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Objective: To investigate whether and how experience accumulation and technical refinements simultaneously implemented in auxiliary orthotopic liver transplantation (AOLT) may impact on outcomes., Background: AOLT for acute liver failure (ALF) provides the unique chance of complete immunosuppression withdrawal after adequate native liver remnant regeneration but is a technically demanding procedure. Our department is a reference center for ALF and an early adopter of AOLT., Methods: This is a single-center retrospective before/after study of a prospectively maintained cohort of 48 patients with ALF who underwent AOLT between 1993 and 2019. In 2012, technical refinements were implemented to improve outcomes: (i) favoring the volume of the graft rather than that of the native liver, (ii) direct anastomosis of graft hepatic artery with recipient right hepatic artery instead of the use of large size vessels, (iii) end-to-side hepaticocholedocostomy instead of bilioenteric anastomosis. Early experience (1993-2011) group (n=26) and recent experience (2012-2019) group (n=22) were compared. Primary endpoint was 90-day severe morbidity rate (Clavien-Dindo≥IIIa) and secondary endpoints were overall patient survival and complete immunosuppression withdrawal rates., Results: Compared with the earlier experience group, the recent experience group was associated with a lower severe complication rate (27% vs 65%, P <0.001), as well as less biliary (18% vs 54%, P =0.017) and arterial (0% vs 15%, P =0.115) complications. The 1-, 3-, and 5-year patient survival was significantly improved (91%, 91%, 91% vs 76%, 61%, 60%, P =0.045). The rate of complete immunosuppression withdrawal increased to 94% vs 70%, ( P =0.091) with no need of long-term graft explant., Conclusion: These technical refinements favoring the liver graft and reducing morbidity may promote AOLT implementation among LT centers., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Liver transplantation has become an effective and valuable option for patients with end-stage liver disease and hepatocellular carcinoma. Liver failure, an acute or chronic condition, results in impaired bile production and excretion, clotting factor production, protein synthesis, and regulation of metabolism and glucose. Some acute conditions of liver disease have the potential to recover if the liver heals on its own. However, chronic conditions, such as cirrhosis, often lead to irreversible disease and require liver transplantation. In this publication, we review the pathophysiology of liver failure, examine common conditions that ultimately lead to liver transplantation, and discuss the postoperative management of patients who are either hemodynamically stable (type A) or unstable (type B). [ABSTRACT FROM AUTHOR]

Rationale: Visceral artery pseudoaneurysm is a rare complication of chronic pancreatitis (CP), all pancreatic or peripancreatic arteries have been reported to be involved, while hepatic artery is less common., Patient Concerns: This case report illustrated a 42-year-old man with CP who developed right hepatic artery pseudoaneurysm (HAP), and finally he was treated with intravascular embolization., Diagnoses: The patient suffered from HAP due to acute attack of CP., Interventions: The pseudoaneurysm located in a fine branch of right hepatic artery was embolized., Outcomes: The HAP of the patient was cured. He had no recurrent bloody stool or abdominal pain. The symptoms gradually relieved., Conclusion: Herein, we report a patient with CP who developed right HAP causing infected hematoma, gastrointestinal bleeding, and obstructive jaundice, and a literature review is also presented. HAP caused by CP is a rare disease in the clinic, but rupture of pseudoaneurysm is fatal. Careful evaluation, early detection, and prompt treatment should be performed when the patient is admitted and followed up., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

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Rationale: Chronic pancreatitis is an ongoing fibroinflammatory disease of the pancreas characterized by irreversible damage to the pancreatic parenchyma and ductal system. Besides, chronic pancreatitis can present with a variety of life-threatening complications., Patient Concerns: The patients visited our hospital due to abdominal pain and anemia, and had chronic pancreatitis as an underlying disease., Diagnoses: Computed tomography showed a large gastroduodenal artery pseudoaneurysm, arterioportal vein fistula, and portal vein stenosis., Interventions: We would like to report the successful use of the coils, and N-butyl cyanoacrylate glue for the therapeutic embolization of the pseudoaneurysm and fistula between the gastroduodenal artery and the portal vein, and stenting for portal vein stenosis., Outcomes: On the day following the endovascular management, the patient reported remission of abdominal pain, and hemoglobin level returned to normal after transfusion. It was confirmed that it was still well maintained in the follow-up examination after 1 month., Lessons: Although chronic pancreatitis causes many vascular complications, simultaneous occurrence of these lesions is extremely rare. Herein, we share our experience with a unique case of an extrahepatic arterioportal fistula induced by the rupture of gastroduodenal artery pseudoaneurysm with concomitant portal vein stenosis. In these complex cases, combined transarterial embolization and transportal stenting can be helpful., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: The authors report no conflicts of interest.

The article reports that atherosclerosis and dyslipidemia induced by chronic intermittent hypoxia (CIH) are attenuated by deficiency of stearoyl coenzyme a desaturase. An overview of the study is offered. It concludes that CIH is related with overexpression of hepatic stearoyl coenzyme A desaturase (SCD) and dyslipidemia in both humans and mice alike.

Objective: To assess the effects of low hepatosplanchnic blood flow on regional blood flow control and oxygenation.Design: Three randomized, controlled animal experiments.Setting: Two university experimental research laboratories.Subjects: Pigs of either gender.Interventions: Isolated abdominal blood flow reduction: An extracorporeal shunt with reservoir and roller pump was inserted between proximal and distal aorta in 11 pigs. Abdominal aortic blood flow was reduced by 50% by activating the shunt. Mesenteric ischemia: In seven pigs, superior mesenteric arterial flow was reduced to 4 mL.kg.min for 4 hrs. Cardiac tamponade: In 12 pigs, aortic blood flow was reduced by cardiac tamponade to 50 mL (moderate tamponade) and further to 30 mL.kg.min (severe tamponade) for 1 hr each. In each experimental condition, the same number of control animals was used.Measurements and Main Results: Abdominal blood flow reduction, acute mesenteric ischemia, and moderate tamponade resulted in a portal venous flow (QPV) reduction to 51 +/- 23%, 52 +/- 18%, and 61 +/- 25% (mean +/- sd) of baseline flow, respectively. During abdominal blood flow reduction, QPV and hepatic arterial flow (QHA) decreased proportionally, whereas in moderate tamponade and acute mesenteric ischemia QPV reduction was associated with an increase in QHA of 30 +/- 39% and 102 +/- 108%, respectively (p = .001 and .018). Prolonged mesenteric ischemia restored total hepatic blood flow (Qliver) completely. During all conditions, decreasing mesenteric oxygen consumption was partly prevented by increased mesenteric oxygen extraction (p < .001 for all conditions). In contrast, decreasing hepatic oxygen delivery was associated with increased oxygen extraction in tamponade (p = .009) but not in abdominal blood flow reduction.Conclusions: Blood flow redistribution can restore Qliver totally when mesenteric blood flow is reduced selectively, partially when cardiac output is reduced, and not at all during abdominal blood flow reduction. Since hepatic oxygen extraction does not increase in abdominal blood flow reduction, hepatic oxygenation is at risk in this condition. [ABSTRACT FROM AUTHOR]

The article discusses the effective use of combination chemoembolization and focal radiation therapy for patients with unresectable, but locally confined, hepatocellular carcinoma (HCC). Eighty percent of HCCs arise in the presence of chronic liver inflammation, the majority secondary to Hepatitis B and C infection. Transarterial chemoembolization of liver tumors exploits the relative difference in blood supply to liver tumors and hepatic parenchyma, with hepatic tumors obtaining over 80 percent of their blood supply from the hepatic artery, in contrast to the 30 percent for normal hepatic tissue.

PURPOSE. Colorectal cancer metastatic to the liver, when technically feasible, is resected with a moderate chance of cure. The most common site of failure after resection is in the remaining liver. To enhance survival, chemotherapy has been delivered directly to the liver postresection via the hepatic artery. This study was designed to assess the effect of posthepatic resection, hepatic artery chemotherapy on overall survival. METHODS. Trials were sought in Medline, the Cochrane Controlled Trial Register, The Cochrane Hepatobiliary Group Trials Register, and through contact of trial authors and reference lists using key words: colorectal, cancer, hepatic metastases, hepatic artery, chemotherapy, and randomized. Trials were chosen in which patients having resection of colorectal cancer metastatic to the liver were randomized to hepatic artery chemotherapy or any alternative treatment. Survival data were obtained principally from abstraction from survival curves in published studies using the method of Parmar to calculate a study-specific, log-hazard ratio and then combined-effect, log-hazard ratio, as well as a combined Kaplan-Meier survival probability curve. RESULTS. Overall survival at five years in the hepatic artery group was 45 percent and 40 percent in the control group. Forty-three individuals developed recurrent liver metastases in the hepatic artery chemotherapy group, and 97 developed liver recurrence in the control group. However, no significant advantage was found in the meta-analysis for hepatic artery chemotherapy measuring overall survival and calculating survival based on “intention to treat” (log-hazard ratio = 0.0848, favoring the control group; 95 percent confidence interval = ±0.2037). Adverse events related to hepatic artery therapy were common, including five therapy-related deaths. CONCLUSIONS. Although recurrence in the remaining liver happened less frequently in the hepatic artery chemotherapy group, overall survival was not improved. The log-hazard ratio even favored the control group, although not significantly. This added intervention for the treatment of metastatic colorectal cancer cannot be recommended at this time. [ABSTRACT FROM AUTHOR]

There are many treatment options for patients with metastatic colorectal carcinoma confined to the liver. Surgical resection alone can result in significant prolongation of survival in patients with favorable prognostic factors. Randomized studies of hepatic artery infusion therapy after complete resection of liver metastases have demonstrated improvements in hepatic recurrence-tree survival but no impact on overall survival. Randomized trials evaluating the treatment of unresectable disease with hepatic artery infusion therapy have demonstrated higher response rates (31%- 50%) than those seen with systemic chemotherapy (8%-20%) but no survival benefit. Vascular isolation and perfusion of the liver with chemotherapy with or without biologic agents under hyperthermic conditions is another regional modality that has been explored for the treatment of unresectable colorectal cancer liver metastases. Large series report high partial response rates (68%-77%), with responses being achieved in patients with advanced tumor burden and in those who have disease progression though prior treatment of hepatic metastases. [ABSTRACT FROM AUTHOR]

OBJECTIVE To describe our approach in the decision-making for taking the middle hepatic vein with the graft or leaving it with the remnant liver in right lobe live donor liver transplantation.SUMMARY BACKGROUND DATA Right lobe living donor liver transplantation has been successfully performed. However, the extent of donor hepatectomy is still a subject of debate and the main considerations in the decision making are graft functional adequacy and donor safety.METHODS An algorithm based on donor-recipient body weight ratio, right lobe-to-recipient standard liver volume estimate, and donor hepatic venous anatomy was used to decide the extent of donor hepatectomy. This algorithm was applied in 25 living donor liver transplant operations performed between January 1999 and January 2002. In grafts taken without the middle hepatic vein, anterior segment tributaries draining into it were not reconstructed. Outcomes between right lobe liver transplants with (Group I) and without (Group II) the middle hepatic vein were compared.RESULTS Ten grafts included the middle hepatic vein and 15 did not. The mean graft to recipient standard liver volume ratio was 58% and 64% in Groups I and II, respectively, and the difference was not statistically significant. Donors from both groups had comparable recovery, with 2 complications, 1 from each group, requiring a percutaneous drainage procedure. The recipient outcomes were, likewise, comparable and there was 1 case of structural outflow obstruction in Group I, which required venoangioplasty and stenting. There were 2 recipient mortalities, 1 due to a biliary complication and the other to recurrent hepatitis C. Another patient required retransplantation for secondary biliary cirrhosis. The overall actuarial graft and patient survival rates are 84% and 96%, respectively, at a median follow-up of 16 months.CONCLUSION Based on certain preoperative criteria, a right lobe graft can be taken with or without the middle hepatic vein with equally successful outcomes in both the donors and recipients. The decision, therefore, of the extent of right lobe donor hepatectomy should be tailored to the particular conditions of each case. [ABSTRACT FROM AUTHOR]

OBJECTIVE To evaluate the safety of donors who have donated the middle hepatic vein in right lobe live donor liver transplantation (LDLT) and to determine whether such inclusion is necessary for optimum graft function.SUMMARY BACKGROUND DATA The necessity to include the middle hepatic vein in a right lobe graft in adult-to-adult LDLT is controversial. Inclusion of the middle hepatic vein in the graft provides uniform hepatic venous drainage but may lead to congestion of segment IV in the donor.METHODS From 1996 to 2002, 93 right-lobe LDLTs were performed. All right-lobe grafts except 1 contained the middle hepatic vein. In the donor operation, attention was paid to preserve the segment IV hepatic artery and to avoid prolonged rotation of the right lobe. The middle hepatic vein was transected proximal to a major segment IVb hepatic vein whereas possible to preserve the venous drainage in the liver remnant.RESULTS There was no donor death. Two donors had intraoperative complications (accidental left hepatic vein occlusion and portal vein thrombosis) and were well after immediate rectification. Twenty-four donors (26%) had postoperative complications, mostly minor wound infection. The postoperative international normalized ratio on day 1 was better in the donors with preservation of segment IVb hepatic vein than those without the preservation, but, in all donors, the liver function was largely normal by postoperative day 7. The first recipient had severe graft congestion as the middle hepatic vein was not reconstructed before reperfusion. In 7 other recipients, the middle hepatic vein was found occluded intraoperatively owing to technical errors. The postoperative hepatic and renal function of the recipients with an occluded or absent middle hepatic vein was worse than those with a patent middle hepatic vein. The hospital mortality rate was also higher in those with an occluded middle hepatic vein (3/9 vs. 5/84, P = 0.028).CONCLUSIONS Inclusion of the middle hepatic vein in right-lobe LDLT is safe and is essential for optimum graft function and patient survival. [ABSTRACT FROM AUTHOR]

OBJECTIVETo examine survival and toxicity by querying a single-institutional experience with adjuvant hepatic arterial infusional (HAI) chemotherapy.SUMMARY BACKGROUND DATAThree randomized series in the literature have examined adjuvant HAI after complete resection of liver metastases. Only one of these trials showed an overall survival benefit at 2 years but not over the entire time period of the study. Previous studies in patients with unresectable disease were plagued by high rates of biliary toxicity.METHODSA retrospective review of a prospectively maintained database was performed. Hepatic arterial pumps were placed in the standard fashion. Patients received floxuridine at doses previously demonstrated as safe in the literature. Standard statistical methods were used.RESULTSTwenty-one of 92 patients underwent placement of hepatic arterial pumps at the time of liver resection. The HAI group was similar in all demographic measures to the non-HAI group, with the exception that the HAI patients were significantly younger. No differences were seen between the groups in either disease-free or overall survival, although a trend toward improved hepatic progression-free survival was noted. Significant biliary sclerosis developed in six patients in the HAI group, requiring chronic indwelling stents in four patients. One patient died of progressive liver failure associated with this toxicity.CONCLUSIONSBiliary toxicity is an important potential side effect of hepatic arterial chemotherapy. Although larger randomized studies and this one suggest significant improvements in hepatic recurrences, these have not reliably translated into overall survival benefit. This fact, in light of the potential toxicity, would argue for a larger confirmatory trial of HAI in the adjuvant setting, incorporating recent advances in systemic therapy and careful attention to hepatotoxicity. [ABSTRACT FROM AUTHOR]

Abstract: To investigate the clinical benefits of transcatheter arterial infusion chemotherapy compared with intravenous chemotherapy in patients with colorectal cancer (CRC).From May 2013 to March 2018, 83 patients (50 men and 33 women) with surgically proven CRC were retrospectively included. Before surgery, 62 patients received conventional systemic chemotherapy, and 21 transcatheter arterial chemotherapy. Basic characteristics, disease control rate (DC), adverse reactions, postoperative complications, and toxicity profiles were collected and compared between the 2 groups.The sigmoid colon (43.37%) was the most common primary tumor location, and the least was the transverse colon (6.02%). Most lesions invaded the subserosa or other structures T3-4 (78.31%), and other lesions invaded the muscular layer T1-2 (21. 69%). The overall DC was 80.65% in the intravenous chemotherapy group and 90.48% in the arterial chemotherapy group (P < .05). Adverse events included myelosuppression and gastrointestinal reactions such as nausea, vomiting, diarrhea, abnormal liver function, and neurotoxicity, which were significantly less common in the intra-arterial group than in the intravenous group (P < .05). Postoperative complications included abdominal infection (11.29% vs 14.29%), intestinal obstruction (6.45% vs 4.76%), anastomotic bleeding (1.61% vs 0.00%), and anastomotic fistula (6.45% vs 4.76%) in the intravenous and intra-arterial groups, respectively (P > .05).Preoperative transcatheter arterial infusion chemotherapy is a safe and effective neoadjuvant chemotherapy measure for CRC with fewer adverse reactions and a higher overall DC., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

The article presents case study of a 74-year-old man diagnosed with pancreatic head cancer with biliary obstruction, who received a plastic stent placement for biliary drainage. After 4 months, he developed melena and jaundice and computed tomography scan revealed suspicious active bleeding from the right hepatic artery from the invasion of the proximal flap of the stent.

Our clinical experience with 69 patients with metastatic colorectal cancer to the liver treated with hepatic artery chemotherapy is reviewed. All patients have had a minimum of six months follow-up. The Infusaid® implantable drug delivery system was used by direct laparotomy in one third, and via the transaxillary approach in the remaining two thirds. Two thirds of the patients had at least 25 percent of the liver replaced with tumor. Chemotherapeutic agents included FUdR, mitomycin C, and BCNU. The overall response rate was 51 percent and 69 percent for the three-drug combination. Efficacy was not different in patients who had received prior systemic fluorouracil. Median survival from start of hepatic artery chemotherapy was one year. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of the addition of preoperative hepatic and regional arterial chemotherapy (PHRAC) on prognosis of stage II and III colorectal cancer (CRC) in a multicenter setting., Summary of Background Data: Our previous single-center pilot trial suggested that PHRAC in combination with surgical resection could reduce the occurrence of liver metastasis (LM) and improve survival in CRC patients., Methods: A prospective multi-center randomized controlled trial was conducted from December 2008 to December 2012 at 5 hospitals in China. Eligible patients with clinical stage II or III CRC who underwent curative resection were randomized to receive PHRAC plus adjuvant therapy (PHRAC arm) or adjuvant therapy alone (control arm). The primary endpoint was DFS. Secondary endpoints were cumulative LM rates, overall survival (OS), and safety (NCT00643877)., Results: A total of 688 patients from 5 centers in China were randomly assigned (1:1) to each arm. The five-year DFS rate was 77% in the PHRAC arm and 65% in the control arm (HR = 0.61, 95% CI 0.46-0.81; P = 0.001). The 5-year LM rates were 7% and 16% in the PHRAC and control arms, respectively (HR = 0.37, 95% CI 0.22-0.63; P < 0.001). The 5-year OS rate was 84% in the PHRAC arm and 76% in the control arm (HR = 0.61, 95% CI 0.43-0.86; P = 0.005). There were no significant differences regarding treatment related morbidity or mortality between the two arms., Conclusions: The addition of PHRAC could improve DFS in patients with stage II and III CRC. It reduced the incidence of LM and improved OS without compromising patient safety., Trial Registration: ClinicalTrials.gov identifier: NCT00643877., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

For the treatment of huge unresectable hepatocellular carcinoma (HCC), transcatheter arterial chemoembolization (TACE) or transcatheter arterial embolization (TAE) generally had poor effects and high complication rates. Our previous study found that Hepatic arterial infusion chemotherapy (HAIC) is a safe procedure and provides better survival than symptomatic treatment for the patients with huge unresectable HCC. The aim of the study is to compare the effect of HAIC vs TAE in patients with huge unresectable HCC.Since 2000 to 2005, patients with huge (size > 8 cm) unresectable HCC were enrolled. Twenty-six patients received HAIC and 25 patients received TAE. Each patient in the HAIC group received 2.5 + 1.4 (range: 1-6) courses of HAIC and in the TAE group received 1.8 + 1.2 (range: 1-5) courses of TAE. Baseline characteristics and survival were compared between the HAIC and TAE group.The HAIC group and the TAE group were similar in baseline characteristics and tumor stages. The overall survival rates at 1 and 2 years were 42% and 31% in the HAIC group and 28% and 24% in the TAE group. The patients in the HAIC group had higher overall survival than the TAE group (P = .077). Cox-regression multivariate analysis revealed that HAIC is the significant factor associated with overall survival (relative risk: 0.461, 95% confidence interval: 0.218-0.852, P = .027). No patients died of the complications of HAIC but three patients (12%) died of the complications of TAE.In conclusion, HAIC is a safe procedure and provides better survival than TAE for patients with huge unresectable HCCs.

Objective: To investigate the impact of adjuvant hepatic artery infusion (HAI) in relation to KRAS mutational status in patients with resected colorectal cancer liver metastases (CRLM)., Background: Patients with KRAS-mutated CRLM have worse outcomes after resection. Adjuvant HAI chemotherapy improves overall survival after liver resection., Methods: Patients with resected CRLM treated at MSKCC with and without adjuvant HAI who had available KRAS status (wild-type, WT; mutated, MUT) were reviewed from a prospectively maintained institutional database. Correlations between KRAS status, adjuvant HAI, clinical factors, and outcomes were analyzed. Cox proportional hazard model was used to adjust for confounders., Results: Between 1993 and 2012, 674 patients (418 KRAS-WT, 256 MUT) with a median follow up of 6.5 years after resection were evaluated. Fifty-four percent received adjuvant HAI. Tumor characteristics (synchronous disease, number of lesions, clinical-risk score, 2-stage hepatectomy) were significantly worse in the HAI group; however, there were more patients with resected extrahepatic metastases in the no-HAI group. In KRAS-WT tumors, 5-year survival was 78% for patients treated with HAI versus 57% for patients without HAI [hazard ratio (HR) 0.51, P < 0.001]. In KRAS-MUT tumors, 5-year survival was 59% for patients treated with HAI versus 40% for patients without HAI (HR 0.56, P < 0.001). On multivariate analysis, HAI remained associated with improved OS (HR 0.53, P < 0.002) independent of KRAS status and other clinicopathologic factors., Conclusion: Adjuvant HAI after resection of CRLM is independently associated with improved outcomes regardless of KRAS mutational status. Adjuvant HAI may mitigate the worse outcomes seen in patients with resectable KRAS-MUT CRLM.

Objectives: Propionic acidemia (PA) is a rare inborn error of metabolism resulting from deficiency in the enzyme necessary for catabolism of branched-chain amino acids, some odd chain fatty acids and cholesterol. Despite optimal medical management, PA often leads to acute and progressive neurological injury. Reports on liver transplantation (LT) as a cellular therapy are limited and varied. The objective of this study was to examine the largest collection of patients who underwent LT for PA., Methods: Examining the Scientific Registry of Transplant Recipients and the Pediatric Health Information System administrative billing databases, we performed a multicenter, retrospective analysis of LT over a 16-year period. During this period, 4849 pediatric LT were performed out of which 23 were done for PA at 10 different centers., Results: The majority of recipients were 5 years of age or younger and had status 1b exception points at the time of transplant. The 1-, 3-, and 5-year graft survival for PA LT recipients was 84.6% and the 1-, 3, and 5-year patient survival was 89.5%. There was no significant difference in graft or patient survival between PA and non-PA LT recipients. Despite historical data to the contrary, we did not find an increased incidence of hepatic arterial thrombosis in patients undergoing LT for PA. Patients in the PA LT group, however, had a significantly higher postoperative rate of readmission compared with the non-PA LT group (90.5% vs 72.8%, P = 0.021)., Conclusion: LT for children with PA is a viable treatment option with acceptable outcomes.

Rationale: Despite vast improvements in technique, several complications still challenge surgeons and medical practitioners alike, including biliary and vascular complications, acute and chronic rejection, and disease recurrence., Patient Concerns: A 59-year-old man was admitted to hospital on July, 2016. He had hepatitis B cirrhosis related recurrent hepatocellular carcinoma and underwent living donor liver transplantation in our hospital., Diagnosis: At the time of admission, the patient's spirit, diet, sleep, normal urine and stool, and weight did not change significantly. The test indicators are as follows: total bilirubin: 100.1 μmol/L, direct bilirubin: 65.0 μmol/L. Emergency CT in the hospital after admission showed that hepatic artery pseudoaneurysm formation after liver transplantation was observed., Interventions: This patient underwent minimal invasive endovascular treatment. The demographic, clinical, and laboratory data were collected and reviewed. He was treated successfully by endovascular stent grafting and thrombolytic treatment., Outcomes: The blood concentration of tacrolimus (FK506) was 6.3 ng/mL total bilirubin 19.6 μmol/L before discharge. The changing of total bilirubin and direct bilirubin were investigated (Fig. 1). The patient recovered well and was discharged 2 weeks later. The patient is doing well and regularly followed up., Lessons: Coil embolization of aneurysmal sac or placement of a stent graft is a minimally invasive alternative to surgery and definitively excludes a bleeding hepatic artery pseudoaneurysm. This technique can be considered as an effective treatment option for hepatic artery pseudoaneurysm instead of a difficult surgical repair.

B Learning Objectives: b Effective chest compressions for cardiopulmonary resuscitation (CPR) are commonly associated with sternum and rib fractures. Herein, we present a case of chest compression induced liver injury requiring hepatic artery embolization for persistent hemorrhagic shock after return of spontaneous circulation (ROSC). Emergent dialysis was being arranged when patient went into cardiac arrest requiring advanced cardiac life support (ACLS) including chest compressions. [Extracted from the article]

The article presents a case study of a 53-year-old female who presented with an exacerbation of chronic obstructive pulmonary disease to a hospital. Topics discussed include the involvement of computed tomography (CT) in the imaging of the patient, the use of the propranolol drug for the treatment of disease, and the occurrence of dissecting aneurysms that characterizes the segmental arteriolar mediolysis (SAM).

Objectives: To describe characteristics of liver transplant patients with severe sepsis in the PICU., Design: Retrospective descriptive analysis., Setting: Tertiary children's hospital PICU., Patients: Liver transplant recipients admitted January 2010 to July 2016 for pediatric severe sepsis., Interventions: None., Measurements and Main Results: Between January 2010 and July 2016, 173 liver transplants were performed, and 36 of these patients (21%) were admitted with severe sepsis (54 episodes total). Median age at admission was 2 years (1-6.5 yr), 47.2% were male. Bacterial infections were the most common (77.8%), followed by culture negative (12.9%) and viral infections (7.4%). Fungal infections accounted for only 1.9%. Median time from transplant for viral and culture negative infections was 18 days (8.25-39.75 d) and 25 days (9-41 d), whereas 54.5 days (17-131.25 d) for bacterial infections. Bloodstream and intra-abdominal were the most common bacterial sites (45% and 22.5%, respectively). Multidrug-resistant organisms accounted for 47.6% of bacterial sepsis. Vancomycin-resistant Enterococcus and extended-spectrum beta-lactamase producers were the most frequently identified multidrug-resistant organisms. Patients with multidrug-resistant organism sepsis demonstrated higher admission Pediatric Logistic Organ Dysfunction scores (p = 0.043) and were noted to have an odds ratio of 3.8 and 3.6 for mechanical ventilation and multiple organ dysfunction syndrome, respectively (p = 0.047 and p = 0.044). Overall mortality was 5.5% (n = 2 patients), with both deaths occurring in multidrug-resistant organism episodes., Conclusions: We report that multidrug-resistant organisms are increasingly being identified as causative pathogens for sepsis in pediatric liver transplant recipients and are associated with significantly higher odds for mechanical ventilation and higher organ failure. The emergence of multidrug-resistant organism infections in pediatric liver transplant patients has implications for patient outcomes, antibiotic stewardship, and infection prevention strategies.

Rationale: Coils migration following endovascular treatment of arterial bleeding is rare. There was no clear route to deal with this complication., Patient Concerns: A 55-year-old woman underwent choledochal cyst excision with hepaticojejunostomy. At the 18th day after operation, intra-abdominal hemorrhage occurred. Angiography showed active bleeding of 1 branch of the right hepatic artery and the gastroduodenal artery. That was treated by micro-coils embolization. 122 days after embolization, the patient was readmitted for chills, fever with temperature of 40°C, and jaundice., Diagnosis: Obstructive cholangitis., Interventions: Endoscopy was performed, which showed the micro-coils were embedded in biliary-jejunum anastomosis. Biliary sludges were adherent around micro-coils that were considered the cause of obstructive jaundice, which were washed by endoscopy., Outcomes: Two days later endoscopy therapy, the total bilirubin (TBIL) was decreased to 58.7 μmol/L, and the patient was discharged. After 2 months of follow-up, the level of TBIL was in normal range., Lessons: Coils migration following endovascular treatment of arterial bleeding is rare. For cases with coils migrated into the biliary tract, further treatment is often needed because of the secondary cholangitis or stones. Endoscopy might be useful to deal with this intractable problem.

Purpose: The aim of this study was to evaluate the feasibility of a prototype volume-interpolated breath-hold examination (VIBE) sequence using compressed sensing (VIBECS) for rapid multiphase arterial magnetic resonance imaging (MRI) at different temporal resolution during free-breathing in comparison with a conventional breath-hold approach (VIBESTD)., Material and Methods: A total of 40 patients with liver malignancies were prospectively included in this study and underwent contrast-enhanced liver MRI at 1.5 T to evaluate the performance of VIBECS for rapid arterial multiphase imaging. An additional 40 patients examined with a VIBESTD were included serving as standard of reference. The VIBECS study cohort was subdivided into 2 groups (each n = 20). In both groups, VIBECS was continuously acquired for 60 seconds starting with the contrast agent administration (group A, temporal resolution 4 seconds; group B, temporal resolution 8 seconds). Subsequently, the time point with the subjectively best image quality was selected and defined as hepatic arterial dominant (HAD) phase. Overall image quality, lesion conspicuity, vessel contrast, and artifacts of HAD phase were assessed by 2 radiologists independently on a 5-point Likert scale (5 = excellent) and compared with arterial phase images of VIBESTD. In addition, signal attenuation/time curves of VIBECS were plotted for each patient to quantify the hepatic arterial enhancement., Results: No patients were excluded and all HAD phases were reliably recorded in the investigated VIBECS cohort. Most commonly, HAD was observed at the ninth time point (36 seconds after intravenous contrast injection) in group A and at the fifth time point (40 seconds after intravenous contrast injection) in group B. Timing with VIBESTD was only adequate in 65% (26/40). Image quality, lesion conspicuity, and vessel contrast were good to excellent without significant differences between both VIBECS groups (P ≥ 0.2) and with significantly higher reading scores as compared with VIBESTD with respect to lesion conspicuity (P ≤ 0.006) and image quality (group B; P < 0.001). VIBECS showed reconstruction artifacts, which were significantly higher in group A (P = 0.001). Mean peak arterial enhancement was observed at the ninth time point (36 seconds) in group A and at the sixth (48 seconds) in group B., Conclusion: VIBECS allows for robust multiphase arterial imaging during free-breathing at high spatial and temporal resolution (preferably 8 seconds) with improved image quality and lesion conspicuity as compared with VIBESTD.

Background: In current studies of ex situ liver perfusion there exists considerable variability in perfusate composition, including the type of oxygen carrier. Herein, we aim to clarify the minimal hemoglobin level necessary during normothermic porcine ex situ liver perfusion., Methods: Livers procured from 35 to 45 kg domestic pigs were connected to our experimental ex situ circuit (n = 10). In the treatment group, perfusate was sequentially diluted hourly to predetermined hemoglobin levels. At the end of each hemoglobin dilution, perfusate samples were analyzed for liver transaminases, lactate dehydrogenase (LD), total bilirubin, and lactate levels. Liver oxygen consumption was measured. In the control group, livers were perfused continually for a duration of 24 hours at target hemoglobin levels of 30 and 20 g/L., Results: Rising liver transaminases, significantly higher lactate (P < 0.001), and LD levels (P < 0.001) were noted at lower perfusate hemoglobin levels in the treatment group. Liver oxygen utilization (P < 0.001) and hepatic artery oxygen delivery (P < 0.001) were significantly lower at lower hemoglobin levels, whereas liver vessel resistance remained relatively constant. Histology demonstrated increasing parenchymal damage at lower hemoglobin levels. In control livers, higher perfusate transaminases, higher lactate, and LD levels were noted at a perfusion hemoglobin level of 20 g/L., Conclusions: Ex situ liver function decompensated during perfusion between a mean hemoglobin level of 30 to 20 g/L, as evidenced by notably rising lactate and LD levels. This study demonstrates optimal hemoglobin concentration during normothermic ex situ liver perfusion to ensure a fully metabolically functioning graft.

Objectives: We have previously shown that refractory neuroendocrine tumors can respond to moderate doses of chemoradiotherapy. We completed a dose-escalation phase I/II trial combining hepatic arterial (HA) chemotherapy, chemoembolization, and dose-escalated whole liver radiotherapy to determine the maximum safe dose of radiation that could be delivered and to make a preliminary assessment of response., Materials and Methods: From 2002 to 2009, 19 patients with symptomatic neuroendocrine liver metastases who failed somatostatin analog therapy were enrolled. HA fluorodeoxyuridine, leucovorin, and streptozotocin were delivered, as concurrent whole liver radiotherapy was dose escalated from 24 to 32 Gy in 2 Gy fractions, with a target rate of dose-limiting grade ≥3 radiation-induced liver disease of 10%. Eight weeks later, for patients without grade ≥3 liver or grade ≥4 any toxicity, a 72-hour infusion of HA fluorodeoxyuridine and leucovorin was given, followed by transarterial chemoembolization., Results: Eleven patients completed the entire protocol and received 24 to 32 Gy. No patients developed radiation-induced liver disease; 7 had grade 3 to 4 transiently increased liver function tests, and 4 had other grade 4 toxicities. Three patients (14%) had partial response, 16 (84%) stable disease. Median freedom from local progression and overall survival were 35.3 and 54.6 months, respectively., Conclusions: Thirty-two in 2 Gy daily fractions can be delivered safely when combined with HA chemotherapy and subsequent transarterial chemoembolization. However, although objective responses were observed, this combination was not significantly better than our prior approaches. Further treatment intensification strategies, including individualized dose escalation for radiation-tolerant livers, and improved radiosensitization should be investigated, along with improved systemic therapy.

Sorafenib is the most widely used multikinase inhibitor in patients with advanced hepatocellular carcinoma (HCC). Despite its efficacy, only a small proportion of patients experience tumor regression. Hepatic artery infusion chemotherapy (HAIC) can be used as an alternative treatment for HCC.A total of 139 patients with advanced HCC, treated with HAIC (HAIC group, n = 95) or sorafenib (sorafenib group, n = 44), were retrospectively analyzed in a single hospital. We compared the efficacy and overall survival (OS) between the 2 groups, and investigated the factors affecting response rate in the HAIC group.The objective response rate (ORR) was significantly higher in the HAIC group than in the sorafenib group (23.2% vs 2.3%; P = .01). The progression-free survival time was longer in the HAIC group than in the sorafenib group (274 vs 166 days; P = .03). However, there was no significant difference in OS between the 2 groups (359 vs 223 days; P = .05). In the multivariate analysis, international normalized ratio (INR), serum bilirubin, and presence of objective response were significant prognostic factors associated with OS (P = .03, P = .01, and P = .01, respectively). In the HAIC group, INR, nonobjective response group, and < 4 HAIC cycles were identified as independent risk factors of OS (P = .03, P = .01, and P = .01, respectively).The ORR in patients treated with HAIC was found to be superior to that in advanced HCC patients treated with sorafenib. Better tumor response and prolonged OS can be expected in patients who receive ≥ 4 HAIC cycles.

Background: Hepatic artery complications are feared complications after liver transplantation and may compromise the biliary tract, graft, and patient survival. The objective of this systematic review and meta-analysis was to compare risk of hepatic artery and biliary complications after liver transplantation in patients who underwent neoadjuvant transarterial chemoembolization (TACE) versus no TACE., Methods: Comprehensive searches were performed in Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases to identify studies concerning hepatocellular cancer patients undergoing preliver transplantation TACE. Quality assessment of studies was done by the validated checklist of Downs and Black. Meta-analyses were performed to evaluate the incidence of all hepatic artery complications, hepatic artery thrombosis, and biliary tract complications, using binary random-effect models., Results: Fourteen retrospective studies, representing 1122 TACE patients, met the inclusion criteria. Postoperative hepatic artery complications consisted of hepatic artery thrombosis, stenosis, and (pseudo)-aneurysms. Preliver transplantation TACE was significantly associated with occurrence of posttransplant hepatic artery complications (odds ratio, 1.57; 95% confidence interval, 1.09-2.26; P = 0.02). No significant association between neoadjuvant TACE and hepatic artery thrombosis alone or biliary tract complications was found., Conclusions: Patients treated with TACE before liver transplantation may be at increased risk for development of hepatic artery complications after liver transplantation.

Rationale: Esophageal variceal bleeding caused by portal hypertension is massive and life-threatening to those patients with decompensated liver cirrhosis. A transjugular intrahepatic portosystemic shunt (TIPS) can effectively stop bleeding. But the process of puncture may lead to bile duct injury and even form fistulas between the hepatic artery and bile duct., Patient Concerns: The case report illustrated a 52-year-old Chinese female patient who underwent TIPS., Diagnoses: She suffered from acute upper gastrointestinal hemorrhage and acute pancreatitis because of the bile duct injury after TIPS., Interventions: The fistulas between the hepatic artery and bile duct was embolized., Outcomes: The acute upper gastrointestinal hemorrhage and acute pancreatitis of the patient were cured., Lessons: The arteriobiliary fistula should be paid more attention after TIPS while early-stage prevention should be carried out., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Whilst causes of hepatic artery thrombosis (HAT) after liver transplantation (LT) are multifactorial, early HAT (E-HAT) remains pertinent complication impacting on graft and patient survival. Currently there is no screening tool that would identify patients with increased risk of developing E-HAT., Methods: We analyzed the native procoagulant state of LT recipients, identified through pretransplant thromboelastographic (TEG) data among other known risk factors, to identify risk factors for E-HAT., Results: The outcomes of 828 adult patients undergoing LT between 2008 and 2013 were analyzed. Overall, 79 (9.5%) patients experienced HAT, E-HAT was diagnosed in 23, and in the remainder this was "late" HAT. The maximum amplitude (MA) on preoperative TEG was significantly higher in patients diagnosed with E-HAT compared with those who did not (71.2 mm vs 57.9 mm; P < 0.0001). Receiver operating characteristic analysis with the cutoff value for MA of 65 mm or greater returned area under the curve of 0.750 (P < 0.001) predicting E-HAT with a sensitivity of 70%. A total of 7% of patients with an MA of 65 mm or greater went on to develop E-HAT (hazard ratio, 5.28; 95% confidence interval, 2.10-12.29; P < 0.001), whereas only 1.2% patients with an MA less than 65 mm experienced E-HAT., Conclusions: Preoperative TEG may reliably identify group of recipients at greater risk of developing E-HAT, and intense surveillance and anticoagulation prophylaxis may avoid this serious complication after LT.

Purpose: Transarterial radioembolization is used to treat primary and secondary liver malignancies. Two commercially available drugs are utilized for the purpose. The aim of our study is to compare the radiation dose delivered to the tumor by these drugs., Materials and Methods: This study included 86 patients (M : F - 7.6 : 1, median age=50.5 years), 46 patients were treated by Y-TheraSphere and 42 patients were treated by Y-SIRSphere. Activity administered in Y-TheraSphere and Y-SIRSphere was calculated using a modified partition model and a modified body surface area model, respectively. The radiation dose delivered by two drugs was calculated and compared in our study., Result: Activity administered in Y-TheraSphere was significantly higher than that of Y-SIRSphere. Hence, the radiation dose delivered to the tumor by Y-SIRSphere was significantly lower (58.4%) than that of Y-TheraSphere (P=0.000)., Conclusion: As the radiation dose delivered by Y-SIRSphere was lower than Y-TheraSphere, we believe that the formula for Y-SIRSphere activity calculation needs to be modified so that the optimal dose can be delivered to the tumor.

Objective: To determine whether any patient or hepatic tumor characteristics are predictive of hepatopulmonary shunt fraction when performed before radioembolization., Materials and Methods: A retrospective review was performed on 190 patients who underwent preradioembolization hepatic arteriography with calculation of hepatopulmonary shunt fraction using technetium-99m-labeled macroaggregated albumin perfusion scintigraphy. Patient and tumor characteristics including imaging features were reviewed for correlation with absolute shunt fraction, shunt fraction greater than 10%, and shunt fraction greater than 20%., Results: Most tumor types showed some cases of elevated shunt fraction greater than 10%. Six patients had a shunt fraction greater than 20%: four were hepatocellular carcinoma and two were neuroendocrine tumor metastases. Univariate analysis showed that dominant tumor diameter, hepatic tumor burden, vascular invasion, hepatic venous invasion, and hypervascularity on angiography were associated with a shunt fraction greater than 10%. Only dominant tumor diameter and vascular invasion were associated with a shunt fraction greater than 20%. On multivariate analysis, only tumor diameter (odds ratio 1.2) and hepatic venous invasion (odds ratio 23.0) were associated independently with an increased shunt fraction greater than 10%., Conclusion: Multiple patient and tumor-related characteristics were significantly correlated with the hepatopulmonary shunt fraction on univariate analysis. However, on multivariate analysis, only the dominant tumor diameter and presence of hepatic venous invasion were associated independently with a greater than 10% shunt fraction.

Objective: The aim of this study was to assess whether a short breath-hold technique can improve hepatic arterial phase (HAP) image quality in gadoxetic acid-enhanced magnetic resonance (MR) imaging compared with a conventional long breath-hold technique., Materials and Methods: Institutional review board approval and patient consent were obtained for this prospective randomized control study. One hundred nineteen patients undergoing gadoxetic acid-enhanced MR imaging were randomly assigned to groups A or B. Group A patients underwent an 18-second long breath-hold MR technique (conventional VIBE [volumetric interpolated breath-hold examination] technique with GRAPPA [generalized autocalibrating partially parallel acquisition]), and group B patients underwent a 13-second short breath-hold MR technique (VIBE technique with CAIPIRINHA [controlled aliasing in parallel imaging results in higher acceleration]). Respiratory-related graphs of the precontrast and HAP were acquired. The breath-hold degree was graded based on the standard deviation (SD) value of respiratory waveforms. Gadoxetic acid-related dyspnea was defined as when the SD value of the HAP was 200 greater than that of the precontrast phase without degraded image quality in the portal and transitional phases (SD value of the HAP - SD value of the precontrast phase). The overall image quality and motion artifacts of the precontrast and HAP images were evaluated. The groups were compared using the Student t or Fisher exact test, as appropriate., Results: The incidence of breath-holding difficulty (breath-hold grades 3 and 4) during the HAP was 43.6% (27/62) and 36.8% (21/57) for group A and B, respectively. The SD value during the precontrast phase and the SD value difference between the precontrast and HAP were both significantly higher in group A than in group B (P = 0.047 and P = 0.023, respectively). Gadoxetic acid-related dyspnea was seen in 19.4% (12/62) of group A and 7.0% (4/57) of group B. Group B showed better precontrast and HAP image quality than group A (P < 0.001). Degraded HAP (overall image quality ≥4) was observed in 9.7% (6/62) and 3.5% (2/57) of group A and B, respectively., Conclusions: The short breath-hold MR technique, CAIPIRINHA, showed better HAP image quality with less degraded HAP and a lower incidence of breath-hold difficulty and gadoxetic acid-related dyspnea than the conventional long breath-hold technique.

Transarterial chemoembolization (TACE) is frequently used for treatment of unresectable hepatocellular carcinoma (HCC) and can also be used for case of liver metastases from rectal cancer. Although it is recognized as safe and effective treatment, various complications have been reported. However, post-TACE duodenal perforation with duodenal and esophageal ischemia has not been reported in the literature. A 43-year-old male had experienced duodenal perforation combined with duodenal and lower esophageal ischemia after 8 times of repeated TACE for recurrent and unresectable HCCs, that was confirmed on esophagogastroduodenoscopy and abdominal computed tomography. Interestingly, operative findings showed complete recovery of duodenal ischemia except perforation, and he recovered with just the segmental duodenectomy and gastrojejunostomy. We report a case of duodenal perforation with necrosis and esophageal ischemia after 8th TACE for unresectable HCC. Although this complication is rare and unexpected, it may result in severe sequelae requiring surgical repair.The careful procedure during TACE followed by post-TACE careful monitoring is required in patients with posthepatectomy or repeated TACE, especially in the case with unusual clinical manifestations., Competing Interests: The authors have no conflicts of interest to disclose.

The role of hepatic resection in hepatocellular carcinoma (HCC) with accompanying portal vein tumor thrombus (PVTT) remains controversial. This study aimed to evaluate the surgical outcomes of hepatic resection compared with those of transarterial chemoembolization (TACE) in HCC patients. A retrospective study was conducted using the medical records of 230 HCC patients with portal vein invasion who underwent hepatic resection (96 patients) or TACE (134 patients). The baseline characteristics, tumor characteristics, clinicopathological parameters, and overall survival rates were compared between the 2 groups. The baseline and tumor characteristics were comparable between the hepatic resection and TACE groups. The overall complication rate was 35.4% in the hepatic resection group, which was significantly lower than that in the TACE group (73.0%, P <0.001). However, the serious complication rate (grade ≥3) in the hepatic resection group was 13.5%, which was significantly higher than that in the TACE group (P = 0.003). The cumulative overall survival rates at 1, 3, and 5 years in the hepatic resection group were 86.5%, 60.4%, and 33.3%, respectively. These rates were much higher than those in the TACE group (1-year: 77.6%; 3-year: 47.8%; and 5-year: 20.9%; P = 0.021). The long-term survival was notably better in the patients with types I and II PVTT than in the patients with types III and IV PVTT (P <0.05). The univariate and multivariate analyses indicated that types III and IV PVTT and TACE may have contributed to the poor overall survival following surgery. In HCC patients with PVTT and compensated liver function, hepatic resection is a safe and effective surgical protocol, particularly for patients with type I or II PVTT.

In this paper, we present the successful therapeutic approach of unresectable liver metastases in a patient with rectal cancer.A 63-year-old male underwent endoscopic polypectomy followed by rectosigmoid resection for an adenocarcinoma of the rectum diagnosed in pT2N0 stage. The angio-computed tomography (CT) revealed four metastatic hepatic nodules ranging from 12 to 130 mm in diameter. After one cure of trans-arterial chemoembolization (TACE) with lipiodol and 5-fluorouracil, combined with FOLFOX4 + capecitabine systemic chemotherapy, the diameter of all hepatic nodules decreased to half size, at 6 months after TACE. Further curative surgical hepatic metastasectomy was done and complete pathologic response was obtained. The patient is free of recurrences and metastases after 26 months of follow-up.This representative case shows that an efficient trans-disciplinary approach could lead to successful therapeutic management even in patients with advanced-staged colorectal carcinomas.

Combined arterial resection during pancreatectomy can be a challenging treatment, and outcome would be more favorable if the tumor becomes technically removable from the artery. Neoadjuvant chemoradiotherapy (NACRT) is expected to achieve locoregional control and enable margin-negative resection. To investigate the effects of NACRT in patients with pancreatic adenocarcinoma (PDAC) which were deemed borderline resectable through preoperative imaging due to abutment of the major artery, including the superior mesenteric artery (SMA) or common hepatic artery (CHA), but were still considered to be technically removable. In the current study, comparisons were make between 71 patients who underwent upfront surgery and 21 patients who underwent NACRT followed by surgery in the strategy to preserve the artery, using unmatched and inverse probability of treatment weighting analysis (UMIN000017115). Fifty patients in the upfront surgery group and 18 in the NACRT group underwent curative resection (70% vs 86%, respectively; P = 0.16). The results of the propensity score weighted logistic regressions indicated that the incidences of pathological lymph node metastasis and a pathological positive resection margin were significantly lower in the NACRT group (odds ratio, 0.006; P < 0.001 and odds ratio, 0.007; P < 0.001, respectively). Among the propensity-score matched patients, the estimated 1- and 2-year survival rates in the upfront surgery group were 66.7% and 16.0%, respectively, and those in the NACRT group were 80.0% and 65.2%, respectively. In conclusion, it was suggested that chemoradiotherapy followed by surgery provided clinical benefits in patients with PDACs in contact with the SMA or CHA.

Single-port laparoscopic cholecystectomy is considered as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy. It is a technically demanding procedure, and no adequately powered trial has assessed the safety of this technique. Vascular injuries are less common than bile duct injuries during this procedure, but they can be rapidly fatal. The development of a right hepatic artery pseudoaneurysm is a rare but serious complication associated with single-port laparoscopic cholecystectomy. Two weeks following a single-port laparoscopic cholecystectomy for angiocholitis, a 40-year-old male patient presented with obstructive jaundice and persistent abdominal pain. The diagnosis of compressive hematoma due to a ruptured right hepatic artery pseudoaneurysm was confirmed by computed tomography scan and angiography. It was successfully treated by selective embolization of the right hepatic artery. In our experience, endovascular management was a noninvasive and effective treatment of ruptured pseudoaneurysms.

Purpose: Evaluate conversion rate of patients with unresectable colorectal-liver metastasis to complete resection with hepatic-arterial infusion plus systemic chemotherapy including bevacizumab (Bev)., Patients and Methods: Forty-nine patients with unresectable colorectal liver metastases (CRLM) were included in a single-institution phase II trial. Conversion to resection was the primary outcome. Secondary outcomes included overall survival (OS), progression-free survival, and response rates. Multivariate and landmark analyses were performed to evaluate survival differences between resected and nonresected patients., Results: Median number of tumors was 14 and 65% were previously treated patients. A high biliary toxicity rate was found in the first 24 patients whose treatment included Bev. The remaining 25 patients were treated without Bev. Overall response rates were 76% (4 complete responses). Twenty-three patients (47%) achieved conversion to resection at a median of 6 months from treatment initiation. Median OS and progression-free survival for all patients were 38 (95% confidence interval: 28 to not reached) and 13 months (95% confidence interval: 7-16). Bev administration did not impact outcome. Conversion was the only factor associated with prolonged OS and progression-free survival in multivariate analysis. On landmark analysis, patients who had undergone resection had longer OS than those who did not undergo resection (3-year OS: 80% vs 26%). Currently, 10 of 49 (20%) patients have no evidence of disease (NED) at a median follow-up of 39 months (32-65 months)., Conclusions: In patients with extensive unresectable CRLM, the majority of whom were previously treated, 47% were able to undergo complete resection after combined HAI and systemic therapy. Conversion to resection is associated with prolonged survival.