Linda L. Wong

Long-term Follow-up Outcome of Patients Undergoing Radiofrequency Ablation for Unresectable Hepatocellular Carcinoma

The long-term outcome of radiofrequency thermal ablation (RFA) for unresectable hepatocellular carcinoma (HCC) has not been reported. This study was performed to evaluate the long-term survival of patients with unresectable HCC after RFA and to identify possible factors that might affect survival. In this prospective study, 65 patients with unresectable HCC who underwent RFA were followed. A total of 84 RFA operations were performed percutaneously (n = 49), laparoscopically (n = 20), or by open surgery (n = 15), to ablate 191 tumors. Twenty-two patients died within 16 months; otherwise, the follow-up period was at least 16 months, up to 71 months, with median 20.0 months and mean (± standard deviation) 24.8 ± 18.4 months for all patients. Local tumor recurrence developed in 12 of 191 tumors (6.3%) in 11 of 84 operations (13.1%), or 11 of 65 patients (16.9%). New liver and/or extrahepatic recurrence developed in 48 operations (57.1%). The overall median, mean, and 5-year survivals were 40.0 months, 33.7 ± 2.9 months, and 39.9%. The disease-free survivals were 16.0 month, 32.9 ± 3.0 months, and 27.9%. Factors that had a significant effect on survival outcome after RFA were TNM cancer stage and the operative approach method employed for RFA. Age, gender, race, etiology, alpha-fetoprotein, previous or subsequent treatment, and liver function (Child-Pugh class) did not affect survival. For patients with unresectable HCC, RFA is an effective and repeatable local treatment that can afford long-term survival, although often with disease recurrence.

Current status of liver transplantation for hepatocellular cancer

The incidence of hepatocellular cancer is increasing in the United States and is one of the most common cancers worldwide. Traditionally, the gold standard treatment for hepatocellular cancer has been surgical resection, but most patients were not suitable candidates due to advanced disease. Other treatments include locally ablative techniques (cryosurgery, radiofrequency ablation and various injection therapies), chemotherapeutic options and rarely, radiation therapies. In the 1980s, liver transplant emerged as the treatment of choice for end-stage liver disease and also became an option for patients with hepatocellular cancer. When comparing liver transplant with resection in retrospective studies, liver transplant patients had better survival and reduced recurrence. However, not all patients with hepatocellular cancer will be candidates for liver transplant. Size, stage, and histological grade of tumor all affect prognosis after transplant. Use of chemotherapeutic treatments and locally ablative techniques may be beneficial prior to liver transplant, but larger controlled studies are needed. Liver transplant is the most effective treatment for hepatocellular cancer in the subgroup of smaller tumors, but ultimately we are limited by the number of available donors. Future goals in this area include increasing the donor pool and determining optimal management to allow patients to wait for an appropriate donor.

A salvage technique for continuous ambulatory peritoneal dialysis catheters with exit-site infections

Catheter infection is a major complication of continuous ambulatory peritoneal dialysis (CAPD) therapy for end-stage renal disease. Catheter exist-site infections were treated with a new surgical technique consisting of dissection and removal of the existing catheter in the subcutaneous layer, insertion of a catheter connector and new catheter piece, and creation of a new subcutaneous tunnel. The new surgery can be performed on an outpatient basis and allows for the continuation of CAPD, thereby avoiding the cost associated with inpatient admission and interim hemodialysis.

Liver transplant in Hawaii: the survival of a small centre.

Abstract:  Although many report the importance of case volume in complex cases, liver transplantation (LT) can be carried out successfully in a small centre. During a 11.5‐yr period, 88 patients underwent LT in a single transplant centre in Hawaii. Indications for LT were primarily hepatitis C (n = 49) and hepatitis B (n = 13) and 22 patients (25%) had hepatocellular cancer (HCC) on explanted liver. There was no primary graft nonfunction, one retransplant for recurrent hepatitis C and two late hepatic artery thromboses, which did not require a retransplant. One patient developed partial portal vein thrombosis related to a hypercoagulable state and was rescued with anticoagulation. Of the 22 patients with HCC, 18 are alive, two died from recurrent disease (253 and 1428 d post‐LT, respectively), one died because of a ruptured hepatic artery aneurysm (151 d) and one from complications caused by noncompliance (723 d). One‐, 3‐ and 5‐yr survival rates were 89%, 82% and 71%, respectively. Mean survival was 3034.9 d. During this time period, 142 liver resections, 77 pancreatic resections and 43 splenorenal shunts were performed by this group of surgeons. Because of the recent explosion of information on case volumes and centres of excellence, LT can be performed successfully at a small centre. Other major hepatobiliary/transplant procedures can help the surgeons maintain their operative skills. A smaller LT program may require a longer period of evolution, but it can provide a service for a geographically isolated population that would otherwise have limited opportunity for LT.

Organ donation in Hawaii: impact of the final rule

Background. In an effort to increase organ donation, the Department of Health and Human Services issued the Final Rule in 1998. The Health Care Financing Administration (HCFA) later required hospitals to notify organ procurement organizations (OPO) of all deaths and imminent deaths in order to remain eligible for Medicare and Medicaid reimbursement. We set out to determine the impact of the Final Rule on organ donation in Hawaii.