Influence of transcatheter arterial embolization on symptom distress and fatigue in liver cancer patients

BACKGROUND Hepatocellular carcinoma(HCC)is a prevalent malignancy,and transcatheter arterial embolization(TAE)has emerged as a pivotal therapeutic modality.How-ever,TAE may induce symptom distress and fatigue,adversely affecting the quality of life of patients.AIM To investigate symptom distress,fatigue,and associated factors in HCC patients undergoing TAE.METHODS We used a cross-sectional design and purposive sampling to enroll HCC patients who underwent TAE at our institution from January to December 2022.Question-naires were utilized to collect data on symptom distress and fatigue scores from the first to the third day after TAE.RESULTS Our study revealed a significant reduction in fatigue and symptom distress among patients after TAE.Pain,fatigue,insomnia,fever and abdominal dis-tension were the most common symptoms troubling patients during the first 3 d post-TAE.Marital status,presence of family support,physical functional status,age,and symptom distress were identified as predictors of fatigue in patients.CONCLUSION Healthcare professionals should educate HCC patients on symptom distress and INTRODUCTION Hepatocellular carcinoma(HCC)ranks as the fifth most prevalent cancer and the third leading cause of cancer-related mortality globally.Surgical intervention remains the cornerstone of HCC treatment;however,due to the challenges associated with early diagnosis and the lack of specific diagnostic markers,a considerable proportion of patients are diagnosed at advanced stages,rendering them ineligible for surgical interventions.Transcatheter arterial embolization(TAE)is an interventional therapeutic approach involving the insertion of a fine catheter via the femoral artery to reach the vasculature near the tumor site.TAE aims to obstruct the arterial supply to the tumor by deploying embolic agents,thereby inducing necrosis in cancer cells.This procedure is suitable for patients with good liver function and overall health,particularly those with large HCCs that have not invaded the portal vein[1,2].Nonetheless,following TAE,hepatocytes incur variable degrees of damage,leading to the development of a constel-lation of symptoms reminiscent of acute hepatitis.These symptoms include fatigue and systemic discomfort,such as nausea,vomiting,fever,abdominal pain,as well as transient elevations in aspartate aminotransferase(AST)and alanine aminotransferase(ALT),collectively referred to as postembolization syndrome[3,4].These symptoms may arise due to ischemia of the liver and gallbladder,temporary liver enlargement,and peritoneal irritation.While many studies have explored fatigue and symptom distress in cancer patients both nationally and internationally,with some focusing on symptom distress following transcatheter arterial chemoembolization,there has been limited in-depth investigation into the fatigue and symptom distress resulting from TAE treatment[5-8].Fatigue and pain are both subjective experiences,typically arising from the gradual depletion of energy reserves during the course of illness[9].Fatigue is particularly prevalent among cancer patients,with rates soaring as high as 90%.Despite extensive research exploring cancer-related fatigue and its influencing factors,a unanimous consensus remains elusive.Hence,the primary objective of this study was to investigate the symptom distress and fatigue experienced by liver cancer patients following TAE treatment and to analyze potential contributing factors.

Usefulness of transcatheter arterial embolization for eighty-three patients with secondary postpartum hemorrhage:Focusing on difference in angiographic findings

BACKGROUND Transcatheter arterial embolization(TAE)has been widely used as an effective and a safe treatment method and was often used as an alternative to the surgical management,but there are limited studies on the efficacy and the safety for patients undergoing their secondary postpartum hemorrhage(PPH).AIM To evaluate the usefulness of TAE for secondary PPH focusing on the angiographic findings.METHODS We conducted a research from January 2008 to July 2022 on all 83 patients(mean:32 years,range:24-43 years)presented with secondary PPH and they were treated with TAE in two university hospitals.The medical records and angiography were retrospective reviewed in order to evaluate the patients’characteristics,delivery details,clinical status and peri-embolization management,angiography and embolization details,technical/clinical success and complications.The group with active bleeding sign and the group without it were also compared and analyzed.RESULTS On angiography,46(55.4%)patients showed active bleeding signs such as contrast extravasation(n=37)or pseudoaneurysm(n=8)or both(n=1),and 37(44.6%)patients showed non-active bleeding signs such as only spastic uterine artery(n=2)or hyperemia(n=35).In the active bleeding sign group there were more multiparous patients,low platelet count,prothrombin time prolongation,and high transfusion requirements.The technical success rates were 97.8%(45/46)in active bleeding sign group and 91.9%(34/37)in non-active bleeding sign group,and the overall clinical success rates were 95.7%(44/46)and 97.3%(36/37).An uterine rupture with peritonitis and abscess formation occurred to one patient after the embolization,therefore hysterostomy and retained placenta removal were performed which was a major complication.CONCLUSION TAE is an effective and a safe treatment method for controlling secondary PPH regardless of angiographic findings.

Pancreatic arteriovenous malformation treated with transcatheter arterial embolization:Two case reports and review of literature

BACKGROUND Various treatment methods are available for the treatment of pancreatic arteriovenous malformation(P-AVM);however,there are no established treatment options for asymptomatic P-AVM.CASE SUMMARY A 47-year-old and a 50-year-old male patients sought treatment for P-AVM in the pancreas,which was incidentally detected during routine abdominal computed tomography and magnetic resonance imaging conducted as part of a health check-up.They underwent transcatheter arterial embolization(TAE),and over the course of a 9-year follow-up period,the AVM did not worsen and was asymptomatic.CONCLUSION TAE can be considered as an alternative treatment option for P-AVM in selective cases where patients are asymptomatic or have a high surgical risk.

Prognosis following transcatheter arterial embolization for 121 patients with unresectable hepatocellular carcinoma with or without a history of treatment

AIM： To retrospectively evaluate the prognosis of patients with hepatocellular carcinoma （HCC） with or without a history of therapy for HCC following transcatheter arterial embolization （TAE）. METHODS： One hundred and twenty-one patients with HCC treated with TAE from 1992 to 2004 in our hospital were enrolled in this study. Eighty-four patients had a history of treatment for HCC, while 37 did not. At the time of entry, patients with extra-hepatic metastasis, portal vein tumor thrombosis, or Child-Pugh class C were excluded. TAE was repeated when recurrence of HCC was diagnosed by elevated tumor markers, or ultrasonography or dynamic computed tomography findings. RESULTS： Tumor size was larger and the number of tumors was fewer in patients without past treatment （P〈0.01）. However, there were no differences in tumor node metastasis （TNM） stage or survival rate between the 2 groups. A bilobular tumor and high level of α-fetoprotein （AFP） （〉100 ng/mL） were factors related to a poor prognosis in patients with a history of HCC. CONCLUSION： The prognosis following TAE is similar between HCC patients with and without past treatment. Early diagnosis of HCC or recurrent HCC and obtaining good local control against HCC before entry to a repeated TAE course can improve prognosis.

Radiofrequency ablation in a porcine liver model:Effects of transcatheter arterial embolization with iodized oil on ablation time,maximum output,and coagulation diameter as well as angiographic characteristics

AIM:To evaluate the effects of combined radiofrequen-cy ablation and transcatheter arterial embolization with iodized oil on ablation time,maximum output,coagula-tion diameter,and portal angiography in a porcine liver model. METHODS: Radiofrequency ablation (RFA) was applied to in vivo livers of 10 normal pigs using a 17-gauge 3.0 cm expandable LeVeen RF needle electrode with or with-out transcatheter arterial embolization (TAE) with iodized oil (n = 5). In each animal,2 areas in the liver were ab-lated. Direct portography was performed before and af-ter RFA. Ablation was initiated at an output of 30 W,and continued with an increase of 10 W per minute until roll-off occurred. Ablation time and maximum output until roll-off,and coagulated tissue diameter were compared between the 2 groups. Angiographic changes on portog-raphy before and after ablation were also reviewed. RESULTS: For groups with and without TAE with iodized oil,the ablation times until roll-off were 320.6 ± 30.9 seconds and 445.1 ± 35.9 seconds,respectively,maxi-mum outputs were 69.0 ± 7.38 W and 87.0 ± 4.83 W and maximal diameters of coagulation were 41.7 ± 3.85 mm and 33.2 ± 2.28 mm. Significant reductions of abla-tion time and maximum output,and significantly larger coagulation diameter were obtained with RFA following TAE with iodized oil compared to RFA alone. Portography after RFA following TAE with iodized oil revealed more occlusion of the larger portal branches than with RFA alone. CONCLUSION: RFA following TAE with iodized oil can increase the volume of coagulation necrosis with lower output and shorter ablation time than RFA alone in nor-mal pig liver tissue.

Survival outcome of lobar or segmental transcatheter arterial embolization with ethanol-lipiodol mixture in treating hepatocellular carcinoma

AIM: To evaluate the dinical outcome and cost-effectiveness of transcatheter arterial ethanol-lipiodoi embolotherapy on hepatocellular carcinoma (HCC). METHODS: One hundred patients with HCC who were treated only by lobar or segmental transarterial embolization (TAE) with ethanol-lipiodoi mixture were enrolled in this study. The 1st- and 2nd-year survival rates were analyzed to evaluate the feasibility of its method. These outcomes of our patients were individually correlated to the Child-Pugh classification and the computed tomographic features of HCC. RESULTS: The overall 1st- and 2nd-year survival rates were 72% and 46%, respectively. The patients were classified into three groups according to their liver function status: 68 patients as Child-Pugh class A, 26 as Child B, and 6 as Child C. Child A had better survival rate than the Child B and/or C. The 1st-year survival rates of patients with Child A-C were 84%, 50%, and 33.3% respectively and the 2nd-year survival rates were 55.5%, 28.5%, and 33.3%, respectively. According to the computed tomographic features, solitary HCC with maximum diameter less than 5 cm had the best outcome with the lst-year survival rate of 100% and the 2nd-year survival rate of 71.4%, while solitary HCC with maximum diameter over 5 cm and multiple HCC had the lst-year survival rates of 75% and 63.7%, respectively, and the 2nd-year survival rates of 33.3% and 44.4%, respectively. Only one patient was complicated with abscess formation and was cured with antibiotic therapy. No mortality resulted from the procedures performed. CONCLUSION: TAE with ethanol-lipiodoi mixture is an economic, safe and feasible method for treating HCC, especially for the patients with smaller solitary HCC or with liver function status of Child-Pugh class A.

Minimally invasive treatment of hepatic hemangioma by transcatheter arterial embolization combined with microwave ablation:A case report

BACKGROUND Hepatic hemangioma is the most common benign tumor of the liver.However,patients with large hemangiomas that cause compression symptoms or that are at risk of rupture may need further intervention.It is necessary to explore additional minimally invasive and personalized treatment options for hemangiomas.CASE SUMMARY A 47-year-old woman was diagnosed with a right hepatic hemangioma for more than 10 years.Abdominal contrast-enhanced computed tomography(CT)and contrast-enhanced ultrasound revealed that there was a large hemangioma in the right liver,with a size of approximately 95 mm×97 mm×117 mm.Due to the patient's refusal of surgical treatment,hepatic artery embolization was performed in the first stage.After 25 d of liver protection treatment,the liver function indexes decreased to normal levels.Then,ultrasound-guided microwave ablation of the giant hepatic hemangioma was performed.Ten days after the treatment,hepatobiliary ultrasonography showed that the hemangioma of the right liver was smaller than the previous size(the volume was reduced by approximately 30%).Then the patient was discharged from the hospital.One year after discharge,CT showed that the hepatic hemangioma had shrunk by about 80%CONCLUSION Transcatheter arterial embolization combined with microwave ablation is a safe and effective minimally invasive treatment for hepatic hemangioma.

Quantitative analysis of plasma HBV DNA for early evaluation of the response to transcatheter arterial embolization for HBV-related hepatocellular carcinoma

AIM： To assesse changes in plasma HBV DNA after TAE in HBV-related HCC and correlate the levels with the pattern of lipiodol accumulation on CT. METHODS： Between April and June 2001, 14 patients with HBV-associated HCC who underwent TAE for inoperable or recurrent tumor were studied. Levels of plasma HBV DNA were measured by real-time quantitative PCR daily for five consecutive days after TAE. More than twofold elevation of circulating HBV DNA was considered as a definite elevation. Abdominal CT was performed 1-2 mo after TAE for the measurement of lipiodol retention. RESULTS： Circulating HBV DNA in 10 out of 13 patients was elevated after TAE, except for one patient whose plasma HBV DNA was undetectable before and after TAE. In group Ⅰ patients （n = 6）, the HBV DNA elevation persisted for more than 2 d, while in group Ⅱ （n = 7）, the HBV DNA elevation only appeared for i d or did not reach a definite elevation. There were no significant differences in age or tumor size between the two groups. Patients in group Ⅰ had significantly better lipiodol retention （79.31±28.79%） on subsequent abdominal CT than group Ⅱ （18.43±10.61%） （P = 0.02）. CONCLUSION： Patients with durable HBV DNA elevation for more than 2 d correlated with good lipiodol retention measured 1 mo later, while others associated with poor lipiodol retention. Thus, circulating HBV DNA may be an early indicator of the success or failure of TAE.

Prophylactic transcatheter arterial embolization reduces rebleeding in non-variceal upper gastrointestinal bleeding: A meta-analysis

BACKGROUND Despite the improvement in the endoscopic hemostasis of non-variceal upper gastrointestinal bleeding(NVUGIB),rebleeding remains a major concern.AIM To assess the role of prophylactic transcatheter arterial embolization(PTAE)added to successful hemostatic treatment among NVUGIB patients.METHODS We searched three databases from inception through October 19th,2020.Randomized controlled trials(RCTs)and observational cohort studies were eligible.Studies compared patients with NVUGIB receiving PTAE to those who did not get PTAE.Investigated outcomes were rebleeding,mortality,reintervention,need for surgery and transfusion,length of hospital(LOH),and intensive care unit(ICU)stay.In the quantitative synthesis,odds ratios(ORs)and weighted mean differences(WMDs)were calculated with the random-effects model and interpreted with 95%confidence intervals(CIs).RESULTS We included a total of 3 RCTs and 9 observational studies with a total of 1329 patients,with 486 in the intervention group.PTAE was associated with lower odds of rebleeding(OR=0.48,95%CI:0.29–0.78).There was no difference in the 30-d mortality rates(OR=0.82,95%CI:0.39–1.72)between the PTAE and control groups.Patients who underwent PTAE treatment had a lower chance for reintervention(OR=0.48,95%CI:0.31–0.76)or rescue surgery(OR=0.35,95%CI:0.14–0.92).The LOH and ICU stay was shorter in the PTAE group,but the difference was non-significant[WMD=-3.77,95%CI:(-8.00)–0.45;WMD=-1.33,95%CI:(-2.84)–0.18,respectively].CONCLUSION PTAE is associated with lower odds of rebleeding and any reintervention in NVUGIB.However,further RCTs are needed to have a higher level of evidence.

Expression of MMP-2 in residual VX2 liver tumor after transcatheter arterial embolization combined with portal venous embolization in an animal model

Objective:This study aimed to analyze the effects of transcatheter arterial embolization(TAE)combined with portal venous embolization(PVE)on the expression of MMP-2 in residual VX2 liver tumor tissues,liver function and non-embolic lobe regeneration.Methods:A total of 72 rabbits were randomly divided into Sham,TAE,PVE and TAE+PVE groups(n=18/group).The tissue samples from each group were taken at 6 h,3 days and 7 days after interventional operation,respectively.MMP-2 expression was detected by immunohistochemistry,Real-time PCR,and Western-blotting.The main indicators(such as AST,ATL,and TBIL)of liver function and the volume of non-embolized hepatic lobes were measured in each group after operation.One-way ANOVA and Kruskal-wallis method were used for statistical analysis.Results:The expression of MMP-2 mRNA and protein remained the highest in the Sham group,and the expression of MMP-2 mRNA and protein in TAE,PVE and TAE+PVE groups were successively increased,and the expression of MMP-2 in TAE+PVE group was always significantly higher than TAE group.The AST and ALT levels in each group on day 7 after operation showed a significant declination,and all groups have recovered to the preoperative baseline level and TBIL has a slight fluctuation in each group after operation with no statistical difference.On day 7 after operation,the increasing volume of non-embolized liver lobes in TAE+PVE group showed a more significant effect than those in PVE group,but there was no statistical significance(37.62±1.54 ml VS 36.18±1.15 ml,P=0.881),and its volume was significantly higher than those in the sham group(27.03±1.11 ml).Conclusion:TAE+PVE is considered to be an efficient and safe approach for treating rabbit VX2 liver transplantation tumor,but the expression of MMP-2 increased fastest after TAE+PVE,which might promote tumor cell invasion and metastasis.

Successful transcatheter arterial embolization treatment for chest wall haematoma following permanent pacemaker implantation: A case report

BACKGROUND Haematoma is one of the main complications associated with pacemaker implantation.Pseudoaneurysm is a rare condition that is not easy to identify and is often overlooked.CASE SUMMARY A female patient diagnosed with high-grade atrioventricular block underwent permanent pacemaker implantation.During the operation,puncturing a small branch of the right subclavian artery developed into a pseudoaneurysm and resulted in further haematoma formation.Conventional treatment of compression haemostasis and haemostatic drugs was not effective.A series of timely transcatheter arterial embolizations avoided serious complications.CONCLUSION More possible conditions should be taken into consideration as haematoma is discovered,and timely treatment might prevent severe adverse events.

Safety and efficacy of transcatheter arterial embolization for management of refractory hematuria of prostatic origin

Objective: To estimate the safety and efficacy of transcatheter arterial embolization(TAE) in the treatment of refractory hematuria of prostatic origin(RHPO).Methods: This retrospective study included 23 patients who underwent TAE for RHPO between May 2013 and August 2021. Technical and clinical success rates were calculated, and arteriogram findings and complications were detected.Results: Embolization was performed 24 times in 23 patients. Technical success was achieved in 24/24(100%)embolization procedures. Contrast agent extravasation was detected during 2 of the 24 angiographic procedures.Bilateral embolization was performed in 23(95.8%) of the 24 procedures. The clinical success rate was 21/23(91.3%), and hematuria stopped 1–4 days after TAE. No serious complications were observed.Conclusion: TAE is a safe and effective minimally invasive technique for treating patients with RHPO.

Transcatheter Arterial Embolization as a Treatment for Life-Threatening Retroperitoneal Hemorrhage in COVID-19 Patients on Anticoagulant Therapy

Retroperitoneal hemorrhage is a possible complication that has been noticed in COVID-19 patients on anticoagulant therapy. The data related to treatment and outcomes in this condition are scarce. We present a case series of four COVID-19 patients with lumbar artery bleeding, who were treated with transcatheter arterial embolization using embolization particles. The procedure was executed without any complications, and hemostasis was achieved in all four patients. Despite the patients survived the procedure, one patient died due to respiratory failure three weeks after the procedure, and one died due to hypovolemic shock two days later. Considering the ongoing state of COVID-19 pandemic, it is essential to be aware of transcatheter arterial embolization as a safe and effective procedure for treating retroperitoneal hemorrhage in COVID-19 patients.

Extravasated contrast volumetric assessment on computed tomography angiography in gastrointestinal bleeding:A useful predictor of positive angiographic findings

BACKGROUND Gastrointestinal bleeding(GIB)is a severe and potentially life-threatening condition,especially in cases of delayed treatment.Computed tomography angiography(CTA)plays a pivotal role in the early identification of upper and lower GIB and in the prompt treatment of the haemorrhage.AIM To determine whether a volumetric estimation of the extravasated contrast at CTA in GIB may be a predictor of subsequent positive angiographic findings.METHODS In this retrospective single-centre study,35 patients(22 men;median age 69 years;range 16-92 years)admitted to our institution for active GIB detected at CTA and further submitted to catheter angiography between January 2018 and February 2022 were enrolled.Twenty-three(65.7%)patients underwent endoscopy before CTA.Bleeding volumetry was evaluated in both arterial and venous phases via a semi-automated dedicated software.Bleeding rate was obtained from volume change between the two phases and standardised for unit time.Patients were divided into two groups,according to the angiographic signs and their concordance with CTA.RESULTS Upper bleeding accounted for 42.9%and lower GIB for 57.1%.Mean haemoglobin value at the admission was 7.7 g/dL.A concordance between positive CTA and direct angiographic bleeding signs was found in 19(54.3%)cases.Despite no significant differences in terms of bleeding volume in the arterial phase(0.55 mL vs 0.33 mL,P=0.35),a statistically significant volume increase in the venous phase was identified in the group of patients with positive angiography(2.06 mL vs 0.9 mL,P=0.02).In the latter patient group,a significant increase in bleeding rate was also detected(2.18 mL/min vs 0.19 mL/min,P=0.02).CONCLUSION In GIB of any origin,extravasated contrast volumetric analysis at CTA could be a predictor of positive angiography and may help in avoiding further unnecessary procedures.

Fatal arterial hemorrhage after pancreaticoduodenectomy:How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND Although arterial hemorrhage after pancreaticoduodenectomy(PD)is not frequent,it is fatal.Arterial hemorrhage is caused by pseudoaneurysm rupture,and the gastroduodenal artery stump and hepatic artery(HA)are frequent culprit vessels.Diagnostic procedures and imaging modalities are associated with certain difficulties.Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD.Although complete hemostasis may be obtained by endovascular treatment(EVT)or surgery,liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur.We herein discuss therapeutic options for fatal arterial hemorrhage after PD.AIM To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.METHODS We retrospectively investigated 16 patients who developed arterial hemorrhage after PD.The patients’clinical characteristics,diagnostic procedures,actual treatments[transcatheter arterial embolization(TAE),stent-graft placement,or surgery],clinical courses,and outcomes were evaluated.RESULTS The frequency of arterial hemorrhage after PD was 5.5%.Pancreatic leakage was observed in 12 patients.The onset of hemorrhage occurred at a median of 18 d after PD.Sentinel bleeding was observed in five patients.The initial EVT procedures were stent-graft placement in seven patients,TAE in six patients,and combined therapy in two patients.The rate of technical success of the initial EVT was 75.0%,and additional EVTs were performed in four patients.Surgical approaches including arterioportal shunting were performed in eight patients.Liver infarction was observed in two patients after TAE.Two patients showed a poor outcome even after successful EVT.These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT.Fourteen patients were successfully treated.CONCLUSION Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Intrahepatic Arterial Delivery of Sorafenib Eluting Beads:A Pharmacokinetics Study

Objective:To determine the slow-release effect of Sorafenib carried beads and its impact on the normal liver of dogs.Materials and Methods:(1)To obtain the maximal drug-carrying of beads,different sizes of beads(300-500μm and 500-700μm)were tried.Five bottles of different sizes of beads were added into 75% solution of Sorafenid-alcohol with different concentrations:Bottle a,50mg/20ml;Bottle b,100mg/20ml;Bottle c,100 mg/40ml;Bottle d,200mg/40m;Bottle e,250mg/50ml.(2)In vivo study:12 dogs were randomly divided into four groups[group A,Sorafenib carried bead(500-700μm);group B,only bead(300-500μm);group C,Lipiodol-sorafenib and four dogs in each group].Each group was treated with TAE with emulsion mentioned above.Sorafenib concentration in plasma and liver tissue was determined with HPLC respectively.Result:(1)In vitro research:Sorafenib can be dissolved into 75% alcohol and the best concentration for drug-carrying was 100mg/20ml.(2)In vivo study:①Compared with group D,the Cmax and AUC in plasma in group A and B has a significant statistics difference(p<0.05).②Sorafenib concentration in liver tissue could be determined in group A in the 3rd day and even after one week while it could not be determined in group D.Conclusion:Sorafenib can be carried in DC-Bead in a certain condition.Compared with emulsion with Sorafenib and lipiodol,DC-bead has a definite slow-release function and it is superior to lipiodol.

Evaluation of HCPTd_1, d_(14)-double passaged intervening chemotherapy protocol for hepatocellular carcinoma

AIM. To establish a kind of standardization of the clinical chemotherapeutic prototypes for unresectable hepatocellular carcinomas （HCC）. METHODS： 10-Hydroxycamptothecin （HCPT） was applied through transcatheter arterial embolization （TAE） to HCC patients who were categorized into three groups： （1） test group： treatment with HCPT twice （HCPT dl and 14） through TAE and portal venous embolization. （2） Control Ⅰ： treatment with anticancer drugs without HCPT. （3） Control Ⅱ： treatment with HCPT as a major component in anticancer drugs once （HCPT dl）. A set of comparisons between test groups and control Ⅰ and Ⅱ groups were performed before and after the treatment to study the effectiveness of each treatment, in terms of tumor volumes, dynamic variations in serum alpha-fetoprotein （AFP）, gamma-glutamyl transferase hepatoma-specific band （GGT-Ⅱ）, patient survival and adverse events. RESULTS： The general effectiveness rate of the test group reached 62.1% （72/116）, remarkably higher than that of control Ⅰ （32.1%, 40/124） and control Ⅱ （54.7%, 47/56）, （P〈0.01 and P〈0.05, respectively）. Especially, the reduction rate or disappearance of the portal vein tumor emboli was as high as 88.4% （61/69） in the test group, in contrast with 13.9% （10/72） in control Ⅰ and 35.9% （18/51） in control Ⅱ （P〈0.01 and P〈0.01, respectively）. After treatment, AFP decreased or turned to negative levels at 52.3% （34/65） in control Ⅰ, 67.3% （35/52） in control Ⅱ, and 96.8% （60/62） in the test group. Also GGT-Ⅱ declined or became negative at 37.8% （28/74） in control Ⅰ, 69.5% （57/82） in control Ⅱ, and 94.7% （89/94） in test group （P〈0.01 and P〈0.05, respectively）. CONCLUSION： We have designed a good protocol （test group） to treat HCC with excellent advantages of high efficiency, low cost, low toxicity and low adverse events and easy application. It could be recommended as one of the standardizations for HCC treatment in clinical practice.

Treatment of massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy

AIM： To compare the treatment modalities for patients with massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy （PDT）.METHODS： A retrospective study was undertaken to compare the outcomes of two major treatment modalities： transcatheter arterial embolization （TAE） and open surgical hemostasis. Seventeen patients with acute massive hemorrhage after PDT were recruited in this study. A comparison of two treatment modalities was based upon the clinicopathological characteristics and hospitalization stay, complications, and patient prognosis of the patients after surgery.RESULTS： Of the 11 patients with massive hemorrhage after PDT treated with TAE, 1 died after discontinuing treatment, the other 10 stopped bleeding completely without recurrence of hemorrhage. AIJ the 10 patients recovered well and were discharged, with a mean hospital stay of 10.45 d after hemostasis. The patients who underwent TAE twice had a re-operation rate of 18.2% and a mortality rate of 0.9%. Among the six patients who received open surgical hemostasis, two underwent another round of open surgical hemostasis. The mortality was 50%, and the recurrence of hemorrhage was 16.67%, with a mean hospital stay of 39.5 d.CONCLUSION： TAE is a safe and effective treatment modality for patients with acute hemorrhage after PDT. Vasography should be performed to locate the bleeding site.

Extrahepatic collaterals and liver damage in embolotherapy for ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery

AIM: To evaluate the effects of extrahepatic collaterals to the liver on liver damage and patient outcome after embolotherapy for the ruptured hepatic artery pseudoa- neurysm following hepatobiliary pancreatic surgery. METHODS: We reviewed 9 patients who underwent transcatheter arterial embolization (TAE) for the ruptured hepatic artery pseudoaneurysm following major hepato- biliary pancreatic surgery between June 1992 and April 2006. We paid special attention to the extrahepatic arte- rial collaterals to the liver which may affect post-TAE liver damage and patient outcome. RESULTS: The underlying diseases were all malignan- cies, and the surgical procedures included hepatopancre- atoduodenectomy in 2 patients, hepatic resection with removal of the bile duct in 5, and pancreaticoduodenec- tomy in 2. A total of 11 pseudoaneurysm developed: 4 in the common hepatic artery, 4 in the proper hepatic artery, and 3 in the right hepatic artery. Successful he- mostasis was accomplished with the initial TAE in all patients, except for 1. Extrahepatic arterial pathways to the liver, including the right inferior phrenic artery, the jejunal branches, and the aberrant left hepatic artery, were identified in 8 of the 9 patients after the completion of TAE. The development of collaterals depended on the extent of liver mobilization during the hepatic resection, the postoperative period, the presence or absence of an aberrant left hepatic artery, and the concomitant arte- rial stenosis adjacent to the pseudoaneurysm. The liver tolerated TAE without significant consequences when at least one of the collaterals from the inferior phrenic ar-tery or the aberrant left hepatic artery was present. One patient, however, with no extrahepatic collaterals died of liver failure due to total liver necrosis 9 d after TAE. CONCLUSION: When TAE is performed on ruptured hepatic artery pseudoaneurysm, reduced collateral path- ways to the liver created by the primary surgical proce- dure and a short postoperative interval may lead to an unfavorable outcome.

Transcatheter arterial embolization-salvaged ALPPS, a novel ALPPS procedure especially for patients with hepatocellular carcinoma and severe fibrosis/cirrhosis

Background:The associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)for hepatocellular carcinoma(HCC)with fibrosis/cirrhosis is often associated with limited growth of future liver remnant(FLR).We introduced a new procedure named transcatheter arterial embolization-salvaged ALPPS(TAE-salvaged ALPPS)which was shown to be especially suitable for HCC patients with cirrhosis or fibrosis who failed adequately to respond to conventional ALPPS.The short-term efficacy and safety for the TAE-salvaged ALPPS on patients with HCC and fibrosis/cirrhosis were studied.Methods:Consecutive HCC patients who underwent TAE-salvaged ALPPS in our hospital between November 2016 and June 2020 were retrospectively studied.The new ALPPS procedure included conventional ALPPS stage-1 using associating liver partition and portal vein ligation.When FLR failed to reach sufficient hypertrophy,TAE was carried out 2 weeks later followed by liver resection 3 weeks after ALPPS stage-1.Results:Nine of 10 patients had a single tumor(median diameter 14.0 cm,range,5.2-17 cm).The remaining patient had multiple tumors(diameter of one tumor 14.0 cm,and two satellite foci 2.0 and 3.0 cm).R0 resection was achieved in all patients(100%)after a median of 21 days.Six patients had cirrhosis,1 had METAVIR grade-3 fibrosis,and 3 had METAVIR grade-2 fibrosis.The median increase in FLR volume after TAE-salvaged ALPPS was 69.7%(34.4-143.9%).The absolute and relative kinetic growth rates(KGRs)were 9.9(7.1-17.3)mL/day and 3.4%(1.9-7.2%)/day,respectively.The median absolute KGRs were 15.7,2.6,and 19.5 mL/day in the first,second,and third postoperative weeks after ALPPS stage-1,respectively.The rapid increase in KGR on the third week was induced by TAE.The overall postoperative morbidity rates were 50,0%(5/10),20.0%(2/10)and 70.0%(7/10)after ALPPS stage-1,TAE and ALPPS stage-2,respectively.The 90-day mortality rate was 10.0%(1/10).The median overall survival was 40 months.Conclusions:The new TAE-salvaged ALPPS induced significant increases in FLR volumes within 3 weeks in patients with HCC and fibrosis/cirrhosis.The procedure is promising in treating patients with HCC and fibrosis/cirrhosis who fail to achieve sufficient FLR hypertrophy after conventional ALPPS stage-1.