Non-anatomical liver resection for hepatocellular carcinoma: the SegSubTe classification to overcome the problem of heterogeneity

BACKGROUND

The superiority of anatomical resection (AR) vs. non-anatomical resection (NAR) in the surgical management of hepatocellular carcinoma (HCC) is debated. ARs are well-defined procedures, whereas the lack of NAR standardization results in heterogeneous outcomes. This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor.

METHODS

A single-center retrospective analysis of pre- and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted. The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section (segmental, subsegmental or terminal next to the tumor) of vascular pedicles feeding the HCCs; then, the population was divided in "SegSubTe-IN" or "SegSubTe-OUT" groups, and the tumor recurrence and survival were analyzed.

RESULTS

Ninety-seven patients who underwent NAR were included; 76% were SegSubTe-IN and 24% were SegSubTe-OUT. Total disease recurrence, local recurrence and cut-edge recurrence in the SegSubTe-IN vs. SegSubTe-OUT groups were 50% vs. 83% (P = 0.006), 20% vs. 52% (P = 0.003) and 16% vs. 39% (P = 0.020), respectively. SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis. One-, three-, and five-year disease-free survival rates in the SegSubTe-IN vs. SegSubTe-OUT groups were 81%, 58% and 35% vs. 46%, 21% and 11%, respectively (P < 0.001).

CONCLUSIONS

The SegSubTe classification is a useful tool to stratify and standardize NAR for HCC, aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

Endovascular management of KILT syndrome and COVID-19-related extensive deep vein thrombosis in a pregnant patient: A case report

We report on a 20-year-old pregnant woman who tested positive for SARS-CoV-2 and was diagnosed with KILT syndrome, a rare condition that increases the risk of thrombotic events. The patient showed signs of deep vein thrombosis that extended from the bilateral iliac vein to the inferior vena cava (IVC), which was treated with placement of an IVC filter and endovascular thromboaspiration/thrombolysis. The IVC was successfully recanalized; however, during follow-up, thrombotic restenosis occurred at the filter level, requiring filter removal. This case highlights the potential benefits of endovascular thromboaspiration/thrombolysis and IVC filter placement in patients with KILT syndrome presenting with acute thrombotic events.

Arterio-venous fistula causing acute right heart failure: A rare complication of veno-arterial extracorporeal membrane oxygenation

Introduction: Vascular complications are a major issue in V-A ECMO and can affect long term outcome. Among these, Artero-Venous (AV) fistulas may lead to right heart failure.Case History: A 73-years patient supported with V-A ECMO for post-cardiotomy biventricular failure developed right heart failure after V-A ECMO decannulation, requiring V-A ECMO recannulation. The presence of an AV femoral fistula was incidentally revealed during femoral vein cannulation, from which oxygenated blood was unexpectedly drawn. The angiographic assessment confirmed the presence of a fistula between superficial femoral artery and vein, at the site of the first venous ECMO cannulation. This was caused by the venous cannula that inadvertently passed across the artery and created an AV fistula that was opened by the venous cannula removal. The exclusion of the endovascular fistula allowed the right heart failure resolution.Conclusions: In the presence of right heart failure after recent vascular manipulation, AV fistula should be ruled out.

Any role for transarterial radioembolization in unresectable intrahepatic cholangiocarcinoma in the era of advanced systemic therapies?

Intrahepatic cholangiocarcinoma (iCCA) is recognized as the second most frequently diagnosed liver malignancy, following closely after hepatocellular carcinoma. Its incidence has seen a global upsurge in the past several years. Unfortunately, due to the lack of well-defined risk factors and limited diagnostic tools, iCCA is often diagnosed at an advanced stage, resulting in a poor prognosis. While surgery is the only potentially curative option, it is rarely feasible. Currently, there are ongoing investigations into various treatment approaches for unresectable iCCA, including conventional chemotherapies, targeted therapies, immunotherapies, and locoregional treatments. This study aims to explore the role of transarterial radioembolization (TARE) in the treatment of unresectable iCCA and provide a comprehensive review. The findings suggest that TARE is a safe and effective treatment option for unresectable iCCA, with a median overall survival (OS) of 14.9 months in the study cohort. Studies on TARE for unresectable iCCA, both as a first-line treatment (as a neo-adjuvant down-staging strategy) and as adjuvant therapy, have reported varying median response rates (ranging from 34% to 86%) and median OS (12-16 mo). These differences can be attributed to the heterogeneity of the patient population and the limited number of participants in the studies. Most studies have identified tumor burden, portal vein involvement, and the patient's performance status as key prognostic factors. Furthermore, a phase 2 trial evaluated the combination of TARE and chemotherapy (cisplatin-gemcitabine) as a first-line therapy for locally advanced unresectable iCCA. The results showed promising outcomes, including a median OS of 22 mo and a 22% achievement in down-staging the tumor. In conclusion, TARE represents a viable treatment option for unresectable iCCA, and its combination with systemic chemotherapy has shown promising results. However, it is important to consider treatment-independent factors that can influence prognosis. Further research is necessary to identify optimal treatment combinations and predictive factors for a favorable response in iCCA patients.

Compressive ultrasound can predict early pulmonary embolism onset in COVID patients

PURPOSE

To evaluate the usefulness of compressive ultrasound (CUS) for the diagnosis of deep vein thrombosis (DVT) in patients with SARS-CoV-2-related infection.

METHODS

112 hospitalized patients with confirmed SARS-CoV-2 infection were retrospectively enrolled. CUS was performed within 2 days of admission and consisted in the assessment of the proximal and distal deep venous systems. Lack of compressibility, or direct identification of an endoluminal thrombus, were the criteria used for the diagnosis of DVT. Pulmonary embolism (PE) events were investigated at computed tomography pulmonary angiography (CTPA) within 5 days of follow-up. Logistic binary regression was computed to determine which clinical and radiological parameters were independently associated with PE onset.

RESULTS

Overall, the incidence of DVT in our cohort was about 43%. The most common district involved was the left lower limb (68.7%) in comparison with the right one (58.3%) while the upper limbs were less frequently involved (4.2% the right one and 2.1% the left one, respectively). On both sides, the distal tract of the popliteal vein was the most common involved (50% right side and 45.8% left side). The presence of DVT in the distal tract of the right popliteal vein (OR = 2.444 95%CIs 1.084-16.624, p = 0.038), in the distal tract of the left popliteal vein (OR = 4.201 95%CIs 1.484-11.885, p = 0.007), and D-dimer values (OR = 2.122 95%CIs 1.030-5.495, p = 0.003) were independently associated with the onset on PE within 5 days.

CONCLUSIONS

CUS should be considered a useful tool to discriminate which category of patients can develop PE within 5 days from admission.

Changes of liver fat content and transaminases in obese children after 12-mo nutritional intervention

AIM: To assess a relationship between longitudinal changes in liver fat content and biochemical parameters in obese children after 1-year nutritional intervention.

METHODS: Forty-six obese children, 21 males and 25 females, aged 6-14 years, underwent metabolic measurements, liver ultrasonography (US) and chemical-shift magnetic resonance imaging (MRI) examinations at baseline and after 1-year nutritional intervention. A child was defined obese if her/his body mass index (BMI) was above the age- and sex-adjusted BMI Cole’s curve passing through the cut-off of 30 kg/m² at 18 years. BMI Z scores were calculated and adjusted for age and gender by using the Cole’s LMS-method and Italian reference data. Biochemistry included serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Abdominal US and chemical-shift MRI were performed according to a randomized sequence. The same radiologist performed US by a GE Logiq 9 (General Electric Healthcare Medical Systems, Milwaukee, WI, United States) using a 3.5-MHz convex array transducer. Liver echogenicity was evaluated independently on videotape by 3 radiologists unaware of the child and MRI outcomes, and a consensus was established. Another experienced radiologist, unaware of the child and US data, performed the abdominal chemical-shift MRI with a 1-t system NT-Intera (Philips Medical Systems, Best, The Netherlands) and a phased-array coil. Liver fat fraction (FF) on MRI was judged elevated when greater than 9%. A FF > 18% was considered expressing more severe cases of fatty liver according to Fishbein. A nutritional-behavioral intervention was recommended to promote a normocaloric balanced diet and active lifestyle based on the Italian guidelines for treatment of childhood obesity.

RESULTS: Compared to baseline, at the end of intervention children showed lower intakes of energy (mean ± SD: 2549 ± 1238 Kcal vs 1770 ± 622 Kcal, P < 0.0001), total fat (90 ± 47 g vs 52 ± 23 g, P < 0.0001), carbohydrates (356 ± 174 g vs 241 ± 111 g, P = 0.001), and protein (99 ± 48 g vs 75 ± 23 g, P = 0.006) intakes. Prevalence of FF ≥ 9% declined from 34.8% to 8.7% (P < 0.01), with a mean reduction of 7.8% (95%CI: 5.0-10.6). At baseline, FF was associated with liver biochemical parameters (maximum P < 0.001). At the end of the intervention association was found with AST (P = 0.017). Change of FF was associated with change in AST (P = 0.027) and ALT (P = 0.024). Rate of increased liver echogenicity declined from 45.6% to 21.7% (P < 0.0001). Liver echogenicity was associated with ALT at baseline only (P < 0.001). An age- and sex- adjusted multiple regression analysis showed that FF change was independently associated with change in serum AST (adjusted regression coefficient 0.348, P = 0.048).

CONCLUSION: The results suggest that in obese children longitudinal changes in liver fat content based on MRI may be associated with change in serum transaminases suggesting novelty in monitoring nonalcoholic fatty liver disease.

Linear asymptomatic pneumatosis as an unexpected finding of computed tomography colonography: a case report

INTRODUCTION

We discuss asymptomatic colonic pneumatosis, an unexpected finding of computed tomography colonography that we must see as distinct from perforation. Among the papers detailing complications with computed tomography colonography, we found only one report focusing on linear pneumatosis.

CASE PRESENTATION

We report the case of a 75-year-old Caucasian woman who had a high level of carcinoembryonic antigen, and who underwent computed tomography colonography. Our patient accidentally fell from a chair in the radiology department just before the examination, experiencing a right hip trauma. The examination was negative for colonic lesions but revealed the presence of some air bubbles in her right colon. Our patient remained asymptomatic throughout the procedure and afterwards; no intervention or treatment was necessary.

CONCLUSION

Radiologists should consider colonic linear pneumatosis among the potential complications of computed tomography colonography, even if it is a rare event, to avoid unnecessary therapy and anxiety for the patient.

Wrist median nerve motor conduction after end range repeated flexion and extension passive movements in Carpal Tunnel Syndrome. Pilot study

Carpal Tunnel Syndrome (CTS) can be due to a variety of different pathological conditions. These etiological and epidemiological differences may explain the non-homogeneous response to ordinary conservative therapeutical options observed in this syndrome. The aim of our study was to investigate on the possibility of identifying different sub-groups of patients among conservatively treatable CTS with different susceptibility to physiotherapeutic treatments. We decided to utilize an objective approach measuring some median motor nerve function parameters. Short term variations of Compound Motor Action Potential (CMAP) from the thenar eminence were compared in two groups of 55 hands (CTS patients and normal controls) after performance of two different types of end range passive movement. We found a different distribution of CMAP amplitude modifications within a sub-group of patients that suddenly improved more than the controls after two series of 10 end range passive flexions or after two series of ten end range passive extensions. Amplitude changes proved to be much more useful than latency variation studies in the provocative test neurophysiological approach. The method we propose appears to be useful for better surgical indication and/or for improvement of conservative therapeutic choice.

[Is a monthly biochemical check-up useful more than 2 years after kidney transplantation?]

Over the course of the years many transplantation centres have altered their pattern of periodical check-ups in patients with stable renal function, in some cases considerably prolonging the intervals. Peripheral centres, which are attended by patients after kidney transplantation, must reconcile the follow-up requirements made by various reference centres. The authors carried out a retrospective evaluation of 39 patients who, at 30-6-1992, had had kidney transplants for more than two years, taking into consideration a series of hematochemical tests indicative of the main functional alterations (creatininemia, hepatic enzymes, hemochrome, cyclosporin assay). In the 31 patients receiving monthly check-ups after the second year, changes in cyclosporinemia were on average significantly more frequent in comparison to variations in other parameters. This finding, together with the need for a careful control of transplant patients, would appear to confirm the value of monthly check-ups. However, the positive experience of some centres which begin to space out periodical check-ups at an early stage and report good organ survival, opposes the previous affirmation. Lastly, it emerges from this study that patients undergoing frequent controls even after the second year of transplantation have significantly lower organ survival.

Prevalence of HCV antibodies in a uraemic population undergoing maintenance dialysis therapy and in the staff members of the dialysis unit

We studied, by both 1st and 2nd generation assay, the prevalence rate of HCVAb in a population of 141 dialysis patients, 37 transplanted patients and 55 staff members. From this study emerges a higher sensitivity of the 2nd generation HCVAb test (15.38 versus 36.79% of positive responses, respectively), and a significant positive correlation between lengths of dialysis period. We have not found a significant difference between HCVAb-positive and -negative patients in relation to the blood transfusions. None of the 21 CAPD patients (home dialysis) resulted positive, even if transfused. Two nurses were positive. In our experience, the environmental factor seems more important. Since the isolation of the positive patients is an effective but not feasible measure, it is necessary to improve the operating management of the hemodialysis sessions, avoiding any contact between patients via material (instrumentation, monitors) and teaching the staff members to use severe preventive standards with all hemodialysis patients.

[Remarks on a clinical case of partial carbamyl phosphate synthetase deficiency]

A preliminary undiagnosed case of partial carbamyl-phosphate-synthetase deficiency in a 14 year old patient is described. This extremely rare metabolic disorder is unlikely to produce clinical symptoms at such an advanced age. Details are given of the clinical picture, the diagnosis (by liver biopsy and post mortem liver examination) and the attempts at treatment.

[Study of serum ferritin in a population of 3-month-old breast feeding children]

The evaluation of serum ferritin level in a population of 30 three months old babies is made by the Authors following a radioimmunological method. The reckoned average values reflect exactly the wellknown elements of iron kinetics during the first months of life. The Authors underline that those values show how complete is breast-feeding; moreover they emphasize the importance of a referring value which, together with those already known in subjects of different ages, allows on early diagnosis of syndromes due to iron decrease and subsequent check-up after therapeutic trial.

[Attempt to solve technical problems involved in the re-utilization of coil filters for hemodialysis]

The problem of the reutilization of coil filters in haemodialysis is discussed. The methodologies in current use are examined and the technical risks and inconveniences that limit any real economic advantage are pointed out. On the basis of these observations, a system of reutilization is proposed which does not call for any direct handling of the filter nor any special techniques for eliminating risks of transmitting infection, and cuts to the minimum extra work involving the use of hospital staff. The proposed equipment is illustrated in detail. It consists of a small accessory individual monitor which has opened the way to the concept of "weekly dialyser". Attention is called to the need for further research into the physiopathology of the regenerated membrane, particularly in relation to the type of filter, the number of reutilizations, and the behaviour of ultrafiltration and the various solutes.