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Introduction: Pressurized intraperitoneal aerosol chemotherapy-oxaliplatin (PIPAC-OX) induces direct DNA damage and immunogenic cell death in patients with gastric cancer peritoneal metastases (GCPM). Combining PIPAC-OX with immune checkpoint inhibition remains untested. We conducted a phase I first-in-human trial evaluating the safety and efficacy of PIPAC-OX combined with systemic nivolumab (NCT03172416)., Methods: Patients with GCPM who experienced disease progression on at least first-line systemic therapy were recruited across three centers in Singapore and Belgium. Patients received PIPAC-OX at 90 mg/m 2 every 6 weeks and i.v. nivolumab 240 mg every 2 weeks. Translational studies were carried out on GCPM samples acquired during PIPAC-OX procedures., Results: In total, 18 patients with GCPM were prospectively recruited. The PIPAC-OX and nivolumab combination was well tolerated with manageable treatment-related adverse events, although one patient suffered from grade 4 vomiting. At second and third PIPAC-OX, respectively, the median decrease in peritoneal cancer index (PCI) was -5 (interquartile range: -12 to +1) and -7 (interquartile range: -6 to -20) and peritoneal regression grade 1 or 2 was observed in 66.7% (6/9) and 100% (3/3). Translational analyses of 43 GCPM samples revealed enrichment of immune/stromal infiltration and inflammatory signatures in peritoneal tumors after PIPAC-OX and nivolumab. M2 macrophages were reduced in treated peritoneal tumor samples while memory CD4+, CD8+ central memory and naive CD8+ T-cells were increased., Conclusions: The first-in-human trial combining PIPAC-OX and nivolumab demonstrated safety and tolerability, coupled with enhanced T-cell infiltration within peritoneal tumors. This trial sets the stage for future combinations of systemic immunotherapy with locoregional intraperitoneal treatments., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Peritoneal metastasis (PM), the regional progression of intra-abdominal malignancies, is a common sequelae of colorectal cancer (CRC). Immunotherapy is slated to be effective in generating long-lasting anti-tumour response as it utilizes the specificity and memory of the immune system. In the tumour microenvironment, tumour associated macrophages (TAMs) are posited to create an anti-inflammatory pro-tumorigenic environment. In this paper, we aimed to identify immunomodulatory factors associated with colorectal PM (CPM). A publicly available colorectal single cell database (GSE183916) was analysed to identify possible immunological markers that are associated with the activation of macrophages in cancers. Immunohistochemical analysis for V-set and immunoglobin containing domain 4 (VSIG4) expression was performed on tumour microarrays (TMAs) of tumours of colorectal origin (n = 211). Expression of VSIG4 in cell-free ascites obtained from CPM patients (n = 39) was determined using enzyme-linked immunosorbent assay (ELISA). CD163-positive TAMs cluster expression was extracted from a publicly available single cell database and evaluated for the top 100 genes. From these macrophage-expressed genes, VSIG4, a membrane protein produced by the M2 macrophages, mediates the up-regulation of anti-inflammatory and down-regulation of pro-inflammatory macrophages, contributing to an overall anti-inflammatory state. CRC TMA IHC staining showed that low expression of VSIG4 in stromal tissues of primary CRC are associated with poor prognosis (p = 0.0226). CPM ascites also contained varying concentrations of VSIG4, which points to a possible role of VSIG4 in the ascites. The contribution of VSIG4 to CPM development can be further evaluated for its potential as an immunotherapeutic agent., (© 2024. The Author(s).)

Introduction: Field cancerization is suggested to arise from imbalanced differentiation in individual basal progenitor cells leading to clonal expansion of mutant cells that eventually replace the epithelium, although without evidence., Methods: We performed deep sequencing analyses to characterize the genomic and transcriptomic landscapes of field change in two patients with synchronous aerodigestive tract tumors., Results: Our data support the emergence of numerous genetic alterations in cancer-associated genes but refutes the hypothesis that founder mutation(s) underpin this phenomenon. Mutational signature analysis identified defective homologous recombination as a common underlying mutational process unique to synchronous tumors., Discussion: Our analyses suggest a common etiologic factor defined by mutational signatures and/or transcriptomic convergence, which could provide a therapeutic opportunity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Tan, Shannon, Lim, Teo, Yap, Lek, Tan, Tan, Hendrikson, Liu, Ng, Chong, Guo, Koh, Ng, Rajasegaran, Wong, Seo, Ong, Lim, Teh, Kon, Chia, Soo, Iyer and Ong.)

Background: Peritoneal sarcomatosis (PS) is a difficult entity to treat with limited options and guarded prognosis. We aimed to determine if the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) could offer superior local recurrence-free survival in patients with retroperitoneal sarcoma at high risk of developing PS as opposed to extended resection alone., Methods: This is a single arm, phase II intervention study where all patients with recurrent localized retroperitoneal sarcoma considered at high risk of developing PS were considered for enrolment (ClinicalTrials.gov identifier: NCT03792867). Upon enrolment, patients underwent vigorous preoperative testing to ensure fitness for the procedure. During surgery, patients underwent extended resection and HIPEC with doxorubicin. Patients were followed-up every 2 weeks (± 10 days) for the first month and subsequently every three months (± 1 month) up to a year post-surgery, and were assessed for potential chemotherapy toxicity and post-treatment complications. After a year from resection and HIPEC, patients were followed-up either during routine clinic review or contacted via telephone every year (± 1 month) for 3 years., Results: Six patients were recruited but one patient dropped out due to adverse and unexpected intraoperative events. The remaining patients completed the procedure uneventfully. Post-HIPEC, all patients recurred with a disease-free interval ranging from six to 24 months. Three patients died due to complications from recurrent disease whereas the remaining three patients are alive as of their last visit. The overall survival at time at reporting ranged between 22 to 56 months., Conclusion: The procedure is feasible with no major morbidity to patients. However, we are unable to recommend for it to be implemented as a routine procedure at this current stage due to lack of improved survival outcomes. Further multi-institutional studies may be conducted to yield better results., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Seo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Palliative surgical oncology patients represent a unique group with complex needs who often require multidisciplinary input for the provision of timely and holistic care. The authors assembled a multi-disciplinary palliative intervention team and evaluated its association with the quality of discussions on goals of care (GOC) among advanced cancer patients undergoing palliative interventions., Methods: This prospective cohort study analyzed advanced cancer patients undergoing palliative interventions at a single urban academic center from October 2019 to March 2022. In January 2021, a multi-disciplinary palliative surgical intervention (MD-PALS) team was assembled. All palliative surgical oncology patients were discussed at multi-disciplinary meetings and managed by members of the MD-PALS team. An interrupted time series (ITS) model was built to evaluate the association of MD-PALS implementation and the quality of GOC discussions as measured by a consensus-derived four-point GOC discussion quality score., Results: The study recruited 126 palliative surgical oncology patients: 44 in the pre-MD-PALS group and 82 in the post-MD-PALS group. The two groups did not differ significantly in baseline demographics, treatment, or postoperative and survival outcomes. Compared with the pre-MD-PALS group, the post-MD-PALS group had a significantly higher mean GOC discussion quality score (1.34 vs 2.61; p < 0.001). Based on the ITS model, the average quarterly GOC discussion quality score increased significantly among patients after implementation of the MD-PALS team (change = 1.93; 95 % confidence interval, 0.96-2.90; P = 0.003)., Conclusion: The implementation of an MD-PALS team was associated with improvements in the quality of GOC discussions among palliative surgical oncology patients., (© 2023. The Author(s).)

Objective: To examine the association between the performance of mapping biopsies and surgical outcomes postexcision of extramammary Paget's disease (EMPD)., Background: Primary EMPD is a rare entity associated with poorly defined surgical margins and difficult-to-access sites of lesions. Surgical resection with clear margins remains the preferred management method. The use of mapping biopsies might be beneficial, particularly in lowering disease recurrence., Methods: Available literature was reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology before a fixed-effect meta-analysis was performed to identify the presence of a correlation between performing mapping biopsies and positive margins on permanent sections as well as disease-free survival. Additional study results not included in the quantitative assessment were qualitatively assessed and reported., Results: A total of 12 studies were shortlisted for final analysis. 294 patients who underwent mapping biopsies and 48 patients who did not undergo mapping biopsies were included in the assessment. Forest plot analysis revealed a pooled rate ratio of 0.50 (95% CI, 0.32-0.77) in the prevalence of positive margins in patients with mapping biopsies performed as compared to patients without. The pooled rate ratio of the prevalence of disease-free survival in patients with mapping biopsies performed as compared to patients without was 1.38 (95% CI, 1.03-1.84). Qualitative assessment of the remaining selected studies revealed equivocal results., Conclusions: Mapping biopsies are able to improve EMPD surgical excision outcomes but given the rarity of the disease and heterogeneity of mapping biopsy procedures, further confirmation with randomized controlled trials or a larger patient pool is necessary., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

The use of open cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has shown improved oncological survival in terms of treating peritoneal surface malignancies (PSM). However, this procedure often comes with associated morbidity. The move towards use of laparoscopic surgery in this field is postulated to lead to a reduction in morbidity and earlier return to function, but literature on its use for CRS and HIPEC has been scarce. We performed a retrospective review of 6 patients with PSM who underwent laparoscopic CRS and HIPEC in our institution and analysed the patient characteristics, oncological history, perioperative and postoperative outcomes. Median peritoneal cancer index (PCI) score was 0 (IQR 0-1.25). All 6 patients had appendiceal primaries. Median operative time was 285 min (IQR 228.8-300); median length of stay was 7.5 days (IQR 5-8.8). All patients achieved complete cytoreduction, and there was no conversion to open surgery. One patient developed port site infection and another 2 patients subsequently developed adhesions. Median follow-up time was 35 (IQR 17.5-41) months. No patients had developed recurrence at the time of data collection. We conclude that in patients with limited PCI sore (< 2), laparoscopic CRS and HIPEC are safe and feasible. With increasing experience, a select group of patients with limited PSM may be treated via minimally invasive surgery, minimising the morbidity of a traditional laparotomy., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s), under exclusive licence to Indian Association of Surgical Oncology 2022. Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Peritoneal surface malignancies (PSM) present insidiously and often pose diagnostic challenges. There is a paucity of literature quantifying the frequency and extent of therapeutic delays in PSM and its impact on oncological outcomes., Methods: A review of a prospectively maintained registry of PSM patients undergoing Cytoreductive Surgery and Hyperthermic Intra-peritoneal Chemotherapy (CRS-HIPEC) was conducted. Causes for treatment delays were identified. We evaluate the impact of delayed presentation and treatment delays on oncological outcomes using Cox proportional hazards models., Results: 319 patients underwent CRS-HIPEC over a 6-years duration. 58 patients were eventually included in this study. Mean duration between symptom onset and CRS-HIPEC was 186.0 ± 37.1 days (range 18-1494 days) and mean duration of between patient-reported symptom onset and initial presentation was 56.7 ± 16.8 days. Delayed presentation (> 60 days between symptom onset and presentation) was seen in 20.7% (n=12) of patients and 50.0% (n=29) experienced a significant treatment delay of > 90 days between 1 st presentation and CRS-HIPEC. Common causes for treatment delays were healthcare provider-related i.e. delayed or inappropriate referrals (43.1%) and delayed presentation to care (31.0%). Delayed presentation was a significantly associated with poorer disease free survival (DFS) (HR 4.67, 95% CI 1.11-19.69, p=0.036)., Conclusion: Delayed presentation and treatment delays are common and may have an impact on oncological outcomes. There is an urgent need to improve patient education and streamline healthcare delivery processes in the management of PSM., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Tan, Wong, Seo, Lim, Zhu, Ong and Chia.)

To evaluate the trajectories and sustainability of health-related quality of life (HRQoL) outcomes after palliative gastrointestinal (GI) surgery and perioperative factors associated with HRQoL improvement postsurgery., Background: Palliative patients face a wide range of physical, emotional, social, and functional challenges. In evaluating the efficacy of palliative surgical interventions, a major pitfall of traditional surgical outcome measures is that they fall short of measuring outcomes that are meaningful to patients during end-of-life. HRQoL tools may provide a more comprehensive assessment of the true value and impact of palliative surgery., Methods: We prospectively recruit advanced cancer patients undergoing palliative GI surgery. The Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire was administered before and at regular intervals after surgery. HRQoL improvement was defined as ≥4-points increment in FACT-G total score over baseline. Duration of sustained HRQoL improvement above this threshold and factors associated with varying extents of HRQoL change were evaluated., Results: Of the 65 patients, intestinal obstruction was the most common indication for surgery (70.8%). The mean baseline FACT-G total score was 70.7 (95% CI: 66.3-75.1). Forty-six (70.8%) patients experienced HRQoL improvement after surgery. This HRQoL improvement was sustained over a median duration of 3.5 months and was driven mainly by improvements in patients' physical and emotional well-being. Albumin was significantly associated with the extent of HRQoL improvements ( P = 0.043)., Conclusion: A clinically significant and sustained improvement in HRQoL was observed after palliative GI surgery. Patients with higher preoperative albumin levels were more likely to experience HRQoL improvements., Competing Interests: The authors declare that there is no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The performance of MRI versus CT in the detection and evaluation of peritoneal surface malignancies (PSM) remains unclear in the current literature. Our study is the first prospective study in an Asian center comparing the two imaging modalities, validated against intra-operative findings. Methods: A total of 36 patients with PSM eligible for CRS-HIPEC underwent both MRI and CT scans up to 6 weeks before the operation. The scans were assessed for the presence and distribution of PSM and scored using the peritoneal cancer index (PCI), which were compared against PCI determined at surgery. Results: Both MRI and CT were 100% sensitive and specific in detecting the overall presence of PSM. Across all peritoneal regions, the sensitivity and specificity for PSM detection was 49.1% and 93.0% for MRI, compared to 47.8% and 95.1% for CT (p = 0.76). MRI was more sensitive than CT for small bowel disease, although the difference did not reach statistical significance. Comparing PCI on imaging with intra-operative PCI, the mean difference was found to be −3.4 ± 5.4 (p < 0.01) for MRI, and −3.9 ± 4.1 (p < 0.01) for CT. The correlation between imaging and intra-operative PCI was poor, with a concordance coefficient of 0.76 and 0.79 for MRI and CT, respectively. Within individual peritoneal regions, there was also poor agreement between imaging and intra-operative PCI for both modalities, other than in regions 1 and 3. Conclusion: MRI and CT are comparable in the detection and evaluation of PSM. While sensitive in the overall detection of PSM, they are likely to underestimate the true disease burden.

Objective: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) represent a mainstay of treatment for peritoneal malignancies. There is evidence that HIPEC using high intra-abdominal pressure (IAP) results in increased tissue penetration, although its safety profile remains relatively unknown. We thus aim to evaluate differences in intra- and post-operative outcomes in patients undergoing CRS-HIPEC with different levels of IAP., Methods: This pilot prospective cohort study was conducted from January 2020 to February 2021 with patients undergoing CRS-HIPEC. Low IAP during HIPEC was defined as <18 mmHg and high IAP as ≥18 mmHg. Data was collected on patient and tumor characteristics, intra-operative clinical and biochemical parameters, and immediate post-operative outcomes., Results: 40 patients underwent CRS-HIPEC ( n low = 20, n high = 20). Median IAP in the low and high IAP groups were 12.0 and 19.0 mmHg respectively. During HIPEC, both groups experienced increase in heart rate, central venous pressure, end tidal CO2, temperature, and serum glucose, with decrease in mean arterial pressure and base excess. There were no significant differences in hemodynamics between the 2 groups. Mild electrolyte derangements and a decrease in hemoglobin were noted in the high IAP group but were of small magnitude. Post-operatively, high IAP did not result in increased rate of complications, time to full feeds, ICU or total hospital stay., Conclusions: High IAP in HIPEC is well tolerated and did not result in additional adverse events.

Angiosarcomas account for only 1-2% of all soft tissue sarcomas, with the most common site of origin being in the head and neck region. Peritoneal angiosarcoma is an extremely rare tumour and few cases have been reported previously. Presentation of peritoneal angiosarcoma can be very variable, hence making diagnosis difficult. Herein, we review the current literature and describe a rare case of a patient who presented with haemorrhagic ascites, 17 years after radiotherapy for endometrial carcinoma and was subsequently diagnosed with peritoneal angiosarcoma. Due to extensive disease, surgery was not a viable option. She was started on palliative chemotherapy, but despite treatment, her condition deteriorated further and she eventually passed away. We highlight the diagnostic challenges and considerations in these patients as well as current treatment and management options available., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: The management of haemorrhagic radiation proctitis is challenging because of the necessity for repeated intervention. The efficacy of argon plasma coagulation has been described before but the optimum treatment strategy remains debatable. This is a review of our experience over a decade treating patients with haemorrhagic radiation proctitis and their follow-up., Methods: This is a retrospective review of consecutive patients who underwent argon plasma coagulation for haemorrhagic radiation proctitis between January 2003 and December 2013. The patients were followed up using a prospectively maintained database., Results: Ninety-one patients were included with a mean follow-up of 13.1 months. Majoity (n = 85, 93.4 %) of the patients were female. Mean age at the time of treatment was 58.2 (range 23-87) years old. Majority of the patients (n = 73, 80.2 %) received radiotherapy for gynaecological malignancies followed by colorectal (n = 13, 14.3 %) and urological (n = 5, 5.5 %) malignancies. Mean interval between radiation and proctitis was 13.8 (range 3-40) months. Seventy-nine percent of patients were successfully treated after 1-2 sessions. Seventeen (18.7 %) patients experienced self-limiting early complications, and three (3.3 %) had late complications of rectal stenosis which was managed conservatively. Severity of bleeding during the initial presentation is an independent factor that predicts the number of sessions required for successful haemostasis (p = 0.002)., Conclusions: Argon plasma coagulation is a reasonable treatment option in patients with haemorrhagic radiation proctitis with good safety profile. Our study suggests that the number of APC sessions required to arrest bleeding correlates with the severity of bleeding on initial presentation.

Background/aims: Smoking and alcohol intake are two wellknown risk factors for chronic pancreatitis. However, there are few studies examining the association between smoking and changes in computed tomography (CT) findings in chronic pancreatitis. The authors evaluated associations between smoking, drinking and the progression of calcification on CT in chronic pancreatitis., Methods: In this retrospective study, 59 patients with chronic pancreatitis who had undergone initial and follow-up CT between January 2002 and September 2010 were included. Progression of calcification among CT findings was compared according to the amount of alcohol intake and smoking., Results: The median duration of followup was 51.6 months (range, 17.1 to 112.7 months). At initial CT findings, there was pancreatic calcification in 35 patients (59.3%). In the follow-up CT, progression of calcification was observed in 37 patients (62.7%). Progression of calcification was more common in smokers according to the multivariate analysis (odds ratio [OR], 9.987; p=0.006). The amount of smoking was a significant predictor for progression of calcification in the multivariate analysis (OR, 6.051 in less than 1 pack per day smokers; OR, 36.562 in more than 1 pack per day smokers; p=0.008)., Conclusions: Continued smoking accelerates pancreatic calcification, and the amount of smoking is associated with the progression of calcification in chronic pancreatitis.

Hepatoblastoma usually occurs in children under the age of 2 years, with very few cases reported in adults. We experienced a case of adult hepatoblastoma in a 36-year-old female with chronic hepatitis B. She had experienced sudden onset abdominal pain. Her serum alpha-fetoprotein level was markedly elevated, and abdominal CT showed a 9-cm mass with internal hemorrhage in the right hepatic lobe with hemoperitoneum, so an emergency hepatic central bisectionectomy was performed. The initial histologic examination revealed that the mass mimicked combined hepatocellular carcinoma and cholangiocarcinoma with spindle-cell metaplasia of the cholangiocarcinoma element. Follow-up abdominal CT performed 3 months later showed a 5.5-cm metastatic mass in the left subphrenic area. Laparoscopic splenectomy with mass excision was performed, and hepatoblastoma was confirmed histologically. A histologic re-examination of previously obtained surgical specimens also confirmed the presence of hepatoblastoma. Metastatic hepatoblastoma was found at multiple sites of the abdomen during follow-up, and so chemotherapy with cisplatin, 5-fluorouracil (5-FU), and vincristine was applied, followed by carboplatin and doxorubicin. Despite surgery and postoperative chemotherapy, she died 12 months after symptom onset.

As the population of the Western world ages, the number of major surgical procedures performed in the elderly population will by necessity increase. Within virtually every surgical specialty, studies have shown that patients should not be denied surgery on the basis of chronological age alone. It has recently been recognized that physiological age is far more important within the decision-making algorithm as to whether or not to proceed with major surgery in the septuagenarian and octogenarian populations and beyond. Not unexpectedly, not only the results of these operations, but also the associated morbidities, are similar in older and younger populations. Therefore, it is not surprising that postoperative ileus (POI) affects patients of all ages. POI is a multifactorial condition that is exacerbated by opioid analgesics, bed rest and other conditions that may be rather prevalent in the postoperative elderly patient. Therefore, as major surgical interventions are considered in this population, appropriate assessment and, ideally, correction of any physiological disturbances should be undertaken along with implementation of standardized enhanced recovery protocols. Ideally, through this combined approach, an appreciable impact can be made on reducing POI while controlling postoperative pain and limiting postoperative thromboembolic, cardiopulmonary, cerebral and infectious complications. This article reviews the potential impact of pharmacological agents, laparoscopy and other manoeuvres on POI in the elderly.

McCune-Albright syndrome (MAS) is a rare disorder that develops from an activating mutation in the Gs gene. It is characterized by an association with Polyostotic fibrous dysplasia, and precocious puberty, Caf-au-lait pigmentation, and other endocrinopathies that result from the hyperactivity of a variety of endocrine glands. Recently we encountered a patient with MAS with fibrous dysplasia, skin pigmentation, acromegaly, hyperprolactinemia and a thyroid nodule. A 23-year-old male presented for an evaluation of a change in his facial structures. Fibrous dysplasia was diagnosed by a bone biopsy and radiographic studies. The GH level increased paradoxically after an oral glucose load. The plasma prolactin, IGF-1 and alkaline phosphatase were high. Thyroid ultrasonography revealed multiple nodules. The brain MRI demonstrated a mass in the left pituitary gland. Genetic analysis identified a change from Arg (CGT) at codon 201 to Cys (TGT).

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.

This study was designed to evaluate the clinical usefulness of 3-dimensional computed tomography (CT) laryngography for the determination of subglottic extension in laryngeal cancer and for the involvement of the pyriform sinus apex in hypopharyngeal cancer. Twenty-one patients with laryngeal cancer and 19 patients with hypopharyngeal cancer underwent spiral CT during quiet breathing, /E/ phonation, Valsalva's maneuver, and modified Valsalva's maneuver. Three-dimensional volume rendering with CT data was performed on a workstation. Three-dimensional CT laryngography was compared to laryngoscopy, axial CT, endoscopy, and/or histopathologic findings. Three-dimensional CT laryngography was useful for showing subglottic extension in laryngeal cancer and involvement of pyriform sinus apex in hypopharyngeal cancer. Three-dimensional CT laryngography with quiet breathing was most informative for the determination of subglottic extension, whereas 3-dimensional CT laryngography with modified Valsalva's maneuver was most informative for the diagnosis of pyriform sinus apex involvement. In patients with vocal cord palsy, the contour of the vocal cord was the same during all 4 maneuvers. Three-dimensional CT laryngography during quiet breathing, /E/ phonation, Valsalva's maneuver, and modified Valsalva's maneuver may be useful in assessing laryngeal and hypopharyngeal cancers. This technique may provide important information not provided by conventional CT images.