Altered hepatic hemodynamics and improved liver function following intrahepatic vascular infusion of prostaglandin E1

Prostaglandin E1 (PGE1) has cytoprotective effects in the liver. To find how PGE1 influenced hepatic hemodynamics, oxygen metabolism, and hepatic function, we carried out an experimental and a clinical study. PGE1 was continuously administered into the hepatic artery (n = 5) or portal vein (n = 5) at a rate of 0.01 μg/kg per min in healthy mongrel dogs. In the clinical study, in eight patients PGE1 was administered through the hepatic artery at a rate of 0.01 μg/kg per min after hepatic lobectomy. In the experimental study, hepatic hemodynamics and oxygen metabolism did not change during the administration of PGE1 into the portal vein. During administration of PGE1 into the hepatic artery, hepatic arterial flow increased 1.5-fold after administration compared to the rate before administration (P < 0.01). Hepatic arterial pressure, hepatic arterial resistance, and post-sinusoidal resistance significantly decreased after administration (P < 0.01, P < 0.01, and P < 0.05, respectively). Hepatic oxygen supply increased significantly (P < 0.01). In the patients, serum glutamic oxaloacetic transaminase (GOT) and glutamic pyruvic transaminase (GPT) levels remained low after surgery, and the recovery of protein synthesis was improved compared with that in eight hepatectomized patients without PGE1 administration (controls). The intrahepatic arterial infusion of PGE1 was considered useful for the recovery of liver function. (Received Apr. 21, 1997; accepted Sept. 26, 1997)     

乙酸灌注兔肝门静脉分支的实验研究

目的观察乙酸灌注兔肝门静脉分支后兔肝组织的大体及显微镜下病理变化,探讨乙酸栓塞门静脉分支引起兔肝组织坏死的机制.方法19只兔分为5组,0.250 ml/kg组2只,0.188 ml/kg组3只,0.125 ml/kg组3只,0.050ml/kg组3只,0.025 ml/kg组8只,剖腹后经门静脉右外支按每公斤体重注入50%乙酸.观察肝组织改变,并作病理检查.结果乙酸灌注兔肝门静脉分支后,可造成门静脉分支管腔内膜炎症,管腔狭窄,甚至血栓形成,伴行的肝动脉分支亦因乙酸作用形成内膜炎及血栓,导致相应区域肝组织变性坏死,肝、肾功能指标随之变化.结论经门静脉分支灌注乙酸同时,在门静脉、肝动脉内造成程度不等的栓塞,降低或阻断了相应肝组织的血供,其结果等同于门静脉、肝动脉双栓塞,为临床超选肝癌门静脉供血支灌注乙酸治疗肝癌提供了理论依据.     

影响消化道肿瘤肝转移介入治疗疗效的因素

目的探讨影响消化道肿瘤肝转移介人治疗疗效的因素,并评价介入治疗的价值。方法９２例消化道肿瘤肝转移患者经肝动脉介人治疗３１６次,其中２９例行单纯灌注化疗,６３例行灌注化疗加栓塞治疗。化疗药物选用表阿霉素（ＥＡＤＭ）、或／和顺铂（ＰＤＤ）、丝裂霉素（ＭＭＣ）、５－一氟尿嘧啶（５—ＦＵ）＋甲酰四氢叶酸钙（ＣＦ）联台方案,栓塞剂为超液化碘油和／或明胶海绵。对可能影响介人治疗疗效的因素行ＣＯＸ模型多因素分析。结果近期疗效以ＣＴ征象作为评价依据,总有效率（ＣＲ＋ＰＲ）为４５．６５％;平均生存期１９６月;０．５．１,２,３,５年生存率分别为９５７％,７３８％,３６．３％,２０．６％,１１６％。Ｃｏｘ比例风险模型分析结果显示９例孤立性肝转移者较多发转移预后好,平均生存期为３１２个月,差异有显著性,Ｐ＜０．０５;综合治疗较单纯介人治疗疗效好,差异有非常显著性,Ｐ＜０．０１;其它因素对疗效的影响无统计学差异。全组无严重副作用或并发症。结论经肝动脉介人治疗是治疗消化道肿瘤不能手术切除肝转移瘤的较好方祛。单发肝转移、介人治疗前后的综合治疗是影响消化道肿瘤肝转移介人治疗疗效的重要因素。     

Two cases of hepatic artery interruption after hepatopancreatobiliary surgery treated by prostaglandin E1 infusion via the superior mesenteric artery

In two cases of hepatic arterial flow interruption after hepatopancreatic surgery, continuous PGE₁ infusion from the superior mesenteric artery (SMA) was applied to oxygenate the liver through the portal vein. Case 1 was a 69-year-old woman with a non-functioning islet cell tumor of the pancreas. She underwent pancreatic resection following hepatic arterial infusion of anticancer drugs. Serum alanine aminotransferase (ALT) was elevated to 5500 IU/l on postoperative day (POD) 2; angiography revealed complete celiac artery obstruction. Continuous PGE₁ was administered from SMA at a rate of 0.01 μg/kg/min for 7 days. Serum ALT was normalized within 2 weeks and the peak level of serum total bilirubin (T. Bil) was 4.5 mg/dl. Case 2 was a 66-year-old man suffering from metastatic liver cancer. Complete obstruction of the proper hepatic artery was noted at the time of liver resection after hepatic arterial chemotherapy. Serum ALT was elevated to 2930 IU/l on POD 1, and PGE₁ infusion from SMA was done for the succeeding 7 days. Necrotic area was so vast that serum T. Bil rose to 19 mg/dl. However, it decreased with time. Both cases required 3 months for necrotic liver shrinkage. Doppler ultrasonography revealed that PGE₁ infusion actually increased portal blood flow. In conclusion, based on the preceding experimental backgrounds and clinical experiences, continuous PGE₁ infusion via the SMA can be a useful measure to prevent severe liver damage after hepatic arterial flow interruption through portal blood oxygenation.     

晚期肝癌的一种新的有效治疗方法——反复暂时性肝动脉门静脉阻断并介入治疗

在反复暂时性肝动脉阻断治疗肝癌的基础上,作者设计了反复暂时性肝动脉、门静脉阻断并双介入治疗方法对12例晚期肝癌患者晚期患者进行了临床观察,发现患者经去血供等介入治疗后,临床症状改善,AFP 下降,生活质量提高,生存期明显延长。本方法既发挥反复暂时性肝动脉阻断治疗肝癌的优点,又可以阻断肿瘤内的门脉供血,同时配合双介入治疗,对门静脉癌栓有一定效果,因此不失为晚期肿癌的一种新的有效的辅助治疗方法。     

Hepatic arterial infusion chemotherapy in hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate the prognostic factors and efficacy of hepatic arterial infusion chemotherapy in hepatocellular carcinoma with portal vein tumor thrombosis. METHODS: Fifty hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) were treated using hepatic arterial infusion chemotherapy (HAIC) via a subcutaneously implanted port. The epirubicin-cisplatin-5-fluorouracil (ECF) chemotherapeutic regimen consisted of 35 mg/m 2 epirubicin on day 1, 60 mg/m 2 cisplatin for 2 h on day 2, and 500 mg/m 2 5-fluorouracil for 5 h on days 1-3. The treatments were repeated every 3 or 4 wk. RESULTS: Three (6%) of the 50 patients achieved a complete response (CR), 13 (26%) showed partial responses (PR), and 22 (44%) had stable disease (SD).The median survival and time to progression were 7 and 2 mo, respectively. After 2 cycles of HAIC, CR was achieved in 1 patient (2%), PR in 10 patients (20%) and SD in 26 patients (52%). Significant pre-treatment prognostic factors were a tumor volume of < 400 cm 3 (P = 0.01) and normal levels of protein induced by vitamin K absence or antagonist (PIVKA)-Ⅱ (P = 0.022). After 2 cycles of treatment, disease control (CR + PR + SD) (P = 0.001), PVTT response (P = 0.003) and α-fetoprotein reduction of over 50% (P = 0.02) were independent factors for survival. Objective response (CR + PR), disease control, PVTT response, and combination therapy during the HAIC were also significant prognostic factors. Adverse events were tolerable and successfully managed. CONCLUSION: HAIC may be an effective treatment modality for advanced HCC with PVTT in patients with tumors < 400 cm 3 and good prognostic factors.     

Indications for portal vein embolization in perihilar cholangiocarcinoma

Preoperative portal vein embolization (PVE) is often performed as a routine procedure before extended hepatectomy to minimize postoperative liver failure. However, the indications for PVE in perihilar cholangiocarcinoma (PCCA), which differ between institutions, remain controversial. In the present study, we examined the indications for PVE in patients with PCCA. A comprehensive meta‐analysis of PVE was performed using the PubMed, Medline, and Cochrane databases. The present study, which included 3033 patients (45 publications), compared the results of 836 cases in the PCCA group and 2197 cases in the other hepatic tumor (OHT) group. In the PCCA group, percent future remnant liver (%FRL) and ratio of %FRL to indocyanine green (ICG) were used as criteria in 71% and 25% of cases, respectively, and a %FRL < 40% was used as indication for PVE in 90% of cases. The rates of resection of the bile duct, simultaneous pancreaticoduodenectomy, and reconstruction of the portal vein and hepatic artery were high in the PCCA group (P < 0.001). Mortality after hepatectomy was 3.7% in the PCCA group and 1.9% in the OHT group (P < 0.001). The indication for PVE in PCCA patients is %FRL < 40% in many institutions. The indications for PVE in PCCA patients should be distinguished from those in other hepatic tumors because of the complex surgery required for PCCA.     

Source of blood supply and embolization treatment in cavernous hemangioma and sclerosis of the liver

AIM: To investigate the source of the blood supply in carvenous hemangioma of liver (CHL), and provide a feasible treatment for CHL via thehepatic artery.METHODS: (1) Portovenography, hepatic arteriography and portal vein staining were performed in 5 patients to determine the origin of the blood supply. Two casts of hepatic blood vessels from resected specimens were observed. (2) Clinical data from 75 patients (30 males, 45 females, aged 25-57 years, mean of 37.4) were obtained. Of these, 56 were of solitary type (44 on the right lobe, 12 on the left, with 4 having intraparenchyma), and 19 were of multiple type (9 on the right, 2 the left, 8 whole liver). Twenty-two patients were treated with sclerosis, 50 by embolization via hepatic artery, and 3 were excised.RESULTS: In the 5 cases where portography was used, the contrast medium did not enter the tumor, and the tumor appeared as low density area, with the intrahepatic branches of the portal vein pushed aside. In the 5 cases with where portal vein staining was used, the normal liver parenchyma stained a deep blue; however, the tumor was not stained. The tumor area appeared as a round vacant cavity in the 2 specimen casts. For the 72 patients treated with sclerosis or embolization via hepatic artery or through interventional method, the tumors diminished by 10%-30% in diameter, and no tumors grew larger.CONCLUSION: The blood supply of CHL originates from the hepatic artery. Tumors treated with sclerosis and embolization decreased in size or got fibrotic.     

Angioechographic evaluation of tumor thrombi and the effect of transcatheter arterial embolization in patients with hepatocellular carcinoma

Background: Background: Transcatheter arterial embolization (TAE) is considered to be relatively ineffective in the treatment of portal and/or hepatic vein tumor thrombi associated with hepatocellular carcinoma (HCC). However, we have seen patients with a positively enhanced tumor thrombus on angioechography where necrosis has occurred after TAE. In this study, we compared the angioechographic enhancement of tumor thrombi with the effect of TAE to assess the use of this method in predicting the efficacy of TAE, and in predicting survival. Methods: Angioechography, using a small amount of CO₂ gas injected into the hepatic artery, was performed before TAE in 41 HCC patients with tumor thrombi of the portal vein (PVTT; n= 35) or hepatic vein (HVTT; n= 6). The relationship between the enhancement of the thrombi and the efficacy of TAE was investigated by follow-up ultrasonography. Results: All 13 PVTT that decreased in size had shown positive enhancement (PE) before treatment (P < 0.001), while 6 of the 7 cases (86%) in which the lesions increased in size had shown negative enhancement (NE). The survival of patients with PE was significantly longer than that of patients with NE (P < 0.005). Multivariate analysis identified two clinical variables associated with survival, angioechographic findings of PVTT, and age. There were no correlations between enhancement and HVTT. Conclusions: Determination of enhancement of PVTT on angioechography was useful in predicting the efficacy of TAE treatment of HCC and the survival time. Angioechography may be valuable in treatment decisions for HCC patients with PVTT, especially as a guide to the effectiveness of TAE. Received: March 1, 2001 / Accepted: November 2, 2001     

Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: Clinical Characteristics, Prognosis, and Patient Survival Analysis

Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is associated with a poor prognosis. New therapeutic modalities, such as continuous hepatic arterial infusion chemotherapy (CHAIC), have recently been reported to be promising strategies. The aim of this study was to evaluate the clinical characteristics, prognosis, and survival of patients with PVTT according to treatment regimen. One hundred ninety-three patients with HCC complicated with PVTT at the time of diagnosis were included in this study. All patients were newly diagnosed to have HCC and were observed from January 1992 to December 2003. CHAIC was performed using an implanted drug delivery system with low-dose cisplatin and 5-fluorouracil. Clinical characteristics, prognosis, and patient survival were analyzed by the Kaplan-Meier method and Cox's proportional hazards model. The mean age of the patients complicated with PVTT was 64.3+/-10.3 years (range, 20-88 years). The survival of the 193 patients with PVTT was 37.5%, 24.0%, 18.9%, and 8.3% at 1, 2, 3, and 5 years, respectively. According to treatment, the survival of patients who underwent surgical treatment was the best, followed by CHAIC, transcatheter arterial infusion/embolization, and supportive care. The 3-year survivals for each treatment regimen were 53.0%, 19.3%, 15.0%, and 4.0%, respectively. Although the survival of patients who received surgical treatment was best, such patients were restricted. There was no difference in survival between treated and untreated patients demonstrating Child-Pugh grade C. In Child B patients, treatment for HCC significantly increased survival (P<0.01). Cox's proportional hazards model revealed the Child-Pugh classification to be an independent prognostic factor for patients with HCC and PVTT (P<0.01). We conclude that the prognosis of HCC with PVTT was quite poor. The treatment did not improve the survival of Child C patients. As a result, the prevention, early diagnosis, and development of new treatment strategies are required.     

The effect of somatostatin on insulin and glucose levels during insulin infusion in anesthetized dogs

The purpose of the study was to examine the transhepatic and peripheral effects of somatostatin (SN) infusion on plasma glucose and insulin during insulin (IN) infusion. Hepatic blood flow was measured electromagnetically during intermittent sampling from the portal and hepatic veins, femoral artery, and right external jugular vein. Hepatic blood flow [sum of portal vein (PV) and hepatic artery] was similar during IN or IN + SN infusions. IN concentrations decreased in the portal vein from 374.8 +/- 50.3 to 295.8 +/- 25.9 pM (p less than 0.01) when SN was infused with IN. Hepatic venous plasma IN concentration also decreased from 143.6 +/- 26.6 to 88.3 +/- 10.1 pM (p less than 0.01). Plasma IN concentrations in the femoral artery and jugular vein remained unchanged. Hepatic insulin extraction changed from 64 +/- 4% during IN to 72 +/- 3% during IN + SN (p less than 0.01). Hepatic clearance and total body clearance were unchanged. Peripheral venous glucose with a nadir of 3.82 +/- 0.2 mM during IN alone decreased to a nadir of 3.16 +/- 0.27 mM (p less than 0.01) during IN + SN infusion. Mean portal venous glucose concentrations were 5.0 +/- 0.27 and 3.4 +/- 0.19 mM, respectively (p less than 0.01). In two additional experiments in which endogenous C-peptide concentrations were examined in the portal vein and femoral artery, C-peptide levels were lower during IN + SN compared to IN alone. We conclude that SN used to suppress endogenous insulin secretion increases hepatic insulin extraction, lowers glucose concentrations, and suppresses endogenous C-peptide levels to a greater extent than insulin infusion alone.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multimodality treatment in hepatocellular carcinoma patients with tumor thrombi in portal vein

AIM To compare the therapeutic effect andsignificances of multimodality treatment forhepatocellular carcinoma (HCC) with tumorthrombi in portal vein (PVTT).METHODS HCC patients (n=147) with tumortrombi in the main portal vein or the first branchof portal vein were divided into four groups bythe several therapeutic methods. There wereconservative treatment group in 18 out ofpatients (group A); and hepatic artery ligation(HAL) and/or hepatic artery infusion (HAI)group in 18 patients (group B), in whompostoberative chemoembolization was doneperiodically; group of removal of HCC with PVTTin 79 (group C) and group of transcatheterhepatic arterial chemoembolization (TACE) orHAI and/or portal vein infusion (PVI) afteroperation in 32 (group D).RESULTS The median survival period was 12months in our series and the 1-, 3-, and 5-yearsurvival rates were 44.3%, 24.5% and 15.2%,respectively. The median survival times were 2,5, 12 and 16 months in group A, B, C and D,respectively. The 1-, 3- and 5-year survival rateswere 5.6%, 0% and 0% in group A; 23.2%,5.6% and 0% in group B; 53.9%, 26.9% and16.6% in group C; 79.3%, 38.9% and 26.8% ingroup D, respectively. Significant differenceappeared in the survival rates among the groups (P<0.05).CONCLUSION Hepatic resection with removalof tumor thrombi and HCC should increase thecurative effects and be encouraged for theprolongation of life span and quality of life forHCC patients with PVTT, whereas the besttherapeutic method for HCC with PVTT is withregional hepatic chemotherapy orchemoemblization after hepatic resection withremoval of tumor thrombi.     

Pathological Complete Remission of Advanced Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombosis by Hepatic Arterial Infusion Chemotherapy

Cures for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) are rare and difficult. We report a case of pathologically confirmed complete remission of HCC induced by hepatic arterial infusion chemotherapy (HAIC). A 45-year-old male patient had a massive HCC in the right lobe of the liver and tumor thrombus in the right and main portal veins. He achieved a partial response after two cycles of HAIC with 5-fluorouracil (750 mg/m²) and cisplatin (25 mg/m²). After the completion of six cycles he received a curative partial hepatectomy, and histopathology revealed complete necrosis without any viable tumor cell. He was in good health at a 4-month follow-up. These results suggest that this regimen is a promising therapeutic modality for the treatment of advanced HCC with PVTT.     

A long-term survival case underwent repeated hepatic arterial infusion chemotherapy with portal branch ligation and wrapping of the liver using sheets for hepatocellular carcinoma

Despite progress in therapeutic modalities for hepatocellular carcinoma, chemotherapy is the only remaining option for a considerable number of patients because of severe advanced disease and/or cirrhosis. Repeated hepatic arterial infusion chemotherapy with portal branch ligation and decollateralization using a silicone rubber sheet was performed for hepatocellular carcinoma. Tumor size and serum concentration of alpha-fetoprotein markedly decreased after hepatic arterial infusion chemotherapy. Although the patient had no recurrent tumor, he died of hepatorenal failure 7 years after treatment. Hepatic arterial infusion chemotherapy combined with portal branch occlusion and decollateralization is a new therapeutic method for unresectable hepatocellular carcinoma.     

Interleukin-2 as a modulator of 5-fluorouracil in hepatic arterial immunochemotherapy for liver metastases

BACKGROUND/AIMS: Hepatic arterial infusion of interleukin-2-based immunochemotherapy has yielded a high response rate (> 75%) in patients with unresectable liver metastases. In order to clarify the mechanisms that underlie the apparent benefit of combination treatment, the role of IL-2 as a modulator of 5-fluorouracil metabolism was investigated. METHODOLOGY: A single dose of 5-fluorouracil (50 mg/kg) with or without IL-2 (3500 Japan Reference Units/kg) was given via the hepatic artery to rats bearing liver metastases. Thirty minutes later samples of liver metastatic foci or surrounding normal liver tissue were removed for the measurement of thymidylate synthase, thymidine kinase and dihydropyrimidine dehydrogenase activity, and 5-fluorouracil content. RESULTS: 5-fluorouracil levels in tumor were significantly higher than in normal liver. Although the addition of IL-2 reduced 5-fluorouracil levels in both tumor and normal liver tissues by the activation of dihydropyrimidine dehydrogenase, the ratio of tumor/normal liver 5-fluorouracil levels was unchanged. Both thymidylate synthase and thymidine kinase activities were significantly inhibited in tumor tissue when the combination of 5-fluorouracil and IL-2 was administered. CONCLUSIONS: IL-2 increases 5-fluorouracil cytotoxicity through the inhibition of thymidylate synthase/thymidine kinase activities in the hepatic arterial infusion.     

Efficacy of hepatic arterial infusion chemotherapy in advanced hepatocellular carcinoma

AIM: To investigate the efficacy of hepatic arterial infusion chemotherapy (HAIC) using floxuridine (FUDR) in patients with advanced hepatocellular carcinoma (HCC) confined to the liver.METHODS: Thirty-four patients who had advanced HCC with unresectability or unsuccessful previous therapy in the absence of extrahepatic metastasis were treated with intra-arterial FUDR chemotherapy at our hospital between March 2005 and May 2008. Among the 34 patients, 9 patients were classified as Child class C, and 18 patients had portal vein tumor thrombus (PVTT). One course of chemotherapy consisted of continuous infusion of FUDR (0.3 mg/kg during day 1-14) and dexamethasone (10 mg on day 1, 4, 7 and 11), and this treatment was repeated every 28 d.RESULTS: Two patients (5.9%) displayed a complete response, and 12 patients (35.3%) had a partial response. The tumor control rate was 61.8%. The median overall survival times were 15.3 mo, 12.4 mo and 4.3 mo for the patients who were classified as Child class A, Child class B and Child class C, respectively (P = 0.0392). The progression-free survival was 12.9 mo, 7.7 mo and 2.6 mo for the patients who were classified as Child class A, Child class B and Child class C, respectively (P = 0.0443). The cumulative survival differed significantly according to the Child-Pugh classification and the presence of PVTT. In addition to hepatic reserve capacity and PVTT, the extent of HCC was an independent factor in determining a poor prognosis. The most common adverse reactions to HAIC were mucositis, diarrhea and peptic ulcer disease, but most of these complications were improved by medical treatment and/or a delay of HAIC.CONCLUSION: The present study demonstrates that intra-arterial FUDR chemotherapy is a safe and effective treatment for advanced HCC that is recalcitrant to other therapeutic modalities, even in patients with advanced cirrhosis.     

Effects of Dobutamine on Hepatosplanchnic Hemodynamics in Patients with Chronic Liver Disease

Kawasaki T, Moriyasu F, Kimura T, Someda H, Hamato N, Okuma M. Effects of dobutamine on hepatosplanchnic hemodynamics in patients with chronic liver disease. Scand J Gastroenterol 1994; 29:1044-1054.

Background: It is said that catecholamines increase hepatic blood flow in patients without liver diseases, although several reports have suggested a blunted response to catecholamines in patients with liver cirrhosis.

Methods: We investigated changes in splanchnic blood flow distribution induced by the infusion of dobutamine into peripheral veins of healthy adults (NC group), patients with chronic hepatitis (CH group), and patients with liver cirrhosis (LC group), using a Doppler duplex system (protocol 1). We also investigated changes in hepatic hemodynamics induced by dobutamine infusion in patients with liver cirrhosis (cirrhosis group) and patients without liver diseases (control group), using hepatic catheterization (protocol 2).

Results: In protocol 1 the average increase in portal venous blood flow during dobutamine infusion was significant in the NC and CH groups but was not significant in the LC group. Changes in the blood flow in the splenic artery and vein, superior mesenteric artery and vein, and femoral artery were similar to those in the portal vein in each of the three groups. Infusion did not cause a change in the common hepatic arterial flow in any of the three groups. In protocol 2 the portal venous flow, cardiac index, and hepatic venous pressure gradient increased significantly during dobutamine infusion in both the cirrhosis and the control groups. Hepatic vascular resistance in the cirrhosis group increased slightly, whereas, in contrast, that in the control group increased significantly. The rate of change in almost all variables was lower in the cirrhosis group than in the control group.

Conclusion: These results indicate that dobutamine has less effect on hepatic circulation in patients with liver cirrhosis than in those without liver diseases, indicating that the value of dobutamine in increasing hepatic blood flow in cirrhotic patients is very limited.     

Portal thrombosis due to intrahepatic cholangiocarcinoma following successful treatment for hepatocellular carcinoma

A 57-year-old man, who had undergone hepatic arterial infusion chemotherapy with right portal occlusion for hepatocellular carcinoma was admitted to our hospital because of severe abdominal pain. Contrast-enhanced computed tomograms revealed that most areas of the liver were not enhanced, a finding suspicious for perfusion disturbance in the liver. Angiography revealed an interrupted right hepatic artery. Arterial portograms revealed complete obstruction of the right portal vein and a small left branch of the portal vein. Despite anticoagulant therapy with urokinase for portal vein thrombosis, the patient died from hepatorenal failure. Autopsy revealed that cholangiocarcinoma occupied almost the entire parenchyma of the right lobe, although the treated hepatocellular carcinoma lesion was completely necrotic. The right hepatic artery was obstructed due to direct invasion of tumor. There were diffuse thrombi in the left portal branches surrounded by tumor infiltrating along Glisson's sheath to the peripheral portion of the left lobe.     

Hepatic encephalopathy secondary to transtumoral portal-hepatic venous shunting

Intrahepatic portal-systemic shunts causing hepatic encephalopathy are very rare. This is a case report of a patient with hepatic metastases of a pancreatic islet cell tumor that manifested with transtumoral shunts leading to hepatic encephalopathy. The diagnosis was confirmed with Doppler ultrasound and initially treated with selective transhepatic portal vein embolization followed by hepatic artery embolization, and eventually radiofrequency ablation of the largest metastases. Despite excellent short-term palliation, symptom recurrence necessitated liver resection, the results of which proved durable. A multidisciplinary treatment plan for the identification and management of potentially salvageable encephalopathy in similar patients is described.     

Meta-analysis: Perioperative regional liver chemotherapy for improving survival and preventing liver metastases in patients with colorectal carcinoma

OBJECTIVE: To evaluate the effect of prophylactic regional liver chemotherapy during the perioperative period on improving survival and preventing liver metastases in patients with colorectal cancer (CRC). METHODS: A comprehensive retrieval of the relevant literature was performed by searching major biomedical database, mainly from Medline and Embase. Studies reported in the selected literature were categorized into two subgroups according to the type of therapy: a perioperative hepatic artery infusion subgroup and a perioperative portal vein infusion subgroup. Mortality and liver metastasis were analyzed using a fixed-effects model. Statistical analysis was performed using Review Manager software. RESULTS: The results of this meta-analysis illustrated that survival and the rate of liver metastasis in patients receiving perioperative hepatic artery infusion (HAI) chemotherapy were significantly better than for those receiving surgery alone (pooled relative risk 0.46 [95% CI: 0.31–0.69] and 0.44 [95% CI: 0.28–0.68], respectively, P= 0.0002), while survival and the rate of liver metastasis in patients receiving perioperative portal vein infusion (PVI) chemotherapy were not significantly different from those receiving surgery alone (pooled relative risk 0.98 [95% CI: 0.89–1.09], P= 0.73 and 0.86 [95% CI: 0.72–1.02], respectively. P= 0.08). CONCLUSION: As a method of regional liver chemotherapy, HAI might be able to improve survival and reduce the rate of liver metastasis in patients with advanced CRC.