C. Rinaldi A. Lesmana

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

IntroductionThe Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.MethodsThe working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.ResultsParticipants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Diagnostic value of a group of biochemical markers of liver fibrosis in patients with non-alcoholic steatohepatitis

OBJECTIVE: The objectives of this study were to investigate the use of non‐invasive biochemical markers to evaluate the severity of liver fibrosis in patients with non‐alcoholic steatohepatitis (NASH).

Significant hepatic histopathology in chronic hepatitis B patients with serum ALT less than twice ULN and high HBV-DNA levels in Indonesia

OBJECTIVE:  To study the prevalence of significant hepatic histopathology in chronic hepatitis B (CHB) patients with alanine aminotransferase (ALT) ≤ twice upper limit of normal (ULN) and its association with age, HBeAg status, hepatitis B virus (HBV)‐DNA level and viral genotype.

Impact of Endoscopic Ultrasound Procedures in Various Pancreatobiliary Disorders in Indonesia Based on a Case Series in a Private Hospital.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a common technique for assessing the pancreas and the biliary system; however, the potential complications have raised concern among endoscopists and patients. Recently, the need of endoscopic ultrasound (EUS) as an additional tool of assessment before the ERCP procedure has been increasing. The need of EUS in developing countries is still a matter of debate regarding the cost, investment, and training. Here, we report the significant impact of EUS on several unselected interesting cases of pancreatobiliary disorders. Method: We selected several interesting cases from the patients who underwent EUS at our private hospital in Jakarta, Indonesia. The EUS procedures were performed by one experienced endosonographer and one EUS trainee who are very experienced with transabdominal ultrasound. The equipment was an Olympus JF UCT 180 EUS scope which was connected to an Aloka IPF-1701C ultrasound machine (Tokyo, Japan). Results: Five interesting cases were included from patients who underwent EUS due to pancreatobiliary disorders. The cases included recurrent pancreatitis due to pancreatic stone at the small branch that obstructed the main pancreatic duct, common bile duct (CBD) stone with insignificant duct dilatation, pancreatic head cancer with total obstruction at the distal CBD and portal vein infiltration, pancreas divisum in a young girl, and distal CBD mass that caused obstructive jaundice. Conclusions: The EUS procedure has shown a significant impact in managing patients with pancreatobiliary diseases. In most developing countries, EUS needs to be evaluated further regarding the cost, investment, and training.

The Role of Liver Biopsy in the Non-Invasive Methods Era and Liver Stiffness Measurement Using Transient Elastography

Liver biopsy is still the most accurate tool to assess liver histopathology in chronic liver disease (CLD), especially in patients with chronic active hepatitis who need a treatment decision. Nowadays, there are many non-invasive methods are being used to assess liver fibrosis and might replace liver biopsy. One of the new methods is transient elastography (TE/Fibroscan) which has been widely used to predict liver fibrosis in chronic active hepatitis B and C. However, whether TE is ready to replace the liver biopsy is still controversial. In cases like chronic hepatitis B infection (CHB), autoimmune hepatitis (AIH), non-alcoholic steatohepatitis (NASH), drug induced liver injury (DILI), and cholestatic liver diseases, the role of liver biopsy is very important to make the whole information of liver histopathology (not only about liver fibrosis). On the other hand, to make a diagnosis of liver cirrhosis, we have some parameters that can be used, such as clinical stigmata of advanced chronic liver disease (jaundice, hyper pigmentation, spider nevi, palmar erythema, ascites, edema, and others), low level of platelet count, and low level of albumin, prolonged protombin time, and picture of liver cirrhosis based on ultrasound examination. In chronic active hepatitis B infection, the treatment decision is usually based on the increase level of alanine aminotransferase (ALT), high HBV-DNA serum level, and the presence of HBeAg status. In patients with normal ALT level or less than 2x ULN, the liver biopsy is needed to decide whether the antiviral therapy should be started or not. In this group, not only liver fibrosis assessment is important, but also the degree of necroinflammation will influence the decision of antiviral therapy. From the point of view of liver fibrosis itself when using TE, it is not always accurate to differentiate between fibrosis 1 or 2, since this differentiation is also important to start antiviral therapy. Despite the etiology of liver injury, TE itself has problem with overweight and obese patients, and patients with narrowed intercostals space. TE also cannot be performed in ascitic patient because the interposed fluid blocks the shear wave. The increase of liver stiffness cut off is also can be influenced by metabolic syndrome, age, BMI, and the increase of ALT level. The liver biopsy still has the most important role in assessing liver histopathology but we might reduce the need of liver biopsy examination in some patients. At this moment, TE can

Hepatocellular Carcinoma in a Tertiary Referral Hospital in Indonesia: Lack of Improvement of One-Year Survival Rates between 1998-1999 and 2013-2014.

BACKGROUND The survival of hepatocellular carcinoma (HCC) patients is usually low due to late diagnosis. Cipto Mangunkusumo Hospital as the largest tertiary referral hospital in Indonesia, has recently improved its modalities for advanced HCC management, but there has not been any evaluation on any improvement in HCC patient survival. MATERIALS AND METHODS A retrospective analysis on 114 HCC patients in 2013-2014 were conducted and compared with the database for 77 HCC patients in 1998-1999. Clinical characteristics and treatment received were recorded and the survival of both groups was analyzed using the Kaplan-Meier method and compared using the log-rank test. RESULTS The percentage of HBV positive patients had increased after fifteen years from 32.5% to 67.5%. Only two patients (1.8%) in 2013-2014 were diagnosed with HCC during surveillance program. Proportions of Barcelona Clinic Liver Cancer A, B, C, and D in 2013-2014 were 1.8%, 42%, 28.1%, and 28.1%, respectively. There was an increase in the use of potentially curative treatment, such as surgical resection or combination of loco-regional therapies. The one-year survival rate increased from 24.1% in 1998-1999 to 29.4% in 2013-2014, while the median survival decreased from 146 days to 138 days, but the difference was not statistically significant (p=0.913). CONCLUSIONS There was no improvement in the median survival of HCC patients after fifteen years because most continued to present at late stages. There is an urgent need for a nationwide implementation of a hepatitis screening program and HCC surveillance education.