Endoscopic Ultrasound-Guided Vascular Therapy for Portoduodenal Fistula.

Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.

The Impact of Transarterial Chemoembolization for Advanced Stage Hepatocellular Carcinoma: A Single Center Experience.

Objective: The present study aimed to study survival and complications of hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage C who received transarterial chemoembolization (TACE) at Rajavithi Hospital, Thailand. Material and Method: The method used was a descriptive retrospective study using data collected from patient medical records from 2008 to 2012. The general information, complications, and causes of death of the patients were presented with descriptive statistics. Survival was analyzed using the Kaplan-Meier method. Results: During the 5-year period, our institution performed TACE on 396 patients. While 57 cases were classified as BCLC stage C, only 44 cases had complete records. The mean age of the patients was 56.3 years with an age range from 30 to 75 years. Thirty-six cases or 81.8% were male. Twenty-six cases or 59.1% had hepatitis B infections. Thirty-five cases or 79.5% were Child-Pugh A. The median survival time was 7.1 months. The most common complication was post-embolization syndrome which occurred in 39 patients (88.6%). Liver failure was a major procedural-related complication which occurred in 8 patients (18.2%) and was responsible for three deaths (6.8%). Conclusion: TACE in HCC patients with BCLC stage C at Rajavithi Hospital was an effective and safe palliative treatment.

Long-term outcome of patients undergoing liver transplantation at Rajavithi Hospital, Thailand.

OBJECTIVE: Examine long-term outcome and survival of patients with liver transplantation at Rajavithi Hospital, a small-volume transplant center in Bangkok, Thailand. MATERIAL AND METHOD: Between May 1996 and December 2010, 21 liver transplantations were performed Piggyback technique and portal vein flushing with one liter of cold normal saline was used to prevent reperfusion injury. Color Doppler ultrasound was performed routinely. Data collection included demographic data, complications, operation time, ischemic time, duration of stay in intensive care unit (ICU), hospitalization period, and survival. RESULTS: There were two cases withdrawn from immunosuppressant drugs due to loss of follow-up and recidivism. Late death in three patients was from bleeding after hemiarthroplasty, chronic rejection, and lymphoma. Overall, 5-year and 10-year survival were 62% and 42% respectively Biliary complication rate was 9.5%. Two cases were under early reoperation due to bleeding from hepatic artery and retrohepatic vein. Hepatic vein occlusion was found in one case that had underlying Budd Chiari. One case with hepatocellular carcinoma, 10 nodules in both lobes of liver had survived more than three years after transplantation. CONCLUSION: Liver transplantation is a high-cost procedure. Good long-term results depend on expensive drugs, skilled surgeons, state-of-the-art equipment, and good team work. Policy and support from the government play an important role for successful transplantation, especially in developing countries.

Novel technique of mesh fixation with cyanoacrylate in totally extraperitoneal laparoscopic hernia repair: early experience.

Totally extraperitoneal laparoscopic hernioplasty (TEP) is an alternative surgery for inguinal hernia repair, but chronic pain is still a problem. The authors proposed the use of cyanoacrylate for mesh fixation instead of staples which might be the cause of chronic groin pain. The authors also innovated an instrument for delivery of cyanoacrylate for mesh fixation. The present article reported early experience in the first 15 patients who were treated with this technique. Early post-operative pain was comparable to a previous study, no recurrence and no chronic groin pain was detected after surgery.

Prognostic relevance of circulating CK19 mRNA in advanced malignant biliary tract diseases.

AIM: To determine the role of circulating tumor cells (CTCs) in prediction of the overall survival of patients with advanced malignant biliary tract obstruction. METHODS: We investigated the prognostic value of CTCs by examining two markers, cytokeratin (CK) 19 and human telomerase reverse transcriptase (hTERT) mRNA, in 40 patients diagnosed with advanced malignant biliary tract diseases. Quantitative real-time reverse transcription polymerase chain reaction was used to detect CK19 and hTERT mRNA in the peripheral blood of these patients. Overall survival was analyzed using the Kaplan-Meier method and Cox regression modeling. RESULTS: Positive CK19 and hTERT mRNA expression was detected in 45% and 60%, respectively, of the 40 patients. Univariable analysis indicated that positive CK19 mRNA expression was significantly associated with worse overall survival (P = 0.009). Multivariable analysis determined that positive CK19 mRNA expression, patient's age and serum bilirubin were each independently associated with overall survival. CONCLUSION: CK19 mRNA expression levels in peripheral blood appear to provide a valuable marker to predict the overall survival of patients with advanced malignant biliary tract obstruction.

Serum AFP and AFP-L3 in clinically distinguished hepatocellular carcinoma from patients with liver masses.

OBJECTIVE: To determine the ability of alpha fetoprotein (AFP) and AFP-L3% serum level in discriminating hepatocellular carcinoma (HCC) from other types of liver mass. MATERIAL AND METHOD: This study was performed according to a prospective-specimen-collection, retrospective-blinded-evaluation (PRoBE) design. A total of 109 HCC patients and 51 patients with other types of liver mass were consecutively selected. The levels of AFP and AFP-L3% in their sera were measured. RESULTS: AFP levels in serum significantly elevated while AFP-L3% levels significantly decreased in HCC patients (AFP: p < 0.001, AFP-L3%: p < 0.001). The area under the curve (AUC) of a receiver operating characteristic (ROC) curve analysis for the diagnosis of HCC of AFP and AFP-L3% was 0.71 and 0.67, respectively. In addition, the serum level of AFP-L3% was significantly different between the small (mass occupying lesser than 50% of liver volume) and large (mass occupying more than 50% of liver volume) HCC (p = 0.040). CONCLUSION: The diagnostic accuracy of serum AFP and AFP-L3% could provide them as candidate biomarkers to discriminate patients with HCC from patients with other types of liver mass. Serum AFP-L3% as a prognostic factor for HCC should be further evaluated in more details.

Total laparoscopic right hepatectomy for large hepatocellular carcinoma: the first report in Thailand.

Limited cases of total laparoscopic right hepatectomy have been reported worldwide due to technically difficulty, especially in a large hepatocellular carcinoma (HCC). The objective of this article is to describe a simple technique for total laparoscopic right hepatectomy which was successfully performed in two patients with large HCC. Anterior approach technique combined with glissonian approach and principle of liver hanging maneuver were used. The detailed surgical technique was described. Total laparoscopic right hepatectomy for large HCC is feasible and safe.

Establishment and characterization of a cholangiocarcinoma cell line (RMCCA-1) from a Thai patient.

AIM: To establish and characterize a new cell line derived from peripheral cholangiocarcinoma of a Thai patient. METHODS: The peripheral cholangiocarcinoma specimen surgically obtained from the patient was aseptically processed by washing and mincing before culturing in Ham's F12 medium containing 10% fetal bovine serum. After 3 mo, when the cell line has become homogeneous and stabilized, several features were investigated, including growth characteristics, immunofluorescence staining for cytokeratins, expression of tumor markers, chromosomal analysis by G-banding and multicolour fluorescence in situ hybridization (mFISH), in vitro migration and invasion characteristics. RESULTS: The RMCCA-1 cell line has been established. These cells proliferated as a monolayer with a population doubling time of 48 h. Immunofluorescence staining showed positive staining for human cytokeratin 7 and 19 verifying the biliary epithelial origin. RMCCA-1 secreted carbohydrate antigen 19-9 (CA19-9), but insignificant levels of carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP). Chromosome analysis identified aneuploidy karyotypes with a modal chromosome number of 59. RMCCA-1 exhibited a low level of in vitro invasiveness, but a high degree of motility. The cell line exhibited a significant number of chromosomal aberrations as shown by mFISH and G-banding methods. CONCLUSION: A new cell line derived from peripheral cholangiocarcinoma of a Thai patient has been established. This cell line shows a low level of in vitro invasiveness, but a high degree of motility. It will serve as a valuable tool for further studies on tumor biology, molecular pathogenesis, metastatic mechanism and response to therapeutic drugs of cholangiocarcinoma.

Simple technique in the measurement of liver volume.

The measurement of liver volume is considered to be a highly effective prediction of postoperative liver failure in hepatectomized patients and selection of the proper size of the liver obtained from a living donor. The aim of the paper was therefore, to develop a simple, inexpensive and practical technique for the measurement of liver volume. Computerized tomography (CT) imaging sections were used to measure sectional areas of liver sections via a graphic program. The volumes of livers were then calculated from the combined sectional areas using mean-area, end-area, and prismodial methods. The calculated volumes of livers obtained were compared to those manually measured in a water replacement technique. The findings of the results indicated that the liver volume could be estimated from CT scan films with typically less than 5 per cent difference compared to the manual method.