Chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, or whether embolization (TAE) alone gives the same survival advantage, is not known. To evaluate whether specific patient characteristics and/or radiological transarterial techniques result in better outcomes. A PubMed search was carried out for cohort and randomized trials (n = 175) testing transarterial therapies; meta-analysis was performed where appropriate. Anticancer drugs were used as sole agent in 75% of cases (double 15% and triple 6%): doxorubicin (36%), cisplatin (31%), epirubicin (12%), mitoxantrone (8%), mitomycin (8%), and SMANCS (5%). Embolizing agents used were: gelatin sponge particles (71%), polyvinyl alcohol (PVA) particles (8%), degradable starch microspheres (DSM) (4%), and embospheres (4%). Sessions per patient were 2.5 ± 1.5 (interval: 2 months). Objective response was 40 ± 20%; survival rates at 1, 2, 3, and 5 years were: 62 ± 20%, 42 ± 17%, 30 ± 15%, and 19 ± 16%, respectively, and survival time was 18 ± 9.5 months. The post-TACE complications were: acute liver failure, 7.5% (range 0–49%); acute renal failure, 1.8% (0–13%); encephalopathy, 1.8% (0–16%); ascites, 8.3% (0–52%); upper gastrointestinal bleeding; 3% (0–22%); and hepatic or splenic abscess, 1.3% (0–2.5%). Treatment-related mortality was 2.4% (0–9.5%), mainly due to acute liver failure. Our meta-analysis of nine randomized controlled trials (RCTs) confirmed that TACE improves survival; but a meta-analysis of TACE versus TAE alone (3 RCTs, 412 patients) demonstrated no survival difference. No chemotherapeutic agent appears better than any other. There is no evidence for benefit with lipiodol. Gelatin sponge is the most used embolic agent, but PVA particles may be better. TAE appears as effective as TACE. New strategies to reduce the risk of post-TACE complications are required.

/pdf/transarterial-therapy-for-hepatocellular-carcinoma-which-61rehrtmd6.pdf

Transarterial Therapy for Hepatocellular Carcinoma: Which Technique Is More Effective? A Systematic Review of Cohort and Randomized Studies

Background: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures. Methods: Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function. Results: Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4‐9) versus 7·5 (6‐10) days; P = 0·027). Duration of catheterization (P = 0·022) and duration of intravenous infusion (P = 0·007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0·042). Grip strength was maintained in the postoperative period in the optimized group (P = 0·241) but not in the control group (P = 0·049). There were no differences in morbidity or mortality between the groups. Conclusion: Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.

Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection.

Malignant large bowel obstruction occurs in up to 20% of patients with colorectal cancer and carries an appreciable morbidity and mortality [1–3]. Twenty-five per cent of all post-operative deaths following surgery for colorectal cancer occur in those who present initially with obstruction [4]. Patients with obstruction are often elderly with associated co-morbidities and the therapeutic options are varied. This position statement sets out to examine the current literature on this condition and to provide an evidence base upon which practitioners can advise individual management of these patients. The Position Statement is presented in sections dealing with detailed aspects of pathology, diagnosis and treatment. The evidence is briefly summarized in a question, where relevant, under the heading ‘Findings’ and this is followed, where relevant, by ‘Recommendation’.

The Management of Malignant Large Bowel Obstruction: ACPGBI Position Statement

Nonsurgical treatment of hepatocellular carcinoma.

This review aims to provide a comprehensive overview of the in vitro, animal, and clinical studies with the bacterial strain Lactiplantibacillus plantarum 299v (L. plantarum 299v; formerly named Lactobacillus plantarum 299v) published up until June 30, 2020. L. plantarum 299v is the most documented L. plantarum strain in the world, described in over 170 scientific publications out of which more than 60 are human clinical studies. The genome sequence of L. plantarum 299v has been determined and is available in the public domain (GenBank Accession number: NZ_LEAV01000004). The probiotic strain L. plantarum 299v was isolated from healthy human intestinal mucosa three decades ago by scientists at Lund University, Sweden. Thirty years later, a wealth of data coming from in vitro, animal, and clinical studies exist, showing benefits primarily for gastrointestinal health, such as reduced flatulence and abdominal pain in patients with irritable bowel syndrome (IBS). Moreover, several clinical studies have shown positive effects of L. plantarum 299v on iron absorption and more recently also on iron status. L. plantarum 299v is safe for human consumption and does not confer antibiotic resistance. It survives the harsh conditions of the human gastrointestinal tract, adheres to mannose residues on the intestinal epithelial cells and has in some cases been re-isolated more than ten days after administration ceased. Besides studying health benefits, research groups around the globe have investigated L. plantarum 299v in a range of applications and processes. L. plantarum 299v is used in many different food applications as well as in various dietary supplements. In a freeze-dried format, L. plantarum 299v is robust and stable at room temperature, enabling long shelf-lives of consumer healthcare products such as capsules, tablets, or powder sachets. The strain is patent protected for a wide range of indications and applications worldwide as well as trademarked as LP299V®.

Lactiplantibacillus plantarum 299v (LP299V®): three decades of research.

Colic anastomoses are still affected by a high incidence of leakage. We speculate that a supply of fibres and probiotic bacteria improves the healing of colic anastomoses due to a higher production of short-chain fatty acids. These are known to improve the anastomotic healing of colic sutures. Sixty Lewis rats, weighing from 250 g to 350 g, were divided into 6 groups. Groups A + A1 were fed with a low-fibre diet (less than 0.1%), Groups B + B1 with normal rat chow and groups C + C1 with normal rat chow + Lactobacillus plantarum 299v. Transections and re-anastomosis of the distal colon were performed. Groups A1, B1 and C1 were sacrificed after 3 days, and groups A, B, and C after 7 days. The bursting pressure of colic anastomoses was measured. All data are expressed as mean (+/- S.D.). The pH of the colon contents was evaluated by means of a fine needle plastic electrode only in groups A1, B1 and C1. The results were studied by analysis of variance followed by the Student Newman Keuls test for multiple comparisons (significance level P < 0.05). Three days postoperatively, the pH of the colic lumen was lower in animals fed with a normal diet (pH 7.1 +/- 0.3 without Lp supplementation, 6.5 +/- 0.2 with Lp supplementation) than in animals fed with a low-fibre diet (pH 8.0 +/- 0.3). Bursting pressures were significantly higher in the groups fed with fibre and fibre + Lactobacilli than in animals on a low-fibre diet, both on day 3 and day 7. On the basis of these data there seems to be no support for the belief that a supply of fibre-rich food might impair healing and promote development of anastomotic leakage. On the contrary, short-chain fatty acids and fibres would seem to facilitate the healing of colic anastomoses.

Effect of probiotic administration on colic anastomosis healing

One hundred and fourteen consecutive patients with unresectable hepatocellular carcinoma were treated by chemoembolization using ethiodized oil (Lipiodol), anticancer agents. Ninety patients had concomitant chronic liver disease. Hepatocellular carcinoma (HCC) was diagnosed by US, contrast enhanced CT, fine needle biopsy and alpha-feto-protein level. Admission criteria were as follows: tumor confined to the liver with or without hilar nodal involvement, Child class A or B, white blood cell count above 2.000/mmc and platelet count above 75,000/mmc. All the patients underwent angiographic chemoembolization with Lipiodol and anticancer agents. In 98 patients we performed transcatheter hepatic arterial embolization (TAE) with Gelfoam or for Ivalon sponge. In 16 patients TAE was not performed because of portal thrombosis (7 cases) or technical reasons (9 cases). Mitomycin was used in 40 patients and dihydroxyanthracenedione (DADH) in 58 patients. In the TAE group 83 patients were Child A and 15 Child B. In 27 patients HCC was mononodular whereas in 71 it was multinodular. In 41 patients the tumor was more than 5 cm in diameter (in multinodular tumors only the larger lesion was taken into account). In 56 patients chemoembolization plus TAE was repeated. Seven patients died within one month after treatment: two from myocardial infarction, two from liver failure, two from digestive haemorrhage and one from necrotizing pancreatitis. Long-term survival rates were investigated in relation to prognostic factors: anti-cancer agent, number of nodes, tumor size and Child stage using Kaplan-Meier method. Survival rate at 12, 24 and 36 months are 64%, 38%, and 30% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The treatment of hepatocellular carcinoma by chemoembolization

Enteral nutrition (EN) is increasingly used to minimize the rate of septic complications related to bacterial translocation, due to its effectiveness and low cost. Bengmark's self-propelling auto-positioning feeding tube (SPT) absorbs and uses gut motility for rapid transport to the upper small intestine, thereby allowing uninterrupted EN both in surgical and critically ill patients. We report on our experience with 175 SPTs applied over the period from December 1996 to February 2000, and analyse the safety, compliance, and indications of SPT in surgical and ICU practice. Open study: feasibility of insertion, time and rate of placement, compliance and complications related to the tube or to EN were studied. SPTs were successfully placed in 40 patients before liver resection, in 32 patients before extensive maxillo-facial surgery MFS and prior to colon resections in 10 cases. SPTs were also applied in 56 patients with acute vascular neurological diseases, 22 in pancreatic diseases and in another 15 critically ill patients. 92.5% of SPT's crossed the pylorus, while only 7.5% stopped in the stomach and 3.4% in the duodenum; 89.14% reached the first jejunal loop. The tip of the tube reached its final position within a mean period of 5.2 hours, 8% instantly and all within 24 hours. Enteral nutrition was started immediately after introduction of the tube into the stomach. The compliance was excellent, even in maxillo-facial surgery patients: only 2/76 patients (2.6%) showed poor compliance. There were no cases of aspiration pneumonia or other complications related to SPT. Polymeric nutrition was usually supplied at a starting flow rate of 45 ml/hour and rapidly increasing over the following 48 h. Eleven patients experienced diarrhoea and 6 abdominal distension, leading to a temporary reduction of the EN flow rate. Clogging of the SPT occurred in 13 patients: 7/13 were cleansed with pancreatic enzymes, but 6 had to be replaced. SPT is ideal for intensive EN and is characterised by minimal complications and excellent patient compliance.

The Bengmark tube in surgical practice and in the critically ill patient

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Effect of probiotic administration on colic anastomosis healing

The treatment of hepatocellular carcinoma by chemoembolization

The Bengmark tube in surgical practice and in the critically ill patient