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Background: Accurate pharmacokinetic modelling in PET necessitates measurements of an input function, which ideally is acquired non-invasively from image data. For hepatic pharmacokinetic modelling two input functions need to be considered, to account for the blood supply from the hepatic artery and portal vein. Image-derived measurements at the portal vein are challenging due to its small size and image artifacts caused by respiratory motion. In this work we seek to demonstrate, using phantom experiments, how a dedicated PET/MR protocol can tackle these challenges and potentially provide input function measurements of the portal vein in a clinical setup. Methods: A custom 3D printed PET/MR phantom was constructed to mimic the liver and portal vein. PET/MR acquisitions were made with emulated respiratory motion. The PET/MR imaging protocol consisted of high-resolution anatomical MR imaging of the portal vein, followed by a PET acquisition in parallel to a dedicated motion-tracking MR sequence. Motion tracking and deformation information were extracted from PET data and subsequently used in PET reconstruction to produce dynamic series of motion-free PET images. Anatomical MR images were used post PET reconstruction for partial volume correction of the input function measurements. Results: Reconstruction of dynamic PET data with motion-compensation provided nearly motion-free series of PET frame data, suitable for image derived input function measurements of the portal vein. After partial volume correction, the individual input function measurements were within a 16.1% error range from the true activity in the portal vein compartment at the time of PET acquisition. Conclusion: The proposed protocol demonstrates clinically feasible PET/MR imaging of the liver for pharmacokinetic studies with accurate quantification of the portal vein input function, including correction for respiratory motion and partial volume effects. [ABSTRACT FROM AUTHOR]

Simple Summary: Various cancer therapies are often ineffective for advanced metastatic liver disease. While immunotherapy can be effective in some cases, it does not provide significant benefits for metastatic cancer in the liver. CBL0137 is an experimental drug that helps form a special type of DNA called Z-DNA, which may help boost the body's immune response against tumors. We investigated how CBL0137 affects metastatic liver tumor models from colon (CT26) and breast (4T1) cancers focusing on how it triggers immune responses. The results showed that CBL0137 hepatic arterial infusion (HAI) enhanced anti-tumor effects by depleting immune-suppressing cells while preserving effector T cells. Combining CBL0137 HAI with conventional immunotherapy improved survival in 4T1 tumors but not in CT26 tumors, highlighting the importance of targeting specific immune cell populations for effective treatment. Background: Surgery, chemotherapy, and radiation often have limited utility for advanced metastatic disease in the liver, and despite its promising activity in select cancers, PD-1 blockade therapy similarly has minimal benefit in this setting. Curaxin, CBL0137, is an experimental anti-cancer drug that disrupts the binding of DNA to histones, destabilizes chromatin, and induces Z-DNA formation which may stimulate anti-tumor immune responses. Methods: Murine cell lines of colon (CT26) and breast (4T1) cancer were interrogated for survival and CBL0137-associated DNA changes in vitro. Immunocompetent models of liver metastases followed by CBL0137 hepatic arterial infusion (HAI) were used to examine in vivo tumor cell DNA alterations, treatment responses, and the immune contexture associated with CBL0137, both alone and in combination with anti-PD-1 therapy. Results: CBL0137 induced immediate changes to favor tumor cell death in vitro and in vivo with an efficient tumor uptake via the HAI route. Toxicity to CBL0137 was minimal and anti-tumor treatment effects were more efficient with HAI compared to intravenous delivery. Immune effects were pronounced with CBL0137 HAI with concurrent depletion of a specific population of myeloid-derived suppressor cells and maintenance of effector T cell populations. Conclusions: Combination of CBL0137 HAI with PD-1 blockade improved survival in 4T1 tumors but not in CT26 tumors, and therapeutic efficacy relies on the finding of simultaneous and targeted depletion of myeloid-derived suppressor cells and skewing of T cell populations to produce synergy with PD-1 blockade therapy. [ABSTRACT FROM AUTHOR]

Introduction: Post liver transplantation (LT) patients endure high morbidity rate of multi-organ ischemic symptoms following reperfusion. We hypothesize that enhanced external counterpulsation (EECP) as a typical non-invasive assisted circulation procedure, which can efficiently inhibit the relative ischemic symptoms via the systemic improvement of hemodynamics. Case presentation: A 51-year-old male patient, 76 kg, 172 cm, received orthotopic LT surgery for viral hepatitis B induced acute-on-chronic liver failure hepatic failure. His medical records revealed ischemic symptoms in multi-organ at the time of hospital discharge, including headache, refractory insomnia, abdominal paralysis, and lower limb pain. The EECP treatment was introduced for assisted rehabilitation and to improve the postoperative quality of life. Doppler Ultrasound examination showed significant augmentation of blood flow volume in the carotid arteries, the hepatic artery, the portal vein and the femoral artery during EECP intervention. A standard 35-hour EECP treatment led to significant improvement in quality of life, e.g. sleep quality and walking ability. Conclusion: We report a case of multi-organ ischemic symptoms in a post LT patient. EECP treatment can significantly improve the quality of life via the systematic promotion of hemodynamics. [ABSTRACT FROM AUTHOR]

Purpose: To use preoperative MRI data to construct a nomogram to predict survival in patients who have undergone R0 resection for gallbladder cancer. Methods: The present retrospective study included 143 patients (M:F, 76:67; 67.15 years) with gallbladder cancer who underwent preoperative MRI and subsequent R0 resection between 2013 and 2021 at two tertiary institutions. Clinical and radiological features were analyzed using univariate and multivariate Cox regression analysis to identify independent prognostic factors. Based on the multivariate analysis, we developed an MRI-based nomogram for determining prognoses after curative resections of gallbladder cancer. We also obtained calibration curves for 1-,3-, and 5-year survival probabilities. Results: The multivariate model consisted of the following independent predictors of poor overall survival (OS), which were used for constructing the nomogram: age (years; hazard ratio [HR] = 1.04; 95% confidence interval [CI], 1.04–1.07; p = 0.033); tumor size (cm; HR = 1.40; 95% CI, 1.09–1.79; p = 0.008); bile duct invasion (HR = 3.54; 95% CI, 1.66–7.58; p = 0.001); regional lymph node metastasis (HR = 2.47; 95% CI, 1.10–5.57; p = 0.029); and hepatic artery invasion (HR = 2.66; 95% CI, 1.04–6.83; p = 0.042). The nomogram showed good probabilities of survival on the calibration curves, and the concordance index of the model for predicting overall survival (OS) was 0.779. Conclusion: Preoperative MRI findings could be used to determine the prognosis of gallbladder cancer, and the MRI-based nomogram accurately predicted OS in patients with gallbladder cancer who underwent curative resection. [ABSTRACT FROM AUTHOR]

Purpose: To provide detailed reports on radiation doses during transarterial chemoembolization (TACE) in the cone-beam computed tomography (CBCT) era and to identify the associated factors. Methods: This retrospective study included 385 consecutive patients who underwent initial conventional TACE for hepatocellular carcinoma (HCC) between January 2016 and December 2017. In most cases, CBCT was performed at the common hepatic artery or celiac axis to confirm the location of the tumor and the three-dimensional hepatic artery anatomy. Superselective TACE was performed for all technically feasible cases. Information on total dose area product (DAP), total cumulative air kerma (CAK), fluoroscopy time, and DAP and CAK of each digital subtraction angiography (DSA) and CBCT scan was recorded. Multiple linear regression analysis was performed to identify the factors associated with increased DAP during TACE. Results: The mean values of total DAP and CAK were 165.2 ± 81.2 (Gy·cm²) and 837.1 ± 571.0 (mGy), respectively. The mean fluoroscopy time was 19.1 ± 10.3 min. The mean DAP caused by fluoroscopy, DSA, and CBCT was 51.8 ± 43.9, 28.0 ± 24.1, and 83.9 ± 42.1 Gy·cm², respectively. Male sex, a high body mass index, largest tumor size > 3 cm, presence of aberrant right and left hepatic arteries, and superselective TACE were identified as independent predictors of increased total DAP during TACE. Conclusion: We were able to provide detailed reports on radiation doses during TACE and associated factors. [ABSTRACT FROM AUTHOR]

Background: The concept of failure to rescue (FTR) has been used to evaluate the quality of care in several surgical specialties but has not been well‐studied after living donor liver transplantation (LDLT) in children. Methods: This study retrospectively reviewed 500 pediatric LDLT performed at a single center between 1993 and 2022. The recipient outcomes were assessed by means of patient and graft survival rates, retransplantation rates, and arterial/portal/biliary complication rates. Graft and patient losses secondary to these complications were calculated regarding FTR for patients (FTRp) and grafts (FTRg). Results: Overall 1‐ and 5‐year patient survival rates were 94.5% and 92.1%, respectively, the corresponding figures for graft survival being 92.7% and 89.8%. One‐year hepatic artery complication rate was 3.6% (n = 18 cases), the respective rates for portal vein complications and biliary complications being 5.7% (n = 57) and 15.6% (n = 101). One‐year FTRp rates for hepatic artery thrombosis, portal vein thrombosis, anastomotic biliary stricture, and intrahepatic biliary stricture were 28.6%, 9.4%, 3.6%, and 0%, respectively. The corresponding FTRg rates being 21.4%, 6.3%, 0%, and 36.4%. Conclusion: Such novel analytical method may offer valuable insights for optimizing quality of care in pediatric LDLT. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effect of deep learning reconstruction (DLR) on vascular depiction, tumor enhancement, and image quality of computed tomography hepatic arteriography (CTHA) images acquired during transcatheter arterial chemoembolization (TACE). Methods: Institutional review board approval was obtained. Twenty-seven patients (18 men and 9 women, mean age, 75.7 years) who underwent CTHA immediately before TACE were enrolled. All images were reconstructed using three reconstruction algorithms: hybrid-iterative reconstruction (hybrid-IR), DLR with mild strength (DLR-M), and DLR with strong strength (DLR-S). Vascular depiction, tumor enhancement, feeder visualization, and image quality of CTHA were quantitatively and qualitatively assessed by two radiologists and compared between the three reconstruction algorithms. Results: The mean signal-to-noise ratios (SNR) of sub-segmental arteries and sub-sub-segmental arteries, and the contrast-to-noise ratio (CNR) of tumors, were significantly higher on DLR-S than on DLR-M and hybrid-IR (P < 0.001). The mean qualitative score for sharpness of sub-segmental and sub-sub-segmental arteries was significantly better on DLR-S than on DLR-M and hybrid-IR (P < 0.001). There was no significant difference in the feeder artery detection rate of automated feeder artery detection software among three reconstruction algorithms (P = 0.102). The contrast, continuity, and confidence level of feeder artery detection was significantly better on DLR-S than on DLR-M (P = 0.013, 0.005, and 0.001) and hybrid-IR (P < 0.001, P = 0.002, and P < 0.001). The weighted kappa values between two readers for qualitative scores of feeder artery visualization were 0.807–0.874. The mean qualitative scores for sharpness, granulation, and diagnostic acceptability of CTHA were better on DLR-S than on DLR-M and hybrid-IR (P < 0.001). Conclusions: DLR significantly improved the SNR of small hepatic arteries, the CNR of tumor, and feeder artery visualization on CTHA images. DLR-S seems to be better suited to routine CTHA in TACE than does hybrid-IR. [ABSTRACT FROM AUTHOR]

Summary Hepatic artery pseudoaneurysm (HAP) is a rare vascular complication following liver transplantation (LTx) with treatment choice frequently driven by institutional experience. Approximately, 10% of hepatic grafts are lost from this complication, requiring re‐transplantation and placing further demand on the already present organ shortage. Secondly, patients with HAP can present with catastrophic bleeding, with reported mortality of up to 78%. We aim to identify risk factors associated with HAP and assess the survival benefit of different treatment modalities used (endovascular and open surgical techniques). Early detection may facilitate semi‐elective management of this condition. A systematic search was performed in PubMed, Medline and Embase up to 1 October 2023. Case series with ≥5 patients focusing on adult patients who developed extrahepatic pseudoaneurysm following LTx were included. A total of 11 studies were pooled, comprising of 118 patients with survival data available in 61 patients. The most common presentation was haemorrhagic shock or luminal haemorrhage (75.5%). Bile leak was documented in 66.7% (28/42), 15.2% (18/118) associated foregut pathologies and 28.6% (14/49) of microbiology cultures grew a fungal organism. Flow preserving strategies (stenting, revascularization) trended towards better survival at 120 months compared to non‐flow preserving strategies (embolization, HAL); however, this was not statistically significant following log rank (Mantel–Cox) analysis (P 0.169). Any patient following LTx presenting with haemorrhagic shock or luminal bleeding needs HAP excluded urgently. HAP management is complex, requiring careful consideration of patient specific presentation, anatomic factors and associated pathologies. [ABSTRACT FROM AUTHOR]

Hydatid cysts near the porta hepatis present notable medical challenges due to their intricate positioning and potential influence on crucial structures within the liver and its vicinity. While relatively rare, their presence can lead to intricate medical scenarios because of their proximity to vital liver and bile duct structures, but their occurrence can present complex medical situations due to their proximity to critical structures in the liver and bile ducts. We present an unusual case of a 33-year-old male with no known comorbidities presented to the outpatient department of general surgery with pain, insidious in onset and gradually progressive, in the right hypochondrial region for the past 3 months, along with mild fever, reduced appetite, and weight loss of 3 kg. Managing hepatic cysts, especially when near the porta hepatis, poses significant diagnostic challenges. Imaging scans revealed multiple hypodense lesions suggestive of hepatic cysts, with the largest one measuring 5 cm × 8 cm in segment VI. Native post-contrast lesions were also observed in the right lower lobe. Although hepatic duct dilation was not observed, the presence of a cyst near the porta hepatis an atypical site for hydatid cyst, complicated potential PAIR procedures (puncture, aspirate, injection, re-aspirate), raising concerns about the risk of damaging vital structures like the hepatic artery or major bile duct. A multidisciplinary approach engaged interventional radiology to evaluate PAIRS feasibility. PAIRS was performed successfully, except for the cyst near the porta hepatis to avoid complications. Despite this, the patient continued to experience abdominal discomfort post-operation, although liver function tests improved in the postop period. This case underscores the uncommon occurrence of hydatid cysts near the porta hepatis and highlights the need for additional research to comprehend its prevalence and causes. Further investigation is crucial to enhance our understanding of the epidemiology and optimal management strategies involving PAIRS in such challenging cases. [ABSTRACT FROM AUTHOR]

Introduction: In uveal melanoma (UM) patients with hepatic metastases, hepatic artery infusion chemotherapy (HAIC) is a viable, palliative treatment option. To evaluate the impact of two histomorphological patterns (spindle cell vs. epithelioid) of liver metastases on median overall survival (mOS) in UM patients undergoing HAIC. Methods: A retrospective analysis with 60 UM patients (29 females, mean age: 61.6 ± 12.1 years) with hepatic metastases was performed. Histomorphological patterns in metastases were analysed and classified as either predominant spindle cell or epithelioid pattern. mOS between both patient groups was analysed using Kaplan–Meier curves and the log‐rank test. Results: In 73.3% (44/60) of the metastases, a predominant epithelioid pattern, in 21.7% (13/60) a predominant spindle cell pattern, and in 5% (3/60) other patterns were found. No significant differences between patients with an epithelioid (mOS: 14.2 months, 95% CI: 8.8–19.6) and a spindle cell pattern (mOS: 14.4 months, 95% CI: 4.3–24.5) were detected by the log‐rank test, χ2(2) = 0.22, P = 0.881. Conclusion: Histomorphological patterns of UM metastases do not seem to be a predictor for mOS in UM patients undergoing HAIC. [ABSTRACT FROM AUTHOR]

Background: The liver has a region called the hepatic hilum (HH) where structures enter and exit: anteriorly, the left and right hepatic ducts; posteriorly, the portal vein; and between these, the left and right hepatic arteries. The objective of this review is to know how variants in structures of the hepatic hilum are associated with clinical alterations of the liver. Methods: The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were researched until January 2024. The methodological quality was evaluated with an assurance tool for anatomical studies (AQUA). The pooled prevalence was estimated using a random effects model. Results: A total of six studies met the selection criteria established in this study for meta-analysis. The prevalence of hepatic hilus variants was 9% (CI = 5% to 13%), and the heterogeneity was 83%. The other studies were analyzed descriptively and with their respective clinical considerations in the presence of the variant, such as the high incidence of the Michels type III variant; among the portal vein variants, the type III variant of the Cheng classification stands out and in biliary anatomy, and the IIIa variant stands out according to the Choi classification. Conclusions: This review allowed us to know in detail the anatomical variants of HH; the structure with which the greatest care should be taken is the hepatic artery because of the probability of metastatic processes due to increased blood distribution in the hepatic lobules. Finally, we believe that new anatomical and clinical studies are needed to improve our knowledge of the relationship between HH variants and liver alterations or surgeries. [ABSTRACT FROM AUTHOR]

Insulin-producing pancreatic tumors are a common subtype of neuroendocrine tumor. Standard of care includes surgical resection of the pancreatic tumor and medical management with somatostatin analogs. For patients with metastatic disease, tumor control and hypoglycemic symptom relief can be achieved through surgical resection of the tumor, hepatic artery embolization, radiofrequency ablation, or radioembolization using radioactive isotopes as well as with systemic therapy such as somatostatin analogs and everolimus. We present the case of a 74-year-old male with metastatic insulin-producing pancreatic carcinoma. After a long history of successfully controlling his hypoglycemic episodes post-liver wedge resection, bland embolizations subsequently failed to maintain control of the frequency and severity of his hypoglycemic symptoms. Stereotactic body radiotherapy (SBRT) with protons was used to achieve symptomatic control and led to partial radiographic response with complete resolution of his hypoglycemic episodes. This case demonstrates the potential utility of proton SBRT in metastatic insulinomas. [ABSTRACT FROM AUTHOR]

Although anomalies of the celiac and/or superior mesenteric arteries are occasionally encountered during abdominal surgery, anomalous venous confluence is seldom reported during pancreatic surgery. Herein, we present a rare case of laparoscopic spleen‐preserving distal pancreatectomy (LSPDP) for the treatment of a solid pseudopapillary neoplasm in an asymptomatic 37‐year‐old male with an anomalous splenic vein (SpV) confluence. Computed tomography angiography (CTA) revealed an anomaly of the SpV, which coursed transversely through the superior border of the pancreas, over the celiac artery and into the portal vein, along the superior line of the common hepatic artery. We successfully performed an LSPDP without peripancreatic vessel injury by exposing the SpV and splenic artery through an approach from the superior position of the pancreas. Preoperative imaging, especially CTA, is crucial to ensuring a safe, successful laparoscopic pancreatectomy. [ABSTRACT FROM AUTHOR]

Introduction: The effectiveness of transarterial chemoembolization (TACE) in treating hepatocellular carcinoma (HCC) has been well established. The differential impacts of drug-eluting bead TACE (DEB-TACE) as opposed to conventional TACE (cTACE) on vascular changes, such as arterial-portal venous shunts (APSs), have been recognized. However, their subsequent effects on treatment outcomes have not been fully explored. This study aims to identify risk factors associated with the occurrence of APS in HCC patients treated with DEB-TACE and to evaluate its impact on patient survival. Methods: A retrospective analysis was conducted from January 2012 to December 2018 including 74 HCC patients receiving DEB-TACE as initial treatment and a 1:1 cTACE. Kaplan-Meier analysis estimated overall survival (OS) and progression-free survival (PFS). Logistic regression identified significant risk factors for APS occurrence after DEB-TACE. Results: APS incidence was significantly higher after DEB-TACE than cTACE (46.0% vs. 16.2%, p < 0.001). There was no significant difference in median OS between APS and non-APS groups after DEB-TACE: 50 months (24.6–75.4) versus 26.9 months (19.5–43.2), p = 0.111; median PFS was 15.6 months (4.1–27.1) and 9.5 months (6.8–12.1) for the two groups, respectively, p = 0.065. Risk factors for APS occurrence after DEB-TACE were more than two feeding arteries (OR: 7.25, 95% CI: 1.82–28.95, p = 0.005) and non-selective embolization (OR: 8.02, 95% CI: 2.30–27.95, p = 0.001). Conclusion: APS occurrence was higher in DEB-TACE-treated HCC patients, but it did not significantly affect OS and PFS. More than two feeding arteries and non-selective embolization were significant risk factors for APS occurrence after DEB-TACE. [ABSTRACT FROM AUTHOR]

Objective: Portal hypertension leads to hepatic artery dilatation and a higher risk of bleeding. We tried to identify the bleeding risk after gastroesophageal varices (GOV) treatment using hepatic artery diameter of contrast-enhanced CT. Methods: Retrospective retrieval of 258 patients with cirrhosis who underwent contrast-enhanced CT from January 2022 to May 2023 and endoscopy within one month thereafter at Hainan Affiliated Hospital of Hainan Medical University. Cirrhotic patients before GOV treatment were used as the test cohort (n = 199), and cirrhotic patients after GOV treatment were used as the validation cohort (n = 59). The grading and bleeding risk was classified according to the endoscopic findings. Arterial-phase images of contrast-enhanced CT were used for coronal reconstruction, and the midpoint diameter of the hepatic artery was measured on coronal images. The optimal cutoff value for identifying bleeding risk was analyzed and calculated in the test cohort, and its diagnostic performance was evaluated in the validation cohort. Results: In the test cohort, hepatic artery diameters were significantly higher in high-risk GOV than in low-risk GOV [4.69 (4.31, 5.56) vs. 3.10 (2.59, 3.77), P < 0.001]. With a hepatic artery diameter cutoff value of 4.06 mm, the optimal area under the operating characteristic curve was 0.940 (95% confidence interval: 0.908–0.972), with a sensitivity of 0.887, a specificity of 0.892, a positive predictive value of 0.904, and a negative predictive value of 0.874 for identifying bleeding risk in the test cohort, while in the validation cohort, the sensitivity was 0.885, specificity was 0.939, positive predictive value was 0.920, and negative predictive value was 0.912. Conclusion: Hepatic artery diameter has high diagnostic performance in identifying bleeding risk after GOV treatment. [ABSTRACT FROM AUTHOR]

aiming Zhang,4 Honglei Hu,5 Bicheng Zeng,6 Xiang Zheng71Vascular Interventional Surgery, Huazhong University of Science and Technology Union Shenzhen Hospital(Shenzhen Nanshan People's Hospital), Shenzhen, Guangdong, 518000, People's Republic of China; 2Department of Tumor and Vascellum Intervention, DongGuan Tungwah Hospital, DongGuan, Guangdong, 523000, People's Republic of China; 3Department of Interventional Therapy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, 510000, People's Republic of China; 4Department of Radiology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, 510080, People's Republic of China; 5Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, People's Republic of China; 6Hepatobiliary Surgery, The Sixth Affiliated Hospital of Jinan University, Dongguan, Guangdong, 523000, People's Republic of China; 7Department of Interventional Therapy, Zhuhai People's Hospital(Zhuhai Clinical Medical College of Jinan University), Zhuhai, Guangdong, 519000, People's Republic of China *These authors contributed equally to this work Correspondence: Xiang Zheng, Department of Interventional Therapy,Zhuhai People's Hospital(Zhuhai Clinical Medical College of Jinan University), No. 79 Kangning Road, Zhuhai, 519000, People's Republic of China, Email [email protected] Aim: To investigate the efficacy and safety of HAIC combined with programmed cell death protein-1 (PD1) inhibitors in MVI-positive advanced hepatocellular carcinoma(HCC). Methods: From September 2017 to May 2019, we retrospectively collected the clinical data from three medical centers in China pertaining to patients diagnosed with BCLC C stage HCC with MVI and receiving treatment with a combination of HAIC and PD-1 inhibitors treatment or HAIC alone, and we compared the efficacy of HAIC combined with PD-1 inhibitors and HAIC monotherapy. Propensity score matching(PSM) was utilized to adjust for baseline differences between groups. Survival outcomes and tumor response rate were used to assess survival benefits, while the incidence of adverse events was used to evaluate safety. Results: After screening for eligibility, 489 patients diagnosed with HCC and concomitant MVI were enrolled. Of these, 173 patients received treatment combining HAIC with PD-1 inhibitors, while 316 patients underwent HAIC monotherapy. After PSM adjustment, the combination therapy group demonstrate superior survival outcomes. Median overall survival(OS) and progression free survival(PFS) were 31.8 months and 10.8 months, respectively, significantly higher than those in the monotherapy group (OS: 10.0 months; PFS: 6.1 months; both P< 0.0001). Moreover, ORR and DCR remained significantly elevated in the combination therapy group (ORR: 44.3% vs 20.4%, P< 0.0001; DCR: 89.8% vs 82.0%, P=0.041). Safety profiles indicated no significant differences in adverse event rates between the two treatment groups, encompassing both overall and grade-specific assessments. Conclusion: Compared to HAIC alone, the combination of HAIC with PD-1 inhibitors represents a more promising and effective approach for patients with HCC complicated by macrovascular invasion. [ABSTRACT FROM AUTHOR]

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Background: The first-line treatment for advanced hepatocellular carcinoma has evolved significantly. This study aimed to identify the most beneficial regimen. Methods: A systematic search was conducted from July 2012 to August 2024 across the following four databases: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. This search focused on phase III prospective randomized controlled trials that compared first-line treatment for advanced hepatocellular carcinoma. Results: Seventeen studies involving 10322 patients were included in this network meta-analysis. Of the studies we included, twelve studies were global multicenter clinical studies, four were initiated in China, and one was initiated in Korea. The results of our statistical analysis suggest that Hepatic artery infusion chemotherapy with oxaliplatin plus fluorouracil (HAIC-FO) demonstrated significant overall survival (OS) benefits compared with most treatments, including various immune checkpoint inhibitors (ICIs) and anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGF-TKIs). In terms of OS, HAIC had shown similar efficacy with sorafenib plus FOLFOX (HR, 0.88; 95% CI: 0.37-2.09) and transcatheter arterial chemoembolization (TACE) combined with lenvatinib (HR, 0.69; 95% CI: 0.30-1.56). Notably, immune-related treatments, such as ICIs combined with anti-VEGF therapies, also showed improved OS compared with anti-VEGF-TKIs alone. In terms of progression-free survival (PFS), HAIC-FO outperformed anti-VEGF-TKI monotherapy, ICI monotherapy, and several ICI combinations. However, it was not superior to lenvatinib plus TACE or lenvatinib plus pembrolizumab. Based on the Surface Under the Cumulative Ranking Curve (SUCRA) values, HAIC-FO was ranked the most effective in terms of OS (SUCRA = 0.961) and objective response rate (ORR) (SUCRA = 0.971). The results of the subgroup analysis suggested that HAIC-FO achieved the best OS benefit in the macrovascular invasion (MVI) and extrahepatic spread (EHS) subgroup (SUCRA = 0.99) and that tremelimumab combined with durvalumab achieved the best OS benefit in the Asian subgroup (SUCRA = 0.88). Conclusion: This systematic review and network meta-analysis suggest that HAIC-based therapies may become a potential first-line treatment option for advanced HCC, especially for patients in Mainland China with MVI and EHS. Additionally, immune-related treatments may be more suitable for Asian populations. [ABSTRACT FROM AUTHOR]

Background: Tri-combination therapy based on hepatic arterial infusion chemotherapy (HAIC) of infusion fluorouracil, leucovorin, and oxaliplatin (FOLFOX-HAIC) plus immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) for the locally advanced hepatocellular carcinoma (HCC) patients have been proven effective. However, whether it was best for these HCC patients to start with the most potent therapeutic pattern was still under debate. This retrospective study evaluated the efficacy and safety of FOLFOX-HAIC combined with systemic therapies in the patterns of sequential and concurrent schedules. Methods: This real-world study included 117 unresectable HCC patients who initially received either FOLFOX-HAIC monotherapy (HAIC group, n = 44) or concurrent ICIs and TKIs (ConHAIC group, n = 73) from March 2020 and June 2022, during the period of FOLFOX-HAIC monotherapy in HAIC group, patients in the HAIC group (n = 30) experienced progressive disease (PD) would have their treatment pattern converted from the FOLFOX-HAIC monotherapy to the combination of FOLFOX-HAIC plus ICIs and TKIs sequentially (SeqHAIC group). The progression-free survival (PFS) and overall survival (OS), as primary outcomes, were compared between patients in the SeqHAIC and ConHAIC groups. Results: The median follow-up time of the SeqHAIC group was 24.92 months (95% CI, 12.74–37.09 months) and of the ConHAIC group was 17.87 months (95% CI, 16.85–18.89 months) and no significant difference was observed in both PFS (HR, 1.572; 95% CI, 0.848–2.916; p = 0.151) and OS (HR, 1.212; 95% CI, 0.574–2.561; p = 0.614) between the SeqHAIC and the ConHAIC groups. As for the tumor responses, there was no significant difference between the two groups regarding tumor responses, overall response rates (p = 0.658) and disease control rates (p = 0.641) were 50.0%, 45.2%, and 83.3%, 89.0% for the SeqHAIC and the ConHAIC groups, respectively. Conclusion: Our study revealed that sequential systemic ICIs and TKIs in combination with FOLFOX-HAIC provides similar long-term prognosis and better tolerability compared to concurrent therapy for locally advanced HCC patients. Prospective studies with a larger sample size and longer follow-up are required to validate these findings. [ABSTRACT FROM AUTHOR]

Objective: To prepare multifunctional chemoembolization microspheres featuring Near-Infrared II (NIR-II) fluorescence imaging capabilities, and to evaluate their effectiveness in NIR-II fluorescence-guided surgery for Hepatocellular Carcinoma (HCC). Methods: NaGdF4:Nd@NaGdF, nanoparticles (Re NPs) and polylactic-co-glycolic acid (PLGA)-based microspheres.were pre- pared. The morphology and fluorescence properties of Re NPs were analyzed using Transmission Electron Microscopy (TEM) and fluorescence spectrometer. The morphology and elemental composition of PLGA-based microspheres were characterized by Optical Microscopy, Scanning Electron Microscopy (SEM), and Energy Dispersive Spectroscopy (EDS). The loading capacity and release profile of Doxorubicin (DOX) in PLGA microspheres were determined using UV spectrophotometry. Biocompatibility of the PLGA microspheres was evaluated through Cell Counting Kit-8 (CCK-8) and hemolysis assays. The imaging effectiveness and fluorescence stability of PLGA@Re-DOX microspheres were evaluated using a NIR-II imaging system. PLGA@Re-DOX microspheres were delivered to hepatic artery of rats for in-situ tumor imaging. Results: Re NPs were characterized by good monodispersed and uniform spherical structure, with an average particle size of 9.3± 0.4 nm, displaying excellent NIR-II fluorescence imaging capabilities. PLGA and PLGA@Re-DOX microspheres were noted for their high uniformity with diameters of 294± 7 µm and 288± 13 µm, respectively. Good biocompatibility was observed in the PLGA microspheres, as no significant statistical differences in cell viability and hemolysis rates were found compared to the control group (P>0.05). Additionally, a slow drug release was facilitated by a DOX encapsulation rate of up to 2.5%. The PLGA @Re-DOX microspheres demonstrated effective intrahepatic and extrahepatic NIR-II fluorescence imaging capabilities and excellent fluorescence stability, clearly delineating tumor margins post-delivery via hepatic artery. Conclusion: The synthesized PLGA@Re-DOX microspheres are promising for application in NIR-II fluorescence imaging and fluorescence-guided surgery of HCC. [ABSTRACT FROM AUTHOR]

Background: The triple combination of programmed cell death protein-1 (PD-1) inhibitors plus anti-angiogenesis tyrosine kinase inhibitors (TKIs) with or without transarterial chemoembolization (TACE) or hepatic arterial infusion chemotherapy (HAIC) enhance the effect of treatment for unresectable hepatocellular carcinoma (uHCC). The present study compared the efficacy and safety of PD-1 plus TKI with or without transarterial chemo(embolization) for uHCC. Methods: The meta-analysis was conducted using data acquired from PubMed, EMBASE, the Cochrane Library, Ovid, Web of Science, and Clinical Trials.gov from the inception date to December 2023. All clinical outcomes of interest included overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and adverse events (AEs). The hazard ratio (HR) and risk ratio (RR) with 95% confidence intervals (CIs) were used to measure the pooled effect. In addition, subgroup analysis was conducted to determine the specific patient population that benefited. Results: The OS (HR = 0.47; 95% CI: 0.39-0.56, P < 0.05), PFS (HR = 0.52; 95% CI: 0.45-0.60, P<0.05), and ORR (RR = 1.94; 95% CI: 1.60-2.35, P < 0.05) were significantly better in TACE/HAIC+TKI+PD-1(TACE/HAIC TP) group than TKI+PD-1 (TP) group. The incidence of AEs was acceptable. Conclusion: The triple therapy of TACE/HAIC TP had better efficacy for uHCC than TP, with acceptable security. [ABSTRACT FROM AUTHOR]

Anticipating a wide range of morphological variations of arterial anatomy of foregut derivatives beyond the classical pattern, a precise understanding is pertinent to preoperative diagnosis, operative procedure and to avoid potentially devastating post-operative outcome during various traumatic and non-traumatic vascular insult of foregut. The study aimed to revisit the morphological details and update unusual configurations of arteries of foregut to establish clinico-anatomical correlations. This study described the detailed branching pattern of coeliac trunk (CT) as principal artery of foregut with source & course of hepatic, gastric, duodenal and pancreatic branches in 58 cadaveric dissections. Based on morphology, different types and subtypes were made. The descriptions were explained using figures and pertinent tables. Among classical branches of CT, splenic artery was found as most stable whereas other two branches were found to be most variable with missing common hepatic artery in 11 cases. In addition to classical trifurcation (65.52%), different types of bifurcation (12.07%) and tetrafurcations (22.41%) of CT were observed. Regarding variations of hepatic arteries (27.59%), both non-classical origin and accessory hepatic branches were found. In case of gastric branches, more variant origins were seen with right gastric (50%) as compared to left gastric artery (34.48%). Other morphological variations included non-classical origin of gastro-duodenal artery (18.96%) along with presence of accessory pancreatic (17.13%) and duodenal arteries (6.38%). Awareness of anatomical variations regarding circulatory dynamics of foregut is worth knowing in order to facilitate successful planning of surgery involving upper abdominal organs with least complications. [ABSTRACT FROM AUTHOR]

Celiac trunk and superior mesenteric artery (SMA) are the main blood supply to the liver and pancreas. The data of anatomical variations in these arteries or their branches are very important clinically and surgically. The aim of this study was to describe the different variants in these arteries through the examination of the angiographs of a large series of Egyptian individuals. This research involved 389 selective angiographies to celiac artery, its branches, and the SMA. Anatomy of the target arteries of people who experienced visceral angiograph was reviewed and the data were recorded. From the total available angiograms in this work, 286 patients (73.52%) had the standard anatomy of celiac trunk and superior mesenteric arteries, and 103 patients (26.47%) had a single or multiple vessel variation. The inferior phrenic artery originates from celiac trunk in 2.05% of patients, while quadrifurcation of the celiac trunk was noticed in only 0.51% of patients. Absence of celiac trunk is also found in 0.51% of patients. Left gastric artery showed an abnormal origin from the splenic artery in 0.51% of patients. Quadrifurcation of common hepatic artery was also noticed. Variant anatomy of the left hepatic artery (LHA) was seen in 9.51% of patients, while variations of the right hepatic artery (RHA) were 14.13%. With the different origin of hepatic arteries, the gastroduodenal artery arose either from the LHA (2.82%), RHA (2.31%) or even from the celiac trunk (1.79%). [ABSTRACT FROM AUTHOR]

• Rehospitalizations are among the significant factors that increase health care expenditures and costs. • In patients readmitted after living donor liver transplantation, biliary complications are the most common cause of both pre-discharge and post-discharge rehospitalization. • Management of biliary complications with optimal treatment planning will reduce readmission rates and make important contributions to reduce hospital costs. Complications and comorbidities that may develop after living donor liver transplantation may necessitate rehospitalization after discharge. We aimed to investigate the demographic and clinical factors affecting rehospitalization after discharge. Two hundred seventy patients who underwent living-donor liver transplantation (LDLT) for end-stage liver cirrhosis were included in the study. Patients were divided into two groups as readmission group and others for statistical analysis. Age, gender, body mass index (BMI), model for end-stage liver disease (MELD), Child scores, etiology, blood product transfusion, anhepatic phase, cold ischemia time, operation time, graft-to-recipient weight ratio (GRWR), the type of recipient hepatic artery and hepatic vein utilized in the anastomoses, presence of liver segment 5, segment 8 and inferior accessory hepatic vein, presence of thrombosed, single or reconstructed portal vein, number of bile ducts, use of right, left/left lateral segment graft, postoperative intensive care unit and total hospitalization durations, surgical complications such as leakage/stricture, postoperative portal vein thrombosis, postoperative hepatic vein thrombosis, primary graft dysfunction, intra-abdominal hemorrhage, and postoperative early reoperation were statistically analyzed for readmission. In addition, patients with rehospitalization and others were statistically compared in terms of mortality and survival. There was no statistical difference among etiologic factors, demographic findings, decompensation findings, comorbidities, perioperative findings, hospital durations, mortality, and survival (P >.05). Only patients with bile leakage/stricture had a statistically higher rehospitalization rate (P =.000). Biliary complications are the most frequent cause of hospital rehospitalization following living donor liver transplantation. [ABSTRACT FROM AUTHOR]

• The use of operating microscopes may contribute to decreasing risk of hepatic artery thrombosis in pediatric liver transplantation. • This may translate to lower risks of early graft loss and mortality. • Adoption of microsurgical principles in general may have contributed to the improved outcomes in institutions that utilize surgical loupes. To review the impact of the operating microscope (OM) for reconstruction of the hepatic artery (HA) by comparing the outcomes with standard loupe reconstruction (SL) in pediatric liver transplantation (LT). Studies comparing the application of OM and SL for the reconstruction of the HA in primary pediatric LT were included from a systematic search of MEDLINE, Cochrane Library and EMBASE from inception to June 2022. Re-transplantation, dual grafts and auxiliary transplants were excluded. Primary outcome was the rate of HA thrombosis (HAT). Secondary outcomes were graft loss and mortality. There were 1261 liver recipients from 9 included studies published until June 2022. There were 484 patients in the OM group and 777 patients in the SL group. HAT incidence with OM was significantly lower with OR = 0.18 (95% CI: 0.07-0.48). The 1-year graft survival was significantly better in the OM group with OR = 2.77 (95% CI: 1.13-6.80). 1-year overall mortality was also significantly lower with OM with OR = 0.39 (0.18-0.86). The use of OM did not significantly impact the incidence of HAT in the living donor liver transplant subgroup. Differences in time for hepatic HA reconstruction, total operating time and length of hospital stay did not reach statistical significance. The use of OM has reduced the risk of HAT, graft loss and mortality in pediatric liver transplantation. Adoption of microsurgical principles in general may have contributed to the improved outcomes with SL reconstruction of HA in pediatric LT. [ABSTRACT FROM AUTHOR]

The aim of this study was to observe the recovery of liver function in patients with early allograft dysfunction (EAD) at one month postoperatively and explore whether early postoperative ultrasonic hemodynamic parameters can predict this outcome. Patients with EAD postoperatively, who underwent orthotopic liver transplantation (OLT) in our hospital from December 2012 to June 2021, were retrospectively collected. Based on the recovery of liver function within one month, patients were divided into two groups: the recovery group (FR-1M) and the non-recovery group (Non-FR-1M). Ultrasonic hemodynamic parameters within the first seven days postoperatively were compared between the two groups. Among the 254 EAD patients included in this study, 158 (62%) patients recovered their liver function within one month. Of the 96 (38%) patients who did not recover, The RI of the non-FR-1M group was significantly lower than that of the FR-1M group on postoperative day 6 (POD6) and POD7. In the high resistance interval (RI all > 0.7), Group FR-1M represents a significant proportion (29/3, ratio 12/1), while in the low resistance interval (RI < 0.5 at least once), Group non-FR-1M accounts for a relatively high proportion (12/27, ratio 5/11). In the middle resistance interval (more than 1 time ≤ 0.7 and all ≥ 0.5), the proportions of the two groups are balanced (85/88, ratio 1/1). Liver function typically recovers within 1 month in most patients with EAD. The high resistance state of the hepatic artery in the early postoperative period is illustrative an important role in its recovery. Low-resistance state is most unfavorable for the recovery of liver function. [ABSTRACT FROM AUTHOR]

Background: Pediatric liver transplantation is a very resource‐intensive therapy. This study aimed to identify the changes made between two epochs of management and analyze their influence on length of stay (LOS). Methods: Data from a single center were obtained from the liver transplant and Pediatric Intensive Care Unit (PICU) databases for 336 transplants (282 children) performed between 2000 and 2021. Transplants were analyzed in two epochs, before and after July 2012, representing a change in postoperative anticoagulation management. Differences in graft recipient demographics and perioperative management factors were compared between epochs. Multivariate regression was performed to identify the complications that correlated most strongly with hospital LOS. Results: There was a difference in hospital LOS between Epoch 1 (Median = 31.7 days) and Epoch 2 (Median = 26.3 days) (p < 0.001), but not in PICU LOS (E1 Median = 7.3 days, E2 Median = 7.4 days; p = 0.792). Epoch 2 saw increased use of split grafts (60.6% of total), decreased pediatric end‐stage liver disease (PELD) score at transplant (Average = 16.7; p < 0.001), decreased invasive ventilation time (Average = 4.48 days; p < 0.001), and decreased hepatic artery thrombosis (HAT) rates (E1 = 14.4%, E2 = 4.3%; p < 0.001) without an associated increase in bleeding rates. Conclusions: Hospital LOS has reduced in Epoch 2 due to refinements in intraoperative and postoperative management. There is increased emphasis on early extubation and increased use of noninvasive ventilatory techniques in Epoch 2. Split grafts have effectively expanded our graft donor pool and reduced transplant waitlist times. [ABSTRACT FROM AUTHOR]

Background: Although the outcomes of living donor liver transplantation (LDLT) for pediatric acute liver failure (PALF) have improved, patient survival remains lower than in patients with chronic liver disease. We investigated whether the poor outcomes of LDLT for PALF persisted in the contemporary transplant era. Methods: We analyzed 193 patients who underwent LDLT between December 2000 and December 2020. The outcomes of patients managed in 2000–2010 (era 1) and 2011–2020 (era 2) were compared. Results: The median age at the time of LDLT was 1.2 years both eras. An unknown etiology was the major cause in both groups. Patients in era 1 were more likely to have surgical complications, including hepatic artery and biliary complications (p = 0.001 and p = 0.013, respectively). The era had no impact on the infection rate after LDLT (cytomegalovirus, Epstein–Barr virus, and sepsis). The mortality rates of patients and grafts in era one were significantly higher (p = 0.03 and p = 0.047, respectively). The 1‐ and 5‐year survival rates were 76.4% and 70.9%, respectively, in era 1, while they were 88.3% and 81.9% in era 2 (p = 0.042). Rejection was the most common cause of graft loss in both groups. In the multivariate analysis, sepsis during the 30 days after LDLT was independently associated with graft loss (p = 0.002). Conclusions: The survival of patients with PALF has improved in the contemporary transplant era. The early detection and proper management of rejection in patients, while being cautious of sepsis, should be recommended to improve outcomes further. [ABSTRACT FROM AUTHOR]

Purpose: Atezolizumab/bevacizumab (atezo-bev) is the first-line chemotherapy for patients with unresectable hepatocellular carcinoma (HCC). However, hepatic artery infusion chemotherapy (HAIC) can be used as an alternative. Our aim was to compare the prognosis of HAIC treatment between newly diagnosed patients and patients treated after failure of atezo-bev. Methods: We retrospectively assessed 73 patients with HCC treated with HAIC between January 2022 and September 2023. Fifty-seven patients were treated with HAIC at initial diagnosis, while 16 were treated with HAIC after first-line atezo-bev combination chemotherapy. We evaluated tumor responses, such as overall survival (OS), progression-free survival (PFS), and objective response rate (ORR). Results: No significant difference was observed in either OS or PFS between patients with HCC treated with HAIC at the initial diagnosis and those treated after atezo-bev treatment failure. However, the ORR of the initial HAIC group was 19.6% and that of the HAIC group after atezo-bev therapy failure was 43.6%, which was a statistically significantly difference. Conclusion: Although no significant difference was observed for OS and PFS, the ORR of patients in the HAIC group after the failure of atezo-bev therapy was superior to that of newly diagnosed patients. HAIC may prolong survival in patients with HCC after atezo-bev treatment failure. [ABSTRACT FROM AUTHOR]

Purpose: To compare the inter-reader agreement of pancreatic adenocarcinoma resectability assessment at pancreatic protocol photon-counting CT (PCCT) with conventional energy-integrating detector CT (EID-CT). Methods: A retrospective single institution database search identified all contrast-enhanced pancreatic mass protocol abdominal CT performed at an outpatient facility with both a PCCT and EID-CT from 4/11/2022 to 10/30/2022. Patients without pancreatic adenocarcinoma were excluded. Four fellowship-trained abdominal radiologists, blinded to CT type, independently assessed vascular tumor involvement (uninvolved, abuts ≤ 180°, encases > 180°; celiac, superior mesenteric artery (SMA), common hepatic artery (CHA), superior mesenteric vein (SMV), main portal vein), the presence/absence of metastases, overall tumor resectability (resectable, borderline resectable, locally advanced, metastatic), and diagnostic confidence. Fleiss's kappa was used to calculate inter-reader agreement. CTDIvol was recorded. Radiation dose metrics were compared with a two-sample t-test. A p <.05 indicated statistical significance. Results: 145 patients (71 men, mean[SD] age: 66[9] years) were included. There was substantial inter-reader agreement, for celiac artery, SMA, and SMV involvement at PCCT (kappa = 0.61–0.69) versus moderate agreement at EID-CT (kappa = 0.56–0.59). CHA had substantial inter-reader agreement at both PCCT (kappa = 0.67) and EIDCT (kappa = 0.70). For metastasis identification, radiologists had substantial inter-reader agreement at PCCT (kappa = 0.78) versus moderate agreement at EID-CT (kappa = 0.56). CTDIvol for PCCT and EID-CT were 16.9[7.4]mGy and 29.8[26.6]mGy, respectively (p <.001). Conclusion: There was substantial inter-reader agreement for involvement of 4/5 major peripancreatic vessels (celiac artery, SMA, CHA, and SMV) at PCCT compared with 2/5 for EID-CT. PCCT also afforded substantial inter-reader agreement for metastasis detection versus moderate agreement at EID-CT with statistically significant radiation dose reduction. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the ability of 50-keV virtual monoenergetic images (VMI) to depict abdominal arteries in abdominal CT angiography (CTA) compared with 70-keV VMI with photon-counting detector CT (PCD-CT). Methods: Fifty consecutive patients who underwent multiphase abdominal scans between March and April 2023 were included. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were quantitatively assessed for the abdominal aorta (AA), celiac artery (CeA), superior mesenteric artery (SMA), renal artery (RA), and right hepatic artery (RHA) at both 50- and 70-keV VMI. In addition, 3D images from CTA were analyzed to measure arterial lengths and evaluate the visualization of distal branches. Results: Significantly higher SNR and CNR were observed at 50-keV compared to 70-keV VMI for all arteries: AA (36.54 and 48.28 vs. 25.70 and 28.46), CeA (22.39 and 48.38 vs. 19.09 and 29.15), SMA (23.34 and 49.34 vs. 19.67 and 29.71), RA (22.88 and 48.84 vs. 20.15 and 29.41), and RHA (14.38 and 44.41 vs. 13.45 and 27.18), all p < 0.05. Arterial lengths were also significantly longer at 50-keV: RHA (192.6 vs. 180.3 mm), SMA (230.9 vs. 216.5 mm), and RA (95.9 vs. 92.0 mm), all p < 0.001. Conclusion: In abdominal CTA with PCD-CT, 50-keV VMI demonstrated superior quantitative image quality compared to 70-keV VMI. In addition, 50-keV VMI 3D CTA allowed better visualization of abdominal artery branches, highlighting its potential clinical advantage for improved imaging and detailed assessment of abdominal arteries. [ABSTRACT FROM AUTHOR]

Introduction: Intrahepatic cholangiocarcinoma (ICC) is the 2nd most common primary liver malignancy. For nonsurgical candidates, the primary treatment option is systemic chemotherapy, which can be combined with locoregional therapies to enhance local control. Common intra-arterial locoregional therapies include transarterial hepatic embolization, conventional transarterial chemoembolization, drug-eluting bead transarterial chemoembolization, transarterial radioembolization with Yttrium-90 microspheres, and hepatic artery infusion. This article aims to review the latest literature on intra-arterial locoregional therapies for treating ICC. Areas covered: A literature search was conducted on PubMed using keywords: intrahepatic cholangiocarcinoma, intra-arterial locoregional therapy, embolization, chemoembolization, radioembolization, hepatic artery infusion, and immunotherapy. Articles from 2008 to 2024 were reviewed. Survival data from retrospective and prospective studies, meta-analyses, and clinical trials were evaluated. Expert opinion: Although no level I evidence supports the superiority of any specific intra-arterial therapy, there has been a shift toward favoring radioembolization. In our expert opinion, radioembolization may offer superior outcomes when performed by skilled operators with meticulous planning and personalized dosimetry, particularly for radiation segmentectomy or treating lobar/bilobar disease in appropriate candidates. [ABSTRACT FROM AUTHOR]

Spontaneous celiac artery dissection is uncommon. Abdominal pain is a common clinical presentation. Conservative medical treatments, endovascular interventions, and open surgery are used to treat spontaneous celiac artery dissection. A 49-year-old male patient visited our hospital, with back and subxiphoid pain that had persisted for 11 hours. He has been smoking 40 cigarettes a day for 20 years. The blood pressure was 180/100mmHg. Aortic computed tomography angiography (CTA) images revealed dissection of the celiac artery, common hepatic artery, left hepatic artery, right hepatic artery, and splenic artery. Urapidil hydrochloride and isosorbide dinitrate were administered to lower the blood pressure to approximately 110/70 mmHg. However, the back and subxiphoid pain persisted without relief. Angiography was performed and a vascular stent (BARD, LIFE STENT, VASCULAR, 8 × 60) was implanted into the celiac artery without involving the branches. Pain was immediately relieved after interventional therapy. The patient was discharged after 4 days. A subsequent aortic CTA after 10 months confirmed that the celiac artery dissection had still not reoccurred.

Introduction. Graft revascularization in deficient arterial blood flow is usually performed by X-ray endovascular stenting procedure and/or by reconstruction of vascular anastomosis. The most serious complication of catheter intervention is a hepatic artery rupture and the critical ischemia of the liver graft.Objective. To discuss the successful treatment of a hepatic artery rupture which occurred during X-ray endovascular revascularization of the liver graft.Case report. A 48-year-old female patient with advanced alveococcosis underwent orthotopic cadaveric liver transplantation. After restoring the blood flow, it was found to be of low-velocity with RI 0.4 in the common hepatic artery. The gastrointestinal duodenal and splenic arteries were ligated. On the second day, a relaparotomy was performed because of intraabdominal bleeding originated from the parenchyma of the 7th–8th segments. Bleeding was arrested. After 18 hours, a selective angiography revealed stenosis up to 90% in the native hepatic artery. After balloon predilatation, stenting was performed, which accidentally caused the artery rupture. The further treatment included relaparotomy and reanastomosing. The patient was discharged from hospital on Day 19 after transplantation.Conclusion. Low velocity blood flow in the hepatic artery did not meet an adequate level even after the ligation of the gastrointestinal duodenal and splenic arteries. We performed the reconstruction of anastomosis. Another possible approach could be a catheter revascularization. The decision should be made considering the specific disorders of regional blood flow, their origin, and the vascular anatomy. The rupture of the artery in the reported case was caused by disproportionate diameters of the stent and vessel.

Anatomical variations in hepatic arteries are both common and diverse. According to the classic classification systems, a replaced right hepatic artery typically originates from the superior mesenteric artery, supplying blood to the right liver lobe in the absence of the right branch of the proper hepatic artery. This article reports 2 cases of a rare variation, a replaced right hepatic artery arising directly from the celiac trunk. In these cases, the artery courses posterior to the common hepatic artery and then behind the portal vein within the hepatoduodenal ligament. The first case, involving a 62-year-old male with intraductal papillary mucinous neoplasm (IPMN) of the pancreas, was identified intraoperatively during a pancreaticoduodenectomy. The second case, involving a 58-year-old female with chronic sclerosing cholangitis, was detected through contrast-enhanced computed tomography angiography. Identification of such variations is critical in hepatobiliary and pancreatic surgeries to prevent serious postoperative complications. Injury to a replaced right hepatic artery can lead to biliary-enteric anastomosis dehiscence after pancreaticoduodenectomy or ischemic liver complications. While hepatic arteries display numerous anatomical variations, classic classification systems fail to encompass all these anomalies. A more comprehensive classification system, such as CRL and ex-CRL classification, is necessary to ensure safer surgical outcomes.

Normal hepatic arterial anatomy consists of the right hepatic artery and left hepatic artery branching from the common hepatic artery. Despite this being the most common configuration, many variations have been described. Here, we present a rare variant of hepatic arterial anatomy- a replaced right hepatic artery with direct aortic origin. Additionally, the patient was found to have a dorsal pancreatic artery originating from the replaced right hepatic artery This was angiographically identified during mapping for transarterial radioembolization for hepatocellular carcinoma. The unique anatomy in this case and the effect it had on transarterial radioembolization planning described herein demonstrates the necessity of understanding variant hepatic arterial anatomy in endovascular hepatic interventions.

The article discusses a new technique for pancreaticojejunostomy after pancreaticoduodenectomy to reduce the risk of postoperative pancreatic fistula. The study included 141 patients and found that the single-layer interrupted spoke wheel suture technique showed promising outcomes. Factors like soft pancreas, narrow main pancreatic duct, and high BMI did not show associations with clinically relevant postoperative pancreatic fistula. The technique described in the article may offer a safer option for specific situations, although it does not claim superiority over other pancreaticoenteric anastomosis techniques. [Extracted from the article]

Abstract Background The progression of liver fibrosis to cirrhosis is a dynamic process necessitating non-invasive evaluation modalities. This study aims to evaluate the ability of Doppler ultrasound studies (DUS) in defining morphological and hemodynamic blood flow changes in the hepatic vasculature coinciding with advanced liver fibrosis. Methods A prospective study was conducted on 100 patients with liver cirrhosis (F4). All cases underwent liver stiffness (LS) measurement by shear wave elastography (SWE), along with DUS to evaluate the liver texture, splenic size, hepatic artery resistive index (HARI), portal and splenic vein diameters, portal vein velocity (PVV), and hepatic vein waveform (HVV). All measures were assessed concurrently with a highly qualified single operator. Results Patients aged 55.5 ± 10.2 years with male predominance (72%). A highly significant correlation was found between LS by SWE and hepatic parenchymal texture, splenic size, portal vein width, and HVV (monophasic and biphasic) (p

Background: Although advancements in desensitization protocols have led to increased ABO-incompatible (ABOi) living-donor liver transplantation (LDLT), a higher biliary complication rate remains a problem. This study evaluated the effect of baseline anti-ABO antibody titers before desensitization on biliary complications after ABOi LDLT. Methods: The study cohort comprised 116 patients in the ABO-compatible group (ABOc), 29 in the ABOi with the low titer (<1:128) group (ABOi-L), and 14 in the high titer (≥1:128) group (ABOi-H). Results: Biliary complications occurred more frequently in the ABOi-H group than in the ABOi-L and ABOc groups (7 [50.0%] vs. 8 [27.6%] and 24 [20.7%], respectively, p = 0.041). Biliary complication-free survival was significantly worse in the ABOi-H group than in the other groups (p = 0.043). Diffuse intrahepatic biliary strictures occurred more frequently in the ABOi-H group than in the other groups (p = 0.005). Multivariable analysis revealed that the high anti-ABO antibody titer (≥1:128) is an independent risk factor for biliary complications (hazard ratio 3.943 [1.635–9.506]; p = 0.002). Conclusions: A high baseline anti-ABO antibody titer (≥1:128), female sex, and hepatic artery complications are significant risk factors for biliary complications. [ABSTRACT FROM AUTHOR]

Background: Gastric venous congestion (GVC) is one of the complications of total pancreatectomy (TP). Here, we report a case of intraoperative severe GVC during TP with a replaced common hepatic artery (RCHA). Case presentation: A 65-year-old female patient was diagnosed with intraductal papillary mucinous carcinoma. Her CHA branched from the superior mesenteric artery as RCHA. She underwent subtotal stomach preserving TP. The tumor was resected with splenic artery (SpA) and total gastric vein transections. Severe GVC and bleeding from the stomach tube occurred intraoperatively. A strong pulsation was observed in the left gastric artery (LGA), and we suspected an increased blood flow from the celiac artery (CeA) to the LGA after SpA resection. Total gastrectomy (TG) was then performed to control the severe GVC-related bleeding. The patient was discharged without complications 19 days postoperatively. Conclusion: TP with RCHA may increase the risk of severe GVC due to increased blood flow from CeA to LGA. [ABSTRACT FROM AUTHOR]

Aim and objectives: The surgeon must recognize variations in the gallbladder, bile ducts, arteries that supply them, and liver to prevent unintentional ductal ligation, biliary leaks, and strictures after cholecystectomy. This study's objective was to investigate the structural changes that take place in the extrahepatic biliary tree and vasculature after cholecystectomy by comparing pre- and post-operative images. Materials and method: This Prospective Intraoperative observational study was conducted in the department of General Surgery, Santosh Medical College and Hospital from July 2021 to June 2022. The sample size was calculated to be 139 patients. Common Hepatic Duct formation, Right and left hepatic duct union, Types of cystic-hepatic duct union, Cystic duct and common hepatic duct, duct length, Hepato-duodenal ligament structures, Ductal variations, Arterial, duct, and Calot's triangle variations. Results: Majority (31.8%) belonged to 26-35 years followed by 36-45 years (29.1%), 46-55 years (18.9%), Above 55 years (10.8%) and 15-25 years (9.5%). There were 26.4% males and 73.6% females. Calot was frozen among 23.0% and Accessory artery in calot was found among 2.0% subjects. The anomalies were Aberrant right hepatic artery (0.7%), Accessory artery (1.4%), Double cystic duct (0.7%), Empyema (8.8%), Gb polyp (0.7%), Micro Gallbladder (0.7%), Mucocele (1.4%), Necrosed gall bladder (1.4%), Phregian cap (0.7%), Pyocele with moynihan hump (0.7%) and Type 2 bile duct injury (0.7%). Conclusion: Short cystic duct and intrahepatic gall bladder alterations are most common. Cholecystectomy discloses extrahepatic biliary problems. Every surgeon should watch for these variations to avoid unintended ductal cutting, ductal injuries, and haemorrhage during laparoscopic and open cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: The advancement of laparoscopic technology has broadened the application of laparoscopic pancreaticoduodenectomy (LPD) for treating pancreatic head and ampullary tumors. Despite its benefits, postoperative pancreatic fistula (POPF) and postpancreatectomy hemorrhage (PPH) remain significant complications. Ligamentum teres hepatis wrapping around the gastroduodenal artery (GDA) stump show limitations in reducing POPF and PPH. Methods: This study retrospectively analyzed patients undergoing LPD from January 2016 to October 2023, We compared the effectiveness of the two-parts wrapping (the ligamentum teres hepatis wrapping of the gastroduodenal artery stump and the omentum flap wrapping of the pancreatojejunal anastomosis) and ligamentum teres hepatis wrapping around the gastroduodenal artery (GDA) in reducing postoperative pancreatic fistula (POPF) and postpancreatectomy hemorrhage (PPH), using propensity score matching for the analysis. Results: A total of 172 patients were analyzed, showing that the two-parts wrapping group significantly reduced the rates of overall and severe complications, POPF, and PPH compared to ligamentum teres hepatis wrapping around the GDA group. Specifically, the study found lower rates of grade B/C POPF and no instances of PPH in the two-parts wrapping group, alongside shorter postoperative hospital stays and drainage removal times. These benefits were particularly notable in patients with soft pancreatic textures and pancreatic duct diameters of < 3 mm. Conclusion: The two-parts wrapping technique significantly reduce the risks of POPF and PPH in LPD, offering a promising approach for patients with soft pancreas and pancreatic duct diameter of < 3 mm. [ABSTRACT FROM AUTHOR]

Pancreaticoduodenectomy (PD) is a complex surgical procedure performed in patients with periampullary tumors located within the pancreatic head, the papilla of Vater, the distal common bile duct, and the duodenum. In advanced tumors, the operative technique involves the need for dissection and divestment of the arteries located within the pancreaticoduodenal field, including the common hepatic artery (CHA) and the proper hepatic artery (PHA) and its branches. The second most important cause of post-PD visceral aneurysms is irritation of the peri-pancreatic arterial wall by pancreatic juice in a postoperative pancreatic fistula (POPF). Hepatic artery pseudoaneurysm (HAP) is a very dangerous condition because it is usually asymptomatic, but it is a rare and potentially lethal pathology because of the high risk of its rupture. Therefore, HAP requires treatment. Currently, selective celiac angiography is the gold-standard diagnostic and therapeutic management for postoperative bleeding and pseudoaneurysm in patients following PD. Open surgery and less invasive endovascular treatment are performed in patients with HAP. Endovascular treatment involves transarterial embolization (TAE) and stent graft implantation. The choice of treatment method depends on the general and local conditions, such as the patient's hemodynamic stability and arterial anatomy. In patients in whom preservation of the flow within the hepatic artery (to prevent hepatic ischemia complications such as liver infarction, abscess, or failure) is needed, stent graft implantation is the treatment of choice. This article focuses on a review of two common methods for endovascular HAP treatment. In addition, risk factors and diagnostic tools have been described. [ABSTRACT FROM AUTHOR]

Early bifurcation of the common hepatic artery (EBCHA) is a rare anatomical variation (1%), that is often overlooked but can lead to accidental ligation of the right branch of the hepatic artery with consequent arterial ischemia of the right liver and potentially very serious complications during pancreaticoduodenectomy, partial hepatectomy, or liver harvesting for transplantation. It may be difficult to diagnose EBCHA using transverse imaging sections. However, on standard CT sections with intravenous contrast injection, three warning signs should allow the image reader to suspect it: presence of two hepatic arteries to the right of the celiac trunk, presence of a retro-portal hepatic artery, and absence of a right hepatic artery arising from the superior mesenteric artery. Analysis of the CT with reconstruction then allows for definitive diagnosis and limits the risk of accidental arterial injury or ligation. [ABSTRACT FROM AUTHOR]

The goal of this study was to evaluate the performance of a convolutional neural network (CNN) with preoperative MRI and clinical factors in predicting the treatment response of unresectable hepatocellular carcinoma (HCC) patients receiving hepatic arterial infusion chemotherapy (HAIC). A total of 191 patients with unresectable HCC who underwent HAIC in our hospital between May 2019 and March 2022 were retrospectively recruited. We selected InceptionV4 from three representative CNN models, AlexNet, ResNet, and InceptionV4, according to the cross-entropy loss (CEL). We subsequently developed InceptionV4 to fuse the information from qualified pretreatment MRI data and patient clinical factors. Radiomic information was evaluated based on several constant sequences, including enhanced T1-weighted sequences (with arterial, portal, and delayed phases), T2 FSE sequences, and dual-echo sequences. The performance of InceptionV4 was cross-validated in the training cohort (n = 127) and internally validated in an independent cohort (n = 64), with comparisons against single important clinical factors and radiologists in terms of receiver operating characteristic (ROC) curves. Class activation mapping was used to visualize the InceptionV4 model. The InceptionV4 model achieved an AUC of 0.871 (95% confidence interval [CI] 0.761–0.981) in the cross-validation cohort and an AUC of 0.826 (95% CI 0.682–0.970) in the internal validation cohort; these two models performed better than did the other methods (AUC ranges 0.783–0.873 and 0.708–0.806 for cross- and internal validations, respectively; P < 0.01). The present InceptionV4 model, which integrates radiomic information and clinical factors, helps predict the treatment response of unresectable HCC patients receiving HAIC treatment. [ABSTRACT FROM AUTHOR]

Arterial variations in the liver's blood supply play a pivotal role in the success of pancreatoduodenectomy (PD), impacting both its technical execution and oncological outcomes. Among these variations, a common hepatic artery arising from the superior mesenteric artery (SMA) occurs in about 3% of cases. An exceptionally rare variation is the intrapancreatic common hepatic artery (IPCHA). Preserving or reconstructing the IPCHA is vital during PD to prevent liver and biliary necrosis. Particularly for cases of pancreatic cancer with high rates of intrapancreatic perineural spread, preserving IPCHA without compromising radicality presents challenges. We present a detailed report of the technique used for PD in the presence of IPCHA. Surgical technique details include a pylorus-preserving PD with the Cattell–Braasch maneuver, an artery-first approach, and meticulous dissection using "cold" scissors. We emphasize the importance of strategic surgical planning based on high-quality imaging studies, underscoring the need for pancreatic surgeons to be proficient in managing variations in visceral vessels. In conclusion, this case underscores the significance of navigating rare arterial variations in liver supply during PD, highlighting the necessity for meticulous surgical planning and execution. [ABSTRACT FROM AUTHOR]

Purpose: Neuroblastoma, the most common extracranial solid tumor in children under 5 years, often surrounds visceral arteries. This study aimed to analyze the working space provided by standardized surgical techniques at key arterial landmarks in adult cadavers. Methods: We assessed in eight adult cadavers the mobilization of the left colon, spleen and pancreas, right colon, duodenum and mesenteric root, access to the bursa omentalis. The average working space score (AWSS) was evaluated at the left and right renal artery, left and right side of the coeliac trunk, superior mesenteric and common hepatic artery. The score was defined as: (0) vessel not visible, (1) working space at the vessel ≤ 1x diameter of the aorta, (2) < 3x the diameter of the aorta, (3) ≥ 3x diameter of the aorta. Results: The maximum AWSS of 3 was achieved at key vascular landmarks through specific mobilization techniques. Conclusion: Additional mobilization of spleen, pancreas and mesenteric root and access to the bursa omentalis increase surgical working space at major visceral arteries. The results of our investigation provide surgeons with a useful guide to prepare for abdominal neuroblastoma resection. [ABSTRACT FROM AUTHOR]

Background: Ectopic liver tissue (ELT) is a developmental abnormality in which liver tissue develops at an extrahepatic site without connection to the true liver. It is a rare entity with an incidence of 0.24–0.56% according to data described in laparoscopic or autopsy studies. The detailed mechanism behind the development of ELT is poorly understood. ELT predominantly has an asymptomatic nature, even by means of radiological studies the diagnosis of ELT without surgery or autopsy is difficult. ELT has been reported mostly to be found frequently on the gallbladder and rarely on the gastrohepatic ligament. ELT has increased the potential risk of HCC which makes the resection crucial. Due to its variations anatomically, ELT recognition should gain clinical importance and surgeons need to be aware of these possible disparities. Case presentation. We present a 59-year-old female from Western Tanzania was presented to us with 2-month history of painless upper abdominal swelling. An abdominal CT scan was performed, and it revealed a large mass located at the gastrohepatic region with blood supply mainly from the left hepatic artery and omentum. Technically difficult excision of 17 × 12 cm tumor at gastrohepatic ligament was performed, with uneventful recovery. Post-operative histology results revealed capsulated hepatic parenchyma without the biliary components and limited sinusoids with tissue degeneration. To date, no complications happened during follow-up for one year. Conclusion: ELT is a rare entity with a predominantly asymptomatic nature. Preoperatively diagnosis is difficult even with images. It has anatomical variation and is hardly found along the gastrohepatic ligament. ELT has increased the potential risk of HCC which makes the resection crucial. Increased awareness of this congenital anomaly may result in increased detection rates. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic bile duct injury (BDI) is one of the most common complications that challenge surgeons performing laparoscopic cholecystectomy (LC). As the number of LC surgeries increases, a pattern of BDI is emerging, but little is known about this matter. The purpose of this study was to assess the pattern of post-LC BDIs directed in a referral center in Iran. Methods: Post-BDI patients referred to a hepatobiliary center were studied. Demographic data, clinical status, diagnostic examinations, referral time, post-referral management, and morbidity were analyzed. Results: Nine out of 68 patients had Charcot's cholangitis triad featuring right upper quadrant abdominal pain, fever, and icter. Fever, icter, and itching were the most frequent symptoms. Increased bilirubin, leukocytosis, and abnormal liver function test (LFT) were the most common laboratory abnormalities. 30 patients experienced hepatic artery injury. Out of them, six patients experienced hepatectomy due to hepatic ischemia. Two patients were re-admitted and re-operated, and four patients died. Conclusion: Early and correct treatment by a hepatobiliary surgeon experienced in the management of these types of injuries prevents further complications in patients suffering from iatrogenic BDI. Postoperative complications of bile duct repair, such as anastomosis stricture, are possible; thus, patients need long-term and thorough postoperative observation. [ABSTRACT FROM AUTHOR]