Kang-Hoe Lee

Long term outcome and prognostic factors for large hepatocellular carcinoma (10 cm or more) after surgical resection.

BackgroundSurgical resection is the standard treatment for hepatocellular carcinoma (HCC). However, the role of surgery in treatment of large tumors (10 cm or more) is controversial. We have analyzed, in a single centre, the long-term outcome associated with surgical resection in patients with such large tumors.MethodsWe retrospectively investigated 166 patients who had undergone surgical resection between July 1995 and December 2006 because of large (10 cm or more) HCC. Survival analysis was done using the Kaplan-Meier method. Prognostic factors were evaluated using univariate and multivariate analyses.ResultsOf the 166 patients evaluated, 80% were associated with viral hepatitis and 48.2% had cirrhosis. The majority of patients underwent a major hepatectomy (48.2% had four or more segments resected and 9% had additional organ resection). The postoperative mortality was 3%. The median survival in our study was 20 months, with an actuarial 5-year and 10-year overall survival of 28.6% and 25.6%, respectively. Of these patients, 60% had additional treatment in the form of transarterial chemoembolization, radiofrequency ablation or both. On multivariate analysis, vascular invasion (P < 0.001), cirrhosis (P = 0.028), and satellite lesions/multicentricity (P = 0.006) were significant prognostic factors influencing survival. The patients who had none of these three risk factors had 5-year and 10-year overall survivals of 57.7% each, compared with 22.5% and 19.3%, respectively, for those with at least one risk factor (P < 0.001).ConclusionsSurgical resection for those with large HCC can be safely performed with a reasonable long-term survival. For tumors with poor prognostic factors, there is a pressing need for effective adjuvant therapy.

Outcome from molecular adsorbent recycling system (MARS) liver dialysis following drug-induced liver failure.

Abstract: Rationale: Fulminant liver failure from drug ingestion is associated with a high mortality, and the introduction of liver transplantation has improved the mortality significantly if done in a timely fashion. Recently, molecular adsorbent recycling system (MARS™) liver dialysis has been introduced as a support for liver failure with varying results. We review our experience with drug‐induced liver failure and the impact of MARS™ liver dialysis on the outcome, in a setting where cadaveric liver transplantation is rarely available.

MARS®: a futile tool in centres without active liver transplant support

Background and aim: Studies on Molecular Adsorbent Recycling Systems (MARS®) showed inconclusive survival benefits.

Liver transplantation in hepatocellular carcinoma

The initial enthusiasm for orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) soon vanished as early recurrences appeared [3, 5, 6]. OLT in HCC remains a controversial issue. We evaluated the efficacy of preoperative studies to select No-Mo patients and determined whether pT stage and histopathological grade (G) have a prognostic significance. A group of 25 patients, all previously thoroughly studied to rule out extrahepatic disease, underwent OLT for HCC. All patients were pNo after pathological study and none of the six patients who died in the postoperative period showed extrahepatic dissemination at necropsy (pMo). The recurrence rate was 43%. The 2 and 5 years actuarial survival was 62% and 43% respectively. The pT and G were not prognostic factors for long-term survival. We think that HCC is still a good indication for OLT because almost 50% of patients have good survival prospects.

Ten years of experience of liver transplantation in Singapore

Four liver transplants (all cadaveric) were done in three adult and one pediatric patient. Indications were chronic autoimmune hepatitis, primary biliary cirrhosis, fulminant hepatitis, and biliary atresia. Only one of the four patients achieved long-term survival. The other three died of bleeding, posttransplant lymphoproliferative disease, and rejection at 1 day, 21⁄2 months and 27 months posttransplant, respectively.

Adrenal metastasis from intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma is an uncommon disease with surgical resection as the only potentially curative modality of treatment. The pattern of failure in such tumours is recurrence in the remnant liver or metastases to lymph nodes, peritoneum and bones (1, 2). We report a case of intrahepatic cholangiocarcinoma with adrenal metastasis that was treated with simultaneous hepatic and adrenal resection. Adrenal metastasis from intrahepatic cholangiocarcinoma has not yet been reported in the published literature. A 68-year-old Indonesian gentleman was diagnosed with synchronous adrenal nodule with a large tumour in the left lateral segment of the liver. Left lateral segmentectomy with left adrenalectomy was performed on 6 November 2004. The histopathology report of the resected specimen revealed a tumour (9.0 7.0 6.8 cm size) in the liver with features of moderately differentiated intrahepatic cholangiocarcinoma. The nodule in the left adrenal gland was 1 cm in size and had histological features of metastatic cholangiocarcinoma (Fig. 1). Following postoperative recovery, he was treated with four cycles of Gemcitabine and Cisplatin. In April 2006, he had recurrence of the disease in bone (right ilium), both lungs, and in the left adrenal bed. He received palliative radiotherapy for the painful lesion in the right ilium and was started on palliative chemotherapy with Gemcitabine and Xeloda. Two years following adrenalectomy, he is alive with recurrent disease. The options of treatment of a metastatic cholangiocarcinoma are limited. Such patients are generally treated with palliative chemotherapy or supportive care. Lessons from other solid malignancies like colorectal cancers and sarcomas have emphasized the value of surgical resection of metastatic disease when feasible (3, 4). As our patient had a solitary adrenal metastasis, he was treated with simultaneous liver and adrenal resection. This is the first report of adrenal metastasis from intrahepatic cholangiocarcinoma. The patient developed recurrence in spite of an aggressive treatment with surgical resection and postoperative chemotherapy. The therapeutic options need to be further explored in order to provide hope to patients with metastatic cholangiocarcinoma.

Modified rendezvous technique in management of biliary leak in right lobe live donor liver transplant recipients.

Biliary complication is the Achilles heel for live donor liver transplant. Bile leak is particularly difficult to manage as the anastomotic site was often angled acutely. We described a patient with bile leak managed by a modified rendezvous technique whereby the endoscopist and radiologist work simultaneously under fluoroscopy. Unlike the traditionally described rendezvous technique where the grasping of guidewire occurred at the duodenum, the grasping of guidewire occurred at the biloma in this modified technique. Insertion of biliary stent could then be performed over the guidewire through the duodenoscope. The bile leak resolved after keeping the biliary stents in situ for 12 months.

Spontaneous bacterial peritonitis from Salmonella: an unusual bacterium with unusual presentation

Spontaneous bacterial peritonitis (SBP) is a common cause of morbidity and mortality in patients with advanced cirrhosis and portal hypertension. While gram-negative rods and Enterococcus species are the common offending organisms, Salmonella has also been recognized as a rare and atypical offending organism. Atypical features of Salmonella SBP include both its occurrence in cirrhotic patients with immunosuppressive state and its lack of typical neutroascitic response. Diagnosis is often delayed as it requires confirmation from ascitic fluid culture. We report a case of Salmonella SBP occurring in a patient with decompensated cryptogenic cirrhosis with concurrent low-grade non-Hodgkin lymphoma and prior treatment with rituximab. Physicians should be aware of the atypical presentation, especially in cirrhotic patients who are immunosuppressed.