Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma:When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.

Viscoelastic tests in liver disease: where do we stand now?

Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder,and cirrhotic patients were considered naturally anticoagulated.In the light of the new evidence,the theory of rebalanced hemostasis replaced the old concept.According to this model,the hemostatic alteration leads to a unique balance between pro-coagulant,anticoagulant,and fibrinolytic systems.But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors.The standard coagulation tests[INR(international normalized ratio),platelet count and fibrinogen]only explore parts of the hemostasis,not offering an entire image of the process.Rotational thromboelastometry(ROTEM)and thromboelastography(TEG)are both point of care viscoelastic tests(VET)that provide real-time and dynamic information about the entire hemostasis process,including clot initiation(thrombin generation),clot kinetics,clot strength,and clot stability(lysis).Despite prolonged PT/INR(international normalized ratio of prothrombin time)and low platelet counts,VET is within the normal range in many patients with both acute and chronic liver disease.However,bleeding remains the dominant clinical issue in patients with liver diseases,especially when invasive interventions are required.VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests,leading to decrial use of blood products transfusion.Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET.Although VET has shown its benefit,more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.

Combined treatments in hepatocellular carcinoma:Time to put them in the guidelines?

The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma(HCC)we do have a far-reaching arsenal.Moreover,because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options.The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies,discussing their advantages and flaws in comparison to the current standard of care.One particular combination therapy seems to be in the forefront:Transarterial chemoembolization plus ablation for medium-size non-resectable HCC(3-5 cm),which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B.Not only does it improve the outcome in contrast to each individual therapy,but it also seems to have similar results to surgery.Also,the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC.Although the path of combination therapies in HCC is still filled with uncertainty and caveats,in the following years the hepatology and oncology fields could witness an HCC guideline revolution.

Pulmonary complications of portal hypertension:The overlooked decompensation

The systemic nature of cirrhosis and portal hypertension has long been recognized,and the amount of data characterizing the interplay between each system is becoming ever so complex.Lung involvement was among the first described associated entities in cirrhosis,with reports dating back to the late nineteenth century.However,it appears that throughout the years,interest in the pulmonary complications of portal hypertension has generally faded,especially in contrast to other decompensating events,as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers.Despite affecting up to 10%-15%of patients with advanced liver disease and having a proven prognostic impact,hepato-pulmonary syndrome,porto-pulmonary hypertension,and hepatic hydrothorax are frequently misdiagnosed,mistreated,or misinterpreted.This lack of precision might adversely impact patient care,referral to expert centers,and,ultimately,liver disease-related mortality and successful transplantation odds.The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities.The paper focuses on the essential theoretical aspects,addressing the most critical knowledge gaps on the one hand and,on the other hand,critically discussing one key issue for each complication.

Malnutrition and non-compliance to nutritional recommendations in patients with cirrhosis are associated with a lower survival

BACKGROUND Malnutrition is frequently encountered in patients with cirrhosis and appears to significantly impact their prognosis.While evaluating the burden of malnutrition in cirrhosis is gathering momentum,as suggested by multiple recently published reports,there is still a persistent scarcity of solid data in the field,especially with regards to the role of nutritional interventions.AIM To assess the prevalence of malnutrition in patients with advanced cirrhosis and to evaluate its impact on survival.METHODS One hundred and one consecutive patients with advanced cirrhosis were screened for malnutrition using the Subjective Global Assessment(SGA)criteria and the mid-arm circumference(MAC).Malnutrition was defined as SGA class B and C and MAC<10th percentile.All patients were interviewed regarding their food intake using an adapted questionnaire.Subsequently,total energy intake was calculated and further subdivided in main nutrients.The data were then compared to the available recommendations at the time of analysis to assess adherence.RESULTS 54/79 patients(68.4%)in the decompensated group had malnutrition,while only 3/22 patients(13.6%)were malnourished in the compensated group.After a median follow-up time of 27 mo(0-53),the overall mortality was 70%.Survival was significantly lower among patients with malnutrition.The mortality rates were 50%at 1 year and 63%at 2 years for the patients with malnutrition,compared to 21%at 1 year and 30%at 2 years for patients without malnutrition(P=0.01).On multivariate analysis,the factors independently associated with mortality were age,creatinine level and adherence to the protein intake recommendations.The mortality was lower in patients with the appropriate protein intake:8%at 1 year and 28%at 2 years in the adherent group,compared to 47%at 1 year and 56%at 2 years in the non-adherent group.CONCLUSION The prevalence of malnutrition is high among patients with advanced cirrhosis and might be related in part to a low adherence to nutritional recommendations,especially with regards to protein intake.