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Background: Minimally invasive pancreaticoduodenectomy (MIPD) has seen increased adoption due to advancements in surgical techniques and technology. However, the impact of hepatic artery variations (HAV) and clinically relevant HAV (CR-HAV) on MIPD outcomes remains under-investigated. This study aims to explore the differences in surgical and oncological outcomes of MIPD with or without HAV and CR-HAV., Methods: We enrolled 267 consecutive patients who underwent MIPD at Peking Union Medical College Hospital between January and December 2023. HAV was identified preoperatively through enhanced abdominal CT and three-dimensional reconstruction, and classified according to the Michels and Hiatt systems. Clinically relevant hepatic artery variations (CR-HAV) were defined based on their potential impact on the surgical approach. We collected and analyzed perioperative data and oncological outcomes between patients with and without HAV and CR-HAV. Propensity score matching (PSM) was used to minimize baseline confounding. Survival analysis was performed using the Kaplan-Meier method with log-rank tests., Results: HAV was identified in 26.1% of patients, and CR-HAV in 18.9%. The median operation time was significantly longer in HAV (+) group compared to HAV (-) group (6.72 vs. 5.80 h, p = 0.013). No significant differences were found between HAV/CR-HAV (+) and (-) groups regarding intraoperative blood loss, conversion to laparotomy, postoperative complications, surgical mortality, length of stay, re-operation, and re-admission. Kaplan-Meier survival analysis showed no significant differences in overall survival or progression-free survival between HAV/CR-HAV (+) and (-) groups in the malignant cohort., Conclusion: HAV and CR-HAV do not significantly impact overall or progression-free survival in patients undergoing MIPD. While HAV is associated with longer operation times, other perioperative and oncological outcomes remain comparable between HAV/CR-HAV (+) and (-) groups., Competing Interests: Declarations. Ethical approval: This study was approved by the Ethics Committee of Peking Union Medical College Hospital and written informed consent was obtained from all patients. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). We have obtained consent from all authors and they have agreed to publish the results of this study. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: Despite advances in surgical techniques, the rate of early recurrence in perihilar cholangiocarcinoma (PCC) remains high. We sought to develop the Preoperative Recurrence Score (PRS), a model to estimate the risk of early recurrence after resection based on preoperative radiological characteristics., Materials and Methods: Data of patients who underwent surgery for PCC were retrospectively collected, and preoperative imaging was reviewed to assess tumor characteristics. A model to assess the risk of early recurrence based on preoperative radiologic characteristics was internally developed and externally validated on two cohorts of patients from two European major hepatobiliary surgery referral centers., Results: A total of 215 patients among three different patient cohorts were included in the study. Tumor size ≥18 mm (HR 2.70, 95 % CI 1.48-4.92, p = 0.001), macroscopic portal vein involvement (HR 2.28, 95%CI 1.19-4.34, p = 0.013), hepatic arteries involvement (HR 2.44, 95%CI 1.26-4.71, p = 0.008), and presence of suspicious lymph nodes (HR 1.98, 95%CI 1.02-3.83, p = 0.043) were significantly associated with recurrence-free survival (RFS). The model showed excellent discrimination both on the internal (AUC 0.83) and external validation cohorts (external 1: AUC 0.84; external 2: AUC 0.70). High PRS was associated with worse RFS among all three cohorts, with a 1-year recurrence probability of 80.1 %, 100.0 %, and 54.2 % in the internal and external validation cohorts 1 and 2, respectively., Conclusions: The PRS is a simple tool that can accurately assess the risk of early recurrence in patients with PCC. Up-front surgery should be carefully evaluated in patients with high PRS, as it could result in a futile resection., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Surgery has recently been introduced into the multimodal management of patients with locally advanced pancreatic adenocarcinomas (LAPCs) thanks to the major pathological response seen with the advent of the multiagent regimen FOLFIRINOX. Distal pancreatectomy with celiac axis resection (DP-CAR) may be complicated by ischemic liver and gastric events. 1,2 Common hepatic artery reconstruction may prevent the occurrence of ischemic complications and can be an alternative to preoperative embolization of the celiac trunk. 3 METHODS: The patient was a 65-year-old with LAPC of the pancreatic body, with infiltration of the celiac trunk, the splenoportal venous confluence, and the Treitz angle. Preoperative induction chemotherapy with FOLFIRNOX was administered over 12 cycles, resulting in radiological stability and normal carbohydrate antigen (CA) 19-9 levels. Positron emission tomography showed isolated activity of the tumor without distant metastasis. A DP-CARV procedure was performed, and a single saphenous graft was used to reconstruct the common hepatic artery and to create a venous patch to repair the venous confluence. The angle of the Treitz, along with the third and fourth duodenum, were resected and a duodenojejunal anastomosis on the second duodenal portion was performed. The left gastric artery was not reconstructed., Results: Postoperative course was favorable but was complicated by a hematoma of the right groin necessitating evacuation. Pathology showed a pT4N2R0 pancreatic adenocarcinoma. The postoperative computed tomography scan showed no collection and patency of reconstructed vessels. Six months later, the patient is alive and disease-free, with patent reconstructed vessels., Conclusions: Common hepatic artery reconstruction during DP-CAR represents a safe surgical option to reduce ischemic events related to celiac trunk resection, particularly in the FOLFIRINOX era. This technique integrated the surgical armamentarium of surgeons dealing with LAPC., Competing Interests: Disclosure: Pietro Addeo, Pierre de Mathelin, Chloe Paul, and Philippe Bachellier have no conflicts of interest to declare that may be relevant to the contents of this study., (© 2024. Society of Surgical Oncology.)

Objective: To compare the detection rates of hepatic artery digital subtraction angiography (HA-DSA) and magnetic resonance imaging (MRI) gadolinium diethylenetriaminepentaacetic acid (MRI-Gd-DTPA) and MRI gadolinium diethylenetriaminepentaacetic acid (MRI-Gd-EOB-DTPA) for small (diameter ≤2 cm) hepatocellular carcinoma (HCC) lesions., Methods: A prospective analysis of patients admitted to the Tumor Hospital of Guangxi Medical University between January 1, 2015, and December 30, 2016, was conducted. The detection rates of the three methods were analyzed. The diameter of small HCC lesions detected using HA-DSA and MRI-Gd-EOB-DTPA were evaluated. The diagnostic value of HCC Barcelona staging for HA-DSA was analyzed., Results: For 107 small lesions detected in 57 patients, the detection rates of HA-DSA and MRI-Gd-DTPA were 86.0% (92/107) and 71.0% (76/107), respectively (p < .05). Of 77 small lesions detected in 42 patients using MRI-Gd-EOB-DTPA and HA-DSA, 67 were detected using HA-DSA, all of which had a rich blood supply, and 72 were detected using MRI-Gd-EOB-DTPA. The minimum diameter of lesions detected using MRI-Gd-EOB-DTPA was approximately 0.4 cm, whereas that of lesions detected using HA-DSA was approximately 0.5 cm. After HA-DSA, a change in the Barcelona staging occurred in 33.3% (62/186) of cases but not after MRI-Gd-DTPA; HA-DSA was significantly better than MRI-Gd-DTPA for staging (p = .03)., Conclusion: HA-DSA and MRI-Gd-EOB-DTPA have high diagnostic values for the detection of small HCC lesions, which is helpful for accurate staging of HCC and provides the most valuable information for patient treatment and prognosis., (© 2024 Wiley Periodicals LLC.)

Background and Objectives: This study aimed to evaluate the prognostic value of aberrant right hepatic artery (A-RHA) involvement in patients with pancreatic cancer (PC)., Methods: This study enrolled 474 patients who underwent upfront pancreatectomy or neoadjuvant treatment for resectable (R) or borderline resectable (BR) PC from four institutions. The patients were divided into three groups: A-RHA involvement group (n = 12), patients who had sole A-RHA involvement without major arterial involvement; BR-A group (n = 104), patients who had major arterial involvement; R/BR-PV group (n = 358), others., Results: All patients in the A-RHA involvement group underwent margin-negative resection. The median overall survival of the entire cohort in the A-RHA involvement, R/BR-PV, and BR-A groups was 41.2, 33.5, and 25.2 months, respectively. Although survival in the R/BR-PV group was significantly more favorable than that in the BR-A group (p = 0.0003), no significant difference was observed between the A-RHA involvement group and the R/BR-PV (p = 0.7332) and BR-A (p = 0.1485) groups., Conclusions: The prognosis of patients with PC and sole A-RHA involvement was comparable to that of patients with R/BR-PV., (© 2024 Wiley Periodicals LLC.)

Introduction: Hepatectomies associated with vascular resections pose a technical challenge for surgeons, involving multiple reconstruction techniques. Moreover, adding clinical and surgical risks in the postoperative setting of these complex procedures are mainly due to prolonged surgical periods and potential complications inherent to vascular manipulation. Leveraging the expertise of a Cancer Center, we propose an institutional assessment utilizing the case series from A. C. Camargo Cancer Center in hepatectomies associated with vascular resection, evaluating postoperative complications and outcomes while highlighting clinical, laboratory, pathological, and surgical factors that may influence results., Objective: To assess mortality and morbidity associated with hepatectomies involving vascular resection., Materials and Methods: From a prospective database, a study was performed evaluating postoperative survival and morbidity using scoring systems such as Clavien-Dindo through a cohort analysis., Results: From a total of 1021 liver resections for a period of 10 years, 31 cases were evaluated from a unique cancer center in Brazil! Factors such as the performance of major hepatectomies, the need for blood transfusion, and the administration of neoadjuvant or adjuvant systemic therapy did not appear to influence the outcome of morbidity or mortality. However, the resection of the associated bile duct and the type of vascular resection seemed to influence morbidity outcomes with statistical significance (p = 0.006+ …)., Conclusion: Hepatectomies associated with vascular resections are safe in selected cases and when performed in referral centers. Factors such as associated bile duct resection and type of vascular resection should be considered for procedure indication., (© 2024 Wiley Periodicals LLC.)

Background: Locally advanced cancers of the pancreatic body can abut or involve the celiac axis, hepatic artery, or superior mesenteric artery. Recent evidence suggests that these tumors are amenable to surgery after neoadjuvant chemotherapy (Hackert et al., Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60 % of the patients. Ann Surg 264:457-463, 2016; Rangelova et al., Surgery improves survival after neoadjuvant therapy for borderline and locally advanced pancreatic cancer: a single-institution experience. Ann Surg 273:579-86, 2021). An arterial divestment technique can be used for these cancers to get an R0 clearance, thereby avoiding morbid arterial resections (Miao et al., Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC). Pancreatology 16:S59, 2016; Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). Two techniques are described for arterial divestment. In the periarterial divestment technique, the plane of the dissection is between the tumor and the adventitia (Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). In sub-adventitial dissection, the plane of dissection is between the tunica adventitia and the external elastic lamina (Gao et al., Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 406:691-701, 2021). The TRIANGLE operation also is one of the surgical techniques to achieve R0 resection in locally advanced pancreatic cancer (Hackert et al., The TRIANGLE operation: radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single-arm observational study. HPB Oxford 19:1001-1007, 2017). This multimedia article aims to demonstrate peri-arterial and sub-adventitial divestment techniques as well as the TRIANGLE operation for a locally advanced cancer of the body of the pancreas. The video also highlights the technique of posterior radical antegrade modular pancreato-splenectomy (RAMPS) together with lymph node clearance., Patient and Methods: A 57-year-old women was detected to have pancreatic body adenocarcinoma with tumor contact of the artery and superior mesenteric artery. After neoadjuvant chemotherapy, she was planned to undergo surgical resection., Results: The surgical technique consisted of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS (Fig. 1). The procedure was performed within 240 min and involved blood loss of 250 mL. After the procedure, pancreatic leak (POPF-B), chyle leak and diarrhea developed, which were managed conservatively. The final histopathology showed residual, viable, moderately differentiated adenocarcinoma (ypT2N1M0) with all resection margins free., Conclusion: The surgical technique consisting of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS helps in R0 resection of locally advanced pancreatic body cancer without any compromise in oncologic outcomes and offers an alternative surgical approach to morbid arterial resection., (© 2024. The Author(s).)

The increasing age of liver donors and transplant candidates, together with the growing prevalence of metabolic comorbidities, could impact the risk of vascular complications after liver transplantation. We enrolled a consecutive cohort of adult patients undergoing liver transplantation from 2012 to 2021 who had a blinded pathological assessment of atherosclerosis in the donor and recipient hepatic arteries (HA). Patients receiving partial or reduced grafts, retransplantation, or combined organ transplantation were excluded. The relationship between HA atherosclerosis and HA thrombosis after liver transplantation was evaluated using logistic regression in the whole study cohort and in a propensity score-matched subpopulation. Among 443 eligible patients, 272 had a full pathological evaluation of the donor and recipient HA and were included in the study. HA atheroma was present in 51.5% of donors and in 11.4% of recipients. HA thrombosis occurred in 16 patients (5.9%), being more likely in patients who received a donor with HA atherosclerosis than in those without (10.7% vs. 0.8%; p < 0.001). Donor HA atherosclerosis was an independent risk factor of HA thrombosis (OR = 17.79; p = 0.008), and this finding was consistent in the propensity score-matched analysis according to age, sex, complex arterial anastomosis, and alcoholic liver disease (OR = 19.29; p = 0.007). Atheromatous disease in the recipient had no influence on the risk of HA thrombosis (OR = 1.70; p = 0.55). In conclusion, patients receiving donors with HA atherosclerosis are at increased risk for HA thrombosis after liver transplantation. The evaluation of the donor graft vasculature could guide antiplatelet therapy in the postoperative period., (© 2024 The Author(s). Clinical Transplantation published by John Wiley & Sons Ltd.)

Emerging evidence indicates the presence of vascular abnormalities and ischemia in biliary atresia (BA), although specific mechanisms remain undefined. This study examined both human and experimental BA. Structural and hemodynamic features of hepatic arteries were investigated by Doppler ultrasound, indocyanine green angiography, microscopic histology, and invasive arterial pressure measurement. Opal multiplex immunohistochemistry, western blot, and RT-PCR were applied to assess Notch3 expression and the phenotype of hepatic arterial smooth muscle cells (HASMCs). We established animal models of Notch3 inhibition, overexpression, and knockout to evaluate the differences in overall survival, hepatic artery morphology, peribiliary hypoxia, and HASMC phenotype. Hypertrophic hepatic arteriopathy was evidenced by an increased wall-to-lumen ratio and clinically manifested as hepatic arterial hypertension, decreased hepatic artery perfusion, and formation of hepatic subcapsular vascular plexuses (HSVPs). We observed a correlation between overactivation of Notch3 and phenotypic disruption of HASMCs with the exacerbation of peribiliary hypoxia. Notch3 signaling mediated the phenotype alteration of HASMCs, resulting in arterial wall thickening and impaired oxygen supply in the portal microenvironment. Inhibition of Notch3/Hey1 ameliorates portal hypoxia by restoring the balance of contractile/synthetic HASMCs, thereby preventing hypertrophic arteriopathy in BA., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Hepatectomy combined with hepatic artery reconstruction in the operation for hilar cholangiocarcinoma (Klatskin tumor) is a challenging procedure. We present a video of left hepatectomy combined with right hepatic artery reconstruction for hilar cholangiocarcinoma., Patient and Methods: The patient was a 60-year-old male who presented with obstructive jaundice. The imaging examination showed that the confluence of left and right hepatic ducts and the wall of common hepatic duct were thickened, the local lumen was narrowed, the intrahepatic bile duct was dilated, and the right hepatic artery was invaded by tumors nearly 2.3 centimeters. Left hepatectomy with total caudate lobectomy, resection with reconstruction of right hepatic artery, hilar lymphadenectomy, and Roux-en-Y hepaticojejunostomy were performed., Results: The operation time was 345 min, and the amount of bleeding was about 400 ml. There was no blood transfusion. The pathology showed poorly differentiated adenocarcinoma, with negative margins of common bile duct and right hepatic duct, and negative results of all lymph nodes. The patient's recovery was uneventful and he was discharged on postoperative day 14. The patient was disease free at 12-month follow-up evaluation., Conclusions: Hepatic artery resection and reconstruction procedure is safe and feasible for hilar cholangiocarcinoma in a highly tertiary hepatobiliary center., (© 2024. The Author(s).)

Background: The relationship between the course of the segment 4 hepatic artery and proximal ductal margin status in the right hepatectomy (H15678-B) for perihilar cholangiocarcinoma is unclear. This study aimed to evaluate proximal ductal margin status according to the course of the segment 4 hepatic artery in patients with perihilar cholangiocarcinoma treated with right hepatectomy., Methods: Consecutive patients with perihilar cholangiocarcinoma who underwent a right hepatectomy between January 2006 and August 2021 were retrospectively reviewed. The course of the segment 4 hepatic artery was classified based on the positional relationship with the umbilical portion of the left portal vein into R-UP and L-UP types. The R-UP type had the segment 4 hepatic artery running along the right caudal position of the umbilical portion of the left portal vein, whereas the L-UP type had the segment 4 hepatic artery running along the left cranial position of the umbilical portion of the left portal vein, with or without another branch running along the right caudal position of the umbilical portion of the left portal vein. Proximal ductal margin status after the right hepatectomy was compared between types., Results: Among 102 patients, 72 (70.5%) were R-UP type, and 30 (29.5%) were L-UP type. Rates of negative proximal ductal margin were higher with the L-UP type (27/30, 90.0%) than with the R-UP type (51/72, 70.8%; P = .04). On multivariate analysis, Bismuth-Corlette type II and IIIa (risk ratio 4.13, 95% confidence interval 1.52-11.5; P = .005) and L-UP type (risk ratio 4.03, 95% confidence interval 1.18-18.8; P = .04) were independent predictors of negative proximal ductal margin after a right hepatectomy for perihilar cholangiocarcinoma., Conclusion: For the course of the segment 4 hepatic artery, L-UP type rather than R-UP type might be anatomically advantageous for achieving negative proximal ductal margin in a right hepatectomy for perihilar cholangiocarcinoma., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Suprapancreatic lymph node dissection for patients with gastric cancer in whom the common hepatic artery is located neither at the suprapancreatic margin nor in front of the portal vein is a more difficult procedure than when the common hepatic artery is in a more typical position. There is an increased risk of injury to the vessels that need to be preserved and inadequate lymph node dissection. Measures that have been reported for use in this situation are preoperative diagnosis with three-dimensional computed tomography angiography, dissection using the portal vain as a guide, and safe exposure of the portal vein with dissection to preserve the nerves at the suprapancreatic margin and in front of the portal vein. We review the literature and report our experience with a patient whose common hepatic artery was not located in the suprapancreatic margin who safely underwent suprapancreatic lymph node dissection using these methods., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Hepatic artery pseudoaneurysms have been reported to occur in approximately 1% of cases after metal stenting for malignant biliary obstruction. In contrast, only a few cases have been reported as complications after plastic stenting for benign biliary disease. We report a 61-year-old man with cholangitis who presented with a rare complication of hemobilia after implantation of 7 Fr double pigtail plastic biliary stents. No bleeding was observed approximately one month after biliary stent tube removal. Contrast-enhanced CT scan revealed a circularly enhanced lesion (5 mm in diameter) in the arterial phase at the tip of the previously inserted plastic bile duct stent. Color Doppler ultrasonography enhanced the lesion and detected arterial blood flow inside. He was diagnosed with a hepatic artery pseudoaneurysm. However, he had no risk factors such as prolonged catheterization, severe cholangitis, liver abscess, or long-term steroid use. Superselective transarterial embolization using two metal microcoils was successfully completed without damage to the surrounding liver parenchyma. If hemobilia is suspected after insertion of a plastic bile duct stent, immediate monitoring using contrast-enhanced computed tomography or Doppler ultrasonography is recommended., (© 2024. Japanese Society of Gastroenterology.)

Objective: To investigate whether liver observations in patients at risk for hepatocellular carcinoma (HCC) display inconsistent arterial phase hyperenhancement (APHE) subtypes on the multi-hepatic arterial phase imaging (mHAP) and to further investigate factors affecting inconsistent APHE subtype of observations on mHAP imaging., Methods: From April 2018 to June 2021, a total of 141 patients at high risk of HCC with 238 liver observations who underwent mHAP MRI acquisitions were consecutively included in this retrospective study. Two experienced radiologists reviewed individual arterial phase imaging independently and assessed the enhancement pattern of each liver observation according to LI-RADS. Another two experienced radiologists identified and recorded the genuine timing phase of each phase independently. When a disagreement appeared between the two radiologists, another expert participated in the discussion to get a final decision. A separate descriptive analysis was used for all observations scored APHE by the radiologists. The Kappa coefficient was used to determine the agreement between the two radiologists. Univariate analysis was performed to investigate the factors affecting inconsistent APHE subtype of liver observations on mHAP imaging., Results: The interobserver agreement was substantial to almost perfect agreement on the assessment of timing phase (κ = 0.712-0.887) and evaluation of APHE subtype (κ = 0.795-0.901). A total of 87.8% (209/238) of the observations showed consistent nonrim APHE and 10.2% (24/238) of the observations showed consistent rim APHE on mHAP imaging. A total of 2.1% (5/238) of the liver observations were considered inconsistent APHE subtypes, and all progressed nonrim to rim on mHAP imaging. 87.9% (124/141) of the mHAP acquisitions were all arterial phases and 12.1% (17/141) of the mHAP acquisitions obtained both the arterial phase and portal venous phase. Univariate analysis was performed and found that the timing phase of mHAP imaging affected the consistency of APHE subtype of liver observations. When considering the timing phase and excluding the portal venous phase acquired by mHAP imaging, none of the liver observations showed inconsistent APHE subtypes on mHAP imaging., Conclusion: The timing phase which mHAP acquisition contained portal venous phase affected the inconsistency of APHE subtype of liver observations on mHAP imaging. When evaluating the APHE subtype of liver observations, it's necessary to assess the timing of each phase acquired by the mHAP technique at first., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: To determine the safety and efficacy of transcatheter arterial chemoembolization with CalliSpheres® beads loaded with arsenic trioxide (CBATO-TACE) in the first-line treatment of patients with large (5 cm ≤ maximum diameter < 10 cm) or huge (maximum diameter ≥ 10 cm) hepatocellular carcinoma (HCC)., Methods: Patients were randomly allocated to the CBATO-TACE group and the conventional transcatheter arterial chemoembolization (cTACE) group. The primary endpoint was progression-free survival (PFS). The secondary endpoint was overall survival (OS), treatment response, and treatment-related adverse events (TRAEs). The extrahepatic collateral arteries, liver function, and liver fibrosis after the first TACE were also evaluated., Results: From September 2018 to September 2020, a total of 207 patients who underwent TACE were consecutively enrolled in this study. The median PFS was 9.5 months (range: 8.0 - 11.0) in the CBATO group, which was significantly longer than that in the cTACE group (6.0 months, range: 4.0-6.0) (p < 0.0001). Patients in the CBATO group had a median OS of 22 months (range: 20.0 - 27.0) compared with 16 months (range: 15.0 - 20.0) in the cTACE group (p = 0.0084). The most common TRAEs were fever (p = 0.043), and nausea and vomiting (p = 0.002), which were more observed in the cTACE group. In addition, the progressive disease time, pulmonary metastasis rate (p = 0.01), the mean number of extrahepatic collateral arteries (p = 0.01), and average number of TACE sessions (p = 0.025) were significantly decreased in the CBATO group., Conclusions: CBATO-TACE achieved better therapeutic outcomes and similar safety profile compared to cTACE in large or huge HCC patients. Furthermore, CBATO-TACE was able to reduce extrahepatic collateral arteries production and extrahepatic lung metastasis., Clinical Relevance Statement: Our study showed that CalliSpheres® beads loaded with arsenic trioxide (CBATO-TACE) were effective and safe for the treatment of large and giant HCC. In addition, CBATO-TACE can reduce lateral hepatic branch artery formation and extrahepatic pulmonary metastasis, which provides a new treatment approach for unresectable HCC., Key Points: • We compare long-term efficacy and safety of transcatheter arterial chemoembolization with CalliSpheres® beads loaded with arsenic trioxide (CBATO-TACE) and conventional transcatheter arterial chemoembolization (cTACE) in patients with large (5 cm ≤ maximum diameter < 10 cm) or huge HCC (maximum diameter ≥ 10 cm). • Compared with cTACE, CBATO-TACE significantly improved therapeutic outcomes, overall survival, and progression-free survival in patients with large or huge HCC. The safety assessment suggested that CBATO-TACE is a safe treatment that improves the quality of life and has good treatment adherence., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Purpose: To elucidate incidence rates of vascular lake phenomenon (VLP) in hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), hepatic metastasis (HMT) on transarterial angiography before chemoembolization, and to identity CT features predictive for it., Materials and Methods: A comprehensive evaluation involved 665 subjects for incidence analysis, comprising 527 of HCC, 33 of ICC and 105 of HMT. VLP was characterized as intratumoral contrast material pool persisting late into venous phase. Incidences were cataloged on both super-selective and common hepatic artery angiography. For CT features analysis, a subset of 182 cases were analyzed. Enhancement ratio served as an index for comparative analysis of nodule enhancement degrees., Results: In HCC, incidence of VLP ascertained via super-selective angiography was 13.5%, whereas it as 7.8% on common hepatic artery angiography. Remarkably, no incidences of VLP were recorded in either ICC or HMT cases. On pre-interventional CT, the prevalence of pseudocapsule was statistically greater in VLP group than Non-VLP group (66.6% vs. 37.6%, P = 0.015). The Houndsfield units (HU) of tumors in plain scan (P = 0.007), arterial phase (P = 0.001), venous phase (P = 0.041), arterial phase enhancement ratio (P < 0.001) were statistically higher in VLP group compared to Non-VLP group. Arterial phase enhancement ratio (P = 0.025), presence of pseudocapsule (P = 0.001), HU of tumor in plain scan (P = 0.035) serve as independent risk factors for VLP manifestation., Conclusion: VLP is a distinct angiography phenomenon uniquely associated with HCC. High arterial phase enhancement ratio, presence of pseudocapsule, high HU of tumor in plain scan are independent risk factors for VLP., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

Hepatic artery infusion (HAI) delivers localized high-dose floxuridine directly to liver tumors through an implanted pump. While patients are undergoing active treatment, the pump is refilled with chemotherapy alternating with saline every 2 weeks using a specialized noncoring needle. Numerous clinical scenarios influence the dosing of floxuridine, which do not conform to the usual dose modification schema for systemic chemotherapy. This article aims to provide practical clinical management solutions to overcome the common challenges faced by oncologists in the real-world management of HAI pump therapy.

Background: Discontinuation of the Codman 3000 pump in 2018 left no Food and Drug Administration (FDA)-approved hepatic artery infusion (HAI) device for unresectable colorectal liver metastases (uCLM) and intrahepatic cholangiocarcinoma (uIHC). Historically, HAI has been performed at academic medical centers in large metropolitan areas, which are often inaccessible to rural patients. Consequently, feasibility of dissemination of HAI to rural populations is unknown., Patients and Methods: Under an FDA investigational device exemption, we opened the only HAI program in Kentucky and enrolled patients with uCLM and uIHC in a phase I clinical trial. The trial examined the safety of the hybrid Codman catheter/Medtronic SynchroMed II pump (hCMP) combination, defined as successful completion of one cycle of HAI chemotherapy. Rural feasibility was assessed by number of missed pump fills appointments., Results: A total of 21 patients (n = 17 uCLM, n = 4 uIHC) underwent hCMP implantation before accrual was stopped early owing to FDA approval of the Intera 3000 pump. 20/21 (95%) patients met the primary safety endpoint. Serious adverse events (AEs) included a grade 5 coronavirus disease 2019 (COVID-19) infection (n = 1) and a grade 3 catheter erosion into the bowel (n = 1). Biliary sclerosis developed in two patients (9.5%). Median distance to infusion center was 47.6 miles (2-138 miles), and 62% were from Appalachia, yet there were no missed pump fill appointments. The 2-year overall survival was 82.4% (uCLM) and 50% (uIHC)., Conclusions: The hCMP device had an acceptable safety profile. Despite the complexity of starting a new HAI program, early results showed feasibility for HAI delivery in a rural catchment area and comparable outcomes to larger urban-based HAI centers., (© 2023. Society of Surgical Oncology.)

Hepatocellular carcinoma (HCC) is one of the most common malignancies and the third leading cause of cancer-related deaths globally. Hepatic arterial infusion chemotherapy (HAIC) treatment is widely accepted as one of the alternative therapeutic modalities for HCC owing to its local control effect and low systemic toxicity. Nevertheless, although accumulating high-quality evidence has displayed the superior survival advantages of HAIC of oxaliplatin, fluorouracil, and leucovorin (HAIC-FOLFOX) compared with standard first-line treatment in different scenarios, the lack of standardization for HAIC procedure and remained controversy limited the proper and safe performance of HAIC treatment in HCC. Therefore, an expert consensus conference was held on March 2023 in Guangzhou, China to review current practices regarding HAIC treatment in patients with HCC and develop widely accepted statements and recommendations. In this article, the latest evidence of HAIC was systematically summarized and the final 22 expert recommendations were proposed, which incorporate the assessment of candidates for HAIC treatment, procedural technique details, therapeutic outcomes, the HAIC-related complications and corresponding treatments, and therapeutic scheme management., (© 2023. Asian Pacific Association for the Study of the Liver.)

Understanding anatomical anomalies of the branch of the celiac artery for safe gastrectomy is important. We report a case of laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer with a vascular anatomical anomaly of the celiac artery. A 45-year-old woman was referred to our hospital because of early gastric cancer. Computed tomography showed an anatomical variation of the gastroduodenal artery, which branched from the celiac artery. The celiac artery also branched into the left gastric artery, the splenic artery, and the common hepatic artery. Preoperative understanding of an unusual branch of the celiac artery enabled a safe laparoscopic surgery. There were no postoperative complications. The Adachi classification or Michel classification is used for an anatomical anomaly of the celiac artery, but to the best of our knowledge, this case has not been previously classified and is the first reported case., (© 2023 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Hepatic arterial infusion (HAI) pumps are used to deliver liver-directed therapy by allowing the administration of selective chemotherapy to the liver via a catheter implanted most commonly into the gastroduodenal artery connected to a subcutaneous pump. This selective administration helps maximize the chemotherapeutic effect within the hepatic tumors while minimizing systemic toxicity. While HAI therapy has primarily been used to treat liver-only metastatic colorectal cancer, the indications have expanded to other malignancies, including intrahepatic cholangiocarcinoma. Radiologists play an important role in pre-operative planning, assessment of treatment response, and evaluation for potential complications using various imaging studies, including computed tomography angiography, magnetic resonance imaging, and perfusion scintigraphy. This article describes the radiologist's role as part of a multi-disciplinary oncology team to help maximize the success of HAI therapy and also helps radiologists familiarize themselves with various aspects of HAI pumps., Competing Interests: Declaration of competing interest No relevant disclosures for any authors., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Hepatic artery infusion chemotherapy (HAI) has been proposed as a valuable adjunct for multimodal therapy of primary and secondary liver malignancies. This review provides an overview of the currently available evidence of HAI, taking into account tumor response and long-term oncologic outcome., Summary: In colorectal liver metastases (CRLM), HAI in combination with systemic therapy leads to high response rates (85-90%) and conversion to resectablity in primary unresectable disease in up to 50%. HAI in combination with systemic therapy in CRLM in the adjuvant setting shows promising long-term outcomes with up to 50% 10-year survival in a large, non-randomized single-center cohort. For hepatocellular carcinoma patients, response rates as high as 20-40% have been reported for HAI and long-term outcomes compare well to other therapies. Similarly, survival for patients with unresectable intrahepatic cholangiocarcinoma 3 years after treatment with HAI is reported as high as 34%, which compares well to trials of systemic therapy where 3-year survival is usually below 5%. However, evidence is mainly limited by highly selected, heterogenous patient groups, and outdated chemotherapy regimens. The largest body of evidence stems from small, often non-randomized cohorts, predominantly from highly specialized single centers., Key Message: In well-selected patients with primary and secondary liver malignancies, HAI might improve response rates and, possibly, long-term survival. Results of ongoing randomized trials will show whether a wider adoption of HAI is justified, particularly to increase rates of resectability in advanced malignant diseases confined to the liver., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Background: Liver metastasis is one of the most common causes of death in patients with colorectal cancer. Therefore, improving the treatment effect of liver metastatic carcinoma of colorectal cancer is also one of the effective ways to improve the survival time of patients with colorectal cancer. The main treatment method for liver metastasis of colorectal cancer is preoperative neoadjuvant chemotherapy through intravenous administration. However, no one has reported a conversion therapy approach for the treatment of colorectal cancer liver metastases patients through arterial infusion chemotherapy combined with targeted agents and PD-1 monoclonal antibody. This case reports a conversion therapy method of liver metastases of colorectal cancer by hepatic arterial infusion chemotherapy (HAIC), sintilimab injection combined with lenvatinib to achieve radical resection of liver metastatic carcinoma after treatment., Case Presentation: The patient was a 69-year-old man who had previously undergone laparoscopic left hemicolectomy for descending colorectal cancer and multiple interventional and surgical treatments for hepatocellular carcinoma. During this treatment, the patient underwent radiological and serological tests, and primary liver cancer was considered at the initial diagnosis stage. Therefore, this liver malignant tumor lesion was treated according to the primary liver cancer treatment protocol before surgical resection. Therefore, the patient received HAIC combined with sintilimab injection and lenvatinib. After three treatment cycles, radiological examination showed no obvious tumor activity, alpha-fetoprotein (AFP) decreased to normal, protein induced by vitamin K absence or antagonist II (PIVKA II) decreased significantly, and the curative effect was evaluated as complete remission. Subsequently, we performed surgical resection of this liver lesion. The pathological response of left lobe tumor was partial remission (PR). Most of the tumors were necrotic and the necrosis rate was greater than 95%. A small amount of live tumor tissue remains (<5%). The pathological classification of this tumor was confirmed as moderately differentiated adenocarcinoma by immunohistochemical staining of multiple tumor indicators in the pathology department. No significant adverse drug events were observed in this patient during treatment., Conclusion: Hepatic arterial infusion chemotherapy combined with sintilimab injection and lenvatinib conversion therapy provides the opportunity for radical surgical resection of colorectal cancer liver metastases., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Peng, Li, Su, Lan, Huang, Wei, Liao, Peng, Peng and Zhu.)

Purpose: Identify risk factors for biliary toxicity in patients with colorectal liver metastases who received floxuridine (FUDR) via a surgically implanted hepatic artery infusion pump (HAIP). Describe the incidence of biliary toxicity and evaluate relevant patterns in the biliary toxicity cohort., Methods: A single center, retrospective, case-control study included adult colorectal cancer patients with liver metastases who received at least one cycle of FUDR via a surgically implanted HAIP from 1 January 2017, to 1 October 2021. Patients were excluded if they had incomplete records, cholangiocarcinoma diagnosis, or received concurrent mitomycin and FUDR. Biliary toxicity criteria derived from existing HAIP literature were utilized to determine whether patients experienced biliary toxicity. Multiple variables were compared by univariate statistical analysis between the biliary toxicity and non-biliary toxicity cohorts to identify potential risk factors for development of FUDR-induced biliary toxicity., Results: Out of 50 patients who had a HAIP implanted, 39 met the inclusion criteria. Five of the 39 patients (12.7%) included in the analysis met the pre-specified biliary toxicity criteria. No risk factors for biliary toxicity were identified. All five patients who developed biliary toxicity demonstrated elevations in alkaline phosphatase (ALP) prior to meeting the toxicity criteria., Conclusion: Biliary toxicity remains a significant and therapy-limiting consequence of FUDR administration. Rising ALP may be an early indicator of subsequent biliary toxicity. Future studies with more patients may identify risk factors that can facilitate risk mitigation strategies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The abscopal effect has recently attracted much attention because this effect is enhanced by immune checkpoint inhibitors (ICIs). However, little is known about the association between induction of the abscopal effect and local treatment against hepatocellular carcinoma (HCC). We describe a patient with advanced HCC who underwent selective transcatheter arterial chemoembolization (TACE) after treatment with an ICI that was found to remarkably regress in lesions in areas outside that targeted by selective TACE. An 82-year-old man had multiple recurrences in both lobes of the liver despite of repeated TACE and radiofrequency ablation, after resection of an HCC five years previously. After chemotherapy with atezolizumab and bevacizumab, his des-gamma-carboxy prothrombin (DCP) increased. CT during hepatic arteriography revealed multiple recurrent HCCs in both lobes of the liver. TACE with selective embolization at the level of the medial segmental arteries was performed against an approximately 50 mm-diameter tumor in the right lobe. Hepatic arterial phase imaging of contrast-enhanced CT performed 6 days after TACE showed hypo-enhancement of tumors in segment II and III in the left lobe. This case highlights that abscopal effects can be induced by local treatment against HCCs in combination with treatment with ICIs., (© 2023. Japanese Society of Gastroenterology.)

Purpose: Chemotherapy-naive patients with unresectable colorectal liver metastases (CRLM) have been the best responders to hepatic arterial infusion (HAI) therapy. The current treatment paradigm has drifted away from HAI in the first-line setting. We aimed to analyze outcomes of combined first-line systemic therapy with HAI therapy (HAI+SYS) in the modern era., Methods: We conducted a retrospective study of consecutive chemotherapy-naive patients with unresectable CRLM who received HAI+SYS between 2003 and 2019. Patients were selected from a prospectively maintained database. Outcomes included radiological response rate, conversion to resection (CTR) rate, and overall survival (OS)., Results: Fifty-eight chemotherapy-naive patients were identified out of 546 patients with unresectable CRLM managed with HAI. After induction treatment, 4 patients (7%) had a complete radiological response, including two durable responses. In total, 32 patients (55%) underwent CTR. CTR or complete response without resection was achieved after seven cycles of systemic therapy and four cycles of HAI therapy. Median OS for the whole cohort was 53.0 months (95% confidence interval 23.0-82.9). Three- and 5-year OS in patients who achieved CTR or complete response versus patients who did not was 88% and 72% versus 27% and 0% respectively. Of patients who underwent CTR, complete and major pathological response (no and <10% viable tumor cells, respectively) was observed in 7 (22%) and 12 patients (38%)., Conclusions: Combined HAI+SYS in chemotherapy-naive patients resulted in durable and substantial response in a large proportion of patients. Nearly two-thirds of patients achieved a complete response or proceeded to conversion surgery, which was associated with prolonged survival., (© 2023. Society of Surgical Oncology.)

Purpose: To compare tumor perfusion on cone-beam computed tomography (CBCT) after hepatic artery infusion port implantation with the tumor response to hepatic arterial infusion chemotherapy (HAIC) in patients with hepatocellular carcinoma (HCC)., Methods: This retrospective study was conducted in patients with advanced HCC treated with HAIC from 2015 to 2020. We performed CBCT with contrast injection via a port on the day following implantation. We classified tumor perfusion on CBCT into three groups: hyperperfusion, isoperfusion, and hypoperfusion. We also evaluated tumor response to HAIC on follow-up images using RECIST 1.1 and compared it with tumor perfusion on CBCT., Results: This study included 206 tumors in 193 patients (mean: 60.5 years) with HCC. There were 100 hyperperfusion tumors (48.5%), 92 isoperfusion tumors (44.7%), and 14 hypoperfusion tumors (6.8%). The tumor response to HAIC included 10 tumors with a complete response (CR) (4.9%), 66 tumors with a partial response (32%), 60 tumors with stable disease (29.1%), and 70 tumors with progressive disease (34%). Hyperperfusion tumors had a 65% objective response rate (ORR) and a 92% disease control rate (DCR). Isoperfusion tumors had a 12% ORR and a 46.8% DCR, while hypoperfusion tumors had a 0% ORR and a 7.1% DCR. A CR was shown only in hyperperfusion tumors. The ORR and DCR of the three groups were different, with statistical significance ( P < 0.001)., Conclusion: Hyperperfusion tumors on CBCT showed a better tumor response to HAIC, with a 65% ORR in patients with HCC. Tumor perfusion on CBCT after implantation of the hepatic arterial infusion port was associated with the tumor response to HAIC.

Hepatic arterial infusion chemotherapy (HAIC) using a combination of oxaliplatin, fluorouracil, and leucovorin (FOLFOX) has shown promise for hepatocellular carcinoma (HCC) patients classified under Barcelona Clinic Liver Cancer (BCLC) stage C. In China, the combined therapy of camrelizumab and apatinib is now an approved first-line approach for inoperable HCC. This study (NCT04191889) evaluated the benefit of combining camrelizumab and apatinib with HAIC-FOLFOX for HCC patients in BCLC stage C. Eligible patients were given a maximum of six cycles of HAIC-FOLFOX, along with camrelizumab and apatinib, until either disease progression or intolerable toxicities emerged. The primary outcome measured was the objective response rate (ORR) based on the Response Evaluation Criteria in Solid Tumors (RECIST) v1.1. Thirty-five patients were enrolled. Based on RECIST v1.1 criteria, the confirmed ORR stood at 77.1% (95% CI: 59.9% to 89.6%), with a disease control rate of 97.1% (95% CI: 85.1% to 99.9%). The median progression-free survival was 10.38 months (95% CI: 7.79 to 12.45). Patient quality of life had a transient deterioration within four cycles of treatment, and generally recovered thereafter. The most frequent grade ≥3 or above treatment-related adverse events included reduced lymphocyte count (37.1%) and diminished neutrophil count (34.3%). The combination of camrelizumab, apatinib, and HAIC demonstrated encouraging results and manageable safety concerns for HCC at BCLC stage C., (© 2023. West China Hospital, Sichuan University.)

The safety and efficacy of hepatic artery embolization (HAE) in treating intrahepatic cholangiocarcinoma (IHC) was evaluated. Initial treatment response, local tumor progression-free survival (L-PFS), and overall survival (OS) were evaluated in 34 IHC patients treated with HAE. A univariate survival analysis and a multivariate Cox proportional hazard analysis to identify independent factors were carried out. Objective response (OR) at 1-month was 79.4%. Median OS and L-PFS from the time of HAE was 13 (CI = 95%, 7.4-18.5) and 4 months (CI = 95%, 2.09-5.9), respectively. Tumor burden < 25% and increased tumor vascularity on preprocedure imaging and surgical resection prior to embolization were associated with longer OS ( p < 0.05). Multivariate logistic regression analysis demonstrated that tumor burden < 25% and hypervascular tumors were independent risk factors. Mean post-HAE hospital stay was 4 days. Grade 3 complication rate was 8.5%. In heavily treated patients with IHC, after exhausting all chemotherapy and other locoregional options, HAE as a rescue treatment option appeared to be safe with a mean OS of 13 months. Tumor burden < 25%, increased target tumor vascularity on pre-procedure imaging, and OR on 1 month follow-up images were associated with better OS. Further studies with a control group are required to confirm the effectiveness of HAE in IHC.

Transcatheter arterial chemoembolization (TACE) is an effective method for treating hepatocellular carcinoma (HCC). In this study, chitosan (CS), sodium glycerophosphate (GP), and sodium alginate (SA) were used as the main raw materials to develop clinically non-degradable embolization microspheres (Ms). Chitosan/sodium alginate embolization Ms. were generated using an emulsification cross-linking method. The Ms. were then uniformly dispersed in CS/GP temperature-sensitive gels to produce Gel/Ms. composite embolic agents. The results showed that Gel/Ms. had good morphology and a neatly arranged three-dimensional structure, and the Ms. dispersed in the Gel as evidenced by SEM. Furthermore, Gel/Ms. has good blood compatibility, with a hemolysis rate of ≤5 %. The cytotoxicity experiments have also proven its excellent cell compatibility. The degradation rate of Gel/Ms. was 58.869 ± 1.754 % within 4 weeks, indicating that Gel/Ms. had good degradation performance matching its drug release purpose. The Gel/Ms. adheres better at the target site than Ms. alone and releases the drug steadily over a long period, and the maximum release rate of Gel/Ms. within 8 h was 38.33 ± 1.528 %, and within 168 h was 81.266 ± 1.193 %. Overall, Gel/Ms. demonstrate better slow drug release, reduced sudden drug release, prolonged drug action time at the target site, and reduced toxic side effects on the body compared to Gel alone., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Pretransplant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) has been associated with an increased risk of hepatic artery thrombosis (HAT) after liver transplantation (LT). Innovative surgical LT and interventional vascular radiology TACE techniques may mitigate the risk of HAT. We sought to investigate the incidence of HAT after LT in patients who received pre-transplant TACE at our center., Methods: We performed a single-center retrospective review of all LT patients, >18 years of age, from October 1, 2012, to May 31, 2018. Outcomes were compared between patients who received pre-LT TACE and those who did not. Median follow-up was 26 months., Results: Among the 162 LT recipients, 110 (67%) patients did not receive pre-LT TACE (Group I), while 52 (32%) received pre-LT TACE (Group II). The <30-day incidence rates of post-LT HAT were as follows: Group I = 1.8% and Group II = 1.9% (P = .9). Most hepatic arterial complications occurred >30 days after LT. Based on competing risks regression analysis, TACE was not associated with an increased risk of HAT. Patient or graft survivals were comparable between the 2 groups (P = .1 and .2, respectively)., Conclusions: Our study shows a similar incidence of hepatic artery complications post-LT in patients who received TACE before LT compared with those who did not. In addition, we suggest that the surgical technique of early vascular control of the common hepatic artery during LT, in combination with a super-selective vascular intervention radiology approach, has clinical utility in reducing the risk of HAT in patients requiring pre-transplant TACE., Competing Interests: Declaration of Competing Interest This work was supported in part by The J. Scott Harkness Organ Transplantation Research and Education Fund to JCH., (Copyright © 2023 Elsevier Inc. All rights reserved.)

First introduced in the late 1980s in the setting of unresectable liver metastasis, the use of the hepatic artery infusion pump was expanded to deliver chemotherapy in the adjuvant setting after hepatic resection about 1 decade later. Though the initial randomized clinical trial comparing the hepatic artery infusion pump to resection alone failed to show an improvement in overall survival, 2 large randomized clinical trials, namely the Memorial Sloan Kettering Cancer Center (1999) and European Cooperative Group (2002) trials, did report improved hepatic disease-free survival with the use of a hepatic artery infusion pump. There remained limited evidence of a replicable improvement in overall survival, and the expansion of hepatic artery infusion pump into the adjuvant space was cautioned by a Cochrane review in 2006, highlighting the need for further studies to establish a consistent benefit. Those data were forthcoming over the 2000s and 2010s in large-scale retrospective analyses for the most part, but the recommendations from international guidelines remain equivocal to this day. With widespread retrospective data and high-quality randomized clinical trial evidence that a hepatic artery infusion pump in the setting of resected hepatic metastasis from colorectal liver metastasis decreases hepatic recurrence and indications that it may improve overall survival, it is clear that there is a subset of patients that greatly benefit from this treatment modality. New randomized clinical trials, specifically in the adjuvant setting, are currently enrolling and should continue to elucidate the benefit that hepatic artery infusion pumps may confer. That being said, it remains a challenge to reliably identify these patients, and the procedure is limited by complexity and resources to high-volume academic centers, leaving accessibility as a further potential barrier for patients. It remains to be seen what volume of literature may shift the hepatic artery infusion pump into the standard of care, but adjuvant hepatic artery infusion pump in the setting of colorectal liver metastasis should certainly be explored further as a validated treatment for patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Patients with unresectable colorectal liver metastases are commonly treated with systemic chemotherapy to convert their disease to an operable state. Unfortunately, many patients remain unresectable after first-line chemotherapy and resort to second- and third-line regimens with poor results. Liver-directed strategies have historically been used in this setting. There has been a renewed interest in offering hepatic artery infusion chemotherapy combined with systemic chemotherapy to improve resectability or palliate disease. Prospective studies over the past 2 decades have produced encouraging data, even in chemorefractory patients. This therapy has expanded to multiple centers across North America and worldwide with similar results. This review addresses these data, specifically focusing on conversion to resection and palliation of colorectal liver metastases after patients have received multiple lines of systemic chemotherapy., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Vascular resection (VR) is extended surgery to attain a negative radial margin (RM) for distal cholangiocarcinoma (DCC). The present study explored the significance of VR for DCC, focusing on VR, RM, and findings suggestive of vascular invasion on multidetector-row computed tomography (MDCT)., Methods: Patients with DCC who underwent resection between 2002 and 2019 were reviewed., Results: Among 230 patients, 25 received VR. The overall survival (OS) in the VR group was significantly worse than in the non-VR group (16.7% vs. 50.7% at 5 years, P < 0.001). Patients who underwent VR with a negative RM failed to show a better OS than those who did not undergo VR with a positive RM (19.7% vs. 35.7% at 5 years, P = 0.178). Of the 30 patients who were suspected of having vascular invasion on MDCT, 11 did not receive VR because the vessels were freed from the tumor; these patients had a significantly better OS (57.9% at 5 years) than those who underwent VR., Conclusions: VR for DCC was associated with a poor prognosis, even if a negative RM was obtained. VR is not necessary for DCC when the vessels are detachable from the tumor., (© 2022. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Hepatic artery intervention combined with immunotarget therapy exerts excellent disease control and prolongs survival. However, the arrangement of hepatic artery intervention and systemic therapy confuses clinical decisions., Methods: A two-center, retrospective clinical study was approved by the Institutional Ethics Committee. From December 2018 to February 2022, patients with Barcelona Clinic Liver Cancer stage C (BCLC-C) hepatocellular carcinoma (HCC) who received targeted therapy plus PD-1 inhibitors with or without hepatic artery intervention were included. According to the treatment mode, the patients were assigned to three groups: initial hepatic artery intervention combined with immunotarget therapy, immunotarget therapy sequential hepatic artery interventional therapy, and immunotarget therapy only. The survival, response, and adverse events were compared among the three groups. Subgroup analysis and univariate and multivariate prognostic analyses were also evaluated., Results: The median follow-up time was 18.3 months (95% CI 16.7 to 20.0 months). A total of 163 patients with BCLC-C stage HCC were assigned to three groups: initial hepatic artery intervention plus PD-1 inhibitors plus targeted therapy (HPT, n = 66), PD-1 inhibitors plus targeted therapy followed by hepatic artery intervention (PTH, n = 56) and PD-1 inhibitors plus targeted therapy (PT, n = 41). The median progression-free survival was 8.37 months (95% CI 6.35-10.39) with HPT versus 5.3 months (95% CI 3.48-7.12) with PTH versus 6.33 months (95% CI 3.75-8.92) with PT. The progression-free survival of the HPT group was better than that of the PTH group (HR 0.66, 95% CI 0.45-0.97, p = 0.027) and PT group (HR 0.60, 95% CI 0.39-0.92, p = 0.01). The median overall survival was 14.6 months (95% CI 10.6-18.7) with HPT, 10.0 months (95% CI 8.2-11.8) with PTH and 11.3 months (95% CI 8.3-14.3) with PT. The 1-year overall survival (OS) rates in the HPT, PTH and PT groups were 50%, 33.9%, and 34.1%, respectively. Overall survival was significantly longer in the HTP group than in the PT group (HR 0.60, 95% CI 0.361-0.996, p = 0.032). Compared with the PTH group, the overall survival of the HTP group had a prolonged survival trend (HR 0.66, 95% CI 0.416-1.032, p = 0.059). All treatment modalities were deemed equally safe. Multivariate analysis suggested that the mode of treatment, albumin level, Child‒Pugh grade and hepatectomy history were independent prognostic factors for BCLC-C HCC patients., Conclusions: Initial hepatic artery intervention combined with immunotarget therapy gained survival benefits with tolerable side effects compared with immunotarget sequential hepatic artery intervention and immunotarget therapy alone. Multivariate analysis suggested that liver reserve function was closely correlated with prognosis., (© 2022. The Author(s).)

Intrahepatic cholangiocarcinoma is an aggressive tumor that commonly presents at an advanced stage requiring multimodal treatment. Surgical resection remains the only curative option; however, only 20% to 30% of patients present with resectable disease as these tumors remain asymptomatic at an early stage. Diagnostic workup for intrahepatic cholangiocarcinoma includes contrast-enhanced cross-sectional imaging (eg, computed tomography, magnetic resonance imaging) to determine resectability and percutaneous biopsy for patients receiving neoadjuvant therapy or with unresectable disease. Surgical treatment of resectable intrahepatic cholangiocarcinoma is centered on complete resection of the mass with negative (R0) margins while preserving sufficient future liver remnant. Intraoperative measures that aid in ensuring resectability include diagnostic laparoscopy to rule out peritoneal disease or distant metastases and ultrasound to evaluate for vascular invasion or intrahepatic metastases. Predictors of survival after surgery for intrahepatic cholangiocarcinoma include margin status, vascular invasion, nodal disease, and tumor size and multifocality. Patients with resectable intrahepatic cholangiocarcinoma may also benefit from systemic chemotherapy in either the neoadjuvant or adjuvant setting; however, guidelines do not presently support the use of neoadjuvant chemotherapy outside of ongoing clinical trials. For unresectable intrahepatic cholangiocarcinoma, the combination of gemcitabine and cisplatin has been the first-line chemotherapeutic option, but recent advancements in triplet regimens and immunotherapies may offer novel strategies. Hepatic artery infusion presents an efficacious adjunct to systemic chemotherapy as it takes advantage of the hepatic arterial blood supply that feeds intrahepatic cholangiocarcinomas to deliver high-dose chemotherapy to the liver through a subcutaneous pump. Thus, hepatic artery infusion takes advantage of first-pass hepatic metabolism and provides liver-directed therapy while minimizing systemic exposure. In unresectable intrahepatic cholangiocarcinoma, using hepatic artery infusion therapy in conjunction with systemic chemotherapy has been associated with better overall survival and response rates when compared to systemic chemotherapy alone or other liver-directed therapies, such as transarterial chemoembolization and transarterial radioembolization. This review focuses on surgical intervention for resectable intrahepatic cholangiocarcinoma and the utility of hepatic artery infusion for patients with unresectable disease., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The number of lymph nodes is used to determine the prognosis in patients with gastric cancer undergoing D2 lymph node dissection. However, a group of extraperigastric lymph nodes, including lymph node 8a, are also considered to be effective in prognosis. In our clinical experience, in most patients during D2 lymph node dissection, the lymph nodes are removed en-bloc with the specimen and are not marked separately. The aim was to analyze the importance and prognostic impact of 8a lymph node metastasis in patients with gastric cancer., Methods: Patients who underwent gastrectomy and D2 lymph node dissection for gastric cancer between 2015 and 2022 were included in the study. Patients were divided into two groups based on metastasis to the 8a lymph node: metastatic and nonmetastatic. The effect of clinicopathologic features and the prevalence of lymph node metastasis on the prognosis of the two groups were analyzed., Results: The present study included 78 patients. The mean number of dissected lymph nodes was 27 (IQR, 15-62). There were 22 (28.2%) patients in the 8a lymph node metastatic group. Patients with 8a lymph node metastatic disease had shorter overall survival and shorter disease-free survival. Those with metastatic 8a lymph nodes among pathologic N2/3 patients had shorter overall and disease-free survival rates (p < 0.05)., Conclusion: In conclusion, we believe that anterior common hepatic artery (8a) LN metastasis is a key factor that negatively affects both disease-free and overall survival in patients with locally advanced gastric cancer., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The purpose of this study was to evaluate perfusion parameters of triphasic computed tomography (CT) scans in predicting microvascular invasion (MVI) in hepatocellular carcinoma (HCC). All patients were pathologically diagnosed as HCC and underwent triple-phase enhanced CT imaging, which was used to calculate the blood perfusion parameters of hepatic arterial supply perfusion (HAP), portal vein blood supply perfusion (PVP), hepatic artery perfusion Index (HPI), and arterial enhancement fraction (AEF). Receiver operating characteristic (ROC) curve was used to evaluate the performance. The mean values of PVP(Min), AEF(Min), the difference in PVP, HPI and AEF related parameters, the relative PVP(Min) and AEF(Min) in MVI negative group were significantly higher than those in MVI positive group, while for the difference in HPI(Max), the relative HPI(Max) and AEF(Max), the value of MVI positive group significantly higher than that of negative group. The combination of PVP, HPI and AEF had the highest diagnostic efficacy. The two parameters related to HPI had the highest sensitivity, while the combination of PVP related parameters had higher specificity. A combination of perfusion parameters in patients with HCC derived from traditional triphasic CT scans can be used as a preoperative biomarker for predicting MVI., (© 2023. The Author(s).)

Purpose: Locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) involving the celiac artery (CeA), the common hepatic artery and the gastroduodenal artery (GDA) is considered unresectable. We developed the novel procedure of pancreaticoduodenectomy with celiac artery resection (PD-CAR) for such LA-PDACs., Methods: From 2015 to 2018, we performed curative pancreatectomy with major arterial resection for 13 LA-PDACs as a clinical study (UMIN000029501). Of those, four patients with pancreatic neck cancer involving the CeA and GDA were candidates for PD-CAR. Prior to surgery, blood flow alterations were performed to unify the blood flow to the liver, stomach, and pancreas, resulting in feeding from the cancer-free artery. During PD-CAR, arterial reconstruction of the unified artery was performed as needed. Based on the records of PD-CAR cases, we retrospectively analyzed the validity of the operation., Results: R0 resection was achieved in all patients. Arterial reconstruction was performed in three patients. In another patient, the hepatic arterial flow was maintained by preserving of the left gastric artery. The mean operative time was 669 min, and the mean blood loss was 1003 ml. Although Clavien-Dindo classification III-IV postoperative morbidities occurred in three patients, no reoperations nor mortalities occurred. Although two patients died of cancer recurrence, one patient survived for 26 months without recurrence (died of cerebral infarction), and another is alive at 76 months without recurrence., Conclusion: PD-CAR, which enabled R0 resection and preservation of the residual stomach, pancreas, and spleen, provided acceptable postoperative outcomes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Adjuvant hepatic artery infusion chemotherapy (HAIC) has been shown to be beneficial to the patient outcomes in hepatocellular carcinoma (HCC)., Methods: Randomized controlled trials (RCTs) and non-RCTs were identified from six databases up to January 26, 2023. Patient outcomes were assessed using overall survival (OS) and disease-free survival (DFS). Data were presented as hazard ratios (HR, 95% confidence intervals, or CIs)., Results: The present systematic review included 2 RCTs and 9 non-RCTs with a total of 1290 cases. Adjuvant HAIC improved OS (HR of 0.69; 95% CI of 0.56-0.84; p < 0.01) and DFS (HR of 0.64; 95% CI of 0.49-0.83; p < 0.01). Subgroup analysis showed that HCC patients with portal vein invasion (PVI) or microvascular invasion (MVI) benefit from adjuvant HAIC in terms of OS ((HR of 0.43; 95% CI of 0.19-0.95; p < 0.01) and (HR of 0.43; 95% CI of 0.19-0.95; p = 0.0373), respectively) and DFS ((HR of 0.38; 95% CI of 0.21-0.69; p < 0.01) and (HR of 0.73; 95% CI of 0.60-0.88; p = 0.0125), respectively). Adjuvant HAIC with the oxaliplatin-based approach significantly improved OS (HR of 0.60; 95% CI of 0.36-0.84; p = 0.02) and (HR of 0.59; 95% CI of 0.43-0.75; p < 0.01), respectively)., Conclusion: This meta-analysis demonstrated that postoperative adjuvant HAIC was beneficial in HCC patients with PVI and MVI. It remains unclear whether HAIC can improve the survival outcome in all HCC patients after hepatic resection., (© 2023. The Author(s).)

A 79-year-old man was scheduled for surgery for hepatocellular carcinoma(HCC)after transcatheter hepatic arterial embolization for rupture. Two weeks before surgery, the patient came to our hospital with a chief complaint of back pain. First, we performed biliary drainage, under the diagnosis of HCC with obstructive jaundice due to haemobilia. Hepatectomy was performed when the patient's condition stabilized. It should be kept in mind that haemobilia may occur after TAE for HCC with bile duct tumor thrombus, and appropriate treatment should be performed when bleeding occurs.

In cases of pancreatic cancer with anatomical variations of the hepatic artery, it is important to evaluate the hemodynamics of each case for surgical indication. We report the case of a 68-year-old man with locally advanced pancreatic cancer and an aberrant right hepatic artery who underwent distal pancreatectomy with celiac axis resection(DP-CAR). He was admitted to our institute due to abdominal discomfort. A CT scan showed pancreatic cancer invading the common hepatic artery. He underwent chemoradiotherapy with a diagnosis of locally advanced pancreatic cancer. After the tumor downstaging, we performed DP-CAR, which included a gastroduodenal artery and a proper hepatic artery resection. Even though delayed gastric emptying was observed after the operation, he was discharged on postoperative day 36.