James G. Caridi

Preoperative portal vein embolization for extended hepatectomy.

ObjectiveTo examine the authors’ experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy. Summary Background DataExtended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications. MethodsSixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients. ResultsThere were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group. ConclusionsPreoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Transcatheter treatment of hepatocellular carcinoma with doxorubicin-loaded dc bead (DEBDOX): Technical recommendations

Tranarterial chemoembolization (TACE) has been established by a meta-analysis of randomized controlled trials as the standard of care for nonsurgical patients with large or multinodular noninvasive hepatocellular carcinoma (HCC) isolated to the liver and with preserved liver function. Although conventional TACE with administration of an anticancer-in-oil emulsion followed by embolic agents has been the most popular technique, the introduction of embolic drug-eluting beads has provided an alternative to lipiodol-based regimens. Experimental studies have shown that TACE with drug-eluting beads has a safe pharmacokinetic profile and results in effective tumor killing in animal models. Early clinical experiences have confirmed that drug-eluting beads provide a combined ischemic and cytotoxic effect locally with low systemic toxic exposure. Recently, the clinical value of a TACE protocol performed by using the embolic microsphere DC Bead loaded with doxorubicin (DEBDOX; drug-eluting bead doxorubicin) has been shown by randomized controlled trials. An important limitation of conventional TACE has been the inconsistency in the technique and the treatment schedules. This limitation has hampered the acceptance of TACE as a standard oncology treatment. Doxorubicin-loaded DC Bead provides levels of consistency and repeatability not available with conventional TACE and offers the opportunity to implement a standardized approach to HCC treatment. With this in mind, a panel of physicians took part in a consensus meeting held during the European Conference on Interventional Oncology in Florence, Italy, to develop a set of technical recommendations for the use of DEBDOX in HCC treatment. The conclusions of the expert panel are summarized.

The combination of sorafenib with transarterial chemoembolisation for hepatocellular carcinoma

Aliment Pharmacol Ther 2011; 34: 205–213

Hepatic artery embolization for control of symptoms, octreotide requirements, and tumor progression in metastatic carcinoid tumors

Hepatic artery embolization (HAE) has been utilized for treatment of advanced hepatic carcinoid metastases, with promising symptom palliation and tumor control. Our institution employs transcatheter HAE using Lipiodol/Gelfoam for treatment of carcinoid hepatic metastases, and this report presents our experience with twenty-four patients, examining symptom control, quality-of-life, octreotide dependence, and tumor progression. Twenty-four (11 male, 13 female, mean age = 59.4 ± 2.5 yr) patients with carcinoid and unresectable hepatic metastases, confirmed by urinary 5-hydroxyindole acetic acid (5-HIAA) measurement and biopsy, were treated with Lipiodol/Gelfoam HAE from 1993–2001. Median follow-up was 35.0 months. Before HAE, 14 patients (58.3%) had malignant carcinoid syndrome, with symptoms quantified using our previously reported Carcinoid Symptom Severity Score, and 13 patients (54.2%) required octreotide for symptom palliation. Following treatment, symptom severity, octreotide dose, and tumor response were measured. Asymptomatic patients did not develop symptoms or require following treatment. Hepatic metastases remained stable (n = 4) or decreased (n = 19) in 23 patients (95.8%). Mean pretreatment Symptom Severity Scores (3.8 ± 0.2), decreased to 1.4 ± 0.1 post-treatment (P < 0.00001), with 64.3% of patients becoming asymptomatic. Mean pretreatment octreotide dosages (679.6 ± 73.0 μg/d), decreased to 262.9 ± 92.7 μg/d (P = 0.0024) post-treatment, with 46.2% of patients discontinuing octreotide. There were no treatment-related serious complications or deaths. This study demonstrates that Lipiodol/Gelfoam HAE produces excellent control of malignant carcinoid syndrome, allowing patients to decrease or eliminate use of octreotide, while controlling hepatic tumor burden.

Evaluation of percutaneous transhepatic balloon dilatation of benign biliary strictures in high-risk patients*

During the period from 1979 through 1984, 17 patients with benign biliary strictures underwent percutaneous transhepatic balloon dilatation. All patients presented with either hyperbilirubinemia and acute cholangitis, a history of intermittent chills and fever, or both. Balloon dilatation was most successful in those patients with intrahepatic strictures, sclerosing cholangitis, strictured biliary enteric anastomoses, and distal common bile duct strictures with retained calculi. Two patients with postsurgical common bile duct injury had treatment failure 3 and 18 months after dilatation and subsequently underwent elective hepaticojejunostomy. Although our longest treatment success is now more than 4 1/2 years in an 83 year old woman who is 15 years posthepaticojejunostomy, the mean follow-up of the entire group has only been 2 years. On the basis of our early experience and that of others, we now recommend an initial attempt at balloon dilatation in most patients with postsurgical benign biliary strictures. Further technical advances and longer follow-up in present and future series may certainly broaden the appeal of this nonoperative procedure.

ANGIOGRAPHY WITH CARBON DIOXIDE (CO2)

CO2 possesses many advantages over conventional iodinated contrast agents used for arteriography. It is nonallergic and lacks renal toxicity. Its unique properties permit use of smaller catheters in diagnostic and therapeutic angiographic procedures, allow optimal vascular imaging of various neoplasm, assist in detection of occult gastrointestinal bleeding, and facilitate TIPS procedures. With digital subtraction techniques and stacking programs, CO2 arteriography is as accurate as iodinated contrast studies in most patients and thus is the preferred arterial imaging technique in patients with contrast allergy and renal insufficiency. CO2 is also extremely inexpensive compared with available contrast agents. Understanding of the effects of buoyancy and compressibility is necessary for safe, controlled delivery of CO2 during arteriography, but only rare complications have occurred in our large experience with CO2 angiography. Thus, use of CO2 as an arterial contrast agent significantly expands the safety and utility of arterial imaging in patients with peripheral vascular disease.

Technical Success and Safety of Retrieval of the G2 Filter in a Prospective, Multicenter Study

PURPOSE To assess the technical success and safety for retrieval of the G2 filter. MATERIALS AND METHODS The authors performed a prospective, multicenter study of 100 patients with temporary indication for caval interruption. Patients were enrolled consecutively between December 2005 and July 2006. There were 67 men and 33 women with a mean age of 52.1 years (range, 19-82 years). Indications for filter placement were trauma (n = 56), perioperative risk (n = 16), and medical indications (n = 28). Forty-two patients had venous thromboembolism at filter placement. Fifty-eight filters were placed prophylactically. RESULTS Retrieval was attempted in 61 patients. Fifty-eight of the 61 filters (95%) were successfully retrieved after a mean dwell time of 140 days (range, 5-300 days). In all failed retrievals, the filter tip was against the caval wall. There was no difference in dwell times between successful and unsuccessful retrievals. Although there were no cases of cranial migration, caudal migrations were observed in 12% of cases (10 of 85 patients with a complete data set). Other device-related complications included filter fracture (1/85, 1.2%), filter tilt of more than 15 degrees (15/85, 18%), and leg penetration (16/61, 26%). The recurrent pulmonary embolism (PE) rate was 2%, with no PE in the 30-day period after filter retrieval. CONCLUSIONS Retrieval of the Recovery G2 filter was safe and successful in most patients. Caudal migration was observed as an unexpected phenomenon.

CT diagnosis of hernia of Morgagni.

A single case of hernia of Morgagni diagnosed by computed tomography (CT) is presented. CT is an accurate, noninvasive method of evaluating this entity and can replace many of the other imaging modalities previously employed.

CARBON DIOXIDE DIGITAL SUBTRACTION ANGIOGRAPHY FOR RENAL ARTERY STENT PLACEMENT

PURPOSE To determine the efficacy of renal artery stent placement with use of carbon dioxide as the primary contrast agent. MATERIALS AND METHODS Seventeen hypertensive patients with renal ostial stenosis were evaluated and underwent stent placement with use of CO2 digital subtraction angiography (DSA). Besides hypertension, 11 patients had decreased renal function, three had iodinated contrast material allergy, one patient had both, and two had neither. Supplemental iodinated contrast material (25 mL or less) was used in five patients. Preprocedure and postprocedure serum creatinine levels were obtained to evaluate the effect of CO2 on renal function. Arteriography was used to evaluate stent positioning. RESULTS Twenty-three Palmaz stents were placed in 17 patients. Six placements were bilateral, with a total of nine right and 14 left. No additional stents were required to correct malposition. One patient had a mildly significant, yet transient, rise in the postprocedure creatinine level. This patient received 10 mL of iodinated contrast material in addition to CO2. There were no allergic reactions. CONCLUSION The utilization of CO2 DSA facilitates the accurate placement of renal artery stents by eliminating the concern for contrast material-associated nephropathy and allergy. These attributes, coupled with the benefit of low viscosity, permit unrestricted imaging, guidance, and precise positioning not afforded by iodinated contrast material.

Factors Predicting Survival after Transjugular Intrahepatic Portosystemic Shunt Creation: 15 Years' Experience from a Single Tertiary Medical Center

PURPOSE This retrospective analysis was conducted to identify factors predictive of survival after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS Patients who underwent TIPS creation between January 1991 and December 2005 at a tertiary-care center were identified. Log-rank tests were used to compare the cumulative survival functions among groups of patients who underwent TIPS creation for various indications. Thirty-day mortality after TIPS creation was examined by logistic regression. Cox proportional-hazards analyses were performed to analyze the cumulative 90-day and 1-year survival. Selected variables such as creatinine, bilirubin, and International Normalized Ratio (INR) were assessed with respect to survival. RESULTS The study included 352 patients, of whom 229 (65.1%) were male. The mean age at the time of TIPS creation was 53.6 years (range, 21-82 y). A Model for End-stage Liver Disease (MELD) score greater than 15 was significantly associated with poor survival (P < .05) at 30 days, 90 days, and 1 year after TIPS creation. Independently, a serum total bilirubin level greater than 2.5 mg/dL, an INR greater than 1.4 (P < .05), and a serum creatinine level greater than 1.2 mg/dL were predictive of poor survival. Finally, age greater than 70 years was associated with poor survival at 90 days and 1 year after TIPS creation (P < .05). CONCLUSION The choice to create a TIPS in individuals whose MELD score is greater than 15 and/or whose age is greater than 70 years should involve a careful consideration of risk/benefit ratio, taking into account the finding that such patients have significantly poorer survival after TIPS creation.