Variation of hepatic artery by 3-D reconstruction MDCT scan of liver in Siriraj Hospital.

OBJECTIVE: To evaluate the prevalence of hepatic arterial variant in Siriraj Hospital. MATERIAL AND METHOD: A retrospective study that was approved by ethic committee of Siriraj Hospital. Between August and October 2006, 200 studies of abdominal MDCT were randomly sampled and multi-planar reformatted by using program Vitrea 2. Both axial, two- and three-dimensional images were evaluated for possible variants of hepatic vasculature. The results were classified by Michel classification and analyzed in percentage. Moreover, a small group (23 studies) that had digital subtraction angiography (DSA) was compared to know accuracy and Intercorelation between the two reviewers (Kappa value). RESULTS: Of 200 studies, 83.5% had type I, 1% type II, 6% type III, 0.5% type IV, 3.5% type V, 1% type VI, 0.5% type VIII, 1% type IX, 0.5% Type X, and 2.5% others type. Accuracy of MDCT for detection hepatic artery variation as compared with DSA was 78.3%. CONCLUSION: All variation is about 16%. Type III is most common variation of patients in Siriraj Hospital.

Novel aspects in the management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the commonest cancers in Thailand, which usually develops on a background of cirrhosis. We report a multimodal approach to the management of HCC. Though surgical treatment is the only opportunity for curing HCC, it is only feasible in a minority of patients. Various non-surgical treatment modalities have been developed and used extensively, but their efficacy is far from satisfactory and the prospect for the development of more effective treatments is dismal. Multidisciplinary treatment such as the combination of transcatheter oily chemoembolization and percutaneous ethanol injection appears to be the current trend of management for nonresectable HCC, and improvement in survival can be achieved compared to single mode treatment. Portal vein embolization is useful in patient in need of wide hepatectomy to induce pre-operative hypertrophy of future remnant liver, which would have been insufficient for safe resection. Moreover, intra-arterial 131-Iodine-Lipiodol given after curative resection significantly decreased the rate of recurrence and increased disease-free and overall survival in patients with HCC.

Treatment of hepatocellular carcinoma by injection of iodine*131-labelled lipiodol into the hepatic artery.

The therapeutic efficacy iodine*131-labelled Lipiodol was studies in the treatment of hepatocellular carcinoma (HCC). The results of the treatment were evaluated for four aspects: size of the tumour; serum alphafetoprotein level ; the quality of the patient’s life;and the survival rate. The hepatocellular carcinoma was diagnosed by evidence of mass in the liver using either computed tomography or ultrasonography with tissue biopsy and/or a high level of alphafetoprotein of more than 500 U. Twenty patients were randomized into two groups for comparison. The patients in group A were treated by intrahepatic injection of iodine*131-labelled Lipiodol 60 miliCuries(mCi). The patients in group B were treated by intra-hepatic injection of a mixture of Lipiodol and chemotherapeutic agents, mitomicin c 20 mg. and 5-fluoracil 500 mg., followed by selective hepatic artery embolisation of small pieces of gelatin sponge (gelfoam). Both groups were evaluated by computed tomography (CT) and the possible repeat of treatment protocol after two months. There were no serious side-effects or major complications in either group of patients. The patients’ conditions worsened by 40 percent in both groups. The tomours’ sizes remained unchanged by 50 percent in both groups. The serum alphafetoprotein levels had increased by 40 percent in group A, and remained unchanged by 50 percent in group B. The survival rates at one and two years in group A were 20 and 20 percent, and in group B there were 30 and 0 percent, respectively. Satisfactory results were obtained in the treatment of small HCC, size less than 5 cm. with intra-hepatic artery injection of iodine*131-labelled Lipiodol. In large HCC (>10cm) no response by the tumour was seen in either group. This was the first study of this type performed in Thailand.

Comparison of contrast angiograpy to Colour-flow Duplex Sonography (CFDS) in lower extremity peripheral arterial diseases.

To study peripheral arterial diseases of the lower extremity by colour-flow duplex sonography (CFDS) and to compare the results between CFDS and angiography. Materials and methods : Ten normal subjects were studied in the control group, together with the second group of nine patients who had occlusive peripheral arterial disease of the legs, by colour-flow duplex sonography (CFDS). AII none patients who had vascular diseases were examined by angiography within one week after CFDS for comparison. The results of both studies were then analysed to determine the sensitivity, specificity, and cost-effectiveness of CFDS 1. In normal subjects (control group), CFDS showed a triphasic flow in the normal vessels. The peak systolic velocity (PSV) showed maximum velocity in the abdominal aorta (100-150)cm/sec and there was decreased velocity in PSV in the peripheral vessels. 2. The study found that in the stenotic segment of artery, there was  (a). Monophasic flow (instead of triphasic flow) ;  (b). Turbulance flow, with spectral broadening ;  (c). Increased PSV above 150 per cent. 3. As angiography is a gold-standard examination for the peripheral vascular disease, the sensitivity and specificity of CFDS are 68.42 and 100 per cent respectively. 4. The limitations of CFDS include :  (a). obese patient or patient with large amount of gas in the bowel loops ;  (b). Calcified wall of vessels, which can obscure sonotransmission.  (c). Experience of sonologist ;  (e). Long examination time. The conclusion is that CFDS is an useful, non-invasive examination for peripheral arterial disease of legs. In the hands of an experience sonologist, arterial diseases can be detected or diagnosed with good accuracy and good result. However, there are still some limitations with CFDS.

Color doppler ultrasonography study in hepatocellular carcinoma with angiographic correlation.

Purpose: To study the blood supply of hepatocellular carcinoma (HCC) by color Doppler ultrasonography (CDUS) and to compare the results with angiography study. Materials and methods: 13 patients, 12 males, 1 female, aged 43 to 67 years, were studied at Siriraj Hospital between February 1995 and September 1995. They were diagnosed by clinica examination, and 7 of the 13 by liver biopsy, as having high levels of alpha fetoprotein more than 1,000 unit. All patients were examined by CDUS, followed by hepatic angiography and were treated by transcatheter oily chemoembolization (TOCE) within 1 week. Results: 12 of the 13 patients had HCC single mass and 9 of those were in the right lobe of the liver. The 13th patient have 2 masses. 12 of the 14 masses were larger than 6 cms; 7 of 14 masses being hyperechoic and 6 of 14 masses mixed echoic, 1 of 14 hypoechoic. The CDUS and angiography showed hypervascularity in 10 of the 14 most of the blood supplies were in the periphery of lesions, and there were both pulsatile, and continuous flow. There was portal vein thrombosis showing in 4 to the 13 cases in both CDUS, and anitography. Angiography showed hepatoportal shunting in 3 of 13 but CDUS suggested hepatoportal shunt in only 2 patients. Conclusion: There is a good correlation between CDUS, and angiography in HCC, CDUS can be used in the diagnosis, of HCC, its staging, and in follow up studies after TOCE treatment.