Post-trans-arterial chemoembolization hepatic necrosis and biliary stenosis: Clinical charateristics and endoscopic approach

Liver cancer is the fifth most common tumor and the second highest death-related cancer in the world.Hepatocarcinoma(HCC)represents 90%of liver cancers.According to the Barcelona Clinic Liver Cancer group,different treatment options could be offered to patients in consideration of tumor burden,liver function,pa-tient performance status and biochemical marker serum concentration such as alpha-fetoprotein.Trans-arterial chemoembolization(TACE)is the treatment of choice in patients with diagnosis of unresectable HCC not eligible for liver trans-plantation,and preserved arterial supply.TACE is known to be safe and its com-plications are generally mild such as post-TACE syndrome,a self-resolving adverse event that occurs in about 90%of patients after the procedure.However,albeit rarely,more severe adverse events such as biloma,sepsis,hepatic failure,chemoagents induced toxicities,and post-TACE liver necrosis can occur.A prompt diagnosis of these clinical conditions is fundamental to prevent further complications.As a result,biliary stenosis could be a rare post-TACE necrosis complication and can be difficult to manage.Complications from untreated biliary strictures include recurring infections,jaundice,chronic cholestasis,and secon-dary biliary cirrhosis.

Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation

AIM To describe the thromboelastography(TEG) "reference" values within a population of liver transplant(LT) candidates that underline the differences from healthy patients.METHODS Between 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease(MELD) score between 15 and 40 were studied. In particular the adult patients(aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time(r), coagulation time(k), Angle-Rate of polymerization of clot(α Angle), Maximum strenght of clot(MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured(A30 and A60), and Fibrinolysis at 30 and 60 min after MA(Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score(higher or lower than 20) and indications for transplantation(liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score. RESULTS Most of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r(41.5% of the values), k(48.6%), α(43.7%), MA(79.3%), A30(74.4%) and A60(80.9%), indicating a prevailing trend to hypocoagulability. The differences between the mean TEG values obtained from healthy subjects and the cirrhotic population were statistically significant for r(P = 0.039), k(P < 0.001), MA(P < 0.001), A30(P < 0.001), A60(P < 0.001) and Ly60(P = 0.038), indicating slower and less stable clot formation in the cirrhotic patients. In the cirrhotic population, 9.5% of patients had an r value shorter than normal, indicating a tendency for faster clot formation. Within the cirrhotic patient population, gender, age and the presence of hepatocellular carcinoma or alcoholic cirrhosis were not significantly associated with greater clot firmness or enhanced whole blood clot formation, whereas greater clot strength was associated with a MELD score < 20, hepatitis C virus and cholestaticrelated cirrhosis(P < 0.001; P = 0.013; P < 0.001).CONCLUSION The range and distribution of TEG values in cirrhotic patients differ from those of healthy subjects, suggesting that a specific thromboelastographic reference range is required for liver transplant candidates.