F.G. Irani

National Cancer Centre Singapore Consensus Guidelines for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the 6th most common cancer in the world, but the second most common cause of cancer death. There is no universally accepted consensus practice guidelines for HCC owing to rapid developments in new treatment modalities, the heterogeneous epidemiology and clinical presentation of HCC worldwide. However, a number of regional and national guidelines currently exist which reflect practice relevant to the epidemiology and collective experience of the consensus group. In 2014, clinicians at the multidisciplinary Comprehensive Liver Cancer Clinic (CLCC) at the National Cancer Centre Singapore (NCCS) reviewed the latest published scientific data and existing international and regional practice guidelines, such as those of the National Comprehensive Cancer Network, American Association for the Study of Liver Diseases and the Asian Pacific Association for the Study of the Liver, and modified them to reflect local practice. These would serve as a template by which treatment outcomes can be collated and benchmarked against international data. The NCCS Consensus Guidelines for HCC have been successfully implemented in the CLCC since their publication online on 26th September 2014, and the guidelines allow outcomes of treatment to be compared to international data. These guidelines will be reviewed periodically to incorporate new data.

Massive upper gastrointestinal bleeding post-Whipple’s surgery from anastomotic varices due to mesenteric hypertension

A 45-year-old man was admitted with hematemesis. He had undergone Whipple’s surgery 7 years previously for a 5-cm serous cystadenoma of the pancreatic head. Upon presentation, he was hypotensive (blood pressure 82/59mmHg) and tachycardic (110 beats/min), with a hemoglobin of 6.8 g/dL. Gastroscopy revealed bleeding anastomotic varices alongside the gastrojejunal anastomosis (▶Fig. 1). Hemostasis was secured with a Boston Resolution clip (▶Video1). Computed tomography (CT) scanning, followed by mesenteric angiography in the portal venous phase and CT arterioportography showed proximal superior mesenteric vein (SMV) occlusion, with a large collateral vein draining the small bowel into the anastomotic varices, which decompressed via the enlarged left coronary vein (LCV) into a patent portal vein (▶Fig. 2). The occluded SMV was recanalized, dilated to 8mm, and stented with a 7×29-mm Omnilink stent via a transhepatic approach, thereby reestablishing antegrade flow with subsequent collapse of the collateral vein and anastomotic varices (▶Fig. 3). Gastrointestinal bleeding is a complication reported in 2%–8% of patients following a Whipple procedure [1]. Sources of upper gastrointestinal bleeding include pseudoaneurysms, pancreatic fistulas, anastomotic ulcers, and ectopic varices [2–5]. We report a case of bleeding anastomotic varices that developed from mesenteric hypertension as a result of SMV occlusion following surgery. As the small bowel was solely draining back to the portal vein via a collateral vein and anastomotic varices, endoscopic glue injection into the anastomotic varices could have led to bowel ischemia. Successful stenting of the occluded SMV resulted in the re-establishment of normal hemodynamics, decompressing the anastomotic varices, and therefore preventing future bleeding episodes.