J. Kelly Wright

Positron Emission Tomography to Stage Suspected Metastatic Colorectal Carcinoma to the Liver

BACKGROUND Accurate detection of recurrent colorectal carcinoma remains a clinical challenge. Positron emission tomography (PET) using 18F-fluorodeoxyglucose (18FDG) is an imaging technique that allows direct evaluation of cellular metabolism. 18F-fluorodeoxyglucose PET was compared to computed tomography (CT) and CT portography for staging metastatic colorectal carcinoma. PATIENTS AND METHODS Twenty-four patients previously treated for colorectal carcinoma who had suspected recurrence to the liver underwent an 18FDG PET scan of the entire body. All patients had either a CT scan of the abdomen (n = 17), a CT portogram (n = 18), or both (n = 11). The final diagnosis was obtained by tissue pathology in 19 patients and clinical follow-up in 5 patients. RESULTS A total of 60 suspicious lesions were identified. Of the 55 intrahepatic lesions, 39 were malignant and 16 were benign. Of the 5 extra-hepatic lesions, 4 were malignant. The 18FDG PET imaging had a higher accuracy (93%) than CT and CT portography (both 76%) in detecting metastatic disease to the liver, and detected unsuspected extrahepatic recurrence in 4 patients. Although the sensitivity of 18FDG PET (90%) was slightly lower than that of CT portography (97%), the specificity was much higher (100% versus 9%), including postsurgical sites. 18FDG PET altered surgical plans in 6 (25%) of 24 patients. CONCLUSIONS 18FDG PET is extremely useful in staging patients with suspected metastatic colorectal carcinoma to the liver.

Effective treatment of biliary cystadenoma.

Objective:Evaluate experience over 15 years with treatment of this lesion. Summary Background Data:Biliary cystadenoma, a benign hepatic tumor arising from Von Meyenberg complexes, usually present as septated intrahepatic cystic lesions. Methods:Data were collected concurrently and retrospectively on patients identified from hospital medical records reviewed for pertinent International Classification of Diseases, Ninth Revision, Clinical Modification and CPT codes, pathology logs, and from operative case logs. Pathology specimens were rereviewed to confirm the diagnosis of biliary cystadenoma or biliary cystadenocarcinoma by 2 GI pathologists. Results:From October 1989 to April 2004 at our institution, 19 (18F:1M) patients had pathologically confirmed biliary cystadenomas, including one with a biliary cystadenocarcinoma. The mean age was 48 ± 15 years at initial evaluation. Complaints included abdominal pain in 74%, abdominal distension in 26%, and nausea/vomiting in 11%. Only 1 patient presented with an incidental finding. Symptoms had been present for 3 ± 5 years, with 1 to 4 different surgeons and many other physicians involved in the diagnosis or treatment prior to definitive ablation. Eight patients had undergone 20 previous treatments, including multiple percutaneous aspirations in 4 and 11 operative procedures. CT or US was diagnostic in 95%, with internal septations present in the hepatic cysts. Definitive operative intervention consisted of hepatic resection in 12 patients, enucleation in 6 patients, and fenestration and complete fulguration in 1 patient. There were no perioperative deaths. No recurrences were observed after definitive therapy, with follow-up of 4 ± 4 years. Conclusions:Biliary cystadenoma must be recognized and treated differently than most hepatic cysts. There remains a need for education about the imaging findings for biliary cystadenoma to reduce the demonstrated delay in appropriate treatment. Traditional treatment of simple cysts such as aspiration, drainage, and marsupialization results in near universal recurrence and occasional malignant degeneration. This experience demonstrates effective options include total ablation by standard hepatic resection and cyst enucleation.

Increased diacylglycerols characterize hepatic lipid changes in progression of human nonalcoholic fatty liver disease; comparison to a murine model.

Background and Aims The spectrum of nonalcoholic fatty liver disease (NAFLD) includes steatosis, nonalcoholic steatohepatitis (NASH), and progression to cirrhosis. While differences in liver lipids between disease states have been reported, precise composition of phospholipids and diacylglycerols (DAG) at a lipid species level has not been previously described. The goal of this study was to characterize changes in lipid species through progression of human NAFLD using advanced lipidomic technology and compare this with a murine model of early and advanced NAFLD. Methods Utilizing mass spectrometry lipidomics, over 250 phospholipid and diacylglycerol species (DAGs) were identified in normal and diseased human and murine liver extracts. Results Significant differences between phospholipid composition of normal and diseased livers were demonstrated, notably among DAG species, consistent with previous reports that DAG transferases are involved in the progression of NAFLD and liver fibrosis. In addition, a novel phospholipid species (ether linked phosphatidylinositol) was identified in human cirrhotic liver extracts. Conclusions Using parallel lipidomics analysis of murine and human liver tissues it was determined that mice maintained on a high-fat diet provide a reproducible model of NAFLD in regards to specificity of lipid species in the liver. These studies demonstrated that novel lipid species may serve as markers of advanced liver disease and importantly, marked increases in DAG species are a hallmark of NAFLD. Elevated DAGs may contribute to altered triglyceride, phosphatidylcholine (PC), and phosphatidylethanolamine (PE) levels characteristic of the disease and specific DAG species might be important lipid signaling molecules in the progression of NAFLD.

Transcatheter arterial chemoembolization as primary treatment for hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma (HCC) in Western populations has historically been associated with poor survival. METHODS In this study, we conducted a 7-year retrospective analysis of patients with HCC undergoing transcatheter arterial chemoembolization (TACE) at our institution and examined demographics, outcomes, and complications. RESULTS During the period of study, 39 patients (25 male [64%], mean age 58 [range 17 to 86]) underwent a total of 78 chemoembolization treatments. During the same time period, an additional 31 patients received supportive care only. The majority of patients had late stage disease (American Joint Committee on Cancer stage III, IVa, or IVb) with no statistical difference noted between the two groups (P = 0.2). However, patients receiving supportive care only had significantly worse hepatic dysfunction by Childs classification (P = 0.005). Twenty-nine patients (74%) had documented cirrhosis, with hepatitis C being the most common cause in 11 of 29 (38%). In patients undergoing TACE, overall actuarial survival was 35%, 20%, and 11% at 1, 2, and 3 years with a median survival of 9.2 months, significantly improved over the group receiving supportive care only (P < 0.0001). Median survival for the group receiving supportive care was less than 3 months. Neither age nor stage had a significant impact on survival. The most common complications of TACE included transient nausea, abdominal pain, vomiting, and fever. CONCLUSIONS TACE is a safe and effective therapeutic option for selected patients with HCC not amenable to surgical intervention.

Continuous versus interrupted suture for end-to-end biliary anastomosis during liver transplantation gives equal results†

Biliary complications following orthotopic liver transplantation have been reported in 10% to 30% of patients. Most surgeons perform an end‐to‐end choledochocholedochostomy with interrupted sutures for biliary reconstruction. The goal of this study was to compare biliary complications between interrupted suture (IS) and continuous suture (CS) techniques during liver transplantation in which an end‐to‐end choledochocholedochostomy over an internal biliary stent was performed. A retrospective cohort study of 100 consecutive liver transplants occurring between December 2003 and July 2005 was conducted. An end‐to‐end choledochocholedochostomy over an internal biliary stent was performed during liver transplantation. Data were analyzed using Kaplan‐Meier methods, t tests, and chi‐square tests of proportions. IS and CS techniques were used in 59 and 41 patients, respectively, for biliary reconstruction during liver transplantation. Mean follow‐up time for the CS group was 17 ± 8 months and 15 ± 7 months for the IS group (P = .21). The overall biliary complication rate was 15%. There was no difference in the proportion of leaks (CS = 7.3%, IS = 8.5%; P = .83) or strictures (CS = 9.8%, IS = 5.1%; P = .37) between groups. Kaplan‐Meier event rates show no difference in leaks (P = .79), strictures (P = .41), graft survival (P = .52), and patient survival (P = .32) by anastomosis type. In conclusion, there was no difference in biliary complications, graft survival, or patient survival between the 2 groups. CS and IS techniques for biliary reconstruction during liver transplantation yield comparable outcomes. Liver Transpl 13:234–238, 2007.

Survival and functional quality of life after resection for hepatic carcinoid metastasis

Retrospective studies suggest that resection improves 5-year survival for patients with hepatic carcinoid metastasis (HCM). The purpose of our study was to describe clinical outcomes following resection for HCM, including survival and longitudinal functional quality of life (QOL). We reviewed the records of patients undergoing resection for HCM from 1980 to 2001 at our institution. Outcome measures included tumor symptoms, biochemical tumor markers, functional QOL through Karnofsky functional scores, and survival. Thirteen patients underwent a total of 17 resections. Overall 5-year survival was 85%. Eleven patients were symptomatic, including eight with classic carcinoid syndrome. Nine experienced complete relief of symptoms and two had incomplete relief for 30 ± 12 months. Eight patients had elevated tumor markers, and 50% of these had postoperative normalization of all tumor markers that persisted to the close of the study. For the 10 patients with longitudinal follow-up available to 54 months, significant improvement in functional QOL was observed at all follow-up time points compared to preresection functional QOL (P< 0.05). Resection of ≥90% tumor volume was significantly associated with more favorable survival and tumor marker normalization compared to resection of <90% tumor volume P< 0.01 and P< 0.05, respectively), but trajectory of functional QOL improvement did not differ between these two groups (P= 0.24). We conclude that resection for HCM is associated with significantly improved and sustained functional QOL and prolonged survival. Resection of ≥90% tumor volume is significantly associated with extended survival and normalization of tumor markers, but is not required for symptomatic or functional QOL improvement.

Water warming garment versus forced air warming system in prevention of intraoperative hypothermia during liver transplantation: a randomized controlled trial [ISRCTN32154832].

BackgroundThe authors compared two strategies for the maintenance of intraoperative normothermia during orthotopic liver transplantation (OLT): the routine forced-air warming system and the newly developed, whole body water garment.MethodsIn this prospective, randomized and open-labelled study, 24 adult patients were enrolled in one of two intraoperative temperature management groups during OLT. The water-garment group (N = 12) received warming with a body temperature (esophageal) set point of 36.8°C. The forced air-warmer group (N = 12) received routine warming therapy using upper- and lower-body forced-air warming system. Body core temperature (primary outcome) was recorded intraoperatively and during the two hours after surgery in both groups.ResultsThe mean core temperatures during incision, one hour after incision and during the skin closing were significantly higher (p < 0.05, t test with Bonferroni corrections for the individual tests) in the water warmer group compared to the control group (36.7 ± 0.1, 36.7 ± 0.2, 36.8 ± 0.1 vs 36.1 ± 0.4, 36.1 ± 0.4, 36.07 ± 0.4°C, respectively). Moreover, significantly higher core temperatures were observed in the water warmer group than in the control group during the placement of cold liver allograft (36.75 ± 0.17 vs 36.09 ± 0.38°C, respectively) and during the allograft reperfusion period (36.3 ± 0.26 vs 35.52 ± 0.42°C, respectively). In addition, the core temperatures immediately after admission to the SICU (36.75 ± 0.13 vs 36.22 ± 0.3°C, respectively) and at one hr (36.95 ± 0.13 vs 36.46 ± 0.2°C, respectively) were significantly higher in the water warmer group, compared to the control group, whereas the core temperature did not differ significantly afte two hours in ICU in both groups.ConclusionsThe investigated water warming system results in better maintenance of intraoperative normothermia than routine air forced warming applied to upper- and lower body.

Effects of hepatitis C virus infection and its recurrence after liver transplantation on functional performance and health-related quality of life

Our aim was to examine the effects of hepatitis C virus (HCV) infection, a leading cause of end-stage liver disease, and its recurrence after liver transplantation on functional performance and health-related quality of life. Functional performance, liver function, and HCV recurrence were assessed longitudinally in 75 adult transplant recipients (28 with HCV). Quality of life was reported once after transplantation. Functional performance improved through year 2 (P < 0.001) and then declined in those with HCV, whereas the others remained stable (P = 0.05). Time had a positive effect (β = 0.22, P = 0.05) and HCV infection had a negative effect (β = —0.28, P = 0.01) on post-transplant functional performance. Educational level (β = 0.24, P < 0.05) and recent functional performance (β = 0.31, P = 0.01) had positive effects on quality of life. HCV recurrence was associated with relatively poorer pretransplant functional performance, a greater rate of improvement through month 3 (P < 0.05), and abnormal transaminase values between years 1 and 2 (P < 0.001). Rehospitalization for recurrent HCV was associated with reduced functional performance (P < 0.05). Functional performance improves with time following liver transplantation, but HCV infection exerts an opposing and comparably strong effect. Post-transplant functional performance, in turn, directly affects post-transplant quality of life. Severe, recurrent HCV illness is associated with reduced functional performance.

A clinical comparative analysis of crush/clamp, stapler, and dissecting sealer hepatic transection methods

INTRODUCTION Several methods for hepatic parenchymal division exist. The primary aim was to assess differences in postoperative bile leaks, operative blood loss, and margin status between three transection methods: crush/clamp (CC), stapler (SP), or dissecting sealer (DS). METHODS A single institution, retrospective cohort study was performed on data collected over a three-year period in patients undergoing elective liver resection using the CC, SP, or DS. Patients were excluded if multiple methods of transection were used or for intraoperative death. The association of bile leak with transection type was assessed. A logistic regression model was tested to assess if blood loss was associated with the covariates of transection method, use of portal inflow occlusion, extent of liver resection, and other concurrent major operations. RESULTS Analyses included 141 patients. The stapler method was quicker than the other methods (p=0.01). The risk of postoperative bile leak was no different between CC, SP, and DS transection methods (p=0.23). There was no difference in mean blood loss or transfusions; however, hepatectomies performed with DS were associated with an increased risk of blood loss > or = 1000 mL compared to CC (p=0.04). There were no differences in mean surgical margin between the three methods. CONCLUSION The risk of bile leaks was not different between the three methods. While mean blood loss was similar, hepatectomy performed with the DS was associated with an increased risk of having operative blood loss > or = 1000 mL compared to CC. Margins were equal by all methods. The stapler method was quicker.

Reduction in Corticosteroids Is Associated with Better Health-Related Quality of Life after Liver Transplantation

BACKGROUND Corticosteroid use during post-transplant immunosuppression contributes to documented long-term complications in liver transplant recipients. However, the effects of steroids on post-transplant physical and mental health-related quality of life (HRQOL) have not been established. We aimed to test the association between steroid-based immunosuppression and post-transplant HRQOL in liver transplant recipients. STUDY DESIGN We performed a retrospective analysis of prospective, longitudinal HRQOL measured using the Short Form 36 Health Survey physical and mental component summary scores, Beck Anxiety Inventory, and Center for Epidemiologic Studies Depression Scale. Steroid use (none, low [<10 mg/d], high [≥10 mg/d]) and temporally associated acute rejection (within previous 6 weeks, previous 7 to 12 weeks, and never or >12 weeks before HRQOL measurement) were determined at every post-transplant HRQOL data point. Linear mixed-effects models tested the effects of contemporaneous steroid use and dosing on post-transplant HRQOL. RESULTS The sample included 186 adult liver transplant recipients (mean age 54 ± 8 years, 70% male) with pre- and at least 1 post-transplant HRQOL data point. Individual follow-up post-transplant averaged 21 ± 18 months (range 1 to 74 months). After controlling for pre-transplant HRQOL, time post-transplant, pre-transplant diagnosis group, and temporally associated episodes of rejection, post-transplant high-dose steroid use (≥10 mg/d) was associated with lower physical component summary (p < 0.001) and mental component summary (p = 0.049) scores and increased Beck Anxiety Inventory (p = 0.015) scores. Low-dose steroid use (<10 mg/d) was not associated with post-transplant HRQOL in any model (all p ≥ 0.28). CONCLUSIONS High-dose steroid use for post-transplant immunosuppression in liver transplant recipients was associated with reduced physical and mental HRQOL, and increased symptoms of anxiety. There was an association between better HRQOL and steroid reduction to <10 mg/d in liver transplant recipients during a broad follow-up period.