Murad Aljiffry

Evidence-Based Approach to Cholangiocarcinoma: A Systematic Review of the Current Literature

adjusted mortality rate increased from 0.07 per 100,000 in 1973 to 0.69 per 100,000 in 1997, with average age at presentation in the 7th decade of life and male-to-female ratio of 1.5. 9 Extrahepatic CC In the United States, age-adjusted incidence of extrahepatic CC (ECC) is 1.2 per 100,000 in men and 0.8 per 100,000 in women 10 and has decreased by 14% compared with two decades earlier. ECC usually present in the 7th decade of life.

Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases

OBJECTIVES Portal vein embolization (PVE) can facilitate the resection of previously unresectable colorectal cancer (CRC) liver metastases. Bevacizumab is being used increasingly in the treatment of metastatic CRC, although data regarding its effect on post-embolization liver regeneration and tumour growth are conflicting. The objective of this observational study was to assess the impact of pre-embolization bevacizumab on liver hypertrophy and tumour growth. METHODS Computed tomography scans before and 4 weeks after PVE were evaluated in patients who received perioperative chemotherapy with or without bevacizumab. Scans were compared with scans obtained in a control group in which no PVE was administered. Future liver remnant (FLR), total liver volume (TLV) and total tumour volume (TTV) were measured. Bevacizumab was discontinued ≥ 4 weeks before PVE. RESULTS A total of 109 patients and 11 control patients were included. Portal vein embolization induced a significant increase in TTV: the right lobe increased by 33.4% in PVE subjects but decreased by 34.8% in control subjects (P < 0.001), and the left lobe increased by 49.9% in PVE subjects and decreased by 33.2% in controls (P= 0.022). A total of 52.8% of the study group received bevacizumab and 47.2% did not. There was no statistical difference between the two chemotherapy groups in terms of tumour growth. Median FLR after PVE was similar in both groups (28.8% vs. 28.7%; P= 0.825). CONCLUSIONS Adequate liver regeneration was achieved in patients who underwent PVE. However, significant tumour progression was also observed post-embolization.

Analytical review of diagnosis and treatment strategies for dominant bile duct strictures in patients with primary sclerosing cholangitis

BACKGROUND The diagnosis and treatment of indeterminate dominant strictures (DS) in patients with primary sclerosing cholangitis (PSC) is challenging and the literature on the subject is scarce. OBJECTIVES This review aims to appraise and synthesize the evidence published in the English-language medical literature on this topic. METHODS Scientific papers published from 1950 until week 4 of July 2010 were extracted from MEDLINE, Ovid Medline In-Process, the Cochrane Database of Systematic Reviews, the Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, EMBASE, PubMed and the National Library of Medicine Gateway. RESULTS Strategies for the optimal management of DS in PSC patients are supported only by level II and III evidence. Intraductal endoscopic ultrasound appears to be the most sensitive (64%) and specific (95%) diagnostic test for the evaluation of DS in PSC. Endoscopic and percutaneous dilatations achieve 1- and 3-year palliation in 80% and 60% of patients, respectively. Although dilatation and stenting are the most common palliative interventions in DS, no randomized trials on the optimal duration of treatment have been conducted. CONCLUSIONS In benign DS, endoscopic dilatation with short-term stenting seems to be effective and safe and does not increase the risks for malignant transformation or complications after liver transplantation. Surgical bile duct resection and/or bilioenteric bypass are indicated only in patients with preserved liver function.

Predictors of response to radio‐embolization (TheraSphere®) treatment of neuroendocrine liver metastasis

BACKGROUND Neuroendocrine tumours (NET) frequently metastasize to the liver. NET liver metastasis has been shown to respond to Yttrium-90 microspheres therapy. The aims of the present study were to define factors that predict the response to radio-embolization in patients with NET liver metastases. METHODS From January 2006 until March 2009, all patients with NET liver metastasis that received radio-embolization using TheraSphere® (glass microspheres) were reviewed. The response was determined by a change in the percentage of necrosis (ΔN%) after the first radio-embolization based on the modified RECIST criteria (mRECIST) criteria. The following confounding variables were measured: age, gender, size of the lesions, liver involvement, World Health Organization (WHO) classification, the presence of extra-hepatic metastasis, octereotide treatment and previous operative [surgery and (RFA)] and non-operative treatments (chemo-embolization and bland-embolization). RESULTS In all, 25 patients were identified, with a median follow-up of 21.7 months. The median age was 64.6 years, 28% had extra-hepatic metastasis and 56% were WHO stage 2. Post-treatment, the mean ΔN% was 48.4%. Previous surgical therapy was a significant predictor of the response with a response rate of 66.7 ΔN% vs. 31.5 ΔN% (P= 0.02). Bilateral liver disease, a high percentage of liver involvement and large metastatic lesions were inversely related to the degree of tumour response although did not reach statistical significance. CONCLUSION Radio-embolization increased the necrosis of NET liver metastasis mainly in patients with less bulky disease. This may imply that surgical therapy before radio-embolization would increase the response rates.

The role of interventional radiology in the management of hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma (hcc) is one of the most common causes of cancer-related death worldwide. Overall, liver transplantation and resection are the only available treatments with potential for cure. Various locoregional therapies are widely used to manage patients with advanced hcc or as a bridging therapy for patients with early and intermediate disease. This article reviews and evaluates the role of interventional radiology in the management of such cases by assessing various aspects of each method, such as effect on rates of survival, recurrence, tumour response, and complications. METHODS A systemic search of PubMed, medline, Ovid Medline In-Process, and the Cochrane Database of Systematic Reviews retrieved all related scientific papers for review. RESULTS Needle core biopsy is a highly sensitive, specific, and accurate method for hcc grading. Portal-vein embolization provides adequate expansion of the future liver remnant, making more patients eligible for resection. In focal or multifocal unresectable early-stage disease, radiofrequency ablation tops all other thermoablative methods. However, microwave ablation is preferred in large tumours and in patients with Child-Pugh B disease. Cryoablation is preferred in recurrent disease and in patients who are poor candidates for anesthesia. Of the various transarterial modalities-transarterial chemoembolization (tace), drug-eluting beads, and transarterial radio-embolization (tare)-tace is the method of choice in Child-Pugh A disease, and tare is the method of choice in hcc cases with portal vein thrombosis. CONCLUSIONS The existing data support the importance of a multidisciplinary approach in hcc management. Large randomized controlled studies are needed to provide clear indication guidelines for each method.

Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass.

Ureteral stricture is the most common urologic complication after renal transplantation. When endourologic management fails, open ureteral reconstruction remains the standard treatment. The complexity of some of these procedures makes it necessary to explore other means of repair. This study evaluated the intermediate‐term outcome of subcutaneous pyelovesical bypass graft (SPBG) on renal transplant recipients. We reviewed 8 patients (6 male and 2 female; mean age 52 years) with refractory ureteral strictures postrenal transplantation, who received SPBG as salvage therapy. All patients failed endourologic management and half failed open management of their strictures. After a mean follow‐up of 19.4 months, 7 out of 8 renal grafts have good function with mean GFR of 58.5 mL/min/1.73 m2, without evidence of obstruction or infection. One patient lost his graft due to persistent infection of the SPBG and one patient developed a recurrent urinary tract infection managed with long‐term antibiotics. SPBG offers a last resort in the treatment of ureteral stricture after renal transplantation refractory to conventional therapy.

Portal vein embolization and its effect on tumour progression for colorectal cancer liver metastases

The aim of this study was to evaluate the long‐term outcomes of patients with colorectal cancer liver metastasis (CRCLM) exhibiting disease progression after portal vein embolization (PVE).

Hepatic Artery Aneurysm Associated with Prune Belly Syndrome: A Case Report and Review of the Literature

Potentially life threatening when they rupture, hepatic artery aneurysms (HAAs) are uncommon and diagnosed at the fifth to sixth decade of life. HAAs are the second most common splanchnic aneurysms after the ones that involve the splenic artery and are more predominant in men than in women with a ratio of 3 to 2. Usually, HAAs are associated with inflammation or traumas to the arteries of the liver. Among the former group, atherosclerosis, arthritis, and collagen vascular disease are the most common, whereas liver biopsy or other radiologic interventions (ie, percutaneous abscess drainage) are frequent iatrogenic causes. HAAs are discovered incidentally in most cases, but some patients can present with intraperitoneal bleeding and hypovolemic shock. The etiology of prune belly syndrome (PBS) is poorly understood, but new evidence suggests that it is caused by mesodermal delay during the fetal development because of an intrauterine injury. We present a case of HAA in a young individual affected by PBS. To our knowledge, this report is the first to describe the existence of these 2 rare conditions in a single patient. We hypothesize that the mesodermal abnormality that involves PBS might be a rare cause of HAA.

Ruptured spontaneous splenic artery aneurysm: A case report and review of the literature

INTRODUCTION Splenic artery aneurysm is a rare condition, however, potentially fatal. The importance of splenic artery aneurysm lies in the risk for rupture and life threatening hemorrhage. PRESENTATION OF CASE This is a case of a ruptured splenic artery aneurysm in a 58-year-old lady. She presented with hypovolemic shock and intra-peritoneal bleeding. Diagnosis was confirmed by CT angiography and she was managed by operative ligation of the aneurysm with splenectomy and distal pancreatectomy. DISCUSSION The literature pointed the presence of some risk factors correlating to the development of splenic artery aneurysm. In this article we discuss a rare case of spontaneous (idiopathic) splenic artery aneurysm and review the literature of this challenging surgical condition. CONCLUSION Splenic artery aneurysm needs prompt diagnosis and management to achieve a favorable outcome, high index of suspicion is needed to make the diagnosis in the absence of known risk factors.

Type II Gall Bladder Perforation with Abdominal Wall Abscess in a Cirrhotic Patient: Case Report and Review of the Literature

Gallbladder perforation is a rare condition even in patients affected by acute cholecystitis. Most patients who present with gallbladder perforations are diagnosed preoperatively by radiologic imaging. Morbidity and mortality for this condition has improved significantly over the last few decades. We encountered a cirrhotic patient who was affected by primary sclerosing cholangitis and who developed a type II gallbladder perforation before undergoing a cadaveric liver transplantation. In this article, we report her clinical course and our review of the current literature on this rare condition.