Jeff W.C. Dai

Long‐term outcomes of entecavir monotherapy for chronic hepatitis B after liver transplantation: Results up to 8 years

Long‐term antiviral prophylaxis is required to prevent hepatitis B recurrence for patients with chronic hepatitis B after liver transplantation. We determined the long‐term outcome of 265 consecutive chronic hepatitis B liver transplant recipients treated with entecavir monotherapy without hepatitis B immune globulin. Viral serology, viral load, and liver biochemistry were performed at regular intervals during follow‐up. The median duration of follow‐up was 59 months. The cumulative rates of hepatitis B surface antigen (HBsAg) seroclearance were 90% and 95% at 1 and 5 years, respectively. At 1, 3, 5, and 8 years, 85%, 88%, 87.0%, and 92% were negative for HBsAg, respectively, and 95%, 99%, 100%, and 100% had undetectable hepatitis B virus (HBV) DNA, respectively. Fourteen patients remained persistently positive for HBsAg, all of whom had undetectable HBV DNA. There was no significant difference in liver stiffness for those who remained HBsAg‐positive compared to those who achieved HBsAg seroclearance (5.5 versus 5.2 kPa, respectively; P = 0.52). The overall 9‐year survival was 85%. There were 37 deaths during the follow‐up period, of which none were due to hepatitis B recurrence. Conclusion: Long‐term entecavir monotherapy is highly effective at preventing HBV reactivation after liver transplantation for chronic hepatitis B, with a durable HBsAg seroclearance rate of 92%, an undetectable HBV DNA rate of 100% at 8 years, and excellent long‐term survival of 85% at 9 years. (Hepatology 2017;66:1036‐1044).

Impact of split completeness on future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma: Complete-ALPPS versus partial-ALPPS

BACKGROUND Recent evidence suggested that associating liver partition and portal vein ligation for staged hepatectomy with a partial split could effectively induce the same degree of future liver remnant hypertrophy as a complete split in non‐cirrhotic and non‐cholestatic livers with better postoperative safety profiles. Our aim was to evaluate if the same phenomenon could be applied to hepatitis‐related chronic liver diseases. METHODS In the study, 25 patients who underwent associating liver partition and portal vein ligation for staged hepatectomy from October 2013 to January 2016 for hepatocellular carcinoma were analyzed. Partial‐associating liver partition and portal vein ligation for staged hepatectomy (n = 12) was defined as 50–80% of the transection surface split and complete‐associating liver partition and portal vein ligation for staged hepatectomy (n = 13) was split down to inferior vena cava. Perioperative outcomes stratified by split completeness were evaluated. RESULTS There was no significant difference in operating times and blood loss for stage I and II operations between complete‐associating liver partition and portal vein ligation for staged hepatectomy and partial‐associating liver partition and portal vein ligation for staged hepatectomy. All patients underwent stage II operation without any inter‐stage complications. Complete split induced greater future liver remnant hypertrophy than partial split (hypertrophy rate: 31.2 vs 17.5 mL/day, P = .022) with more pronounced effect in chronic hepatitis (P = .007) than cirrhosis (P = .283). Complete‐associating liver partition and portal vein ligation for staged hepatectomy was more likely to attain a future liver remnant/estimated standard liver volume ratio >35% within 10 days (76.9% vs 33.3%, P = .024) and proceed to stage II within 14 days after stage I (100% vs 58.4%, P = .009). The overall postoperative morbidity (≥grade 3a) after stage II was 16% (complete versus partial split: 7.7% vs 25%, P = .238) and hospital mortality after stage II was 8% (complete versus partial split: 0% vs 16.7%, P = .125). CONCLUSION Complete‐associating liver partition and portal vein ligation for staged hepatectomy induced more rapid future liver remnant hypertrophy than partial‐associating liver partition and portal vein ligation for staged hepatectomy without increased perioperative risk in chronic liver diseases.

Long Term Survival Analysis of Hepatectomy for Neuroendocrine Tumour Liver Metastases

Background. Liver is the commonest site for metastasis in patients with neuroendocrine tumour (NET). A vast majority of treatment strategies including liver directed nonsurgical therapy, liver directed surgical therapy, and nonliver directed therapy have been proposed. In this study we aim to investigate the outcome of liver resection in neuroendocrine tumour liver metastases (NELM). Method. 293 patients had hepatectomy for liver metastasis in our hospital between June 1996 and December 2010. Twelve patients were diagnosed to have NET in their final pathology and their data were reviewed. Results. The median ages of the patients were 48.5 years (range 20–71 years). Eight of the patients received major hepatectomy. Four patients received minor hepatectomy. The median operation time was 418 minutes (range 195–660 minutes). The median tumor size was 8.75 cm (range 0.9–21 cm). There was no hospital mortality. The overall one-year and three-year survivals were 91.7% and 55.6%. The one-year and three-year disease-free survivals were 33.3% and 16.7%. Conclusion. Hepatectomy is an effective and safe treatment for NELM. Reasonable outcome on long term overall survival and disease-free survival can be achieved in this group of patients with a low morbidity rate.

Validated Nomogram for Prediction of Recurrence in HCC within Milan Criteria

Objective We sought to develop a nomogram for the prediction of tumor recurrence after resection of within Milan hepatocellular carcinoma (HCC) Methods Consecutive HCC patients admitted for hepatectomy from 1994 to 2014 were recruited. Patients were excluded if they had recurrent HCC or tumor beyond Milan criteria. Patients were randomized and assigned to derivation and validation set in to 1:1 ratio. Independent factors for disease free survival were identified using cox-regression model. A nomogram was derived and validated with the receiver-operating characteristic (ROC) and calibration curve. Results There were 617 eligible patients included for analysis, 481 were male and the median age was 59 year-old. Majority of the patients were Hepatitis B carrier (87.8%). The median follow-up duration was 68.7 months. The 5-year overall survival for the whole population was 73.3% and HCC recurrence was detected in 55% of the patients. Figure. No caption available. Figure. No caption available. In the derivation set, a nomogram was constructed based on the seven independent factors for disease free survival, namely age, alpha fetal protein (AFP), preoperative prothrombin time, magnitude of hepatectomy, postoperative complication, number of tumor nodule and presence of microvascular invasion. A good discrimination ability was observed in both derivation set and validation set (c-stat 0.672 and 0.665 respectively). Calibration plot yielded good agreement between predicted and observed outcomes using the derived nomogram Figure. No caption available. Conclusion A validated nomogram predicts the efficacy of liver resection which help to tailor-make postoperative surveillance and plan for salvage or adjuvant treatment.

What Can We Learn from Living Donor Evaluation? A Higher Prevalence of Metabolic Disease and Less Technical Contraindication

Session SF231: Transplantation and Tissue Engineering II. Track: General Surgery (GEN), Basic / Translational Research (BTR)

The role of radiofrequency ablation to liver transection surface in patients with close tumor margin of HCC during hepatectomy—a case matched study

BACKGROUND To review the outcome of using radiofrequency ablation (RFA) for patients with close resection margin during hepatectomy. METHODS From Oct 2004 to Sept 2013, 862 patients received hepatectomy for hepatocellular carcinoma (HCC) in the Department of Surgery, Queen Mary Hospital in Hong Kong. Fourteen patients received additional RFA because of close resection margin (<1 cm) during the operation for HCC. The result of 28 patients with close liver resection margin was selected for comparison. The two groups of patients were matched in terms of tumor size, tumor number, stage of disease and magnitude of resection. RESULTS In the RFA group (n=14), the median age of the patients was 58.5 (range, 25-78 years). The median tumor size was 2.25 cm (range, 1.2-12 cm). In the resection alone group (n=28), the median age for the patients was 61 (range, 36-79 years). The median tumor size was 2.7 cm (range, 1-11 cm). There was no difference in terms of liver function assessment between the two groups. There was no RFA related complication recorded during the study period. There was no hospital mortality in both groups. The 1- and 3-year disease free survival was 38.3% and 25.5% respectively in the RFA group vs. 57.4% and 39.3% respectively in the liver resection alone group (P=0.563). The 1- and 3-year overall survival was 81.5% and 69.8% respectively in the RFA group vs .88.4% and 59.9% respectively in the liver resection alone group (P=0.83). CONCLUSIONS RFA to hepatectomy resection surface in patients with close margin is a safe treatment option but its effectiveness on prevention of local recurrence has yet to be confirmed.