Intraperitoneal Hemorrhage Due to Spontaneous Rupture of Hepatocellular Carcinoma: Comparisons of Tranarterial Oily Chemoembolization and Simple Embolization with Gelfoam

PURPOSE: To compare the safety and effectiveness of transarterial oily chemoembolization (TOCE) and transar-terial embolization (TAE) with Gelfoam in cases of ruptured hepatocellular carcinoma (HCC), and to describe the most important prognostic factors involved in emergency embolization. MATERIALS AND METHODS: Forty-two consecutive patients with spontaneously ruptured HCC underwent emergency TOCE (n = 22) or TGE (n = 20). In the TOCE group, Lipiodol (3 -10 cc), Adriamycin (20 -50 mg), and Mitomycin (2 -10 mg) were used, and these were followed by blockade of the hepatic arterial flow with gelatin sponge particles. In the TAE group, patients underwent only Gelfoam embolization. Using the Kaplan-Meier method, survival time from the time of embolization was estimated, and to analyze prognostic factors, Cox 's proportional hazard regression model was used. RESULTS: Successful hemostasis was achieved in 41 patients (97.6%). Mean survival time was 201 and 246 days in the TOCE and TAE group, respectively, but the difference was not tatistically significant (p > 0.05). Five of the TOCE group (22.7%) and three of the TAE group (15.0%) died of hepatic failure. Analysis of the prognostic factors showed that portal vein involvement by the tumor was the most important factor influencing survival. CONCLUSION: Although TOCE and TAE effectively controlled hemorrhaging from a ruptured HCC, the procedures involve a high risk of hepatic failure. Their goal should, therefore, be solely to achieve hemostasis, and thus decrease parenchymal injury.

Embolization of Seve re Arterioportal Shunts in the Patients with Hepatocellular Carcinoma: Safety and Influence on Patient Survival

PURPOSE: To evaluate the safety and the influence of embolization of severe arterioportal shunts, and the effect of the procedure on the survival rate of patients with hepatocellular carcinoma combined with portal vein tumor thrombosis. MATERIALS AND METHODS: This study involved a total of 54 patients with hepatocellular carcinoma in whom hepatic arteriography revealed severe arterioportal shunt. From among this total, 34 patients (embolization group) underwent chemoinfusion after shunt embolization, while 19 (control group) underwent chemoinfusion only. The embolic materials included PVA particles and/or Gelfoam pieces. The frequency of postembolization symptoms (Chi-squared test) and changes in laboratory values (paired t-test) were compared between the two groups, and shunt improvement was also evaluated. Patient survival was tested using the Kaplan-Meier method. RESULTS: Fever and RUQ pain were more frequent in the embolization group (p<0.001). The complications of embolization included severe postembolization syndrome (n=1), acute hepatic failure (n=2), hepatic infarction (n=1), and sepsis (n=1). There were no significant changes in laboratory values. Among the 28 patients (24 of embolization group and four of control group) who underwent follow-up angiography, arterioportal shunt became less severe or disappeared in ten of the embolization group. For the embolization and control groups, the mean survival interval was 29.5 +/-5.4 weeks and 10.3 +/-3.1 weeks (p=0.0002), respectively. The best results were seen in the PVA particle group (p=0.01). CONCLUSION: The embolization of severe arterioportal shunts is relatively safe and increases patient survival rate.

Transcatheter Arterial Embolization of Ruptured Hepatocellular Carcinoma: Effectiveness and Long-term Follow-up

PURPOSE: To evaluate the effectiveness of emergent transcatheter arterial embolization(TAE) in the treatmentof bleeding from ruptured hepatocellular carcinoma(HCC) and long-term follow-up. MATERIALS AND METHODS: Twentypatients with ruptured HCC underwent emergent TAE; diagnosis was based on clinical and radiologic findings.Mesoportography was used to determine the presence of portal vein thrombosis, and celiac angiography to determinethe presence of hypervascular mass and extravasation of contrast material. All patients underwent TAE; a mixtureof adriamycin, mitomycin, lipiodol, and gelfoam particles was used. In four of the 20 patients, adjuvantembolization was performed, using stainless steel coils. After three week of follow-up CT, follow-up TAE wasperformed between two and ten times. RESULTS: Technical and clinical success was up to 100%. Mesoportographyshowed the presence of portal vein thrombosis in nine patients and its absence in 11. In 15 patients, three weeksof follow-up by CT showed lipiodol uptake by the mass and the disappearance of highly attenuated peritoneal fluid.Within one week of embolization, four of the 20 patients died of sepsis, shock, and hepatic failure, and withinone month of this procedure, one died of renal failure. Three-month, six-month, and one-year survival rates afterTAE were repectively 50%, 45%, and 30%; the mean duration of survival was 260 days. In nine patients with portalvein thrombosis, the one-year survival rate was 11%, while in 11 patients not suffering from this condition, therate was 70%; the difference between the two groups was statistically significant(p < 0.05). CONCLUSION: As thefirst choice of treatment for patients with hemoperitoneum from ruptured HCC, emergent TAE is an effective,life-saving therapeutic procedure; in these patients, portal vein thrombosis may be a factor influencing risk andprognosis.

Experimental Study of Bleeding Control on Liver Biopsy in Rabbit: N-butyl 2-cyanoacrylate(NBCA) injection and RF electrocauterization

PURPOSE: To evaluate the hemostatic effect of N-butyl 2-cyanoacrylate(NBCA) injection and RF electrocauterization of the tract after fine needle biopsy of the liver, and the histopathologic changes of the liver. MATERIALS AND METHODS: Three lobes of rabbit liver were selected and separately punctured four times with 21 gauge biopsy needles. According to the hemostatic procedure on fine needle biopsy, three groups (1, 2, 3) were formed : group 1, in which there was no maneuver for bleeding control, was the control group ; group 2, in which NBCA was injected into the puncture tract while slowly removing the needle ; group 3, in which RF electrocauterization of the tract was carried out. After completely removing the needle, each group was evaluated for amount of bleeding and histologic change. RESULTS: The amount of bleeding was 0.407gm+/-0.245 in group 1,0.028gm+/-0.036 in group 2 and 0.035gm+/-0.028 in group 3. As compared with the control group(group 1), injecting NBCA into the biopsy tract(P=0.0002) and RF electrocauterization of the tract(P=0.0003) significantly reduced the amount of bleeding after liver biopsy. The amount of bleeding was not statistically different between group 2 and 3, however (P=0.58). In Group 1, the tract was fully filled with blood. Group 2 showed NBCA embolized in the biopsy tract, adhering to hepatocytes and mixed with blood; small vessels adjacent to the puncture tract were filled with NBCA. Group 3 showed tissue degeneration, including necrosis of hepatocytes, vacuolation and neutrophil infiltration. CONCLUSION: Injection of NBCA and RF electrocauterization of the tract after puncture of the liver for biopsy efficiently controlled bleeding. In particular, the efficiency of NBCA injection was due to its effect of plugging the tract and causing the embolization of adjacent small vessels. With regard to procedural handling, RF electrocauterization of the tract is superior to injection of NBCA.