Acy Chan

Hepatobiliary and Pancreatic: Cholangiopathy in Ketamine user––An emerging new condition

Ketamine, an N-methyl-D-aspartate antagonist, is becoming a popular drug of abuse in the Asian population. The use of this drug could produce short-term sensations of excitement, hallucinations and vivid imagery. The abuse of this drug has also been reported in places outside Asia. As ketamine is mainly excreted in urine and bile, it can cause dysfunction to the urinary bladder and the bililary system. Here, we describe a case of sphincter of Oddi dysfunction in a patient who abused ketamine. A 20-year-old woman with a 2-year history of ketamine abuse presented with right upper quadrant pain, nausea and fever over 2 weeks. On presentation, the patient had a low-grade fever and mild tenderness in the epigastrium, but no jaundice and was normotensive. Laboratory tests showed elevated white cell count with neutrophilia, and cholestatic liver function test derangements, which were characterised by marked elevation of serum alkaline phosphatase (2129 U/L) and to much lesser extend, bilirubin (5 umol/L), serum aspartate aminotransferase (143 U/L) and alanine aminotransferase (178 U/L). She was tested negative for antimitochondrial antibody, anti-nuclear antibody, and anti-HIV antibody. Her serum CA19.9 and immunoglobulin G4 (IgG4) levels were normal. Contrast computed tomography scan showed dilation of both common bile duct (CBD) and intrahepatic ducts, with imaging evidence of hepatic micro-abscesses (Fig. 1). Thus, an endoscopic retrograde cholangiopancreatography (ERCP) was performed and failed to show any filling defects suggestive of stones or sludges in the biliary tract and gallbladder. Instead, a persistent ultra-short narrowing was noted at the very distal portion of CBD, where sphincter of Oddi would be located (Fig. 2). After a carefully performed long sphincterotomy, repeated cholangiogram showed the very distal CBD narrowing had disappeared, and the contrast was flowed freely into the duodenum (Fig. 3). Her liver function returned to normal together with resolution of fever and abdominal pain after the ERCP. Given the important differential diagnoses such as primary sclerosing cirrhosis, recurrent pyogenic cholangitis, IgG4-positive sclerosing cholangitis, and AIDS-cholangiopathy had been excluded, we believe this lady has ketamine-induced chronic cholangiopathy, characterising predominantly by the persistent sphincter of Oddi spasm that lead to biliary obstruction and infection. Although the pathogenesis of bile duct dilatation from ketamine abuse remains unclear, animal studies have demonstrated increased flow resistance across the sphincter of Oddi with ketamine administration, suggesting the potential role of ketamine in inducing sphincter of Oddi dysfunction. Sphincterotomy or sphincteroplasty has been an effective treatment in these patients.

Risk Factors for Graft Steatosis after Liver Transplantation using Controlled Attenuation Parameter Measurements

Background Liver steatosis is a cause of graft dysfunction after liver transplantation. The current study aims to determine the risk factors associated with the development of graft steatosis in a large cohort of liver transplant recipients. Methods Consecutive adult patients transplanted from 2003 to 2014 underwent liver stiffness and controlled attenuation parameter (CAP) measurements using transient elastography. Liver steatosis was defined as minimal (<5%), mild (5-33%), moderate (34-66%), and severe (≥67%) if the CAP score was <248, 248-267, 268-279, and ≥280 dB/m respectively. Longitudinal history including diabetes, hyperlipidemia, hypertension, and immunosuppressive regimen were recorded. Results A total of 549 liver transplant recipients underwent valid transient elastography, of which 359 (72%) were male. Using the predefined CAP cut-offs, 345 (63%), 48 (9%), 27 (5%), and 129 (23%) had minimal, mild, moderate, and severe steatosis respectively. There was a significant correlation between the CAP score and age at transplant (r=0.104), age at CAP measurement (r=0.116), and body mass index (BMI) at the time of CAP measurement (r=0.567)(all p<0.05). A higher CAP score was observed for male patients (229 vs 212 dB/m, p=0.011), on-treatment diabetes (232 vs 219 dB/m, p=0.029), on-treatment hypertension (237 vs 200 dB/m, p<0.001), and on-treatment hyperlipidemia (239 vs 217 dB/m, p<0.001). No difference in CAP score was observed for those requiring mTOR-inhibitors or mycophenolate, although a lower CAP was observed for prednisone (212 vs 227, p=0.022). A significant correlation was observed between CAP scores and age at the time of liver transplant (r=0.104, p=0.015), age at the time of CAP score measurement (r=0.116, p=0.007), and the BMI (r=0.567, p<0.001). No significant correlation was observed between CAP score and time from transplant to CAP measurement. After multivariate analysis, only hypertension (OR 0.54) and BMI (OR 1.41) remains significant factors associated with moderate-severe graft steatosis. There was no correlation between the CAP score and liver stiffness measurement (p=0.89). Discussion The liver stiffness and CAP score is a non-invasive method of diagnosing hepatic fibrosis and steatosis respectively, with validated cut-offs correlating to different severity. After multivariate analysis on significant univariate variables, only hypertension and BMI was significantly associated with moderate-severe steatosis. However, there was no correlation between liver stiffness and CAP score, suggesting that other causes other than steatosis were responsible for graft fibrosis. Conclusion Post-transplant graft steatosis was common, with 28% developing moderate-severe steatosis. Increase in BMI and the presence of hypertension was significantly associated with the development of moderate-severe graft steatosis. However, there was no correlation between liver stiffness and CAP scores to suggest increase in fibrosis.

Advantage of anterior resection in major resection for colorectal liver metastases

Objective: We described histologic findings bile canalicular–ductule networks in the future liver remnant (FLR) during associating liver partition with portal vein ligation for staged hepatectomy (ALPPS). Background: Little is known about regeneration of bile canalicular–ductule networks during short interval of ALPPS. Methods: Bile canalicular–ductule networks were examined using specimens obtained from 8 patients treated with ALPPS and 6 patients with hepatectomy following portal vein embolization (PVE). The expression of multidrug resistance 1 (MDR1), a membrane transporter of the bile canaliculi (BC), was analyzed immunohistochemically. The morphological changes of the BC and tight junction (TJ) surrounding BC were also assessed electron microscopically. Results: Extrapolated kinetic growth of FLR was greater during ALPPS (17.2 ± 6.8 mL/day) than that after PVE (6.3 ± 3.4 mL/day, P=0.005). The continuity of MDR1–positive bile canalicular networks was less evident in ALPPS than in PVE (P<0.001). Electron microscopically, no significant difference was evident in number of BC, size of BC s̓ lumen between the 2 groups. However, in the ALPPS group, development of microvilli in the BC was poorer than the PVE group (P<0.001). Length of the TJ and desmosome complex were shorter in the ALPPS group (0.69±0.52μm) than in the PVE group (1.09±0.50μm; P<0.001). Leaky TJ was more evident in the ALPPS group (64.9% vs. 23.6%; P=0.001). Conclusions: Regeneration of bile canalicular–ductule networks in FLR was less evident in ALPPS than PVE. This phenomenon may be associated with prolonged cholestasis following final hepatectomy in ALPPS. J Hepatobiliary Pancreat Sci (2017) 24.S1 Oral A150

Intraoperative ICG measurement during major hepatectomy for HCC. Hype or hope

This journal suppl. entitled: Conference Abstracts: 25th Annual Conference of APASL, February 20–24, 2016, Tokyo, JapanAbstracts of the 25th Annual Conference of APASL, February 20–24, 2016, Tokyo, Japans of the 25th Annual Conference of APASL, February 20–24, 2016, Tokyo, Japan Asian Pacific Association for the Study of the Liver 2016 Presidential PlenaryThis journal suppl. entitled: Conference Abstracts: 25th Annual Conference of APASL, February 20–24, 2016, Tokyo, JapanThis journal suppl. entitled: Conference Abstracts: 25th Annual Conference of APASL, February 20–24, 2016, Tokyo, Japan

Survival advantage of primary liver transplantation for resectable hepatocellular carcinoma with vascular invasion

The 21st Conference of the Asian Pacific Association for the Study of the Liver

Late recurrence of HCC after liver transplantation

Conference Theme: Latest Advances in Liver Cancer Research: From Basic Science to Therapeutics

Salvage Transplantation for Recurrent Hepatocellular Carcinoma within Milan Criteria: Is It Worthwhile?

P-203 DISSEMINATED NOCARDIOSIS: A RARE INFECTIOUS COMPLICATION FOLLOWING NON-HEART-BEATING DONOR LIVER TRANSPLANTATION. Santos JiménezGalanes, Juan Carlos Meneu Diaz, Baltasar Perez-Saborido, Almudena Moreno Elola-Olaso, Yiliam Fundora Suarez, Manuel Abradelo Usera, Alberto Gimeno Calvo, Enrique Moreno González. Surgery and Abdominal Organs Transplantation Department, 12 de Octubre University Hospital, Madrid, Spain INTRODUCTION Nocardiosis is an infrequent disease that use to affect patients who present a cellular immunodeficiency, such as transplant recipients on immunosuppression treatment, and although uncommon associate high rates of morbidity and mortality. Disseminated Nocardiasis affecting central nervous system (CNS), abdomen, skin and lungs has been described in bone marrow, lung and kidney transplanted patients. However, to our knowledge, no cases involving these three structures have been reported in liver transplant recipients. CASE REPORT Herein, we report a case of CNS, pulmonary and cutaneous nocardiosis in a liver transplant recipient from a non-heart-beating donor due to hepatitis C virus related cirrhosis and hepatocellular carcinoma. At 7 postransplant month, patient was admitted at emergency department presenting bad general health status, fever, edema and subcutaneous nodules in legs. A computed tomography scan was performed revealing multiple nodules disseminated thorough both lungs, abdomen, brain a subcutaneous tissue. By these clinical and radiogical fi ndings needle biopsy was performed over one of the subcutaneous nodules. Cultures of the material tested positive for Nocardia farcinica. Thus, we started treatment with intravenous sulfamethoxazoletrimethoprim (SMZ-TMP) shifted after one month to oral. Radiological examination performed after two weeks of treatment showed a 70% reduction on subcutaneous, pulmonary and cerebral lesions. After six months of SMZTMP treatment, patient remained free of the symptoms, with involution of the subcutaneous nodules and signifi cant radiological improvement. CONCLUSION Among opportunistic infections appearing in liver transplant recipients, Nocardia spp. should have special consideration according to the success in early treated patients and bad prognosis in cases of delayed diagnose.This journal supplement labeled: The International Liver Transplantation Society: 16th Annual International Congress

Prediction of hospital mortality after liver transplantation for acute liver failure

P-203 DISSEMINATED NOCARDIOSIS: A RARE INFECTIOUS COMPLICATION FOLLOWING NON-HEART-BEATING DONOR LIVER TRANSPLANTATION. Santos JiménezGalanes, Juan Carlos Meneu Diaz, Baltasar Perez-Saborido, Almudena Moreno Elola-Olaso, Yiliam Fundora Suarez, Manuel Abradelo Usera, Alberto Gimeno Calvo, Enrique Moreno González. Surgery and Abdominal Organs Transplantation Department, 12 de Octubre University Hospital, Madrid, Spain INTRODUCTION Nocardiosis is an infrequent disease that use to affect patients who present a cellular immunodeficiency, such as transplant recipients on immunosuppression treatment, and although uncommon associate high rates of morbidity and mortality. Disseminated Nocardiasis affecting central nervous system (CNS), abdomen, skin and lungs has been described in bone marrow, lung and kidney transplanted patients. However, to our knowledge, no cases involving these three structures have been reported in liver transplant recipients. CASE REPORT Herein, we report a case of CNS, pulmonary and cutaneous nocardiosis in a liver transplant recipient from a non-heart-beating donor due to hepatitis C virus related cirrhosis and hepatocellular carcinoma. At 7 postransplant month, patient was admitted at emergency department presenting bad general health status, fever, edema and subcutaneous nodules in legs. A computed tomography scan was performed revealing multiple nodules disseminated thorough both lungs, abdomen, brain a subcutaneous tissue. By these clinical and radiogical fi ndings needle biopsy was performed over one of the subcutaneous nodules. Cultures of the material tested positive for Nocardia farcinica. Thus, we started treatment with intravenous sulfamethoxazoletrimethoprim (SMZ-TMP) shifted after one month to oral. Radiological examination performed after two weeks of treatment showed a 70% reduction on subcutaneous, pulmonary and cerebral lesions. After six months of SMZTMP treatment, patient remained free of the symptoms, with involution of the subcutaneous nodules and signifi cant radiological improvement. CONCLUSION Among opportunistic infections appearing in liver transplant recipients, Nocardia spp. should have special consideration according to the success in early treated patients and bad prognosis in cases of delayed diagnose.This journal supplement labeled: The International Liver Transplantation Society: 16th Annual International Congress

Recurrent hepatitis B infection after liver transplantation for hepatitis B related diseases in Asian population: long term results of a single centre

P-203 DISSEMINATED NOCARDIOSIS: A RARE INFECTIOUS COMPLICATION FOLLOWING NON-HEART-BEATING DONOR LIVER TRANSPLANTATION. Santos JiménezGalanes, Juan Carlos Meneu Diaz, Baltasar Perez-Saborido, Almudena Moreno Elola-Olaso, Yiliam Fundora Suarez, Manuel Abradelo Usera, Alberto Gimeno Calvo, Enrique Moreno González. Surgery and Abdominal Organs Transplantation Department, 12 de Octubre University Hospital, Madrid, Spain INTRODUCTION Nocardiosis is an infrequent disease that use to affect patients who present a cellular immunodeficiency, such as transplant recipients on immunosuppression treatment, and although uncommon associate high rates of morbidity and mortality. Disseminated Nocardiasis affecting central nervous system (CNS), abdomen, skin and lungs has been described in bone marrow, lung and kidney transplanted patients. However, to our knowledge, no cases involving these three structures have been reported in liver transplant recipients. CASE REPORT Herein, we report a case of CNS, pulmonary and cutaneous nocardiosis in a liver transplant recipient from a non-heart-beating donor due to hepatitis C virus related cirrhosis and hepatocellular carcinoma. At 7 postransplant month, patient was admitted at emergency department presenting bad general health status, fever, edema and subcutaneous nodules in legs. A computed tomography scan was performed revealing multiple nodules disseminated thorough both lungs, abdomen, brain a subcutaneous tissue. By these clinical and radiogical fi ndings needle biopsy was performed over one of the subcutaneous nodules. Cultures of the material tested positive for Nocardia farcinica. Thus, we started treatment with intravenous sulfamethoxazoletrimethoprim (SMZ-TMP) shifted after one month to oral. Radiological examination performed after two weeks of treatment showed a 70% reduction on subcutaneous, pulmonary and cerebral lesions. After six months of SMZTMP treatment, patient remained free of the symptoms, with involution of the subcutaneous nodules and signifi cant radiological improvement. CONCLUSION Among opportunistic infections appearing in liver transplant recipients, Nocardia spp. should have special consideration according to the success in early treated patients and bad prognosis in cases of delayed diagnose.This journal supplement labeled: The International Liver Transplantation Society: 16th Annual International Congress

Bile duct anastomotic stricture after right lobe adult-to-adult living donor liver transplantation

P-203 DISSEMINATED NOCARDIOSIS: A RARE INFECTIOUS COMPLICATION FOLLOWING NON-HEART-BEATING DONOR LIVER TRANSPLANTATION. Santos JiménezGalanes, Juan Carlos Meneu Diaz, Baltasar Perez-Saborido, Almudena Moreno Elola-Olaso, Yiliam Fundora Suarez, Manuel Abradelo Usera, Alberto Gimeno Calvo, Enrique Moreno González. Surgery and Abdominal Organs Transplantation Department, 12 de Octubre University Hospital, Madrid, Spain INTRODUCTION Nocardiosis is an infrequent disease that use to affect patients who present a cellular immunodeficiency, such as transplant recipients on immunosuppression treatment, and although uncommon associate high rates of morbidity and mortality. Disseminated Nocardiasis affecting central nervous system (CNS), abdomen, skin and lungs has been described in bone marrow, lung and kidney transplanted patients. However, to our knowledge, no cases involving these three structures have been reported in liver transplant recipients. CASE REPORT Herein, we report a case of CNS, pulmonary and cutaneous nocardiosis in a liver transplant recipient from a non-heart-beating donor due to hepatitis C virus related cirrhosis and hepatocellular carcinoma. At 7 postransplant month, patient was admitted at emergency department presenting bad general health status, fever, edema and subcutaneous nodules in legs. A computed tomography scan was performed revealing multiple nodules disseminated thorough both lungs, abdomen, brain a subcutaneous tissue. By these clinical and radiogical fi ndings needle biopsy was performed over one of the subcutaneous nodules. Cultures of the material tested positive for Nocardia farcinica. Thus, we started treatment with intravenous sulfamethoxazoletrimethoprim (SMZ-TMP) shifted after one month to oral. Radiological examination performed after two weeks of treatment showed a 70% reduction on subcutaneous, pulmonary and cerebral lesions. After six months of SMZTMP treatment, patient remained free of the symptoms, with involution of the subcutaneous nodules and signifi cant radiological improvement. CONCLUSION Among opportunistic infections appearing in liver transplant recipients, Nocardia spp. should have special consideration according to the success in early treated patients and bad prognosis in cases of delayed diagnose.This journal supplement labeled: The International Liver Transplantation Society: 16th Annual International Congress