The efficacy of combined transarterial chemoembolization and 3-dimensional conformal radiotherapy for hepatocellular carcinoma with main portal vein thrombosis.

BACKGROUND/AIMS: The goal of this study was to evaluate the efficacy of combined therapy with TAE and 3-dimensional conformal radiotherapy (3D-CRT) for HCC with main portal vein thrombosis (MPVT). METHODOLOGY: We retrospectively reviewed the medical records of 18 patients who had an unresectable HCC with MPVT and underwent combined TAE and 3D-CRT. Treatment responses for the main tumor and the MPVT were assessed. In addition, patient survival and the prognostic factors associated with survival were analyzed. RESULTS: The overall survival for the 18 patients was 13.0 +/- 8.5 months. For the main tumor response, 8 patients were responders and 10 were non-responders. For the MPVT, an objective response was observed in 10 out of the 18 cases. The univariate analysis revealed that the pretreatment AFP level, presence of regional lymph node metastasis, main tumor response and the MPVT response were prognostic factors for survival; however, these factors failed to reach significance on the multivariate analysis. Most of the treatment-related complications were resolved within 4 weeks. No patient had clinical evidence of progressive hepatic insufficiency related to the treatment. CONCLUSIONS: Combined therapy with TAE and 3D-CRT was safe and effective for the treatment of HCC patients with MPVT and might provide a survival benefit.

Evaluation of esophageal varices on liver computed tomography: receiver operating characteristic analyses of the performance of radiologists and endoscopists.

BACKGROUND AND AIM: Recent liver multi-detector row computed tomography (MDCT) always covers the distal esophagus with an excellent image quality. The aim of this study was to compare the performance of faculty abdominal radiologists with those of radiology residents and endoscopists for the detection of esophageal varices and high-risk esophageal varices on liver MDCT. METHODS: A total of 104 cirrhotic patients that had undergone liver MDCT 4 weeks or less before an upper endoscopy were evaluated. Two faculty abdominal radiologists, two radiology residents, and two endoscopists independently interpreted all of the CT images to detect the presence of esophageal varices and high-risk (grade 2 or 3) esophageal varices. With endoscopic grading as the reference standard, their performances were compared by using receiver operating characteristic (ROC) curve analysis. RESULTS: The areas under the ROC curves for the detection of esophageal varices indicated better performance of the abdominal radiologists (A(z) = 0.868), compared with the radiology residents (A(z) = 0.798) (P = 0.007) and endoscopists (A(z) = 0.784) (P = 0.006). For the detection of high-risk esophageal varices, however, the performance of the abdominal radiologists (A(z) = 0.914) was similar to those of radiology residents (A(z) = 0.900) and endoscopists (A(z) = 0.907) (each P > 0.05). CONCLUSIONS: Experienced readers have a better ability to detect esophageal varices on liver MDCT, but had no higher performance to evaluate high-risk esophageal varices. As the accuracy of detecting high-risk esophageal varices with clinical relevance on liver MDCT is excellent, even by endoscopists, the evaluation of esophageal varices from a recent liver MDCT may be useful to avoid the use of low-yield endoscopy.

[Antiviral efficacy of lamivudine/adefovir combination therapy in chronic hepatitis b patients with resistance to lamivudine and adefovir consecutively].

BACKGROUND/AIMS: The aim of this study was to elucidate the antiviral efficacy of lamivudine (LMV)-adefovir (ADV) combination therapy in chronic hepatitis B patients who showed resistance to LMV and ADV consecutively. METHODS: A retrospective review was performed in eighteen patients with chronic hepatitis B who developed virologic breakthroughs during LMV-ADV sequential mono-therapy and treated with LMV-ADV combination therapy. RESULTS: The median duration of follow up was 17 months (range, 6-27) after the start of LMV-ADV combination therapy. Mean HBV DNA level in log10 IU/mL was 6.08+/-0.95, 4.05+/-1.66, 3.17+/-1.58, 3.18+/-2.16, and 2.35+/-1.52 at 0, 3, 6, 12, and 24 months, respectively. Sixteen patients (88.9%) showed HBV DNA reduction below detection limit (<20,000 IU/mL). HBeAg seroconversion was observed in one patient (7.1%) after 8 months of combination therapy. Virologic breakthrough occurred in only one patient after 21 months of combination therapy. Viral rebound occurred in two patients at 12 months and 14 months of combination therapy. Normalization of serum ALT was achieved in twelve patients (66.7%). Primary non-response was observed in two cases (11.1%). CONCLUSIONS: LMV-ADV combination treatment was effective in 88.9% of patients with resistance to LMV and ADV in a short-term follow up. It may be applied as a bridge therapy until another effective antiviral regimen becomes available.

Comparison of scoring systems for the prediction of outcomes in patients with nonvariceal upper gastrointestinal bleeding: a prospective study.

The authors aimed to compare the clinical utility of five scoring systems for the prediction of rebleeding and death in patients with nonvariceal upper gastrointestinal bleeding (UGIB). A total of 239 consecutive patients who had undergone endoscopy due to nonvariceal UGIB were prospectively investigated on the basis of five scoring systems (Forrest classification, Rockall scoring system, Cedars-Sinai Medical Centre Predict Index, Blatchford scoring system, and Baylor college scoring system). Thirty-five patients (14.6%) experienced rebleeding and 20 patients (8.4%) died. Comparison of the high-risk categories of the four predictive systems showed that the Forrest classification was superior to the others in predicting rebleeding and death. The Cedars-Sinai Medical Centre Predict Index and the Rockall scoring system showed high positive predictive values for predicting rebleeding and death, respectively. We concluded that the Forrest classification was the most useful scoring system for the prediction of rebleeding and death in patients with nonvariceal UGIB.

Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea.

AIM: To determine the prevalence and risk factors of work-related musculoskeletal disorders in gastrointestinal endoscopists in Korea. METHODS: A survey of musculoskeletal symptoms, using a self-administered questionnaire, was conducted on 55 endoscopists practicing in general hospitals or health promotion centers. RESULTS: Forty-nine (89.1%) endoscopists reported musculoskeletal pain on at least one anatomic location and 37 (67.3%) endoscopists complained of pain at rest. Twenty-six (47.3%) endoscopists had severe musculoskeletal pain defined as a visual analogue score greater than 5.5. Factors related to the development of severe pain were (1) standing position during upper endoscopy, (2) specific posture/habit during endoscopic procedures, and (3) multiple symptomatic areas. Finger pain was more common in beginners, whereas shoulder pain was more common in experienced endoscopists. Sixteen percent of symptomatic endoscopists have modified their practice or reduced the number of endoscopic examinations. Only a few symptomatic endoscopists had sought professional consultation with related specialists. CONCLUSION: The prevalence of musculoskeletal pain in endoscopists is very high. The location of pain was different between beginners and experienced endoscopists. Measures for the prevention and adequate management of endoscopy-related musculoskeletal symptoms are necessary.

[Changes in the profiles of causative agents and antibiotic resistance rate for spontaneous bacterial peritonitis: an analysis of cultured microorganisms in recent 12 years].

BACKGROUNDS/AIMS: The causative agents for spontaneous bacterial peritonitis (SBP) and antibiotic resistance rate vary according to the regions and time. This study evaluated the recent changes in the profiles of microorganisms and antibiotic resistance rate for the choice of effective antibiotics in treating SBP. METHODS: The clinical records of 1,018 episodes of SBP from November, 1994 to December, 2005, were analyzed retrospectively. The profiles of the causative agents for SBP and the rate of antibiotic resistance were compared in every 4-year-term. RESULTS: The microorganisms were isolated in 394 out of 1018 episodes (38.7%). Gram negative and positive organisms constituted 71.6% and 21.3%, respectively. The five most commonly isolated organisms were E. coli (35.8%), K. pneumoniae (15.5%), viridans Streptococci (10.4%), S. pneumoniae (4.8%) and Aeromonas group (4.6%). The rate of E. coli resistant to cefotaxime (0%, 5.4%, 7.4%) and ciprofloxacin (4.3%, 21.6%, 28.4%) were increased in recent years. In the gram positive organisms, all isolates of viridans Streptococci and Pneumococci were sensitive to cefotaxime and ciprofloxacin. Recently, methicillin-resistant Staphylococcus aureus (MRSA) (28%) and vancomycin-resistant Enterococci (VRE) (31%) have been isolated. In each period, the overall antibiotic resistance rates to cefotaxime were 12.5%, 14.0%, 14.8%, to ciprofloxacin were 3.1%, 16.7%, 18.0%, and to imipenem were 4.7%, 7.0%, 4.2%. CONCLUSIONS: Cefotaxime may still be the choice of primary empirical antibiotics for the treatment of SBP in Korea because the rate of resistance is acceptable. However, it is important to be aware of the recent increase in ciprofloxacin-resistant E. coli, extended spectrum beta-lactamase (ESBL)-producing gram negative bacilli, MRSA and VRE.

[A case of benign schwannoma in the porta hepatis].

Schwannomas or neurilemmomas are uncommon tumors arising from schwann cells of neural sheath, which most frequently affect the extremities, trunk, head and neck area. Moreover, benign schwannoma in the porta hepatis is extremely rare. Approximately, 2 cases of benign schwannoma in the porta hepatis have been reported in the literatures. We report a case of benign schwannoma in the porta hepatis occurring in a 53-year-old woman who was asymptomatic and incidentally found to have a mass. Abdominal CT scan showed a 4.5 cm-sized low attenuating mass with septum-like enhancing solid portion at porta hepatis. Abdominal exploration revealed a yellowish, cystic and encapsulated mass attached to portal vein, common bile duct, liver and duodenal wall above the hepatoduodenal ligament. There has been no evidence of recurrence during 11 months of follow-up.