 nodules). The selection of patients for liver transplantation is based on pre-operative imaging. The accuracy of imaging correlated with explant histology and the effect of tumour stage has not been evaluated in this selected population. Methods: In this study, prospectively collected data for 30 patients who underwent orthotopic liver transplantation for cirrhosis complicated by small hepatocellular carcinoma (HCC) at a single centre have been reviewed with the aim of correlating radiological findings, explant histology and patient outcome. Patients who underwent orthotopic liver transplantation between 1995 and 1999 had plain and contrast-enhanced dual-phase spiral CT (DCT) scans of the liver. Patients suspected of having HCC on CT scan or due to elevated serum alpha-fetoprotein underwent iodized oil CT (IOCT). Following transplantation, the explanted liver was serially sectioned at 10-mm intervals and examined by a pathologist blinded to the results of imaging. Data collected prospectively on imaging and histology were compared with outcome data. The median period of follow-up was 1,139 days (range 690–1,955 days) after transplantation. All patients were followed up by clinical assessment, assessment of serum alpha-protein levels and imaging when indicated. Results: All the patients transplanted fulfilled the selective criteria on the basis of imaging (solitary HCC <5 cm in diameter or multifocal HCC <3 cm in diameter with <3 nodules). Of the 30 patients transplanted, 46 HCCs were detected on explant histology with a median size of 24 mm (range 6–75 mm). Ten patients had multifocal disease (median number of lesions 2, range 2–4). No significant difference was observed between IOCT and DCT with regards to the sensitivity (67.4 vs. 68%) and specificity (78.97 vs. 88.6%) of detecting HCCs. IOCT had a positive predictive value of 78.9% as compared to 82.8% for DCT. IOCT had an overall sensitivity of 40% as compared to 30% for DCT in detecting multifocal disease (not significant). Histological assessment of the explanted livers showed that 8 patients had well-, 17 moderate and 5 poorly differentiated HCCs. Tumour size and the presence of multifocal disease did not influence survival in this study. Microvascular invasion was more common with larger tumours (from 38% with lesions less than 40 mm in diameter to 60% with lesions >40 mm in diameter; p < 0.01) and with moderately (29.4%) or poorly differentiated (60%) HCCs than well-differentiated HCC (12.5%) (p < 0.04 and 0.01 for well- vs. moderately and poorly differentiated HCC, respectively). Microvascular invasion on explant histology was associated with poor survival. Of the 17 transplant recipients without vascular invasion, 15 were alive at 1 and 2 years in comparison to 7 of 9 with microscopic vascular invasion (p < 0.01). Four patients died in the post-transplant period due to recurrent HCC. Overall survival [after excluding early post-transplant sepsis-induced deaths (n = 4)] at 1 year was 83.3%. Conclusions: Selective criteria for transplantation of HCC in cirrhosis are associated with a 1-year and 3-year survival rate of 73.3% (including early post-transplant sepsis-induced deaths). IOCT and DCT are similar in their ability to detect unifocal or multifocal HCC. Tumour size and number are not predictive of recurrence with these selective criteria, but microscopic vascular invasion is a bad prognostic factor.

Prospective study of contrast‐enhanced computed tomography, computed tomography during arterioportography, and magnetic resonance imaging for staging colorectal liver metastases for liver resection

This study compared the value of contrast‐enhanced helical computed tomography (CT), CT during arterioportography (CTAP), and contrast‐enhanced magnetic resonance imaging (MRI) for staging patients with colorectal liver metastases.

Radiofrequency ablation in the treatment of hepatocellular carcinoma--a clinical viewpoint.

H EPATOCELLULAR carcinoma (HCC) is not only the fifth most common cancer in the world, accounting for 5.4% of all human cancer (l), but it is also a disease with increasing prevalence due to the widespread distribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, the main causes of cirrhosis and hepatocellular carcinoma (2,3). HCC is also a tumor with a high mortality rate (4) due to its chemoresistance and the underlying cirrhosis, which in itself has a high mortality. Although 6-monthly screening programs (using afetoprotein and liver ultrasound) pick up the appearance of small nodules (5-7) larger nodules or multiple nodules are often recognized only during follow up, despite screening. This is because HCC can have a multifocal origin (8) with a very variable and unpredictable doubling growth interval (9) which is poorly correlated with survival (10). Survival is related more to the functional reserve of the liver than to the size and number of tumors (1 l), at least in the early and intermediate stages of HCC (10-12). Thus, all therapeutic options have to be weighed against the underlying functional hepatic reserve.

Carbon-dioxide portography: an expanding role?

We describe a new and inexpensive technique of imaging the portal vein in patients with liver disease by use of carbon dioxide.

Systemic vasculitis with multiple aneurysms complicating systemic lupus erythematosus.

In elderly diabetic patients with renal cholesterol atheroembolism, a common precipitant is manipulation of atherosclerotic vessels during vascular surgery or angiography. It can also result from thrombolytic and anticoagulant therapy, sometimes after a considerable delay1. Spontaneous cholesterol embolism is uncommon-found by Cross2 in 1.9% of serial necropsies, always in patients over 60 years of age. The clinical features are varied and make diagnosis difficult. Risk factors for renal cholesterol atheroembolism are advanced age (mean 66 years), hypertension, coronary atherosclerosis and renal impairment3. Spontaneous renal atheroembolism often leads to progressive decline in renal function, early dialysisdependence and high mortality3; however, renal function can recover4. Flash pulmonary oedema often points to underlying atheromatous renal artery occlusion, and we suspect that this was present in our patient. Regarding treatment, there is some evidence that a statin can stabilize atherosclerotic plaques, reduce the propensity for atheroembolism and thus preserve renal function5. Recurrent spontaneous cholesterol atheroembolism, characterized here by short-lived episodes of acute renal failure and pulmonary oedema, does not seem to have been described previously. This possibility should be considered in any elderly diabetic patient with established atherosclerotic disease who presents with impaired renal function and pulmonary oedema.

Transcatheter Embolisation of a Giant Splenic Artery Aneurysm. Case Report

Splenic artery aneurysms (SAAs) comprise 60% of visceral artery aneurysms and although they can present at any age, they most commonly present in the fifth and sixth decades of life. They are associated with multiparity and portal hypertension and are more common in women. Historically SAAs greater than 2 cm in diameter are treated surgically because the risk of rupture, particularly during pregnancy, is high. The role of transcatheter embolisation – 5 is still evolving but is likely to become increasingly important as more asymptomatic visceral aneurysms are diagnosed as a result of the ready access to ultrasound, CT and MRI.