[Unresectable combined hepatocellular-cholangiocellular carcinoma treated with transcatheter arterial chemoembolization and gemcitabine: a case study].

A 76-year-old female was referred to our hospital because of liver dysfunction. Abdominal contrasted computed tomography (CT) revealed a tumor of 7.5cm in the hepatic hilar area. Based on the biopsy, the tumor was diagnosed by as combined hepatocellular-cholangiocellular carcinoma (with stem-cell features). The tumor was considered unresectable;hence, the patient underwent transcatheter arterial chemoembolization (TACE). However, a CT scan revealed the treatment to be ineffective. Subsequently, systemic gemcitabine (GEM) chemotherapy was administered and tumor shrinkage was observed with reperfusion of the umbilical portion of the left portal vein. The patient's condition is currently stable 17 months after diagnosis, with no tumor regrowth on account of repeated TACE and GEM therapy. The present case of unresectable combined hepatocellular-cholangiocellular carcinoma was successfully treated using TACE and systemic GEM chemotherapy.

Eosinophilic esophagitis in Japanese patients: A mild and slow-progressing disorder.

BACKGROUND AND AIM: Awareness of eosinophilic esophagitis (EoE) has gradually increased in Japan, therefore the characteristics of this disease in the Japanese patient population need to be elucidated. This study aimed to investigate the features of EoE in the Japanese population. METHODS: During a 2-year period, all gastrointestinal endoscopies were performed with maximum attention being paid to identify EoE through endoscopic findings. Clinical features and findings were analyzed among this population. RESULTS: Among a total of 8589 patients (general gastrointestinal endoscopy, performed for evaluation of symptoms or disease follow-up: 3669; medical check-up endoscopy, routinely performed in asymptomatic patients: 4920), 17 patients (0.20%) were diagnosed with esophageal eosinophilia (mean age ± standard deviation: 44±11.9 years; 1 female). Only 6 patients with esophageal eosinophilia were diagnosed by general gastrointestinal endoscopy; among them, 3 patients had dysphagia and 3 were asymptomatic. The remaining 11 patients were diagnosed by medical check-up endoscopy. All patients were treated with a proton pump inhibitor (PPI); 5 were diagnosed with EoE and 12 with PPI responsive esophageal eosinophilia. Chronological endoscopy analysis showed that EoE findings could be observed for a mean of 6.1 years prior to diagnosis, and the disease did not significantly progress in severity. CONCLUSIONS: Most Japanese patients with EoE have mild and slowly progressing disease, which can be diagnosed when close attention is paid to the endoscopic findings. Medical check-up endoscopy in Japan could be a great opportunity for the early diagnosis of EoE.

[A case of a hepatic arterial pseudoaneurysm that occurred after acute cholangitis due to choledocholithiasis].

We describe a 52-year-old male who underwent endoscopic retrograde biliary drainage for acute cholangitis associated with common bile duct stones. Endoscopic papillary balloon dilatation was performed, and the stones were removed using a balloon catheter. Simultaneously, we initiated edoxaban for portal vein thrombosis. Approximately one month later, he visited our hospital complaining of tarry stools and dizziness. Contrast-enhanced computed tomography revealed a pseudoaneurysm in the hepatic artery (A7), and he was diagnosed with hemobilia from bile duct perforation associated with the hepatic arterial pseudoaneurysm. We performed an emergent transcatheter arterial embolization. Notably, re-bleeding has not occurred to date. Hepatic arterial pseudoaneurysms can occur after acute cholangitis;therefore, careful follow-up is essential.

Successful Ombitasvir/Paritaprevir/Ritonavir Plus Ribavirin Retreatment for a Chronic Hepatitis C Genotype 2a Patient Who Relapsed after Sofosbuvir Plus Ribavirin Treatment.

The optimum retreatment strategy for chronic hepatitis C virus (HCV) patients who failed directly-acting antiviral agents (DAA)-based therapy is unknown. We herein report the outcomes of an HCV genotype (GT) 2a-infected patient with virologic failure following treatment with sofosbuvir plus ribavirin (SOF+RBV) who was successfully retreated with ombitasvir/paritaprevir/ritonavir plus ribavirin (OBV/PTV/r+RBV).

Evaluation of the branched-chain amino acid-to-tyrosine ratio prior to treatment as a prognostic predictor in patients with liver cirrhosis.

This study evaluated whether the branched-chain amino acid-to-tyrosine ratio (BTR) is a prognostic predictive factor in patients with liver cirrhosis by determining the relationship of the BTR with event-free survival in a retrospective, observational cohort study. The medical records of patients with liver cirrhosis who visited our institution from February 2000 to May 2012 were examined. Events due to liver cirrhosis were defined as death, worsening of esophageal and/or gastric varices, hepatocellular carcinoma, and liver failure. The primary endpoint was the period from the date of BTR measurement until the first onset of these events. Event-free survival was compared between patients with BTR ≥ 4 and BTR < 4. Relationships between the BTR and other factors predicting prognosis were also examined. Event-free survival was evaluated in patients with and without branched-chain amino acid supplementation using propensity score matching. Significantly longer event-free survival was found in liver cirrhosis patients with BTR ≥ 4 (n = 425) compared with those with BTR < 4 (n = 105), and the BTR was associated with liver cirrhosis events. The BTR showed significant relationships with other predictive factors evaluated. In subcohorts matched by propensity score, branched-chain amino acid supplementation significantly improved event-free survival in patients with BTR <4. The BTR is clinically useful for predicting prognosis in liver cirrhosis patients. BCAA supplementation may be beneficial in those with BTR < 4.

Hemodynamic Changes on Cone-Beam Computed Tomography during Balloon-Occluded Transcatheter Arterial Chemoembolization Using Miriplatin for Hepatocellular Carcinoma: A Preliminary Study.

BACKGROUND/AIM: Balloon-occluded transcatheter arterial chemoembolization (B-TACE) using miriplatin (MPT) is anticipated as a new strategy for hepatocellular carcinoma (HCC). This study was aimed at evaluating the hemodynamic changes with/without balloon occlusion of the hepatic artery, correlation of cone-beam CT (CBCT) pixels, and CT value after B-TACE for HCC. METHODS: A total of 52 patients with HCC, who underwent B-TACE using MPT in addition to the balloon-occluded CBCT hepatic arteriography, were studied. RESULTS: After balloon occlusion, CBCT pixel values increased in 37 lesions, whereas it decreased in 15 lesions. Intratumoral CT values after B-TACE were lower with decreased CBCT pixel values than with increased CBCT pixel values. CONCLUSION: Hemodynamic changes on CBCT during balloon occlusion can be used to predict the efficacy of B-TACE using MPT.

Effect of treatment support on preventing local recurrence of hepatocellular carcinoma directly adjacent to the diaphragm.

Treatment support is anticipated to improve the results of radiofrequency ablation (RFA) treatment in cases in which visualization of tumors using the conventional B-mode is unclear. In the present study, the effectiveness of treatment support for RFA reducing the local recurrence rate of hepatocellular carcinoma (HCC) that are located directly adjacent to the diaphragm, and which are difficult to visualize with B-mode ultrasound imaging, was investigated. A total of 103 HCC tumors measuring <5 cm, which were located abutting the diaphragm, and which were difficult to visualize using the B-mode, were treated using RFA. Thirty-three of those HCC tumors were treated using RFA without treatment support, whereas the remaining 70 HCC tumors were treated using RFA with treatment support, including artificial pleural effusion, contrast-enhanced ultrasonography (CEUS) with the contrasting agent, Sonazoid™, and fusion imaging, either alone or in combination to improve the visualization of the tumors. The rate of local recurrence, and factors affecting local recurrence, were analyzed. Local recurrences were confirmed in 17 of the 103 nodules (16.50%). The overall rate of local recurrence was 13.1% at 6 months, and 20.2% at 12 months. The rate of local recurrence using RFA with artificial pleural effusion was significantly lower compared with those cases of HCC tumors treated without artificial pleural effusion (P=0.008). Similarly, the rate of local recurrence for CEUS RFA with Sonazoid™ was significantly lower compared with those cases of HCC tumors treated without Sonazoid™ (P=0.00081). In a multivariate analysis, CEUS RFA with Sonazoid™ and artificial pleural effusion contributed to the decrease in the rate of local recurrence (hazard ratios, 0.075 and 0.143, respectively). Based on these results, it is possible to conclude that CEUS with Sonazoid™ as a treatment support was the most effective method for reducing the rate of local recurrences abutting the diaphragm that are difficult to visualize using B-mode ultrasonography.

Percutaneous transhepatic obliteration and percutaneous transhepatic sclerotherapy for intractable hepatic encephalopathy and gastric varices improves the hepatic function reserve.

Percutaneous transhepatic obliteration (PTO) and percutaneous transhepatic sclerotherapy (PTS) are widely performed as an emergency measure in cases of variceal hemorrhage and intractable hepatic encephalopathy. The PTO/PTS technique is capable of directly blocking the blood supply in cases in which balloon-occluded retrograde transvenous obliteration (B-RTO) is not effective, or in cases with complicated collateral flow. Although PTO/PTS is not currently the first choice due to the invasiveness of transhepatic puncture, this procedure can modify the blood flow in an antegrade manner. The present study examined the changes in hepatic function reserve following PTO/PTS for intractable hepatic encephalopathy and/or gastric varices. In total, the study included 37 patients (mean age, 61.75±12.77 years; age range, 32-88 years; male to female ratio, 23:14) with a variety of gastrorenal shunts, or B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts. The patients underwent PTO/PTS by embolizing a microcoil or injection of a sclerosing agent (5% ethanolamine oleate iopamidol). Alterations in hepatic function reserve prior to and following the procedure were compared. The patients were treated for hepatic encephalopathy in 11 patients, gastric varices in 19 patients, and both conditions in 7 patients. The results indicated that the blood ammonia level improved from 135.76±75.23 mg/dl to 88.00±42.16 and 61.81±33.75 mg/dl at 3 and 6 months after therapy, respectively. In addition, the Child-Pugh score improved from 8.48±2.01 prior to therapy to 7.70±1.84 and 7.22±2.01 at 3 and 6 months after the procedure, respectively. Although there was a concern that PTO/PTS may cause complications due to an increase in portal venous pressure (PVP) arising from shunt occlusion, no severe complications were observed. In conclusion, for patients with various gastrorenal shunts or those with B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts, PTO/PTS can improve the antegrade blood flow to the liver, as demonstrated by improvement in the hepatic function reserve.

Improved survival with double platinum therapy transcatheter arterial infusion using cisplatin and transcatheter arterial chemoembolization using miriplatin for BCLC-B hepatocellular carcinoma.

Transcatheter arterial chemoembolization (TACE) is the standard therapy for Barcelona Clinic Liver Cancer (BCLC) classification intermediate stage B hepatocellular carcinoma (HCC). However, other transcatheter methods, such as transcatheter arterial infusion (TAI), also play an important role in the treatment of advanced HCC. Although it has been reported that TAI with a high concentration of a fine-powder formulation of cisplatin (DDP-H) reduced intrahepatic recurrence and improved survival, the combined use of TAI with DDP-H and TACE has not yet been investigated. The aim of this study was to evaluate which TACE chemotherapeutic agent in combination with DDP-H TAI contributes more to improved survival in BCLC-B HCC. Survival was analyzed in 55 patients who underwent DDP-H TAI and TACE for BCLC-B HCC. The patients were classified into two groups; Epirubicin was used as the TACE agent in 29 patients, whereas miriplatin was used in 26 patients. The cumulative survival rates at 1 and 2 years were 66.4 and 36.0% in the epirubicin and 95.8 and 61.30% in the miriplatin group, respectively. Survival time was significantly prolonged in the miriplatin group compared with that in the epirubicin group. Multivariate analysis identified Child-Pugh classification and up-to-seven criteria as factors affecting survival. In addition, the selection of miriplatin as the TACE chemoagent was the treatment factor that most significantly affected survival. Thus, double-platinum therapy with DDP-H TAI and miriplatin TACE may be a useful treatment strategy for improving survival in BCLC-B HCC patients.

Clinical efficacy of the highly sensitive hepatitis C virus RNA quantitative assay in patients with relapse following interferon-based therapy with second-generation direct-acting antivirals.

For refractory chronic hepatitis C, interferon (IFN)-based triple-agent combination therapy with second-generation direct-acting antivirals (DAAs) has been established as the standard treatment method. The rate of decrease in the viral load and the negative conversion of hepatitis C virus (HCV) RNA in the early phase following treatment initiation are considered important factors for predicting the therapeutic outcome. In the present study, the Roche Cobas AmpliPrep/COBAS TaqMan (CAP/CTM) HCV v2.0 assay and the AccuGENE m-HCV RNA quantitative assay [Abbott RealTime HCV (ART) assay] were analyzed for their clinical efficacy and ability to predict therapeutic outcomes in the early phase in patients with relapse following IFN-based second-generation DAA therapy. Of the 56 patients who received IFN-based second-generation DAA therapy since December 2013, 6 achieved an end-of-treatment response (ETR), but subsequently experienced relapse. In these 6 patients, fluctuations in viral loads in the early phase detected by the CAP/CTM and ART assays were compared. At 4 weeks after treatment initiation, 4 of the 6 patients were diagnosed as negative by the CAP/CTM assay, whereas 2 of these 4 patients were not identified as negative by the ART assay. Of the 2 patients, one was signal-positive with an HCV RNA load <1.08 Log IU/ml, and the other patient had a viral load of 1.12 Log IU/ml. At 8 weeks after treatment initiation, 1 patient was found to be negative by the CAP/CTM assay, but signal-positive with a viral load <1.08 Log IU/ml by the ART assay. From 4 to 8 weeks after treatment initiation, 3 of the 6 patients appeared to be discrepant cases. In conclusion, of the 6 patients who achieved an ETR, 4 were determined to have achieved a rapid virological response (RVR) by the CAP/CTM assay, but may not have actually become negative. The ART assay is highly sensitive, has a wide measurement range, may be suitable for monitoring HCV RNA loads, and is expected to have an important role in providing a predictive marker for early therapeutic outcomes. In discrepant cases in which no RVR is proved by either assay, it was assumed important to consider continuation of treatment and to attempt to achieve a sustained virological response.

Telaprevir-based triple therapy following partial splenic arterial embolization for chronic hepatitis C with thrombocytopenia can reduce carcinogenesis and improve hepatic function reserve.

Thrombocytopenia in patients with chronic hepatitis C negatively impacts interferon (IFN)-based treatment. The aim of this study was to evaluate the efficacy and safety of telaprevir (TVR)-based triple therapy including IFN for patients who have undergone partial splenic arterial embolization (PSE). Ten patients with thrombocytopenia who were infected with hepatitis C virus (HCV) genotype 1b received 12 weeks of TVR in combination with 24 weeks of pegylated interferon (PEG-IFN)α2b and ribavirin following PSE. A sustained virological response (SVR) was seen in 9 of the 10 patients who could be assessed. Early relapse was seen in 1 patient who had the IL-28B minor allele and a null response to pretreatment. The α-fetoprotein levels of the patients decreased from 17.94±7.30 ng/ml prior to PSE to 4.33±2.41 ng/ml at 6 months after triple therapy (P=0.08). Furthermore, serum albumin levels improved significantly from 3.68±0.49 g/dl pre-PSE to 4.13±0.34 g/dl at 12 months after triple therapy (P=0.043). PSE contributed to the treatment success of triple therapy, particularly for patients who were either treatment-naïve, had a history of relapse or the IL28B major allele. This strategy can reduce carcinogenesis and improve hepatic function reserve.

Prediction of a sustained viral response in chronic hepatitis C patients who undergo induction therapy with double filtration plasmapheresis plus interferon-ß/ribavirin.

The aim of the present study was to determine predictors of a sustained virological response (SVR) with a regimen of double filtration plasmapheresis (DFPP) combined with interferon-ß plus ribavirin (IFN-ß/RBV) induction therapy prior to pegylated (PEG-IFN/RBV) standard of care (SOC) therapy for patients with chronic hepatitis C who had experienced SOC treatment failure. Predictors of a SVR were analyzed in chronic hepatitis C patients with genotype 1b hepatitis C virus (HCV), who had a high viral load. The patients had been unresponsive to previous IFN therapy and underwent induction therapy with IFN-ß/RBV plus DFPP, which was performed five times during the same period, followed by PEG-IFN/RBV. In total, 10 patients received the combination DFPP plus IFN-ß/RBV induction therapy prior to PEG-IFN/RBV therapy for the treatment of chronic hepatitis C. Two weeks after treatment initiation, a decrease in the HCV RNA levels of ≥2 log IU/ml occurred in 9/10 patients (90%), while a decrease of ≥4 log IU/ml was observed in 4/10 patients (40%). The HCV RNA levels at week 2 after treatment initiation in the SVR and non-SVR patients decreased by 5.0±0.8 and 2.9±1.1 log IU/ml, respectively. Despite no response to previous IFN therapy, three of the 10 patients (30%) experienced a SVR. The results indicated that a rapid virological response ensued following IFN-ß/RBV induction and DFPP supplementary therapy. Although the level of interleukin-28B is an important predictor of a SVR, a decrease in the HCV RNA volume of ≥4 log IU/ml at week 2 after the initial treatment is also an important predictor. Therefore, rapid virological reduction using DFPP, in addition to IFN-ß/RBV induction therapy, is an important predictor of a SVR.

Predictive factor of local recurrence after balloon-occluded TACE with miriplatin (MPT) in hepatocellular carcinoma.

BACKGROUND: Miriplatin (MPT) is a novel platinum complex used in TACE that shows promise for the treatment of hepatocellular carcinoma (HCC). However, rapid washout has been reported in some cases. Therefore, various methods of administration with MPT have been attempted to increase its therapeutic efficacy. One hopeful method is balloon-occluded TACE (B-TACE), but the therapeutic efficacy of B-TACE with MPT has not been evaluated. AIM: To investigate the treatment outcomes and factors involved in local recurrence after B-TACE with MPT in HCC. METHODS: This study included 51 patients (55 nodules) with HCC lesions equal or less than 5 cm in diameter who underwent B-TACE with MPT between January 2012 and June 2013. Local recurrence after B-TACE with MPT and factors associated with local recurrence were evaluated. RESULTS: The overall local recurrence rate was 11.1% at 6 months and 26.2% at 12 months. The local recurrence rate did differ significantly depending on CT values immediately after B-TACE with MPT. Multivariate analysis also showed that the CT value after B-TACE with MPT was the only factor related to local recurrence after B-TACE. CONCLUSIONS: B-TACE with MPT achieves relatively good local control of HCC. The plain CT value immediately after B-TACE with MPT is a predictive factor for local recurrence. In patients with unsatisfactory CT values, locoregional therapy or additional treatment is required.

Percutaneous transhepatic portal vein stent placement can improve prognosis for hepatocellular carcinoma patients with portal vein tumor thrombosis.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) has an extremely poor prognosis. One reason is that portal hypertension may progress rapidly and intractable gastric/esophageal variceal hemorrhage may occur in PVTT cases. We studied whether a percutaneous transhepatic portal vein stent placement could improve the prognosis for HCC with PVTT. METHODOLOGY: Five cases of HCC with PVTT where portal hypertension had rapidly progressed were performed portal vein stenting. RESULTS: All cases had been classified into Child-Pugh class C. Only one of them died of liver failure five months after stent placement, but two of the cases successfully avoided dying of liver failure and the other two cases are still alive with a hepatic functional reserve maintained. CONCLUSIONS: Although portal vein stent placement for HCC with PVTT is not by itself a therapy for PVTT, portal vein stent placement plays a prominent role in improving hepatic function reserve preventing fatal hepatic failures due to PVTT and gastric/esophageal variceal hemorrhage associated with portal hypertension. This leads to prolonged survival for HCC patients with PVTT. Further prospective trials including the appropriate timing of portal vein stent placement treatment will be needed for larger numbers of HCC patients with PVTT.

Concurrent partial splenic embolization with transcatheter arterial chemoembolization for hepatocellular carcinoma can maintain hepatic functional reserve.

AIM: Hepatocellular carcinoma (HCC) is frequently complicated with cirrhosis, and it is not unusual for treatment options to be limited as a result of pancytopenia due to hypersplenism. Partial splenic embolization (PSE) has been performed for thrombocytopenia resulting from hypersplenism. We studied the efficacy in terms of hepatic functional reserve and safety in patients who underwent concurrent transcatheter arterial chemoembolization (TACE) with PSE for HCC. METHODS: The study population consisted of 101 HCC patients with thrombocytopenia. Fifty-three patients were treated with concurrent TACE/PSE (PSE group), and the remaining 48 TACE patients without PSE (non-PSE group) were investigated hepatic functional reserve. RESULTS: Platelet counts were significantly higher in the PSE group after 2 weeks, 2 months and 6 months after TACE than the non-PSE group. Child-Pugh score significantly deteriorated from 7.13 ± 1.16 to 7.60 ± 1.20 at 2 weeks, to 7.71 ± 1.25 at 2 months, and 7.71 ± 1.35 at 6 weeks after TACE in the non-PSE group. Hence, it worsened from 7.04 ± 1.05 to 7.21 ± 0.99 at 2 weeks temporally, but improved to 7.00 ± 1.17 after 2 months and 6.70 ± 1.16 at 6 weeks after TACE in the PSE group. CONCLUSION: Thrombocytopenia has been improved and treatment continued using concurrent PSE. In addition, hepatic functional reserve could be maintained even after treatment for HCC. Concurrent TACE and PSE for HCC with thrombocytopenia can be expected to help maintain hepatic reserve, and may contribute to improving the prognosis of HCC.

Branched-chain amino acids to tyrosine ratio (BTR) predicts intrahepatic distant recurrence and survival for early hepatocellular carcinoma.

BACKGROUND/AIMS: The Child-Pugh classification system is the most widely used system for assessing hepatic functional reserve in HCC treatment. In the Child-Pugh classification system, serum albumin levels are used to accurately assess the status of protein metabolism and nutrition. To date, a lack of attention has been given to amino acid metabolism. In the present study, we investigated whether the branched-chain amino acids to tyrosine ratio (BTR) as an indicator of amino acid metabolism can serve as both a prognostic factor for early HCC and a predictive factor for recurrence. METHODOLOGY: We conducted a cohort study of 50 patients with stage I/II HCC enrolled between May 2002 and December 2010. It was investigated whether BTR can serve as both a prognostic factor and a predictive factor for HCC recurrence. RESULTS: Overall survival rates were significantly higher in patients with high baseline BTR than in those with low BTR. Multivariate analysis showed that both BTR and serum albumin were prognostic factors, and that BTR was the best predictive factor for recurrence. CONCLUSIONS: BTR was a prognostic factor for early HCC and the most predictive factor for intrahepatic distant recurrence and contributing factors for survival.

Prevalence of Howell-Jolly bodies caused by partial splenic embolization for portal hypertension.

OBJECTIVE: Postsplenectomy sepsis (PSS) and overwhelming postsplenectomy infection (OPSI) following splenectomy or the development of hyposplenism are associated with a high mortality rate. The presence of Howell-Jolly bodies (HJBs) in peripheral erythrocytes is attracting attention as a parameter of hyposplenism. To date, whether HJBs appear following partial splenic embolization (PSE) has not been investigated. Therefore, we examined the prevalence of HJBs in patients who have undergone PSE. METHODS: Whether HJBs were present in 95 patients who underwent PSE between November 2007 and August 2012 was assessed. RESULTS: No serious complications occurred due to PSE; however, 17 of the 95 patients (17.89%) exhibited HJBs during the follow-up. The residual spleen volume and splenic infarction rate did not differ significantly compared to those observed in the HJB-negative group. CONCLUSION: With the recent increase in the use of autoanalyzers, the opportunities to perform microscopic examinations have been decreasing. Therefore, the presence of HJBs, which can only be confirmed visually, may be overlooked, and the clinical significance of these bodies tends to be disregarded. However, the presence of HJBs is associated with a risk of PSS and OPSI due to hyposplenism. Because HJBs are common in the peripheral erythrocytes of patients who have undergone PSE, irrespective of the residual spleen volume or splenic infarction rate, the presence or absence of HJBs should be assessed visually. In HJB-positive patients, preventing serious infections, for example, by administering the pneumococcal vaccine, is important.

Radiofrequency ablation during continuous saline infusion can extend ablation margins.

AIM: To determine whether fluid injection during radiofrequency ablation (RFA) can increase the coagulation area. METHODS: Bovine liver (1-2 kg) was placed on an aluminum tray with a return electrode affixed to the base, and the liver was punctured by an expandable electrode. During RFA, 5% glucose; 50% glucose; or saline fluid was infused continuously at a rate of 1.0 mL/min through the infusion line connected to the infusion port. The area and volume of the thermocoagulated region of bovine liver were determined after RFA. The Joule heat generated was determined from the temporal change in output during the RFA experiment. RESULTS: No liquid infusion was 17.3 ± 1.6 mL, similar to the volume of a 3-cm diameter sphere (14.1 mL). Mean thermocoagulated volume was significantly larger with continuous infusion of saline (29.3 ± 3.3 mL) than with 5% glucose (21.4 ± 2.2 mL), 50% glucose (16.5 ± 0.9 mL) or no liquid infusion (17.3 ± 1.6 mL). The ablated volume for RFA with saline was approximately 1.7-times greater than for RFA with no liquid infusion, representing a significant difference between these two conditions. Total Joule heat generated during RFA was highest with saline, and lowest with 50% glucose. CONCLUSION: RFA with continuous saline infusion achieves a large ablation zone, and may help inhibit local recurrence by obtaining sufficient ablation margins. RFA during continuous saline infusion can extend ablation margins, and may be prevent local recurrence.

Improved method for transjugular liver biopsy using imaging sheaths developed for balloon-occluded retrograde transvenous obliteration.

BACKGROUND/AIMS: Patients with ascites or coagulation abnormalities and requiring a liver biopsy may undergo transjugular liver biopsy (TJLB) rather than percutaneous liver biopsy. Currently, the difficulty in maneuvering the sheath towards the hepatic vein keeps this procedure from being widely used. Therefore, the utility of imaging sheaths, typically used for balloon-occluded retrograde transvenous obliteration, during TJLB was examined. METHODOLOGY: TJLB was conducted on 41 patients using conventional, Teflon vascular sheaths (9 Fr, 45 cm) and on 60 patients using S1 sheaths (8 Fr, 50 cm). The duration of TJLB procedures, and their associated complications were compared. RESULTS: The mean duration of the procedure was 26.9±7.94 minutes in the group undergoing TJLB with Teflon sheaths, significantly longer (p <0.01) than 20.1±4.52 minutes in the patients using S1 sheaths. However, in two (3.3%) of the S1 sheath patients, the sheaths had to be replaced with Teflon TJLB sheaths. CONCLUSIONS: This study demonstrates that liver biopsies can be successfully collected by TJLB using S1 sheaths instead of the Teflon sheaths. This substitution for a more flexible material allows for a shorter invasive intervention time for patients for which percutaneous liver biopsy is not an option.