Hsiu-Lung Fan

Liver transplantation is an alternative treatment of hepatocellular carcinoma beyond the Milan criteria

BACKGROUND The decision to perform liver transplantation (LT) or liver resection (LR) for patients with hepatocellular carcinoma (HCC) who are beyond the Milan criteria remains controversial. METHODS We retrospectively analyzed outcome data for 179 patients with HCC beyond the Milan criteria who were treated with LR (n = 135) or LT (n = 44). Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and a log-rank test was performed to compare group survival status. RESULTS Patients who underwent LR group were significantly older, had a lower TNM stage, and were more likely to have unilateral disease and noncirrhotic liver. Significantly more patients in the LR group had recurrence (53.3% vs 29.5%) or died (61.5% vs 43.2%) than patients in the LT group. Recurrence-free survival rates were 11.9% for the LR group and 61.5% for the LT group. The median overall survival duration showed no statistically difference between the LR group (28.0 months) and the LT group (50.0 months). CONCLUSIONS LT may be the better choice for patients with HCC beyond the Milan criteria.

Hepatic hemodynamic changes during liver transplantation: A review

Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics during liver transplantation. The representative hemodynamic parameters include portal vein pressure, portal vein flow, and hepatic venous pressure gradient; however, there are still others potential valuable parameters, such as total liver inflow and hepatic artery flow. All the parameters are correlated closely and some internal modulating mechanisms, like hepatic arterial buffer response, occur to maintain stable hepatic inflow. To distinguish the unique importance of each hepatic and systemic parameter in different states during liver transplantation, we reviewed the published data and also conducted two transplant cases with different surgical strategies applied to achieve ideal portal inflow and pressure.

Predictors of the outcomes of acute-on-chronic hepatitis B liver failure

AIM To identify the risk factors in predicting the outcome of acute-on-chronic hepatitis B liver failure patients. METHODS We retrospectively divided 113 patients with acute-on-chronic liver failure-hepatitis B virus (ACLF-HBV) and without concurrent hepatitis C or D virus infection and hepatocellular carcinoma into two groups according to their outcomes after anti-HBV therapy. Their demographic, clinical, and biochemical data on the day of diagnosis and after the first week of treatment were analyzed using the Mann-Whitney U test, Fishers exact test, and a multiple logistic regression analysis. RESULTS The study included 113 patients (87 men and 26 women) with a mean age of 49.84 years. Fifty-two patients survived, and 61 patients died. Liver failure (85.2%), sepsis (34.4%), and multiple organ failure (39.3%) were the main causes of death. Multivariate analyses showed that Acute Physiology and Chronic Health Evaluation (APACHE) II scores ≥ 12 [odds ratio (OR) = 7.160, 95% CI: 2.834-18.092, P < 0.001] and positive blood culture (OR = 13.520, 95% CI: 2.740-66.721, P = 0.001) on the day of diagnosis and model for end-stage liver disease (MELD) scores ≥ 28 (OR = 8.182, 95% CI: 1.884-35.527, P = 0.005) after the first week of treatment were independent predictors of mortality. CONCLUSION APACHE II scores on the day of diagnosis and MELD scores after the first week of anti-HBV therapy are feasible predictors of outcome in ACLF-HBV patients.

Transarterial chemoembolization for intrahepatic multiple recurrent HCC after liver resection or transplantation

BACKGROUND Transarterial chemoembolization (TACE) can reduce tumor progression and help achieve good locoregional effect in hepatocellular carcinoma (HCC) patients with intrahepatic multiple recurrence (IHMR) after liver resection (LR). The effect of TACE on HCC patients with IHMR after liver transplantation (LT) remains unclear. The purpose of this study was to investigate the effect of TACE on IHMR after LR or LT. MATERIAL AND METHODS This hospital-based retrospective study included 968 and 180 HCC patients who had undergone LR or LT, respectively, in the past decade. Parameters included clinical characteristics, alpha-fetoprotein level, Child classification, tumor stage at first treatment, tumor size at recurrence, and recurrence and survival status. The groups were compared using the t test or chi-square test, and univariate and multivariate analyses were performed. Survival and recurrence were analyzed by the Kaplan-Meier method. Differences were significant at P<0.05. RESULTS During follow-up, 112 patients had IHMR: 101 after LR and 11 after LT. Age, sex distribution, and HCV infection rate differed significantly between the LR and LR groups. All patients in the LT group who had recurrent HCC died within 3 years. The risk factors for death from tumor recurrence included a larger tumor size at recurrence, poor Child classification at recurrence, hyperbilirubinemia, hypoalbuminemia, and no TACE treatment. In Cox regression analysis, only vessel invasion, Child class C, and no TACE treatment were independent risk factors for death from tumor recurrence. CONCLUSIONS TACE is beneficial for treating IHMR in patients after LR or LT.

Advanced age is not a contraindication for liver resection in cases of large hepatocellular carcinoma

BACKGROUND The role of surgery in the management of large hepatocellular carcinomas (HCCs) is controversial. Advanced age and comorbidities are taken into account when major surgery is considered. PURPOSE To compare the outcomes of liver resection (LR) and transarterial chemoembolization (TACE) for resectable HCC in patients aged 70 years or older. PATIENTS AND MATERIALS This study included 70 patients aged 70 years or older treated for large HCCs (≥5 cm) between January 2007 and December 2012: 37 underwent LR and 33 underwent TACE. The outcomes of these patients were retrospectively analyzed. Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and survival data were compared using the log-rank test. RESULTS Hospital stay was significantly longer in the LR group than in the TACE group (10 days vs 8.5 days; P = 0.003). Treatment-related complications were more frequent in the TACE group, but this difference was not statistically significant. LR was associated with a better disease-free survival rate, median survival rate and cumulative overall survival rate. CONCLUSION Our results showed that LR could be a safe and effective treatment option for HCC tumors ≥5 cm in patiets aged 70 years or older.

Marked elevation of hepatic transaminases in recipients of an orthotopic liver transplant from a brain-dead donor receiving extracorporeal membrane oxygenation.

BACKGROUND Hemodynamic instability can lead to failure of donor organ procurement in brain-dead donors. Extracorporeal membrane oxygenation (ECMO) has been used in non-heart-beating donors to increase the donor pool, but the use of ECMO to salvage donor organs has been rarely used. We aimed to analyze postoperative liver function test results in patients receiving orthotopic liver transplants from ECMO-supported brain-dead donors. MATERIAL AND METHODS We retrospectively reviewed the records of 43 recipients of orthotopic liver transplantation from May 2009 to June 2012. Six recipients received liver grafts from ECMO-maintained donors designated as the ECMO group (n=6). The remaining patients were assigned to the non-ECMO group (n=37). Complication and mortality rates and liver function test results on postoperative days 1, 3, 5, 7, and 14 were compared between the 2 groups. RESULTS Serum glutamate oxaloacetate transaminase and serum glutamate pyruvate transaminase levels were significantly elevated on postoperative Day 1 in the ECMO group. There were no significant differences in the complication and overall survival rates between the 2 groups (P=0.411). CONCLUSIONS Although serum transaminases markedly elevated on postoperative Day 1, ECMO successfully preserved potential liver grafts in hemodynamically unstable brain-dead donors.

The modified Sugiura procedure as bridge surgery for liver transplantation: a case report

IntroductionEsophagogastric varices bleeding is a common complication due to portal hypertension in patients with liver cirrhosis. With the advancement of nonoperative management including vasoactive agents, endoscopic hemostasis or transjugular intrahepatic portosystemic shunt, surgical management has played a lesser role in recent decades. The present report describes a patient with hepatitis B (HBV)-related liver cirrhosis and portal vein thrombosis with recurrent esophagogastric varices bleeding despite the use of medical and endoscopic therapy. The modified Sugiura procedure was performed as an alternative bridge surgery for liver transplantation in order not to change the anatomic structure of the great vessels and to avoid hepatic encephalopathy related to shunting procedures like the transjugular intrahepatic portosystemic shunt.Case presentationA 56-year-old Chinese man with a history of portal hypertension due to HBV-related liver cirrhosis and known former recurrent esophageal varices bleeding status post Sengstaken-Blakemore tube tamponade was referred to our hospital for liver transplantation evaluation because of persistent esophagogastric varices bleeding with hypovolemic shock, even after medical and endoscopic therapies in a local hospital. As a result, liver cirrhosis with Child-Pugh class B function was diagnosed. Despite the use of vasoactive agents, and endoscopic hemostasis management, esophagogastric varices bleeding still occurred episodically with hypovolemic shock, which could not be reversed by blood transfusion or Sengstaken-Blakemore tube tamponade. The modified Sugiura procedure, as an alternative bridge therapy for patients who are candidates for liver transplantation, was performed, despite the fact that his liver transplantation was not yet completed. He then received a living donor liver transplantation with the right lobe of liver from his daughter. The postoperative course was uneventful, and he was discharged two weeks later. He had no evidence of recurrent esophagogastric varices bleeding during the six-month follow-up.ConclusionsThe treatment experience of this case gave us not only the idea but also the practical way of applying the modified Sugiura operation as a bridge and rescue therapy without alteration of the vascular anatomy and hemodynamic stability for patients who have experienced refractory esophagogastric varices bleeding, despite the use of medication and endoscopic treatment, and are candidates for receiving a liver transplantation.

A successful child-to-adult deceased donor liver transplantation: a case report and literature review.

BACKGROUND Size mismatch, which might result in small-for-size syndrome, is still a major limitation of liver transplantation. Prior data has suggested that a graft-to-recipient weight ratio <0.8% was a risk factor for developing small-for-size syndrome. CASE REPORT We report the case of a 60-year-old woman who received a whole liver graft, with an estimated graft-to-recipient weight ratio of 0.46%, from a 10-year-old child donor weighing 12.8 kg pre-operatively. Delicate graft inflow modulation was performed according to the intra-operative hemodynamic changes, including portal vein flow, hepatic artery flow, portal vein pressure, and hepatic venous pressure gradient, to avoid small-for-size syndrome. CONCLUSIONS The post-transplant course was uneventful and satisfactory. To the best of our knowledge, this is the first reported case of a successful adult deceased donor liver transplantation using a whole liver graft from a brain-dead pediatric donor.

Preliminary Report of One-port Laparoscopy-assisted Extracorporeal Appendectomy in Adult Appendicitis

In our pediatric surgery department, one-port laparoscopy-assisted appendectomy (one-port LAA) is currently a routine procedure for the treatment of acute appendicitis. The benefits of one-port LAA in pediatric surgery have been reported in the literature: it is safe, effective, fast, has a low complication rate, and provides excellent cosmetic results. The feasibility of this surgery in adolescents has already been proved in clinical practice. Only two reports(superscript 1, 2) of this surgery in adults have been published previously. The present study attempts to apply this technique in adult patients. This surgery was successfully performed on 12 patients with no postoperative complications. Only in one patient, the surgery was converted to a three-port laparoscopic appendectomy because of difficulty experienced in removing the appendix through one port. The benefits of the one-port LAA in adults are less postoperative pain, lower cost, and excellent cosmetic results. One-port LAA has proved to be an appropriate alternative procedure to other laparoscopic appendectomy techniques for the management of uncomplicated appendicitis in selected adult patients in our clinical practice.

Long-term outcomes in elderly patients with resectable large hepatocellular carcinoma undergoing hepatectomy

BACKGROUND In contrast to the feasibility of hepatectomy for resectable large hepatocellular carcinoma (HCC, >5 cm) in the younger patients, the concerns of benefits for the elderly patients remain in practice. This study aimed to evaluate the long-term outcomes and safety after hepatectomy in elderly patients with resectable large HCC compared with younger patients. METHODS Between 2003 and 2014, a total of 2211 HCC patients were reviewed using a prospective database and 257 patients with resectable large HCC undergoing hepatectomy were included: 79 elderly patients with age ≥70 years and 178 younger patients with age <70 years. The last follow-up was assessed in December 2017. The complications, long-term outcomes and risk factors of disease-free and overall survival were analysed. RESULTS The 1-, 3-, 5- and 7-year overall survival rates in the elderly and younger groups were 76%, 55%, 48%, and 42% and 79%, 57%, 51%, and 49%, respectively (P = 0.319). The 1-, 3-, 5-, and 7-year disease-free survival rates in the elderly and younger groups were 60%, 40%, 38%, and 27% and 54%, 36%, 32%, and 32%, respectively (P = 0.633). The analysis of post-operative outcomes of interest, including hospital stay and hospital death and hepatectomy-related complications in both groups revealed no significant difference. Serum albumin and AJCC TNM stage were independent risk factors for survival. Serum alpha-fetoprotein, tumour number and AJCC TNM stage predicted HCC recurrence. CONCLUSIONS Our results suggested that hepatectomy can achieve comparable long-term outcomes in the selected younger and elderly patients with resectable large HCC.