Chady Salloum

Sarcopenia Impacts on Short- and Long-term Results of Hepatectomy for Hepatocellular Carcinoma.

OBJECTIVE To evaluate the prevalence of sarcopenia among European patients with resectable hepatocellular carcinoma (HCC) and to assess its prognostic impact on overall and disease-free survival. BACKGROUND Identification of preoperative prognostic factors in liver surgery for HCC is required to better select patients and improve survival. Recent studies have shown that preoperative discrimination of patients with low skeletal muscle mass (sarcopenic patients) using computed tomography was associated with morbidity and mortality after liver and colorectal surgery. Assessment of sarcopenia could be used to evaluate patients before hepatectomy for HCC. METHODS All consecutive patients who underwent hepatectomy for HCC in our institution, between February 2006 and September 2012, were included. Univariate and multivariate analyses evaluating prognostic factors of postoperative mortality and cancer recurrence were performed, including preoperative, surgical, and histopathological factors. RESULTS Among 198 patients who underwent hepatectomy for HCC, 109 patients had an available computed tomographic scan and represent the study cohort. After a median follow-up of 21.23 months, 27 patients (24.8%) died. There were 20 deaths among the 59 patients who had sarcopenia and only 7 deaths in the nonsarcopenic group. Sarcopenic patients had significantly shorter median overall survival than nonsarcopenic patients (52.3 months vs 70.3 months; P = 0.015). On multivariate analysis, sarcopenia was found to be an independent predictor of poor overall survival (hazard ratio = 3.19; P = 0.013) and disease-free survival (hazard ratio = 2.60; P = 0.001). CONCLUSIONS Sarcopenia was found to be a strong and independent prognostic factor for mortality after hepatectomy for HCC in European patients and could be used to evaluate eligibility of patients with HCC before surgery.

Impact of portal vein embolization on long‐term survival of patients with primarily unresectable colorectal liver metastases

Portal vein embolization (PVE) increases the resectability of initially unresectable colorectal liver metastases (CLM). This study evaluated long‐term survival in patients with CLM who underwent hepatectomy following PVE.

Intention-to-treat analysis of liver transplantation for hepatocellular carcinoma: living versus deceased donor transplantation.

For patients who have cirrhosis with hepatocellular carcinoma (HCC), living donor liver transplantation (LDLT) reduces waiting time and dropout rates. We performed a comparative intention‐to‐treat analysis of recurrence rates and survival outcomes after LDLT and deceased donor liver transplantation (DDLT) in HCC patients. Our study included 183 consecutive patients with HCC who were listed for liver transplantation over a 9‐year period at our institution. Tumor recurrence was the primary endpoint. At listing, patient and tumor characteristics were comparable in the two groups (LDLT, n = 36; DDLT, n = 147). Twenty‐seven (18.4%) patients dropped out, all from the DDLT waiting list, mainly due to tumor progression (19/27 [70%] patients). The mean waiting time was shorter in the LDLT group (2.6 months versus 7.9 months; P = 0.001). The recurrence rates in the two groups were similar (12.9% and 12.7%, P = 0.78), and there was a trend toward a longer time to recurrence after LDLT (38 ± 27 months versus 16 ± 13 months, P = 0.06). Tumors exceeding the University of California, San Francisco (UCSF) criteria, tumor grade, and microvascular invasion were independent predictive factors for recurrence. On an intention‐to‐treat basis, the overall survival (OS) in the two groups was comparable. Patients beyond the Milan and UCSF criteria showed a trend toward worse outcomes with LDLT compared with DDLT (P = 0.06). Conclusion: The recurrence and survival outcomes after LDLT and DDLT were comparable on an intent‐to‐treat analysis. Shorter waiting time preventing dropouts is an additional advantage with LDLT. LDLT for HCC patients beyond validated criteria should be proposed with caution. (HEPATOLOGY 2011;)

Comparison of simultaneous or delayed liver surgery for limited synchronous colorectal metastases

The optimal surgical strategy for patients with synchronous colorectal liver metastases (CLMs) is still unclear. The aim of this study was to compare simultaneous colorectal and hepatic resection with a delayed strategy in patients who had a limited hepatectomy (fewer than three segments).

Repeat hepatectomy for recurrent colorectal metastases

The oncological benefit of repeat hepatectomy for patients with recurrent colorectal metastases is not yet proven. This study assessed the value of repeat hepatectomy for these patients within current multidisciplinary treatment.

Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience.

Objective:To analyze the short- and long-term results of cavoportal anastomosis (CPA) and renoportal anastomosis (RPA) in 20 consecutive liver transplantation (LT) candidates with diffuse portal vein thrombosis (PVT). Summary Background Data:Caval inflow to the graft (CIG) by CPA or RPA has been the most commonly used salvage technique to overcome the absolute contraindication for LT in case of diffuse PVT. Methods:From 1996 to 2009, 3 patients (15%) underwent CPA and 17 patients (85%) had an RPA during LT. In addition to routine follow-up, patients were specifically evaluated for signs of portal hypertension (PHT) and for patency of the anastomoses. The follow-up ranged from 3 months to 12 years (median of 4.5 years). Results:Caval inflow to the graft was feasible in all attempted cases. In the short term (<6 months), 35% of patients had residual PHT-related complications (massive ascites and variceal bleeding). These resolved spontaneously or with endoscopic management. Three deaths occurred; none was related to PHT or shunt thrombosis. In the long term (>6 months), 1 death occurred because of recurrent variceal bleeding after RPA thrombosis. At last follow-up, all living patients [n = 13 (65%)] had normal liver function, no signs of PHT and patent anastomoses. There were no retransplantations. Graft and patient survival at 1, 3, and 5 years were 83%, 75%, and 60%, respectively. Conclusions:Caval inflow to the graft is an efficacious salvage technique with satisfactory long-term results, considering the spontaneous outcome in patients denied LT because of diffuse PVT. Adequate preoperative management of PHT and its associated complications is vital in obtaining good results. In the long term, residual PHT resolves and the liver function returns to normal.

Liver transplantation for hepatocellular carcinoma: The impact of human immunodeficiency virus infection†

Liver transplantation (LT) has become an accepted therapy for end‐stage liver disease in human immunodeficiency virus–positive (HIV+) patients, but the specific results of LT for hepatocellular carcinoma (HCC) are unknown. Between 2003 and 2008, 21 HIV+ patients and 65 HIV− patients with HCC were listed for LT at a single institution. Patient characteristics and pathological features were analyzed. Univariate analysis for overall survival (OS) and recurrence‐free survival (RFS) after LT was applied to identify the impact of HIV infection. HIV+ patients were younger than HIV− patients [median age: 48 (range = 41‐63 years) versus 57 years (range = 37‐72 years), P < 0.001] and had a higher alpha‐fetoprotein (AFP) level [median AFP level: 16 (range = 3‐7154 μg/L] versus 13 μg/L (range = 1‐552 μg/L), P = 0.04]. There was a trend toward a higher dropout rate among HIV+ patients (5/21, 23%) versus HIV− patients (7/65, 10%, P = 0.08). Sixteen HIV+ patients and 58 HIV− patients underwent transplantation after median waiting times of 3.5 (range = 0.5‐26 months) and 2.0 months (range = 0.5‐24 months, P = 0.18), respectively. No significant difference was observed in the pathological features of HCC. With median follow‐up times of 27 (range = 5‐74 months) and 36 months (range = 3‐82 months, P = 0.40), OS after LT at 1 and 3 years reached 81% and 74% in HIV+ patients and 93% and 85% in HIV− patients, respectively (P = 0.08). RFS rates at 1 and 3 years were 69% and 69% in HIV+ patients and 89% and 84% in HIV− patients, respectively (P = 0.09). In univariate analysis, HIV status did not emerge as a prognostic factor for OS or RFS. Conclusion: Because of a higher dropout rate among HIV+ patients, HIV infection impaired the results of LT for HCC on an intent‐to‐treat basis but had no significant impact on OS and RFS after LT. (HEPATOLOGY 2011;53:475‐482)

Vascular reconstruction combined with liver resection for malignant tumours.

The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre.

Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion: An Audit of 77 Consecutive Cases.

OBJECTIVE To identify independent predictors of 90-day mortality after liver resection for patients undergoing standard total vascular exclusion (TVE) with hypothermic portal perfusion and venovenous bypass. The secondary endpoint was to evaluate the long-term outcomes. BACKGROUND Tumors invading the vena cava and/or the hepatocaval confluence are indications for standard TVE. The inclusion of liver hypothermic perfusion permits safe TVE. There are a limited number of reports focusing on this complex technique and no relevant analysis of short-term and long-term results. METHODS Seventy-seven consecutive liver resections performed using standard TVE with hypothermic portal perfusion and venovenous bypass between 1998 and 2010 were analyzed. The independent predictors and rates of 90-day mortality, morbidity, and long-term survival were evaluated. RESULTS The 90-day mortality rate was 19.5% (15 cases). Three independent predictors of mortality were identified: age-adjusted Charlson Comorbidity Index 3 or more (P = 0.0231; odds ratio = 47.565; 95% confidence interval = 1.701-1330.414), tumor size 10 cm or more (P = 0.0442; odds ratio = 6.374; 95% confidence interval = 1.049-38.734), and the presence of 50/50 criteria (P = 0.0407; odds ratio = 6.217; 95% confidence interval = 1.080-35.782). The overall 5-year survival rate was 30.4%. CONCLUSIONS Liver resection using standard TVE with hypothermic portal perfusion and venovenous bypass is associated with a high mortality rate. The identification of preoperative predictors of mortality should improve the selection of patients for this aggressive surgery. Compared with nonsurgical management, the long-term results are acceptable and justify this aggressive surgery in selected patients.

Open and laparoscopic resection of hepatocellular adenoma: trends over 23 years at a specialist hepatobiliary unit

BACKGROUND Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA. METHODS Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring >5 cm. RESULTS Between 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA. CONCLUSIONS Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.