Efficacy of Superselective Conventional Transarterial Chemoembolization Using Guidance Software for Hepatocellular Carcinoma within Three Lesions Smaller Than 3 cm

The indication of transarterial chemoembolization (TACE) has advanced to hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A when surgical resection (SR), thermal ablation, and bridging to transplantation are contraindicated; however, TACE for small HCC is frequently difficult and ineffective because of less hypervascularity and the presence of tumor portions receiving a dual blood supply. Here, we report outcomes of superselective conventional TACE (cTACE) for 259 patients with HCCs within three lesions smaller than 3 cm using guidance software. Automated tumor feeder detection (AFD) functionality was applied to identify tumor feeders on cone-beam computed tomography during hepatic arteriography (CBCTHA) data. When it failed, the feeder was identified by manual feeder detection functionality and/or selective angiography and CBCTHA. Regarding the technical success in 382 tumors (mean diameter, 17.2 ± 5.9 mm), 310 (81.2%) were completely embolized with a safety margin (5 mm wide for HCC ≤25 mm and 10 mm wide for HCC >25 mm). In 61 (16.0%), the entire tumor was embolized but the safety margin was not uniformly obtained. The entire tumor was not embolized in 11 (2.9%). Regarding the tumor response at 2–3 months after cTACE in 303 tumors excluding those treated with combined radiofrequency ablation (RFA) or SR and lost to follow-up, 287 (94.7%) were classified into complete response, seven (2.3%) into partial response, and nine (3.0%) into stable disease. The mean follow-up period was 44.9 ± 27.6 months (range, 1–109) and the cumulative local tumor progression rates at 1, 3, 5, and 7 years were 17.8, 27.8, 32.0, and 36.0%, respectively. The 1-, 3-, 5-, and 7-year overall and recurrence-free survival rates in 175 patients, excluding those with Child–Pugh C class, who died of other malignancies, or who underwent combined RFA or hepatic resection, were 97.1 and 68.7, 82.8 and 34.9, 64.8 and 20.2, and 45.3 and 17.3%, respectively. Our results indicate the efficacy of superselective cTACE using guidance software for HCC within three lesions smaller than 3 cm.

Gastric ischaemia: a rare cause of gastric ulcers

Gastric ulcers secondary to gastric ischaemia is rare because of the rich blood supply of the stomach. We present a case where a patient with history of atherosclerotic vascular disease (ASCVD) presented with unintentional weight loss and failure to thrive for several months. Initial imaging studies ruled out any active malignancy. Oesophagogastroduodenoscopy revealed multiple shallow gastric ulcers. CT angiography was performed in later course of the hospital stay, which demonstrated a high-grade stenosis at the origin of both the superior mesenteric artery and the coeliac trunk. This combination stenosis is a rare finding, which can lead to ischaemia of the stomach by blocking the stomach’s dual blood supply. Although the patient underwent revascularisation attempt with stent placement, she expired due to critical postoperative condition. This case signifies the importance of keeping a low threshold for suspicion for gastric ischaemia in patients with ASCVD risk factors and unexplained weight loss.

Hepatic Arterial Infusion Chemotherapy for Unresectable Intrahepatic Cholangiocarcinoma, a Comprehensive Review

Cholangiocarcinoma (CCA) is the second most common primitive liver cancer. Despite recent advances in the surgical management, the prognosis remains poor, with a 5-year survival rate of less than 5%. Intrahepatic CCA (iCCA) has a median survival between 18 and 30 months, but if deemed unresectable it decreases to 6 months. Most patients have a liver-confined disease that is considered unresectable because of its localization, with infiltration of vascular structures or multifocality. The peculiar dual blood supply allows the delivery of high doses of chemotherapy via a surgically implanted subcutaneous pump, through the predominant arterial tumor vascularization, achieving much higher and more selective tumor drug levels than systemic administration. The results of the latest studies suggest that adequate and early treatment with the combination approach of hepatic arterial infusion (HAI) and systemic (SYS) chemotherapy is associated with improved progression-free and overall survival than SYS or HAI alone for the treatment of unresectable iCCA. Current recommendations are limited by a lack of prospective trials. Individualization of chemotherapy and regimens based on selective targets in mutant iCCA are a focus for future research. In this paper we present a comprehensive review of the studies published to date and ongoing trials.

NUMBER AND PATTERN OF HEPATIC AND ACCESSORY HEPATIC VEINS

Introduction: Liver receives dual blood supply from hepatic artery and portal vein. Venous blood from Liver to inferior vena cava is drained by three hepatic veins. The number, pattern and mode of termination of hepatic veins into inferior vena cava is not always same. Variations in number, pattern and positions of the hepatic veins and their mode of termination do exist which significantly influence surgical interventions on liver especially during transplantation. Materials and Methods: 28 wet formalin preserved specimens were taken for the present study. A longitudinal incision was given in the inferior vena cava to observe the number, pattern and arrangement of hepatic veins openings into inferior vena. The specimens were preserved after routine dissection classes Result: 19 livers of 28 (67.86%) were found to be drained by three major hepatic veins, whereas 9 livers out of 28 (32.14) presented with accessory hepatic veins in addition to major hepatic veins. The number of accessory veins ranged from 1-3. Out of the nine specimens with accessory hepatic veins seven (77.77%) presented with three plus one pattern (3 major hepatic veins 1 accessory hepatic vein).Three plus two and three plus three pattern was observed in one specimen each (11.11%). The arrangement of three major veins from left to right was left hepatic, middle hepatic and right hepatic. The openings of all accessory veins were found below the openings of major hepatic veins. Conclusion: A sound knowledge of Accessory hepatic veins and their pattern is essential for Radiologists and also for liver transplant surgeons to reduce postoperative complications.

ACCESSORY THYROID GLAND WITH DUAL BLOOD SUPPLY: A RARE VARIATION

A rare congenital anomaly of thyroid gland due to developmental defect is accessory or ectopic thyroid gland. Ectopic thyroid refers to the presence of thyroid tissue in locations other than the normal in anterior neck region between the second and fourth tracheal cartilages. Abnormal organogenesis of the thyroid gland leads to morphological variations, such as thyroid dysgenesis, hypoplasia, hemiagenesis and agenesis. The ectopic or accessory thyroid being the most common form of thyroid dysgenesis. Here, we are presenting a case with the accessory thyroid tissue with dual blood supply observed during a routine dissection of a female cadaveric body. The accessory thyroid tissue was in the form of an oval structure about 1.5cm x 3 cm was situated in the midline 2cm above the normally located thyroid gland which was supplied by a branch of lingual artery as well as superior thyroid artery. The accessory thyroid tissue could be asymptomatic or it could present with any disorder affecting the main thyroid gland including malignancy. The significance of this case is to show an anatomical variation in the form of developmental defect during the organogenesis of thyroid along with its clinical implications. Thus, this report highlights the importance of knowing and understanding the normal anatomy of thyroid as well as the anatomical variant that could be immensely beneficial while diagnosing thyroid disorders or carrying out surgical procedures involving thyroid.

Hand Perfusion in Patients with Physiological or Pathological Allen's Tests

Background The Allen test (AT) is a widely used clinical tool for the preoperative assessment of sufficient dual vessel hand perfusion although the impact of a pathological AT on tissue perfusion of the hand is not entirely clear. This study reveals perfusion changes of the hand in patients with pathological and physiological AT after terminating the dual blood supply. Methods Patients were distributed into 2 groups (physiological and pathological AT) that each contained 25 members. Perfusion of the thumb, middle, and small fingers was measured with a laser Doppler based (“oxygen-to-see” [O2C]) device. A steady state was measured and also values at 1, 3, 5, and 10 minutes after radial occlusion were measured. Results In patients with a physiological AT, only 1 out of 18 values differed significantly from the steady state measurements after 10 minutes, whereas patients with a pathological AT showed significant alterations in 8 out of 18 values. Oxygen saturation of the superficial and deep tissues appeared to be significantly worse in patients with a pathological AT. Conclusion Patients with a pathological AT suffered significantly more from the loss of dual hand perfusion than patients with a physiological AT. Patients with a pathological AT need more time to compensate for the altered perfusion pattern.

Transradial Access Technique

Transradial access (TRA) competency can be rapidly achieved by the experienced interventionist. Statistically significant reductions in bleeding and other access site complications have been shown in randomized and meta-analysis studies when comparing TRA to both brachial and femoral artery access. Despite accumulating data, vascular interventional radiologists have been hesitant to adopt TRA for a variety of reasons. However, TRA offers distal dual blood supply, easily achievable hemostasis, and no adjacent critical structures. Other advantages of TRA are safer endovascular approach concomitant with earlier ambulation, improved patient comfort, decreased length of stay, as well as potential for cost savings. This chapter discusses the TRA technique, applications, challenges, and potential complications.

Surgical Anatomy of the liver

The liver is the second largest human organ and has got a complex internal vascular and ductal anatomy. It is subdivided into lobes, sections and segments and receives dual blood supply from the hepatic artery and portal vein. The hepatic veins drain the liver directly into the inferior vena to which the liver is intimately related. Anatomical variations are common. A thorough knowledge of the liver anatomy and its variations is of critical importance for safe and successful procedures and surgeries involving the liver.