Clinical benefit of radiation therapy and metallic stenting for unresectable hilar cholangiocarcinoma

AIM： To determine the efficacy of external beam radiotherapy （EBRT）, with or without intraluminal brachytherapy （ILBT）, in patients with non-resected locally advanced hilar cholangiocarcinoma.METHODS： We analyzed 64 patients with locally advanced hilar cholangiocarcinoma, including 25 who underwent resection （17 curative and 8 non-curative）, 28 treated with radiotherapy, and 11 who received best supportive care （BSC）. The radiotherapy group received EBRT （50 Gy, 30 fractions）, with 11 receiving an ad- ditional 24 Gy （4 fractions） ILBT by iridium-192 with remote after loading. ILBT was performed using percu-taneous transhepatic biliary drainage （PTBD） route. Uncovered metallic stents （UMS） were inserted into nonresected patients with obstructive jaundice, with the exception of four patients who received percutaneous transhepatic biliary drainage only. UMS were placed endoscopically or percutaneously, depending on the initial drainage procedure. The primary endpoints were patient death or stent occlusion. Survival time of patients in the radiotherapy group was compared with that of patients in the resection and BSC groups. Stent patency was compared in the radiotherapy and BSC groups.RESULTS： No statistically significant differences in patient characteristics were found among the resection, radiotherapy, and BSC groups. Three patients in the radiotherapy group and one in the BSC group did not receive UMS insertion but received PTBD alone; cholangitis occurred after endoscopic stenting, and patients were treated with PTBD. A total of 16 patients were administered additional systemic chemotherapy （5-fluorouracil-based regimen in 9, S-1 in 6, and gemcitabine in 1）. Overall survival varied significantly among groups, with median survival times of 48.7 mo in the surgery group, 22.1 mo in the radiotherapy group, and 5.7 mo in the BSC group. Patients who underwent curative resection survived significantly longer than those who were not candidates for surgery （P = 0.0076）. Cumulative survival in the radiotherapy group was significantly longer than in the BSC group （P = 0.0031）, but did not differ significantly from those in the non-resection group. Furthermore, the median survival time of patients in the radiotherapy group who were considered for possible resection （excluding the seven patients who were not candidates for surgery due to comorbid disease or age） was 25.9 mo. Stent patency was evaluated only in the 24 patients who received a metallic stent. Stent patency was significantly longer in the radiotherapy than in the BSC group （P = 0.0165）. Biliary drainage was not eliminated in any patient. To determine the efficacy of ILBT, we compared

Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction

AIM:To evaluate the safety and efficacy of partially covered self-expandable metallic stents(SEMSs)in benign pyloric obstruction.METHODS:We retrospectively analyzed data from 10consecutive patients with peptic ulcer-related pyloric obstructive symptoms(gastric outlet obstruction scoring system(GOOSS)score of 1)between March 2012and September 2013.The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center.We assessed the technical success,symptom improvement,and adverse events after stenting.RESULTS:Early symptoms were improved just 3 d after SEMS placement in all 10 patients.The GOOSS score of all patients improved from 1 to 3.There were no serious immediate adverse events.The overall rate of being symptom free was 90%at a median of 11mo of follow-up(range:4-43 mo).Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation.Among them,four patients had sustained symptom improvement after the SEMS procedure.During the follow-up period,migration of the SEMS was observed in two patients(20.0%),both of whom had previous endoscopic balloon dilatation before SEMS insertion.CONCLUSION:Despite the small number in this study,partially covered SEMSs showed a favorable and safe outcome in the treatment of na?ve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.

Clinical characteristics of 96 patients with drug-induced acute liver failure:a comparison between Traditional Chinese and Western Medicine

OBJECTIVE: To compare the causes, clinical symptoms, laboratory test results, and prognosis in patients with acute liver failure(ALF) induced by traditional Chinese medicines(TCM) and by Western Medicines(WM).METHODS: The medical histories of patients who were diagnosed with drug-induced ALF(DALF)(n =96) after hospitalization in the 302 Military Hospital between January 2010 and December 2015 were retrospectively examined.RESULTS: Fifty-eight of the 96 DALF patients(60.4%) had a hepatocellular pattern of DALF, 16 patients(16.7%) had a cholestatic pattern, and 22 patients(22.9%) had a mixed pattern. DALF resolved in 24 patients(25.0%). Twenty-five patients(26.0%)developed chronic liver injury, 43 patients(44.8%)died, and 4 patients(4.2%) underwent liver transplantation. There were 42 ALF patients(43.8%) who received WM, and 32 ALF patients(33.3%) who received TCM. TCM-induced ALF patients had a higher average age [42.4 ± 18.4) vs(33.5 ± 17.9) years,P = 0.04] and higher creatinine and urine nitrogen levels [(155.2 ± 108.8) vs(97.5 ± 130.4) mmol/L, P =0.047;(9.1 ± 7.7) vs(4.3 ± 5.0) mmol/L, P = 0.002, respectively]. Patients with TCM-induced ALF exhibited an increased risk of renal injury [odds ratio(OR),3.75; 95% confidence interval(CI), 1.330-10.577].The 14 patients with TCM-induced ALF who died exhibited higher creatinine levels than the 18 patients with TCM-induced ALF patients who survived[(218.7 ± 111.6) vs(105.8 ± 78.4) mmol/L, P =0.002]. They were also more likely to exhibit ascites(85.7% vs 44.4%, P = 0.017) and hepatorenal syndrome(78.6% vs 22.2%, P = 0.002).CONCLUSION: TCM-induced ALF was more likely to be accompanied by renal injury than was WM-induced ALF, especially in TCM-induced ALF patients who died.