Jennifer Berumen

Impact of Pretransplant Bridging Locoregional Therapy for Patients with Hepatocellular Carcinoma Within Milan Criteria Undergoing Liver Transplantation: Analysis of 3601 Patients from the US Multicenter HCC Transplant Consortium

Objective: To evaluate the effect of pretransplant bridging locoregional therapy (LRT) on hepatocellular carcinoma (HCC) recurrence and survival after liver transplantation (LT) in patients meeting Milan criteria (MC). Summary Background Data: Pre-LT LRT mitigates tumor progression and waitlist dropout in HCC patients within MC, but data on its impact on post-LT recurrence and survival remain limited. Methods: Recurrence-free survival and post-LT recurrence were compared among 3601 MC patients with and without bridging LRT utilizing competing risk Cox regression in consecutive patients from 20 US centers (2002–2013). Results: Compared with 747 LT recipients not receiving LRT, 2854 receiving LRT had similar 1, 3, and 5-year recurrence-free survival (89%, 77%, 68% vs 85%, 75%, 68%; P = 0.490) and 5-year post-LT recurrence (11.2% vs 10.1%; P = 0.474). Increasing LRT number [3 LRTs: hazard ratio (HR) 2.1, P < 0.001; 4+ LRTs: HR 2.5, P < 0.001), and unfavorable waitlist alphafetoprotein trend significantly predicted post-LT recurrence, whereas LRT modality did not. Treated patients achieving complete pathologic response (cPR) had superior 5-year RFS (72%) and lower post-LT recurrence (HR 0.52, P < 0.001) compared with both untreated patients (69%; P = 0.010; HR 1.0) and treated patients not achieving cPR (67%; P = 0.010; HR 1.31, P = 0.039), who demonstrated increased recurrence compared with untreated patients in multivariate analysis controlling for pretransplant and pathologic factors (HR 1.32, P = 0.044). Conclusions: Bridging LRT in HCC patients within MC does not improve post-LT survival or HCC recurrence in the majority of patients who fail to achieve cPR. The need for increasing LRT treatments and lack of alphafetoprotein response to LRT independently predict post-LT recurrence, serving as a surrogate for underlying tumor biology which can be utilized for prioritization of HCC LT candidates.

Hepatitis B and Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death worldwide, and its incidence has been increasing in the last decade largely in parallel to the incidence and duration of exposure to hepatitis B and C. The widespread implementation of hepatitis B vaccine, hepatitis B antivirals, and the introduction of direct antiviral therapies for hepatitis C virus may have a substantial impact in reducing the incidence of HCC. This report reviews the risk factors and underlying mechanisms associated with the development of HCC in hepatitis B, along with advances in the diagnosis, imaging, and management of HCC.

Vascular Reconstruction in Hepatic Malignancy

With surgery for hepatic malignancy, there are poor options for chemotherapy; many patients are deemed unresectable because of vascular involvement or location of tumors. Over the past few decades, advances in surgical technique have allowed resection of these tumors with vascular reconstruction to achieve negative margins and improve chances for survival. This article reviews those reconstruction techniques and outcomes in detail, including in situ perfusion and ex vivo liver surgery, and provides a discussion of implications and operative planning for patients with hepatic malignancy in order to provide surgeons with better understanding of these complicated operations.

Kidney clamp, perfuse, re-implant: a useful technique for graft salvage after vascular complications during kidney transplantation

Although intra‐operative vascular complications during renal transplantation are rare, injuries associated with prolonged ischemia may lead to graft threatening early and late complications. This series describes a novel technique for intra‐operative repair of vascular complications in five patients over a three‐yr period. The method consists of rapid graft nephrectomy and re‐preservation of the graft with cold University of Wisconsin solution, which allows for controlled/precise back table repair of the vascular injury without incurring prolonged warm ischemia time. In three cases, the donor renal vein (2) and donor renal artery (1) were damaged and required back table reconstruction. In two cases, the recipient iliac artery needed reconstruction. Three of the five cases used deceased donor iliac vessels from another donor for reconstruction. Two patients required postoperative dialysis for delayed graft function for three to nine d (average six d) and two patients had slow graft function. All grafts were functioning at 17 months (mean) after transplant, with a median serum of 1.61 mg/dL (0.74–3.69). This series demonstrates the effectiveness of kidney clamp, perfuse, resuscitate as an effective intra‐operative technique to salvage grafts after vascular injury. Although the grafts may suffer from delayed or slow graft function, excellent long‐term function is attainable.

Complications Following Liver Transplantation for Progressive Familial Intrahepatic Cholestasis

A 9-year-old girl with genetically confirmed progressive familial intrahepatic cholestasis Type 1 (PFIC 1) was evaluated for neonatal jaundice. Due to persistent jaundice with pruritus, she underwent biliary diversion with cholecysto-jejunostomy at 8 months of age. Although postoperatively the pruritus initially resolved, she had other manifestations of PFIC, including persistent diarrhea. Over several years, the jaundice and pruritus returned, becoming progressively more severe. Relief from pruritus was not obtained despite the prescription of multiple medications, including diphenhydramine, rifampicin, and cholestyramine, resulting in a decrease in her quality of life. Due to continuing severe, intolerable pruritus, she received a reduced size (left lobe) liver transplant with a choledocho– choledocho biliary anastomosis at age 7 years. Shortly after transplantation, liver function improved and pruritus resolved. Nevertheless, her chronic diarrhea worsened. At age 9, she developed cholangitis that was treated successfully with antibiotics. Magnetic resonance cholangiopancreatography (MRCP) revealed a stricture at her native common bile duct at the level of the ampulla accompanied by delayed bile excretion (Fig. 1). At endoscopic retrograde cholangiopancreatography (ERCP), these findings were confirmed (Fig. 2), and the stricture was dilated and stented. Although she improved after the procedure, she developed two more episodes of cholangitis over the ensuing 8 months requiring repeated ERCP and dilation. During her last episode of cholangitis, liver biopsy revealed rejection and hepatic steatosis (Fig. 3). After treatment for the cholangitis with antibiotics and the rejection with pulse steroids, she underwent Roux-en-Y choledocho-jejunostomy and liver biopsy shortly after at age 9. Since her native common bile duct was strictured at the ampulla, whereas the donor’s common bile duct was patent, but dilated, the jejunum was anastomosed to the healthy donor bile duct. Postoperatively, although some liver-related biochemical tests were abnormal, a biopsy was reported as showing up to 50 % steatosis (Fig. 4) with no evidence of rejection. At present, biliary obstruction is resolved and rejection is treated adequately, though steatosis persists. Persistent severe diarrhea is being treated with rifaximin and occasional loperamide. She has had no recurrence of pruritus.

The effects of Share 35 on the cost of liver transplantation

On June 18, 2013, the United Network for Organ Sharing (UNOS) instituted a change in the liver transplant allocation policy known as “Share 35.” The goal was to decrease waitlist mortality by increasing regional sharing of livers for patients with a model for end‐stage liver disease (MELD) score of 35 or above. Several studies have shown Share 35 successful in reducing waitlist mortality, particularly in patients with high MELD. However, the MELD score at transplant has increased, resulting in sicker patients, more complications, and longer hospital stays. Our study aimed to explore factors, along with Share 35, that may affect the cost of liver transplantation. Our results show Share 35 has come with significantly increased cost to transplant centers across the nation, particularly in regions 2, 5, 10, and 11. Region 5 was the only region with a median MELD above 35 at transplant, and cost was significantly higher than other regions. Several other recipient factors had changes with Share 35 that may significantly affect the cost of liver transplant. While access to transplantation for the sickest patients has improved, it has come at a cost and regional disparities remain. Financial implications with proposed allocation system changes must be considered.

The Use of Solicited Publishing by Academic Surgeons

Background: Few details are known about open‐access surgery journals that solicit manuscripts via E‐mail. The objectives of this cross‐sectional study are to compare solicitant surgery journals with established journals and to characterize the academic credentials and reasons for publication of their authorship. Methods: We identified publishers who contacted the senior author and compared their surgery journals with 10 top‐tier surgical journals and open‐access medical journals. We assessed the senior authorship of articles published January 2017–March 2017 and utilized a blinded survey to determine motivations for publication. Results: Throughout a 6‐week period, 110 E‐mails were received from 29 publishers distributing 113 surgery journals. Compared with established journals, these journals offered lesser publication fees, but also had lesser PubMed indexing rates and impact factors (all P < .002). Professors, division chiefs, and department chairs were the senior authors of nearly half of US‐published papers and spent ≈

Liver transplantation for hepatocellular carcinoma

83,000 to publish 117 articles in journals with a median impact factor of 0.12 and a 33% PubMed indexing rate. Survey responses revealed a dichotomy as 43% and 57% of authors published in these journals with and without knowledge of their solicitant nature, respectively. The most commonly reported reasons for submission included waived publication fees (50%), invitation (38%), and difficulty publishing elsewhere (12%). Conclusion: Despite their sparse PubMed indexing and low impact factors, many senior academic faculty publish in solicitant surgery journals. This study highlights the importance for the academic surgical community to be cognizant of the quality of a journal when reviewing the literature for research and evidence‐based practice.

Combined liver transplant and pancreaticoduodenectomy for inflammatory hilar myofibroblastic tumor: Case report and review of the literature

Over the last several years, liver transplantation has evolved to become a widely used treatment for hepatocellular carcinoma (HCC). The criteria used were developed in order to have acceptable outcomes for transplant with survival similar to other indications for transplant. These criteria are discussed in detail along with alternate options, including surgical resection and downstaging of HCC in cirrhotics. Technical considerations of liver transplantation must be considered, and living donor liver transplant is a possibility for treatment.

Liver Cancer Necessitating Ex Vivo Resection and Reconstruction

IMT, previously known as IPT, is a relatively rare tumor that was originally described in the lungs, but case reports have reported the tumor in almost every organ system. Surgical resection is typically the mainstay of therapy; however, tumors have also been shown to respond to chemotherapy or anti‐inflammatory therapy and some have spontaneously regressed. We present a literature review and case report representing the first documentation to date of liver transplant combined with PD for surgical resection of a myofibroblastic tumor non‐responsive to medical therapy.