To compare the performance of various liver disease scoring systems in predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation.
In this single-institution ...retrospective study, eight scoring systems were used to grade liver disease in 211 patients (male-to-female ratio = 131:80; mean age, 54 y) before TIPS creation from 1999-2011. Scoring systems included bilirubin level, Child-Pugh (CP) score, Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease sodium (MELD-Na) score, Emory score, prognostic index (PI), Acute Physiology and Chronic Health Evaluation (APACHE) 2 score, and Bonn TIPS early mortality (BOTEM) score. Medical record review was used to identify 30-day and 90-day clinical outcomes. The relationship of scoring parameters with mortality outcomes was assessed with multivariate analysis, and the relative ability of systems to predict mortality after TIPS creation was evaluated by comparing area under receiver operating characteristic (AUROC) curves.
TIPS were successfully created for variceal hemorrhage (n = 121), ascites (n = 72), hepatic hydrothorax (n = 15), and portal vein thrombosis (n = 3). All scoring systems had a significant association with 30-day and 90-day mortality (P<.050 in each case) on multivariate analysis. Based on 30-day and 90-day AUROC, MELD (0.878, 0.816) and MELD-Na (0.863, 0.823) scores had the best capability to predict early mortality compared with bilirubin (0.786, 0.749), CP (0.822, 0.771), Emory (0.786, 0.681), PI (0.854, 0.760), APACHE 2 (0.836, 0.735), and BOTEM (0.798, 0.698), with statistical superiority over bilirubin, Emory, and BOTEM scores.
Several liver disease scoring systems have prognostic value for early mortality after TIPS creation. MELD and MELD-Na scores most effectively predict survival after TIPS creation.
To assess clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) treatment of variceal hemorrhage.
A total of 128 patients (82 men and 46 women; mean age, 52 y) with liver ...cirrhosis and refractory variceal hemorrhage underwent TIPS creation from 1998 to 2010. Mean Child-Pugh and Model for End-stage Liver Disease (MELD) scores were 9 and 18, respectively. From 1998 to 2004, 12-mm Wallstents (n = 58) were used, whereas from 2004 to 2010, 10-mm VIATORR covered stent-grafts (n = 70) were used. Technical success, hemodynamic success, complications, shunt dysfunction, recurrent bleeding, and overall survival were assessed.
Technical and hemodynamic success rates were 100% and 94%, respectively. Mean portosystemic gradient reduction was 13 mm Hg. Complications at 30 days included encephalopathy (14%), renal failure (5.5%), infection (1.6%), and liver failure (0.8%). Shunt patency rates were 93%, 82%, and 60% at 30 days, 1 year, and 2 years, respectively. Dysfunction, or loss of TIPS primary patency, occurred more with Wallstent versus VIATORR TIPSs (29% vs 11%; P = .009). Recurrent bleeding incidences were 9%, 22%, and 29% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (19% vs 19%; P = .924). Variceal embolization significantly reduced recurrent bleeding rates (5% vs 25%; P = .013). Overall survival rates were 80%, 69%, and 65% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (35% vs 26% mortality rate; P = .312). Advanced MELD score was associated with increased mortality on multivariate analysis.
Wallstent and VIATORR TIPSs effectively treat variceal hemorrhage, particularly when accompanied by variceal embolization. Although TIPS with a VIATORR device showed improved shunt patency, patient survival is similar to that with Wallstent TIPS. These results further validate TIPS creation for refractory variceal bleeding.
The quantitative relationship between tumor morphology and malignant potential has not been explored in liver tumors. We designed a computer algorithm to analyze shape features of hepatocellular ...carcinoma (HCC) and tested feasibility of morphologic analysis.
Cross-sectional images from 118 patients diagnosed with HCC between 2007 and 2010 were extracted at the widest index tumor diameter. The tumor margins were outlined, and point coordinates were input into a MATLAB (MathWorks Inc., Natick, Massachusetts, USA) algorithm. Twelve shape descriptors were calculated per tumor: the compactness, the mean radial distance (MRD), the RD standard deviation (RDSD), the RD area ratio (RDAR), the zero crossings, entropy, the mean Feret diameter (MFD), the Feret ratio, the convex hull area (CHA) and perimeter (CHP) ratios, the elliptic compactness (EC), and the elliptic irregularity (EI). The parameters were correlated with the levels of alpha-fetoprotein (AFP) as an indicator of tumor aggressiveness.
The quantitative morphometric analysis was technically successful in all cases. The mean parameters were as follows: compactness 0.88±0.086, MRD 0.83±0.056, RDSD 0.087±0.037, RDAR 0.045±0.023, zero crossings 6±2.2, entropy 1.43±0.16, MFD 4.40±3.14 cm, Feret ratio 0.78±0.089, CHA 0.98±0.027, CHP 0.98±0.030, EC 0.95±0.043, and EI 0.95±0.023. MFD and RDAR provided the widest value range for the best shape discrimination. The larger tumors were less compact, more concave, and less ellipsoid than the smaller tumors (P < 0.0001). AFP-producing tumors displayed greater morphologic irregularity based on several parameters, including compactness, MRD, RDSD, RDAR, entropy, and EI (P < 0.05 for all).
Computerized HCC image analysis using shape descriptors is technically feasible. Aggressively growing tumors have wider diameters and more irregular margins. Future studies will determine further clinical applications for this morphologic analysis.
Achalasia Walzer, Natasha; Hirano, Ikuo
Gastroenterology clinics of North America,
12/2008, Letnik:
37, Številka:
4
Journal Article
Recenzirano
Achalasia is the best understood and most readily treatable esophageal motility disorder. It serves as a prototype for disorders of the enteric nervous system with degeneration of the myenteric ...neurons that innervate the lower esophageal sphincter (LES) and esophageal body. Investigations into the pathogenesis have highlighted the importance of nitric oxide and the possible role of an autoimmune response to a viral insult in genetically susceptible individuals. Advances in diagnostic testing have delineated manometric variants of achalasia that have implications for management. Treatment studies have demonstrated the limited efficacy of botulinum toxin as well as less than ideal, long-term effectiveness of both pneumatic dilation and Heller myotomy. This article incorporates these recent developments into the current understanding of achalasia.
PURPOSE OF REVIEWThis review primarily focuses on new developments in the field of hepatocellular carcinoma.
RECENT FINDINGSPotential preventive strategies in the development of hepatocellular ...carcinoma are being recognized. Novel molecular markers identified may aid in the diagnosis of early hepatocellular carcinoma in patients with chronic hepatitis C virus. Prognostic information gained by preoperative tumor biopsy is being investigated. Treatment of early hepatocellular carcinoma with resection versus primary or salvage transplantation continues to be debated. Expansion of selection criteria beyond the Milan criteria appears feasible. The role of living donor liver transplantation in hepatocellular carcinoma will require further study to determine the risk of recurrence. Improvements in chemoembolization with drug eluting beads appear promising.
SUMMARYFurther insight into the pathogenesis of hepatocellular carcinoma will result in the continued evolution of our approach and management of the disease. Tailored therapies based on tumor biology are needed to improve treatment response and ultimately patient survival.
