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ZusammenfassungDie perkutane hepatische Chemosaturation ist eine Behandlungsoption bei nichtresektablen primären oder sekundären Lebertumoren. Dabei wird der Bereich der Lebervenenmündung der Vena cava inferior (VCI) mittels 2 Ballons von der Zirkulation isoliert, sodass die systemische Verteilung des über die Leberarterie applizierten Chemotherapeutikums Melphalan verhindert wird. Nach Passage der Leber und venöser Drainage aus der retrohepatischen VCI durchläuft das chemosaturierte Blut 2 parallel geschaltete extrakorporale Filter. Anschließend wird das gereinigte Blut jugulär rückgeführt. Das Verfahren geht oft mit einer ausgeprägten hämodynamischen Instabilität einher, deren Ursache nicht abschließend geklärt ist. Zusätzlich stellt das Gerinnungsmanagement eine Herausforderung dar. Die Autoren berichten von einem Fall, bei dem sich trotz ausreichender „activated clotting time“ (ACT) ein Thrombus im rückführenden Schenkel der extrakorporalen Zirkulation bildete. Gezielte Problemsuche und -lösung waren parallel zur hämodynamischen Stabilisierung und interdisziplinären Zusammenarbeit notwendig, um die Intervention erfolgreich durchzuführen und der Patientin eine sichere Therapie zukommen zu lassen.

Percutaneous hepatic chemosaturation is a treatment option for unresectable primary or secondary liver tumors. In this procedure the part of the inferior vena cava (VCI) that collects blood from the hepatic veins is isolated using a double balloon catheter. Like this, systemic distribution of the chemotherapeutic agent melphalan which is administered via the hepatic artery can be prevented. After passage through the liver and drainage from the retrohepatic VCI, the chemosaturated blood passes through two extracorporeal filters. Subsequently, the filtered blood is returned via the jugular vein. The procedure is often accompanied by severe hemodynamic instability, the cause of which is still not completely understood. In addition, coagulation management of extracorporeal circulation is often challenging. The authors report a case in which a thrombus formed in the returning leg of the extracorporeal circulation despite sufficient activated clotting time (ACT). Targeted problem search and resolution were necessary simultaneously to hemodynamic stabilization and interdisciplinary collaboration to successfully perform the intervention and provide the patient with safe treatment.Die perkutane hepatische Chemosaturation ist eine Behandlungsoption bei nichtresektablen primären oder sekundären Lebertumoren. Dabei wird der Bereich der Lebervenenmündung der Vena cava inferior (VCI) mittels 2 Ballons von der Zirkulation isoliert, sodass die systemische Verteilung des über die Leberarterie applizierten Chemotherapeutikums Melphalan verhindert wird. Nach Passage der Leber und venöser Drainage aus der retrohepatischen VCI durchläuft das chemosaturierte Blut 2 parallel geschaltete extrakorporale Filter. Anschließend wird das gereinigte Blut jugulär rückgeführt. Das Verfahren geht oft mit einer ausgeprägten hämodynamischen Instabilität einher, deren Ursache nicht abschließend geklärt ist. Zusätzlich stellt das Gerinnungsmanagement eine Herausforderung dar. Die Autoren berichten von einem Fall, bei dem sich trotz ausreichender „activated clotting time“ (ACT) ein Thrombus im rückführenden Schenkel der extrakorporalen Zirkulation bildete. Gezielte Problemsuche und -lösung waren parallel zur hämodynamischen Stabilisierung und interdisziplinären Zusammenarbeit notwendig, um die Intervention erfolgreich durchzuführen und der Patientin eine sichere Therapie zukommen zu lassen.

Study Purpose The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. Methods The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. Results Not applicable. Conclusion DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. Trial Registration Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Background The coronavirus disease 2019 (COVID-19) pandemic led to far-reaching restrictions of social and professional life, affecting societies all over the world. To contain the virus, medical schools had to restructure their curriculum by switching to online learning. However, only few medical schools had implemented such novel learning concepts. We aimed to evaluate students’ attitudes to online learning to provide a broad scientific basis to guide future development of medical education. Methods Overall, 3286 medical students from 12 different countries participated in this cross-sectional, web-based study investigating various aspects of online learning in medical education. On a 7-point Likert scale, participants rated the online learning situation during the pandemic at their medical schools, technical and social aspects, and the current and future role of online learning in medical education. Results The majority of medical schools managed the rapid switch to online learning (78%) and most students were satisfied with the quantity (67%) and quality (62%) of the courses. Online learning provided greater flexibility (84%) and led to unchanged or even higher attendance of courses (70%). Possible downsides included motivational problems (42%), insufficient possibilities for interaction with fellow students (67%) and thus the risk of social isolation (64%). The vast majority felt comfortable using the software solutions (80%). Most were convinced that medical education lags behind current capabilities regarding online learning (78%) and estimated the proportion of online learning before the pandemic at only 14%. In order to improve the current curriculum, they wish for a more balanced ratio with at least 40% of online teaching compared to on-site teaching. Conclusion This study demonstrates the positive attitude of medical students towards online learning. Furthermore, it reveals a considerable discrepancy between what students demand and what the curriculum offers. Thus, the COVID-19 pandemic might be the long-awaited catalyst for a new “online era” in medical education.

High density 1Gb embedded STT-MRAM in 28nm FDSOI technology was successfully demonstrated. Based on the highly reliable and manufacturable eMRAM technology, high yield over 90% was achieved at the operating temperature from −40°c to 105°c with satisfying read, write function and 10 years retention at 105°c. These results are mainly attributed to the advanced process for better control of MTJ CD, highly manufacturable process window and robust circuit design for high density chip. MTJ properties can be systematically adjusted by tailoring the MTJ stack and MTJ module process. Improved endurance up to 1E10 cycles was achieved to broaden eMRAM applications to eDRAM replacement.

Weltweit ist eine steigende Zahl von Patienten von einer Immunsuppression betroffen. Das Krankheits- und Erregerspektrum kann bei diesen Patienten durch das haufige Vorkommen opportunistischer Infektionen deutlich von dem bei Immunkompetenten differieren. Zusatzlich konnen die klinischen Symptome unspezifisch sein, sodass der radiologischen Diagnostik eine Schlusselfunktion im Management dieser Patienten zukommt. Bei immunkompromittierten Patienten ist die Lunge besonders haufig von Infektionen betroffen. Die Rontgenaufnahme des Thorax ist der Ausgangspunkt der Diagnostik, zeigt bei atypischen Erregern aber eine unzureichende Sensitivitat und Spezifitat, sodass die Computertomographie (CT) hier einen wesentlichen Stellenwert hat. Eine exakte Erregerspezifizierung ist leider auch mit der CT nicht moglich. Dennoch kann sie entscheidende Hinweise zur Differenzierung von viralen, bakteriellen und fungalen Infektionen sowie nichtinfektiosen Ursachen liefern. Auch bei der Bildgebung des Abdomens spielt die CT eine wesentliche Rolle und kommt zur Abklarung des akuten Abdomens und bei unklaren sonographischen Befunden zum Einsatz. Gleichzeitig konnen weitere diagnostische und therapeutische Masnahmen, wie eine Probebiopsie oder eine Drainageanlage bei Abszedierung, durchgefuhrt werden.

Background Suboptimal nutrition accompanied by chronic low-grade increases in circulating cytokine levels is more common in elderly people. We explored the improvement in nutritional status, especially in the level of insulin-like growth factor-1 (IGF-1) and its relationship with changes in circulating cytokine levels, after providing extra protein and energy content to community-dwelling older adults at risk of undernutrition. Methods Sixty nondiabetic subjects, aged ≥65 years and living independently in a community for elderly people, with a serum pre-albumin level ≤30 mg dL−1 and a body mass index

Stent protected Angioplasty of extracranial carotid artery stenosis using the dual-layered CGUARD stent is a novel treatment option. In this study we evaluate the feasibility and the safety of the CGUARD in symptomatic and asymptomatic patients in comparison to Casper-RX and Wallstent. This is a multi-center study of consecutive patients treated with the CGUARD, Casper-RX and Wallstent at two German high volume neurovascular centers between April 2017 and May 2018. Patient characteristics, neuroimaging data and angiographic outcome were retrospectively analyzed. The primary end points of the study were acute occlusion of the carotid stent and symptomatic intracerebral hemorrhage (sICH). Carotid artery stenting was performed in 76 patients; of those 26 (34%) were treated with the CGUARD, 25 (33%) with Casper-RX, and 25 (33%) with Wallstent. In 58/76 (76%) cases carotid artery stenosis was symptomatic with a median baseline National Institutes of Health Stroke Scale of 4. Angioplasty and stenting as part of a mechanical thrombectomy for acute ischemic stroke was performed in 25/76 (33%) patients. Baseline patient characteristics were similar between the treatment groups, except for a higher portion of scheduled cases in the Casper-RX group. There were no significant differences in the rate of acute in stent occlusions (CGUARD, 2/26 (8%); Casper-RX, 1/25(4%); Wallstent, 1/25 (4%)) and postinterventional sICH (1/26 (4%), 0/25(0%), 0/25 (0%)). Clinical outcome at discharge did not differ between groups. Treatment of carotid artery stenosis using CGUARD is feasible with a good safety profile comparable to that of Casper-RX and Wallstent.

Purpose: To investigate the effect of an early contrast-enhanced computed tomography (CECT) on clinical course and complications of acute pancreatitis (AP). Material and Methods: 58 patients with AP who had at least one CECT examination were analyzed retrospectively. Laboratory as well as clinical data, and results from the assessment of disease severity (CT severity index (CTSI) and its modified (MCTSI) version) were analyzed. The primary endpoint was the development of severe complications, defined as death, respiratory failure, acute renal failure, and the need for invasive interventions. Patients were divided into two groups: an early group (CECT within the first 48 h after the onset of symptoms, n = 32) and a late group (CECT > 48 h after the onset of symptoms, n = 26). Multivariate regression analysis was performed to identify risk factors for severe complications. Results: There were no statistically significant differences between both groups concerning baseline characteristics, CTSI, and MCTSI. Complications occurred more often in the early CECT group (p = 0.008). Multivariate logistic regression analysis identified an early CECT and a severe MCTSI as independent risk factors for the occurrence of severe complications (p = 0.02 and p = 0.002, respectively). Conclusion: CECT performed within the first 48 h after the onset of symptoms is associated with an unfavorable outcome in AP.

The number of patients with immunosuppression is rising worldwide. The spectrum of diseases and pathogens in these patients differs widely from that of immunocompetent patients due to frequent opportunistic infections. Symptoms are sometimes unspecific, and imaging plays a key role in the management of these patients. The lungs are a frequent site of infection in immunosuppressed patients. Chest X‑ray is the starting point for radiological diagnostics, but shows only limited sensitivity and specificity for infections with atypical pathogens. Thus, computed tomography (CT) is of great importance and allows a better distinction between viral, bacterial, or fungal infections, as well as other noninfectious diseases. Even with CT, however, is exact specification of the pathogen unfortunately not possible. CT is also the main diagnostic tool for assessment of the abdomen, particularly in patients presenting with acute abdomen or when sonographic findings are inconclusive. Moreover, CT allows diagnostic and therapeutic interventions such as percutaneous biopsies, or abscess and fluid drainage.

Background Because of its high rate of early recurrence and its poor prognosis, long-term survival after cholangiocarcinoma is rare; therefore, only limited information on patients surviving more than 5 years after surgical therapy is available. Case presentation We report the case of a 57-year-old white man who developed a distal bile duct carcinoma 9 years after curative surgical therapy of intrahepatic cholangiocarcinoma. He had undergone a right lobe hemihepatectomy 11 years ago. Nine years later, he was diagnosed with a distal bile duct carcinoma and a duodenopancreatectomy was performed. On histologic examination both carcinomas revealed a tubular and papillary growth pattern with cancer-free resection margins and for both carcinomas there were no signs of lymphatic infiltration or metastatic spreading. Targeted next-generation sequencing showed an identical activating mutation pattern in both carcinomas. Conclusions Late recurrence of cholangiocarcinoma, even anatomically distant to the primary, in long-time survivors is possible and could be caused by a distinct tumor biology. A better understanding of the individual tumor biology could help hepatologists as well as hepatobiliary and pancreatic surgeons in their daily treatment of these patients.

BACKGROUND: The success of health care provider counseling–based interventions to address vaccine hesitancy is not clear. In 2011, Washington State implemented Senate Bill 5005 (SB5005), requiring counseling and a signed form from a licensed health care provider to obtain an exemption. Evaluating the impact of a counseling intervention can provide important insight into population-level interventions that focus on interpersonal communication by a health care provider. METHODS: We used segmented regression and interaction and aggregation indices to assess the impact of SB5005 on immunization coverage and exemption rates in Washington State from school years 1997–1998 through 2013–2014. RESULTS: After SB5005 was implemented, there was a significant relative decrease of 40.2% (95% confidence interval: −43.6% to −36.6%) in exemption rates. This translates to a significant absolute reduction of 2.9 percentage points (95% confidence interval: −4.2% to −1.7%) in exemption rates. There were increases in vaccine coverage for all vaccines required for school entrance, with the exception of the hepatitis B vaccine. The probability that kindergarteners without exemptions would encounter kindergarteners with exemptions (interaction index) decreased, and the probability that kindergarteners with exemptions would encounter other such kindergarteners (aggregation index) also decreased after SB5005. Moreover, SB5005 was associated with a decline in geographic clustering of vaccine exemptors. CONCLUSIONS: States in the United States and jurisdictions in other countries should consider adding parental counseling by health care provider as a requirement for obtaining exemptions to vaccination requirements.

Purpose To assess the utility of donor corneoscleral rim cultures. Methods A retrospective review of the culture results of 774 corneoscleral rims that remained after trephination of corneas for transplantation into patients at our academic medical center between January 1992 and November 1997. Results Forty-one (5.3%) corneoscleral rim cultures yielded microorganisms, mostly coagulase-negative staphylococci. Two patients developed endophthalmitis (one with Staphylococcus aureus and one with Pseudomonas aeruginosa) within 3 months after transplantation; each had a negative corneoscleral rim culture and neither patient's infection was temporally related to the transplant procedure. Conclusions Preoperative donor corneoscleral rim cultures are unreliable predictors of endophthalmitis complicating corneal transplantation and, therefore, are not useful in the clinical management of patients having corneal transplants. Moreover, the discrepancy between the results of corneoscleral rim cultures and subsequent endophthalmitis renders them invalid as a quality assurance procedure. Instead, for patients with suspected endophthalmitis after corneal transplantation, we recommend that corneal surgeons select antimicrobial therapy based on current guidelines and the results of directed sampling. Furthermore, eye banks should prospectively track recipients who develop clinical endophthalmitis, immediately notify the corneal surgeon who transplanted the matched cornea of that used for the index case, and, in selected situations, attempt to identify a possible source of contamination.

Evaluation of complications, patient satisfaction and clinical benefit of port systems with authorization for high pressure injection of contrast agent during CT/MR examinations.Ultrasound-guided insertions of central venous port catheters were performed through the lateral subclavian vein at a university teaching hospital. The radiological information system (HIS/RIS) was used to evaluate technical success and complication rates. Assessment of patient satisfaction and clinical benefit was carried out by a questionnaire during a telephone call 6 months after implantation of the port system.A total of 195 port systems in 193 patients were implanted. The catheter remained in place for a mean duration of 169 days (overall 29,210 catheter days). The technical success rate was 99.5 % and the overall complication rate was 17.4 % (24/138; 0.82 per 1000 catheter days). Follow-up revealed 13 early port explantations (9 %). Most of the patients reported high satisfaction in general (satisfied/very satisfied: 94 %). 34/209 contrast-enhanced CT/MRT scans (16 %) were performed using the port for contrast media injection. There were no complications during or after administration of contrast agent via the port system.The Powerport system is a safe alternative for peripheral i. v. contrast media injection during CT/MR scans, but has been infrequently used. Most patients reported high overall satisfaction with the port system.

To evaluate the feasibility of retrieval of misplaced central venous catheters in the subclavian artery with a percutaneous closure device (AngioSeal).According to the radiologic information system of a university hospital, 7 patients (6 women, 1 child) underwent removal of a misplaced central venous catheter (4 × 7 F, 1 × 8 F, 2 × 13 F) in the subclavian artery between January 2008 and June 2012 with the 8 F percutaneous closure device AngioSeal. The body mass index (BMI) of 7 patients was available, 3 of whom were obese (BMI 2 × 35.7 and 1 × 33.0). Both 13 F catheters were removed in a balloon-supported manner as described elsewhere. The Broviak catheter of a 21-month-old boy was removed by surgical support with preparation of the catheter to its vessel entry. Success control was done by a transfemoral DSA in 5 of the 7 patients. 2 patients received clinical follow-up.In all cases the misplaced catheter could be removed successfully. In all 7 patients, there was no arterial bleeding after catheter removal. Complications were not observed.Removal of misplaced central venous catheters in the subclavian artery by the percutaneous closure device AngioSeal is safe. Percutaneous catheter removal should be regarded as the method of choice, even in obese patients.

Based on the quasi-2D scaling equation, a new threshold voltage model for short-channel junctionless cylindrical, surrounding-gate (JLCSG) MOSFETs is developed. The model explicitly shows how the device parameters of the silicon thickness, oxide thickness, drain bias, and channel length affect the threshold voltage behavior. The model can also be extendable to its counterpart of junction-based cylindrical, surrounding-gate (JBCSG) MOSFETs. The model is velidated by the 3D numerical simulator and can be easily used to explore the threshold voltage characteristics of junctionless cylindrical, surrounding-gate MOSFEs for its simple formula and computational efficiency.

Evaluation of the success and complication rates in ultrasound-guided central venous port implantations through the lateral subclavian vein.A total of 1537 subcutaneous central venous ports were implanted in 1532 patients. The catheter remained in place for a mean duration of 202 days (overall 309,464 catheter days). A retrospective analysis within the hospital and radiological information system (HIS/RIS) was performed to assess technical success and complication rates.The implantations of the central venous ports were performed by 21 radiologists (19 residents). The technical success rate was 99.0 % (1517/1537) and the overall complication rate was 8.5 % (130/1537; 0.42 per 1000 catheter days). Procedural and acute complications (24 h) occurred in 22 of 1532 patients (1.4 %). Follow-up revealed 45 port explantations ahead of time due to complications in the early (30 d) or late (31 d) post-interventional period (2.9 %; 0.15 per 1000 catheter days). Catheter-associated vein thrombosis was the most common complication (n = 60, 3.9 %, 0.19 per 1000 catheter days).Ultrasound-guided insertion of central venous port catheters through the lateral subclavian vein provides safe vascular access. Procedural complication rate is low with special regard to post-graduate training. The most common reasons for early port explantations were catheter-associated infections and vessel occlusions.

A RAMI (Reliability, Availability, Maintainability, Inspectability) analysis has been performed for the heating (& current drive) neutral beam (HNB) and diagnostic neutral beam (DNB) systems of the ITER device [1–3]. The objective of these analyses is to implement RAMI engineering requirements for design and testing to prepare a reliability‐centred plan for commissioning, operation, and maintenance of the system in the framework of technical risk control to support the overall ITER Project. These RAMI requirements will correspond to the RAMI targets for the ITER project and the compensating provisions to reach them as deduced from the necessary actions to decrease the risk level of the function failure modes. The RAMI analyses results have to match with the procurement plan of the systems.

In order to assess endogenous and colonic production of acetate, we have developed an assay for determining the isotopic enrichment of plasma acetate using gas chromatography/mass spectrometry (GC/MS). Acidified, deproteinized plasma (200 microliters) was extracted into ethyl ether, and the ether phase was then injected into a gas chromatograph/mass spectrometer fitted with a 30 m x 0.252 mm i.d. capillary column (temperature program 50-245 degrees C at 10 degrees C min-1). Using electron impact GC/MS and selected ion monitoring, peak areas of ions with m/z 60 and 61 (M + 1) were determined. Triplicate extractions of enriched plasma samples (mol.% excess 1.38-1.5%) resulted in a coefficient of variation of 1.6-5.9%. Unenriched plasma samples were found to have an enrichment close to theoretical natural abundance, and analysis of our (1-13C)acetate tracer (99 at.% excess) revealed an ion at m/z 61 and no ion at m/z 60. To verify accuracy, we conducted an in vivo isotope dilution study. In a 1-month-old piglet, fasted for 24 h, changing the rate of a 4 h infusion (mmol h-1) of (1-13C)acetate from 0.141 to 0.282 doubled the isotope enrichment (2.08 x) of the second plateau. The rate of appearance of acetate was 26.0 mumols kg-1 min-1, which is comparable to that reported in fasting sheep.

Wear debris generated from total joint arthroplasty may elicit a granulomatous and inflammatory response and has also been implicated in the development of osteolysis. Technical difficulty in retrieval and isolation of wear material from tissues has hindered the study of their physicochemical properties. The purpose of this study was to retrieve and analyze metallic wear debris from periprosthetic tissue obtained during revision arthroplasty. Tissue from six osteoarthritic patients was obtained during revision arthroplasty. The tissue was minced and then heated in a sodium dodecyl sulfate solution. Undigested tissue was incubated sequentially with papain and pepsin solutions. Metallic wear debris retrieved from the digestion procedure was analyzed by scanning electron microscopy. Wear fragments were seen as irregularly shaped flakes, splinters and polyhedral structures ranging from 1 to 100 microns in size. These structures appeared to be free from non-metallic surface-adherent material. Energy dispersion spectroscopy verified the presence of cobalt, chrome and molybdenum which comprised the implant alloy. Fatigue lines were observed on the surface suggesting brittle wear. Our technique for isolating metallic fragments facilitates the retrieval and preparation of wear debris for analysis of physicochemical properties and how wear debris interacts with cellular elements in surrounding tissue.

Summary form only given. Spatial and temporal variations of plasma density, temperature and potential are measured in a simulated Plasma Display Panel (PDP) cell by using a fast-scanning electric probe system. A PDP simulator was made 200 times bigger than the actual cell. Effect of collisionality on the probe analysis is discussed and changes of plasma parameters due to different gases (Ar, He, Xe) are shown. Thermalizations of electrons are analyzed by comparing the data of single probe with those of triple probe. Time dependent plasma properties are also measured at 5 points within one period (20 kHz) using a single probe with sub harmonic sweep frequency (200 Hz) of applied AC power supply and 100 kHz sampling rate.

Summary form only given. Low pressure hybrid (DC+RF) spraying system is developed and non-thermal properties are measured by electric (single+triple) probes and emission spectroscopy system. Since plasma density and electron temperature have been measured by assuming one-temperature isothermal electrons, which is only valid near the spray nozzle and axis, non-thermal electrons (or two-temperature electrons) are to be measured by a fast-scanning system installed with a single electric probe (SP) and a triple probe (TP). Data from SP and TP are compared to deduce the non-thermal properties. Ion (or excitation) temperature is to be measured under the assumption of local thermodynamic equilibrium (LTE) and non-LTE models. For the measurement of the emission intensity, combination of a 50cm-monochromator and movable optical fiber is develped.

In the last decade, adjuvant chemotherapy has led to significant improvement in survival for large bowel cancer patients. The association of 5-FU plus levamisole was the first described and demonstrated its efficacy in stage Dukes C (T1,2,3,4 N1 M0) completely-resected adenocarcinoma. Recently, chemotherapy with 5-FU and folinic acid was recommended on the basis of randomized trials. Advances in adjuvant chemotherapy may result in increasing 5-FU doses as described in metastatic colorectal carcinomas, and in use of new drugs such as oxaliplatin or raltitrexed, whose activity has been well-studied in Dukes D (M1) carcinomas. Immunotherapy, intraperitoneal and intraportal infusion of chemotherapy are promising approaches but still in evaluation. The main difficulty for the future is to define the best therapeutic regimen in order to reach the highest improvement in survival.