Impact of the Ablative Margin on Local Tumor Progression after Radiofrequency Ablation for Lung Metastases from Colorectal Carcinoma: Supplementary Analysis of a Phase II Trial (MLCSG-0802).

PURPOSE: To explore what extent of ablative margin depicted by computed tomography (CT) immediately after radiofrequency (RF) ablation is required to reduce local tumor progression (LTP) for colorectal cancer (CRC) lung metastases. MATERIALS AND METHODS: This retrospective study was undertaken as a supplementary analysis of a previous prospective trial. Seventy patients (49 men and 21 women; mean age ± standard deviation, 64.9 years ± 10.6 years) underwent RF ablation for CRC lung metastases, and 95 tumors that were treated in the trial and followed up with CT at least 12 months after RF ablation were evaluated. The mean tumor size was 1.0 cm ± 0.5 cm. The ablative margin was estimated as the shortest distance between the outer edge of the tumor and the surrounding ground-glass opacity on CT obtained immediately after RF ablation. The impact of the ablative margin on LTP was evaluated using logistic regression analysis. Multivariate logistic regression analysis was also performed to identify the risk factors for LTP. The result was validated with multivariate logistic regression applying a bootstrap method (1,000 times resampling). RESULTS: The mean ablative margin was 2.7 mm ± 1.3 (range, 0.4-7.3 mm). LTP developed in 6 tumors (6%, 6/95) 6-19 months after RF ablation. The LTP rate was significantly higher when the margin was less than 2 mm (P = .023). A margin of <2 mm was also found to be a significant factor for LTP (P = .048) on multivariate analysis and validated using the bootstrap method (P = .025). CONCLUSIONS: An ablative margin of at least 2 mm is important to reduce LTP after RF ablation for CRC lung metastases.

Natural History of Unruptured Visceral Artery Aneurysms Due to Segmental Arterial Mediolysis and Efficacy of Transcatheter Arterial Embolization: A Retrospective Multiinstitutional Study in Japan.

OBJECTIVE. The purpose of this study was to clarify the natural history of unruptured visceral artery aneurysms due to segmental arterial mediolysis and the efficacy of transcatheter arterial embolization. MATERIALS AND METHODS. Patients with a pathologic or clinical diagnosis of visceral artery aneurysms due to segmental arterial mediolysis between 2005 and 2015 were enrolled. For patients with clinical diagnoses, images were collected and assessed by central radiologic review. To clarify the natural history of unruptured aneurysms, the morphologic changes were assessed. The efficacy and safety of transcatheter arterial embolization for aneurysms due to segmental arterial mediolysis were evaluated. RESULTS. Forty-five patients with 123 aneurysms due to segmental arterial mediolysis were enrolled. Among the 123 aneurysms, 70 unruptured aneurysms were evaluated for natural history. Forty-five of the 70 (64%) aneurysms had no change in morphology. Among the other 25 aneurysms, nine (13% of the 70) were reduced in size, 13 (19%) disappeared, and three (4%) were newly found at follow-up. Aneurysms of the middle colic artery were ruptured in 10 of 11 (91%) cases. Transcatheter arterial embolization was performed on 45 aneurysms and was successful in all cases but caused slight arterial injury in three cases (6.7%). CONCLUSION. At initial diagnosis, unruptured aneurysms due to segmental arterial mediolysis are likely to be stable or to resolve, but the risk of rupture of aneurysms of the middle colic artery appears high. Transcatheter arterial embolization is a useful treatment, but careful manipulation is necessary.

Oxidative stress induced by portal vein embolization in fatty liver: Experimental study of a nonalcoholic steatohepatitis model.

The present study aimed to investigate whether excessive oxidative stress production or reduction of antioxidative stress potential may occur following portal vein embolization (PVE) in an experimental animal nonalcoholic steatohepatitis (NASH) model. A NASH rabbit model (n=11) was established by feeding of a fat diet for 4 weeks, and a normal diet rabbit model (n=11) was prepared as a control. The oxidative status of NASH was examined by measuring derivatives of reactive oxygen metabolites (d-ROM) for oxidative stress and biological antioxidative potential (BAP) for antioxidative potential in the NASH model and normal group. Additionally, oxidative status of PVE after 2 weeks was assessed by measuring d-ROM and BAP in the NASH and normal liver models. Oxidative status in a PVE+NASH model was also detected. In the process of NASH creation (fat diet for 4 weeks), total cholesterol was increased in the NASH group (P<0.0001). In the NASH group, PVE induced an increase in serum aspartate transaminase (P=0.0318). At 4 weeks after initiation of the fat diet, a decrease in BAP was determined as statistically significant (P<0.0001). In normal liver, d-ROM production was stimulated in the Sham group after 2 weeks (P=0.0152), but BAP was not altered (P=0.6119). In NASH liver, d-ROM production was stimulated in PVE and Sham groups (P<0.0001 and P=0.0189, respectively), but BAP did not change (P>0.05). In conclusion, decrease of antioxidant potential may promote NASH progression. Additionally, PVE appeared to cause a surge in oxidative stress in NASH liver.

Comparison of conservative treatment versus transcatheter arterial embolisation for the treatment of spontaneously ruptured hepatocellular carcinoma.

PURPOSE: To elucidate the prognostic factors in the spontaneous rupture of hepatocellular carcinoma (HCC) and to determine whether transcatheter arterial embolisation (TAE) is associated with better prognosis compared to conservative treatment. MATERIAL AND METHODS: A retrospective multicentre study was conducted involving 71 patients with spontaneous rupture of HCC. A conservative treatment group (Cons T group) included 20 patients, while a transcatheter arterial embolisation group (TAE group) included 51 patients. RESULTS: The median survival time (MST) in the Cons T group was only 16 days and the survival rate was 39% at one month, whereas the MST in the TAE group was 28 days and the one month survival rate was 63%. However, there is no statistically significant difference in the overall survival between Cons T and TAE groups (p = 0.213). Multivariable analysis identified only the presence of distant metastasis as an independent prognostic factor (p = 0.023). A subanalysis including patients without distant metastasis showed that the presence of portal vein tumour thrombosis was a significant prognostic factor (p = 0.015). CONCLUSIONS: Distant metastasis appears to be a prognostic factor in spontaneous rupture of HCC. In cases without distant metastasis, portal vein tumour thrombosis could influence the prognosis. Our data failed to prove any benefit of TAE as the primary management.

Preliminary experimental study on splenic hemodynamics of radiofrequency ablation for the spleen.

PURPOSE: To test the splenic blood flow change after radiofrequency ablation (RFA) of the spleen in a porcine experimental model. MATERIAL AND METHODS: Six pigs underwent RFA of the spleen via laparotomy. During the procedure of RFA, clamping of splenic artery (one) and both splenic artery/vein (one) was also performed. Measurement of blood flow of both splenic artery (SA) and splenic vein (SV) with flow-wire at pre- and post-RFA of the spleen was also performed. RESULTS: Ablated splenic lesions were created as estimating ∼50% area of the spleen in all pigs. Resected specimens reveal not only the coagulated necrosis but also the congestion of the spleen. On the SA hemodynamics, maximum peak velocity (MPV) changed from 37 ± 7 to 24 ± 8 cm/s (normal), 11 to 10 cm/s (clamp of the SA), and 12 to 7.5 cm/s (clamp of both SA/SV), respectively. On the SV hemodynamic, MPV changed from 15 ± 5 to 13 ± 4 cm/s (normal), 17 to 15 cm/s (clamp of the SA), and 17 to 26 cm/s (clamp of both SA/SV), respectively. CONCLUSIONS: RFA of the spleen could induce coagulation necrosis and reduce the splenic arterial blood flow.

Radiofrequency Ablation Combined with Hepatic Arterial Chemoembolization Using Degradable Starch Microsphere Mixed with Mitomycin C for the Treatment of Liver Metastasis from Colorectal Cancer: A Prospective Multicenter Study.

PURPOSE: This phase II prospective study investigates possible benefits of radiofrequency ablation (RFA) combined with hepatic arterial chemoembolization using degradable starch microsphere (DSM) mixed with mitomycin C (MMC) in non-surgical candidates with colorectal liver metastases. MATERIALS AND METHODS: This study, approved by the respective institutional review board, included non-surgical candidates with 3 or fewer liver tumors of 3 cm or smaller, or a single lesion 5 cm or smaller. Percutaneous RFA was performed immediately after chemoembolization using DSM-MMC. Primary and secondary endpoints were the local tumor control rate, safety, and 2-year recurrence-free and overall survival rates. RESULTS: This study examined 25 patients (22 males, 3 females) with 38 tumors of mean maximum diameter of 2.2 ± 0.9 cm (standard deviation) (range 1.0-4.2 cm). Their mean age was 70.2 ± 8.2 years (range 55-82 years). Local tumor progression developed in 3 tumors (7.9%, 3/38) of 3 patients (12%, 3/25) during the mean follow-up of 34.9 ± 9.2 months (range 18.3-50.1 months). The 2-year local tumor control rates were 92.0% [95% confidence interval (CI), 81.4-100%] on a patient basis and 94.6% (95% CI, 87.3-100%) on a tumor basis. The respective 2-year overall and recurrence-free survival rates were 88.0% (95% CI, 75.3-98.5%) and 63.3% (95% CI, 44.2-82.5%), with median survival time of 48.4 months. Fever was the only adverse event requiring treatments in 2 patients (8%). CONCLUSIONS: This combination therapy is safe, exhibiting strong anticancer effects on colorectal liver metastasis, which might contribute to patient survival.

Evaluation of split renal function before and after renal arterial embolization for angiomyolipoma using absolute ethanol.

PURPOSE: Transcatheter arterial embolization (TAE) with absolute ethanol is widely accepted as a therapeutic procedure for renal angiomyolipoma (AML). We aim to evaluate the split renal function before and after AE for renal AML by using 99m-technetium (99mTc)-mercaptoacetyltriglycine 3 (MAG3) renography. METHODS: This study was approved by the Institutional Review Board. The study population comprised 11 renal AML patients (three males, eight females, age 55.1 ± 13.8 years, AML in eight right and three left kidneys) who received unilateral renal TAE with absolute ethanol from April 2002 to January 2013. Blood renal function (i.e. serum creatinine and estimated glomerular filtration rate [eGFR] and split effective renal plasma flow [ERPF]) calculated on 99mTc-MAG3 renography was compared before and within 1 week after renal AE. Statistical analysis was calculated using Wilcoxon signed-ranked test. RESULTS: TAE for renal AML was technically successful in all patients. Serum creatinine and eGFR did not change before and after TAE. ERPF on the embolized kidney did not change before (127.3 ± 60.8 ml/min) and after (127.6 ± 47.4 ml/min) TAE (p = 0.9726). ERPF on the nonembolized kidney showed a statistically significant increase before (152.5 ± 46.8 ml/min) and within 1 week after (169.1 ± 41.5 ml/min) TAE (p = 0.0093 and p < 0.05, respectively). CONCLUSION: TAE for renal AML may not induce renal dysfunction on the embolized kidney and may immediately increase the renal blood flow of the nonembolized kidney.

Combination treatment using percutaneous transluminal angioplasty and low-density lipoprotein apheresis in a patient with peripheral arterial disease and a history of chronic hemodialysis.

Peripheral arterial disease (PAD) is very common in dialysis patients, who tend to have diffuse calcification and severe peripheral arterial stenosis that make it difficult to treat limbs using only surgical or endovascular interventions. Better ways to treat this condition are therefore required and also follow-up studies to evaluate the effects of these treatments on the microcirculation. A 59-year-old man who had a cadaveric kidney transplant five years previously after 25 years of regular hemodialysis complained of pain at rest in his right lower limb and subsequently developed an intractable decubitus ulcer on his right fifth toe (Fontaine IV). Digital subtraction angiography revealed a severe obstruction of the right femoral artery and diffuse stenosis of the right superficial femoral artery. The patient underwent percutaneous transluminal angioplasty (PTA) and six sessions of low-density lipoprotein apheresis (LDL apheresis). At the end of these sessions his complaints were almost completely alleviated. The mean elevation in skin temperature after each session was (1.58 ± 0.99)°C [mean ± SD] over the right dorsalis pedis artery and (1.52 ± 0.88)°C at the tip of the right fifth toe. Ultrasound-measured blood flow rates in the right dorsalis pedis artery were 9.2 cm/s before PTA and 20.2 cm/s one month after PTA. Hemodialysis was resumed 3 days after the PTA due to contrast-induced nephropathy. The combination of PTA and LDL apheresis is useful for treating PAD in hemodialysis patients, with the changes in peripheral artery patency are able to be evaluated effectively by measuring skin temperature.

The Asian project for collaborative derivation of reference intervals: (2) results of non-standardized analytes and transference of reference intervals to the participating laboratories on the basis of cross-comparison of test results.

BACKGROUND: The 2009 Asian multicenter study for derivation of reference intervals (RIs) featured: 1) centralized measurements to exclude reagent-dependent variations; 2) inclusion of non-standardized analytes (hormones, tumor makers, etc.) in the target; and 3) cross-check of test results between the central and local laboratories. Transferability of centrally derived RIs for non-standardized analytes based on the cross-check was examined. METHODS: Forty non-standardized analytes were centrally measured in sera from 3541 reference individuals recruited by 63 laboratories. Forty-four laboratories collaborated in the cross-check study by locally measuring aliquots of sera from 9 to 73 volunteers (average 22.2). Linear relationships were obtained by the major-axis regression. Error in converting RIs using the regression line was expressed by the coefficient of variation of slope b [CV(b)]. CV(b) <10% was set as the cut-off value allowing the conversion. The significance of factors for partitioning RIs was determined similarly as in the first report. RESULTS: Significant sex-, age-, and region-related changes in test results were observed in 17, 15, and 11 of the 40 analytes, respectively. In the cross-comparison study, test results were not harmonized in the majority of immunologically measured analytes, but their average CV(b)s were <10% except for total protein, cystatin C, CA19-9, free thyroxine, and triiodothyronine. After conversion, 74% of centrally derived RIs were transferred to each local laboratory. CONCLUSIONS: Our results point to the feasibility of: 1) harmonizing test results across different laboratories; and 2) sharing centrally derived RIs of non-standardized analytes by means of comparative measurement of a set of commutable specimens.

Adrenal venous catecholamine concentrations in patients with adrenal masses other than pheochromocytoma.

The aim of this study was to retrospectively examine adrenal venous catecholamine concentrations and related indices in non-pheochromocytoma patients and to estimate from the obtained results whether measurements of adrenal venous catecholamine concentrations by adrenal venous sampling (AVS) are useful for localizing adrenal pheochromocytoma. The study population comprised 15 patients in whom AVS was performed for evaluation of adrenal non-pheochromocytoma masses (primary aldosteronism, n = 8; Cushing syndrome, n = 5; non-hyperfunctioning tumor, n = 2) without hormonal intervention and was successful in bilaterally judging adrenal vein to infra-renal inferior vena cava cortisol ratios as >3.0. Wide ranges of catecholamine concentrations were seen for both right (epinephrine, 35-175,821 pg/ml; norepinephrine, 115-32,102 pg/ml; dopamine, 9-232 pg/ml) and left (epinephrine, 16-27,251 pg/ml; norepinephrine, 155-9,267 pg/ml; dopamine, 5-234 pg/ml) adrenal veins. High- to low-side adrenal vein concentration ratios also showed wide ranges of up to 779 for epinephrine, 22.5 for norepinephrine, and 7.8 for dopamine. Adrenal venous catecholamine concentrations obtained by AVS and simple comparisons between bilateral adrenal veins might not be useful to localize adrenal pheochromocytoma, as wide variations in concentrations and high- to low-side adrenal vein concentration ratios were noted in patients with adrenal non-pheochromocytoma.

Are catecholamine-derived indexes in adrenal venous sampling useful for judging selectivity and laterality in patients with primary aldosteronism?

In order to investigate retrospectively whether catecholamine concentrations obtained by adrenal venous sampling (AVS) are useful for lateralization of the aldosteronoma-bearing adrenal gland. The study population comprised 35 patients (10 men, 25 women; mean age, 49.8 years) with aldosteronoma and 18 patients (9 men, 9 women; mean age, 51.8 years) with non-functioning adenoma who underwent AVS between 1994 and 2010. In all cases, AVS was performed without administering adrenocorticotrophic hormone. Successful or unsuccessful adrenal vein blood sampling (selectivity) was judged by the ratio of plasma cortisol (C) level in each adrenal vein to that in the infra-renal inferior vena cava [C(side)/C(IVC)] as a gold standard, with successful selectivity defined using four different cut-off values [C(side)/C(IVC) ≥ 3.0, 2.0, 1.36 or 1.1]. Receiver operating characteristics (ROC) analyses were conducted to determine: (1) degree of selectivity; and (2) the best catecholamine (epinephrine, norepinephrine, and dopamine)-derived index for lateralization of the aldosteronoma-bearing adrenal gland. Among the catecholamine-derived indexes, the epinephrine concentration ratio of adrenal vein to IVC was the most reliable for all four different cut-off values in the evaluation of adrenal vein selectivity. Meanwhile, the ratio of aldosterone to norepinephrine between dominant and non-dominant sides was the most reliable index (right: area under the curve (AUC), 0.965 ± 0.024; 95 % confidence interval (CI), 0.874-0.996; left: AUC, 0.937 ± 0.033; 95 % CI, 0.834-0.985) for lateralization of the aldosteronoma-bearing gland. Catecholamine concentrations obtained by AVS are useful for not only judging selectivity, but also lateralization of the aldosteronoma-bearing gland.

Reduction of oxidative stress in liver cancer patients by oral green tea polyphenol tablets during hepatic arterial infusion chemotherapy.

Hepatic arterial infusion chemotherapy (HAI) using an implanted port system is the standard regimen for primary and metastatic liver cancers (MLCs). However, there have been few studies concerning HAI-induced oxidative stress and damage to the liver or other organs. The aim of the present study was to investigate the ability of green tea polyphenols (GTPs) to reduce the oxidative stress or increase the biological antioxidative potential in HAI-treated patients. A total of 19 patients with inoperable hepatocellular carcinoma (HCC) or MLC from colorectal malignancy were eligible for HAI with cisplatin (CDDP) and 5-fluorouracil (5FU). The study subjects were randomly assigned to either a 3 or a 6 oral GTP tablets per day group. Each tablet had a GTP content equivalent to 79 mg of epigallocatechin-3-gallate. The oxidative stress was assessed by measuring the levels of derivatives of reactive oxygen metabolites (d-ROMs) and the biological antioxidative potential (BAP) values in patient plasma using the Free Radical Analytical System 4 (FRAS4), and correlating the results with clinical laboratory data for the patients. The levels of d-ROMs were significantly reduced by the oral intake of 6 GTP tablets for 6-9 months (P=0.0463) but were not significantly reduced by the oral intake of 3 GTP tablets daily. BAP values remained constant in the 3 and 6 tablet groups for 6-9 months during the follow-up study. The total serum bilirubin (T-bil) levels increased significantly at 3 (P=0.028) and 9 (P=0.0151) months and the red blood cell (RBC) count decreased at 6 months (P=0.0458) after intake for the 6 GTP tablet group. Alkaline phosphatase (ALP) levels increased significantly at 9 months (P=0.0298). Cholinesterase (ChE) decreased significantly at 9 (P= 0.0127) and 12 (P= 0.0207) months after intake for the 3 GTP tablet group. The results indicate that the daily intake of 6 GTP tablets containing 474 mg polyphenols significantly reduces HAI-induced oxidative stress in HCC or MLC patients while the antioxidative potentials of the patients remain constant.

Efficacy of venous sac embolization for pulmonary arteriovenous malformations: comparison with feeding artery embolization.

PURPOSE: To examine the efficacy of venous sac embolization (VSE) in comparison with transcatheter feeding artery embolization (FAE) for treatment of pulmonary arteriovenous malformations (PAVMs). MATERIALS AND METHODS: From 1989-2009, 21 patients underwent embolization of 37 PAVMs. Safety and long-term efficacy of VSE were evaluated retrospectively and compared with FAE. RESULTS: FAE was performed in 22 (18 simple and 4 complex type) PAVMs, and VSE was performed in 15 (14 simple and 1 complex type) PAVMs. There were significant differences between FAE and VSE in treated periods, PAVM location, coil type used, number of coil combinations and coils per PAVM, coil position, and reperfusion; there were no significant differences in most PAVM characteristics, follow-up durations (58 mo±54 vs 42 mo±42; P= .32), and minor complications (pleurisy [2 vs 2]). Reperfusion occurred in 11 (50%) of 22 PAVMs in the FAE group and no PAVMs in the VSE group (P<.01). Of 22 PAVMs in the FAE group, 17 (77%) were treated with 0.035-inch coils alone; of 15 PAVMs in the VSE group, 14 (93%) were treated with 0.018-inch interlocking detachable coils (IDCs), 0.018-inch pushable fibered coils, or IDCs and pushable fibered coils combined (P<.01). The number of coils used was 8±4 in the VSE group and 4±4 in the FAE group (P= .002). CONCLUSIONS: The high reperfusion rate in the FAE group was mainly due to the use of large 0.035-inch coils alone. Although more coils are needed, VSE can be used to treat PAVMs with a venous sac safely and achieve long-term efficacy.

Embolization of hepatic arteriovenous shunt with absolute ethanol in a patient with hepatocellular carcinoma.

We report a 76-year-old man who had hepatocellular carcinoma (HCC) with arteriovenous shunting (AVS). Transcatheter chemoembolization (TACE) was selected as treatment because of poor pulmonary function. To prevent pulmonary embolism caused by the flow of embolic materials through the AVS, we performed embolization of the AVS with absolute ethanol under flow control by balloon catheters. Subsequently, we could perform TACE for HCC safely.

Coil embolization of a celiac artery aneurysm using the neck remodeling technique.

Aneurysms of the celiac trunk are rare. Untreated lesions enlarge progressively and may rupture spontaneously. We report the case of a 56-year-old man whose wide neck celiac aneurysm was successfully packed with coils with preservation of the native arterial circulation by percutaneous transcatheter embolization using the neck remodeling technique.

Comparison of survival rates between patients treated with transcatheter arterial chemoembolization and hepatic resection for solitary hepatocellular carcinoma.

The present study aimed to retrospectively compare the survival rates between patients treated with transcatheter arterial chemoembolization and hepatic resection for solitary hepatocellular carcinoma (HCC). According to our database, derived from three affiliated hospitals, the inclusion criteria for this study were: solitary HCC [Child-Pugh class A and International Union Against Cancer (UICC) stage T1-3N0M0] treated between July 1990 and October 2001. Subsequently, hepatic resection (149 patients) as well as chemoembolization (102 patients) groups were selected. Following stratification according to tumor stage [UICC, Cancer of the Liver Italian Program (CLIP) and Milan criteria], survival rates were compared between the treatment groups. Survival rates were calculated using the Kaplan-Meier method. Age, gender and size of the HCC did not differ significantly between the groups. Moreover, no significant difference in the survival rates (average hepatic resection, 58.9 months; average chemoembolization, 45 months; P=0.1697) was observed between the groups. In the subgroup analysis, according to tumor stage, the survival rate was significantly higher for the hepatic resection group than for the chemoembolization group in the UICC T3N0M0 (P=0.017) subgroup. However, no significant differences in survival rates were observed between the hepatic resection and chemoembolization groups for UICC T1 (P=0.7329), T2N0M0 (P=0.5741), CLIP0 (P=0.3593), CLIP1-2 (P=0.3287) and within (>5 cm; P=0.4429) and beyond Milan criteria (≤5 cm; P=0.4003) subgroups. Chemoembolization is as effective as hepatic resection in treating solitary HCC in subpopulations with UICC T1-2N0M0 or CLIP 0-2 HCC or Milan criteria and adequate liver function. In the subgroup with UICC T3N0M0 HCC, hepatic resection is superior to chemoembolization.

Successful portal-systemic shunt occlusion of a direct shunt between the inferior mesenteric vein and inferior vena cava with balloon-occluded retrograde transvenous obliteration following recanalization after placing a covered stent in the portal and superior mesenteric veins.

Extrahepatic portal-systemic shunts cause portal-systemic encephalopathy. Direct communication between the inferior mesenteric vein (IMV) and the inferior vena cava (IVC) is a relatively rare pathway among the variety of portal-systemic shunts. This report describes a case of successful occlusion of an IMV-IVC shunt. Based on laboratory data and computed tomography findings, a 69-year-old woman with liver cirrhosis was diagnosed with portal-systemic encephalopathy due to a shunt between the IMV and the IVC. Her hepatic coma had not been adequately controlled by oral or intravenous pharmacotherapy. First, we placed a covered stent in the main trunk of the portal vein and the superior mesenteric vein (SMV) to block the SMV hepatofugal flow and splenic vein hepatopetal flow, but this therapy showed only a transient therapeutic effect due to recanalization. Next, we performed balloon-occluded retrograde transvenous obliteration (BRTO) of the portal-systemic shunt. After the BRTO, she has had no episodes of portal-systemic encephalopathy for 2 years.

[Analysis of the causal relations between serum ferritin elevation and latent pathologic factors by structural equation modeling].

Serum ferritin increases in various disorders and clinical conditions such as iron overload, tissue disorders, and inflammation. However causal associations between the serum ferritin level and clinical factors that influence serum ferritin level or between these factors are not well characterized. We analyzed the ferritin level and other laboratory data including transferrin saturation (TF%), enzyme activities, and inflammatory protein levels in the sera of 124 patients with hyperferritinemia. We identified latent pathologic factors representing cell damage and inflammatory status and assumed causal relations between serum ferritin elevation and these factors. Structural equation modeling was used to verify causal relations and the adequacy of latent factors. A model that quantitatively explained serum ferritin elevation was identified. The direct effect of the cell damage factor on serum ferritin indicated cell destruction and decreased ferritin clearance. In contrast, the inflammation factor directly increased the ferritin level, but indirectly decreased it via TF%. These causal relations may quantitatively explain the mechanism of serum ferritin levels in patients with hyperferritinemia.

Small arteriovenous malformation of the common bile duct causing hemobilia in a patient with hereditary hemorrhagic telangiectasia.

We report a 54-year-old male patient with arteriovenous malformation located at the common bile duct and hereditary hemorrhagic telangiectasia. The patient was treated as gallstone pancreatitis at first. Three days after endoscopic nasobiliary drainage (ENBD) for biliary drainage to subside gallstone pancreatitis, hemobilia was drained from the ENBD tube and the serum hemoglobin level gradually decreased. Cholangioscopy and angiography revealed that hemobilia was due to a small arteriovenous malformation located at the common bile duct. Subsequently, the patient was successfully treated by endovascular intervention.