Combined versus single locoregional therapy in the treatment of unresectable hepatocellular carcinoma

AbstractIntroductionSurgical and locoregional therapies are different options in HCC treatment, several locoregional techniques are used.PurposeThis study aimed to assess the effectiveness of transarterial chemoembolization (TACE), radiofrequency ablation (RFA) and combined therapy, in HCC management.Materials and methodsThe study was conducted at our University Hospital, from August 2011 to February 2013. It included 60 patients with HCC (40 males and 20 females, age ranged between 45 and 70years). Patients were classified into 3 groups, group 1 treated with TACE, group 2 with RFA, and group 3 with both techniques. Response was assessed by triphasic CT and alpha fetoprotein. Patients were classified into good and poor responders after one and six months and one year. Patients’ survival and incidence of recurrence were recorded.ResultsThe percentage of good responders was greater with combined therapy than with TACE and RFA (90%, 70%, and 60% respectively). The overall survival was 75% and the recurrence free survival was 60% in TACE, 90%, and 45% in RFA and 95% and 90% in combined therapy respectively.ConclusionCombined therapy is superior regarding good response, overall survival, and free recurrence survival than either TACE or RFA alone

Transcatheter arterial chemoembolization of hepatocellular carcinoma in patients with celiac axis occlusion using pancreaticoduodenal arcade as a challenging alternative route

Introduction: Celiac axis occlusion is a challenging condition when catheterization of the hepatic artery is required for chemoembolization of hepatocellular carcinoma (HCC). As a result, the hepatic artery has to be catheterized through the pancreaticoduodenal arcades (PDA) and the gastroduodenal artery (GDA) from the superior mesenteric artery (SMA) which is a tortuous course with acute angles and small caliber branches. Objective: To assess new techniques for facilitating catheterization of the tortuous PDA and the GDA to reach the proper hepatic artery (PHA) and tumor-feeding branches in patients with celiac axis occlusion undergoing chemoembolization of HCC. Methods and materials: The study included eleven patients all admitted to do transcatheter arterial chemoembolization (TACE) for treatment of unresectable HCC. During angiography occlusion of the celiac axis was diagnosed and hypertrophied PDA and GDA was noted in SMA angiography. Catheterization of the PDA was performed by preshaping of the micro-guide wire into a wide curve.Catheterization of the PHA was a challenge and was achieved by reshaping of the micro-guide wire or by looping technique. TACE was done after super selective catheterization of the tumor feeding artery using a mixture of 50 mg of adriamycin, 7cc of lipiodol and gelfoam. Results: In the eleven patients with celiac artery occlusion, DSA showed complete celiac axis occlusion in all patients. Collateral arteries supplying the liver were readily evident via PDA and GDA from SMA. Successful catheterization of the PHA was achieved in all patients. Chemoembolization was performed to all patients after super selective catheterization of the feeding artery. Follow-up triphasic CT was performed in all patients, 9 patients showed good lipiodol trapping with no residual tumor enhancement. Two patients required another session of TACE. Conclusion: Chemoembolization of HCC through the PDA and the GDA using micro-guide wire preshaping technique and the microcatheter looping technique in patients with celiac axis occlusion is a challenging but effective treatment for HCC. Keywords: TACE, Hepatocellular carcinoma, Pancreaticoduodenal arcade, Celiac axis occlusio

Role of infrapopliteal

Objective: To compare the outcomes of infrapopliteal angioplasty between diabetic patients and non-diabetic patients with critical limb ischemia. Patients and methods: From March 2014 to December 2014, infrapopliteal angioplasty was performed on 60 limbs (43 men and 17 women with mean age 70.13 years) with the CLI (Fontaine’s grade III or IV). The number of diabetic patients was 40 (66.66%). Follow-up included clinical examination for rest pain improvement and ischemic ulcer healing, and duplex-documented target vessel patency or re-stenosis at discharge and at 3 months. Results: The technical success rate was 100% in diabetic and non-diabetic groups. The ulcer healing rate was 33/37 (89.18%) in diabetic patients vs. 14/15 (93.3%) in non-diabetic patients. And the re-stenosis and re-occlusion rates of treated vessels after 3 months were 10.0% in diabetic vs. 5.0% in non-diabetic groups. Conclusion: There were no significant differences between the 2 groups in the technical success rate, but the 3 months clinical success rate and the primary patency rate were better in non-diabetic than in diabetic patients with no significant differences

Uterus didelphys with imperforate hemivagina and ipsilateral renal agenesis complicated by hematocolpos, hematometra and hematosalpinex. The challenge of intact hymen

Background: Uterine didelphys with obstructed hemivagina is an extremely rare condition. This diagnosis should be considered whenever an adolescent is presented with severe dysmenorrhea and progressive pelvic mass. Case: A 15-year-old girl presented with uterus didelphys with obstructed left hemivagina and ipsilateral renal agenesis. Excision of the septum was done using monopolar diathermy in the cutting mode under laparoscopic and hysteroscopic guidance, taking into consideration the integrity of the hymen. Complete recovery was achieved within one week. Conclusion: The prompt and accurate diagnosis of this condition is essential to prevent complications from acute illness and to preserve future fertility. Ultrasonography, CT scan and MRI are the initial steps for its diagnosis; however, laparoscopy is a crucial tool for confirmation of the diagnosis. In order to avoid the associated morbidity of delayed management, surgical intervention should be considered as the first line therapy, taking into consideration the social and traditional backgrounds of the parents and patients

Novel strategy in endovascular treatment of coronary steal using histoacryl®

Background: Coronary steal is an often encountered clinical condition attributable to multiple etiologies. Diverse treatment modalities have been previously elucidated. Aim: To elucidate the potential role of interventional approach using N-butyl Cyanoacrylate (Histoacryl®) to treat coronary steal. Material and methods: We present four patients with coronary steal due to different causes. Three patients had coronary arterial fistulas, and the fourth patient underwent prior Coronary Artery Bypass Graft (CABG) surgery with a patent unligated Left Internal Mammary Artery (LIMA) side-branch. We report the attempted trans-catheter closure of the fistulas and LIMA side-branch using n-butyl cyanoacrylate as an embolic agent. Results: In our series, Coronary angiography was the imaging modality used for diagnosing and guiding the treatment of all cases. Multi-detector CT was used to track the pathway and termination of the fistula in one case only. From the three fistula cases, two originated from the left anterior descending (LAD) coronary artery and one from the left circumflex (LCX) coronary artery. We accomplished successful occlusion in two of the three fistula cases and in the LIMA side-branch case as well. Conclusion: N-butyl Cyanoacrylate (Histoacryl®) is a useful interventional embolic agent that could be used to treat coronary steal of diverse etiology

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods: In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results: Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background: End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods: This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results: In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion: Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone