Noriyo Yamashiki

Combination therapy with transcatheter arterial chemoembolization and percutaneous microwave coagulation therapy for hepatocellular carcinoma.

A small number of microwave electrode insertions and microwave irradiations were used to obtain complete tumor necrosis in hepatocellular carcinomas (HCC) measuring > 2.0 cm but ≤ 3.0 cm in greatest dimension. The efficacy of combining transcatheter arterial chemoembolization (TACE) with subsequent percutaneous microwave coagulation therapy (PMCT) was assessed in this study.

Endoscopic Management of Biliary Complications after Adult Living Donor Liver Transplantation

OBJECTIVES:Biliary complications are one of the important issues to be addressed after liver transplantation. Endoscopic management of biliary complications after deceased donor liver transplantation (DDLT) is widely accepted, but it remains to be established in patients after living donor liver transplantation (LDLT). Endoscopic management in LDLT patients is difficult mainly because of the complexity of duct-to-duct reconstruction.METHODS:A total of 174 adult LDLTs with duct-to-duct reconstruction were performed in our institution. Biliary complications developed in 53 patients (30%). Among these, 18 patients were referred for endoscopic management and were the subjects of the present study. Success rate, early morbidity, and outcome were evaluated in these 18 patients.RESULTS:The type of graft was the right liver in six, left liver in eight, and right lateral sector in four patients. Ten out of 18 patients had one biliary anastomosis and the remaining eight had multiple anastomoses. Six patients had a previous history of surgical or percutaneous intervention for biliary complications after LDLT. Seventeen patients had one or more biliary strictures. Biliary casts were found in nine patients, three of whom had concomitant bile leaks. Strictures were successfully treated with endoscopic balloon dilation in 12 (71%) of the 17 patients (nasobiliary catheter placement in eight and stent placement in four patients). Bile leak was successfully managed in two of three patients. Biliary casts were removed by endoscopic papillary balloon dilation in eight of nine patients. Five patients with failed endoscopic therapy were converted to percutaneous or surgical intervention. Endoscopic-procedure-related cholangitis developed in one patient. During follow-up with median periods of 10 months (range 2–20 months), four of nine patients without stent placement developed biliary strictures, and these were relieved by additional endoscopic management.CONCLUSIONS:Endoscopic approach has the potential to be a first-line therapy for the management of biliary complications after LDLT.

A retrospective review of liver transplant patients treated with sirolimus from a single center: an analysis of sirolimus-related complications.

Background. Sirolimus (SRL) is a powerful immunosuppressant used primarily in calcineurin inhibitors (CNI)-related nephrotoxicity. However, reports of drug-related side effects are increasing. The aim of our report is to review the frequency and timing of these complications within our transplant patient population. Methods. We retrospectively reviewed the medical records of liver-transplanted patients treated with sirolimus between November 1998 and April 2002. The data collected included SRL serum levels, frequency of reported and documented SRL-related side effects, and survival outcomes. Statistical evaluation included Pearson chi-square and the Fisher’s exact tests. Results. Overall, 205 patients were identified, with 30 patients removed from the analysis for different reasons. Of the remaining 175 patients, 91 (52%) patients developed a complication other than an increase in serum triglycerides and/or cholesterol. The most frequent complications were: bilateral lower extremity edema (57.1%), dermatitis (25.3%), oral ulcers (24.2%), joint pain (23.0%), pleural effusion (16.5%) and increase in abdominal girth (9.9%). Other complications included: generalized edema (5.5%), pericardial effusion (5.5%), facial edema (2.2%), and upper extremity edema (1.3%). In addition, we reported two cases of hepatic artery thrombosis, one case of wound dehiscence with evisceration that required surgical repair, and one case of skin cancer. Interestingly, we found that a previous history of myocardial ischemia correlates with the development of SRL side effects. Conclusions. SRL is a powerful immunosuppressant but not devoid of side effects. These results have elevated our level of suspicion when instituting SRL and may help with early recognition and prevention of drug related complications.

Obesity Is an Independent Risk Factor for Hepatocellular Carcinoma Development in Chronic Hepatitis C Patients

BACKGROUND & AIMS It is not fully elucidated whether obesity enhances hepatocarcinogenesis in patients with chronic hepatitis C. The aim of this study was to investigate the relationship between body weight and risk of hepatocarcinogenesis in chronic hepatitis C patients. METHODS We enrolled 1431 patients with chronic hepatitis C who visited our liver clinic between 1994 and 2004, excluding those with hepatocellular carcinoma (HCC) at their visit or with a previous history of HCC. They were divided into 4 groups according to body mass index (BMI): underweight (< or =18.5 kg/m(2), N = 112); normal (18.5 to less than 25 kg/m(2), N = 1023); overweight (25 to less than 30 kg/m(2), N = 265); and obese (>30 kg/m(2), N = 31). We assessed the impact of obesity on the hepatocarcinogenesis adjusted by multivariate Cox proportional hazard regression with other risk factors found significant in univariate analysis. RESULTS During the follow-up period (mean, 6.1 y), HCC developed in 340 patients, showing cumulative incidence rates of 10.5%, 19.7%, and 36.8% at 3, 5, and 10 years, respectively. The incidence differed significantly among the BMI groups (P = .007). Adjusting for other significant factors, overweight and obesity were shown to be an independent risk factor of HCC, with a hazard ratio of 1.86 (95% confidence interval, 1.09-3.16; P = .022) and 3.10 (95% confidence interval, 1.41-6.81; P = .005) as compared with the underweight patients. CONCLUSIONS The risk of HCC in patients with chronic hepatitis C increases in proportion to BMI in a wide range of its values, from underweight to obese.

Prediction of recurrence of hepatocellular carcinoma after curative ablation using three tumor markers

Three tumor markers for hepatocellular carcinoma (HCC) are available in daily practice in Japan: alpha‐fetoprotein (AFP), des‐gamma‐carboxy prothrombin (DCP), and lens culinaris agglutinin‐reactive fraction of alpha‐fetoprotein (AFP‐L3). To elucidate the predictability of these tumor markers on HCC recurrence after curative ablation, we enrolled 416 consecutive patients with naïve HCC who had been treated by percutaneous ablation at our department from July 1997 to December 2002. Tumor marker levels were determined immediately before and 2 months after the treatment. Complete ablation was defined on CT findings as nonenhancement in the entire lesion with a safety margin. Tumor recurrence was also defined as newly developed lesions on CT that showed hyperattenuation in the arterial phase with washout in the late phase. We assessed the predictability of recurrence via tumor markers in multivariate analysis, using proportional hazard regression after adjusting for other significant factors in univariate analysis. Until the end of follow‐up, tumor recurrence was identified in 277 patients. Univariate analysis revealed the following factors to be significant for recurrence: platelet count; size and number of tumors; AFP, AFP‐L3, and DCP preablation; and AFP and AFP‐L3 postablation. Multivariate analysis indicated that AFP >100 ng/mL and AFP‐L3 >15%, both pre‐ and postablation, were significant predictors. The positivity of AFP and AFP‐L3 preablation that turned negative postablation was not significant. In conclusion, tumor markers pre‐ and post‐ablation were significant predictors for HCC recurrence and can complement imaging modalities in the evaluation of treatment efficacy. (HEPATOLOGY 2006;44:1518–1527.)

Rapid progression of hepatocellular carcinoma after transcatheter arterial chemoembolization and percutaneous radiofrequency ablation in the primary tumour region.

We report one patient who showed rapid progression of hepatocellular carcinoma (HCC) after undergoing transcatheter arterial chemoembolization (TACE) and percutaneous radiofrequency ablation (PRFA) for a small HCC measuring 2.5 cm in diameter. Enhanced magnetic resonance imaging (MRI) following treatment showed complete tumour necrosis and did not reveal the presence of a tumour around the treated area. Furthermore, the serum alpha-fetoprotein (AFP) level decreased at the completion of therapy. However, the HCC advanced in a very short time. Numerous tumours around the treated area were observed on enhanced computed tomography (CT) 50 days after PRFA. It is strongly suspected that the tumour was disseminated through the portal system because of the presence pattern of tumours. We believe this to be the first case illustrating a hepatic cancer that progressed rapidly following TACE and PRFA.

Percutaneous microwave coagulation therapy for solitary metastatic liver tumors from colorectal cancer: a pilot clinical study

Objective:Percutaneous microwave coagulation therapy (PMCT) was performed for metachronous small solitary liver tumors measuring ≤3.0 cm in diameter that had metastasized from colorectal cancer. PMCT was used for local control of the lesions, and the efficacy of this treatment was assessed.Methods:In 15 patients, a microwave electrode (specially designed for this purpose, 25 cm long and 2.0 mm thick) was inserted percutaneously into the tumor area under ultrasonic guidance. Microwaves at 80 watts were used to irradiate the tumor and the surrounding area.Results:Thirteen of the 15 metastatic tumors were radically ablated by 3–10 applications of microwave irradiation. Although the follow-up period was short (9–37 months), 10 patients survived. No recurrence has been detected in the treated area (except two foci where PMCT was insufficient), and no serious side effects or complications were encountered during or after the PMCT. In four of the five nonsurviving patients, death was due to metastases to the bone, brain, lung, or other areas of the liver despite complete local tumor control by PMCT.Conclusion:PMCT is a safe and effective treatment for metachronous small liver tumors that have metastasized from colorectal cancer.

Systematic grading of surgical complications in live liver donors according to Clavien's system

The lack of consensus on how to evaluate surgical complications of donors in live donor liver transplantation (LDLT) and incoherence of cumulative data hampers efficient comparison of the outcome worldwide. We considered that the application of the internationally validated classification system introduced by Clavien in 2004 might be beneficial. Operative complications of 243 patients who underwent live donor hepatectomy for adult LDLT between January 1996 and October 2005 at the University of Tokyo were analyzed according to the system. Definitions for each grade in the system are: grade I, deviation from the normal postoperative course but without the need for therapy; grade II, complication requiring pharmacologic treatment; grade III, complication with the need for surgical, endoscopic or radiological intervention (IIIa/b: without/with the need for general anesthesia); grade IV, life‐threatening complication requiring intensive care; grade V, death. Surgical morbidity was recognized in 67 donors (28%). No deaths occurred. The numbers of patients with complications were: grade I, 36 (15%); II, 10 (4%); IIIa, 12 (5%); IIIb, 9 (4%); IV, 0; V, 0. Six in IIIb underwent surgical repair for bile leakage. Claviens system is simple and informative. It may serve as a common tool for the quality assessment in live liver donor surgery worldwide, and we propose its application whenever surgical complication of live donor is discussed.

Health‐related quality of life of chronic liver disease patients with and without hepatocellular carcinoma

Background and Aim:  Impaired health‐related quality of life has been reported in patients with cirrhosis and chronic hepatitis. However, only limited data are available concerning the influence of hepatocellular carcinoma.

Outcomes After Living Donor Liver Transplantation for Acute Liver Failure in Japan: Results of a Nationwide Survey

Nationwide surveys of acute liver failure (ALF) are conducted annually in Japan, and 20% of patients with ALF undergo liver transplantation (LT). We extracted data for 212 patients who underwent LT for ALF from the nationwide survey database of the Intractable Liver Diseases Study Group of Japan. After the exclusion of 3 patients who underwent deceased donor LT, 209 recipients of living donor liver transplantation (LDLT) were analyzed. ALF patients were placed into 3 subgroups according to the time from the onset of the disease to the occurrence of encephalopathy: patients who presented with encephalopathy within 10 days of the diseases onset were classified as having acute ALF, patients who presented within 11 to 56 days were classified as having subacute ALF, and patients who presented within 9 to 24 weeks were classified as having late‐onset hepatic failure (LOHF). Long‐term follow‐up data were obtained from the registry of the Japanese Liver Transplantation Society. The 2 data sets were merged, and descriptive and survival data were analyzed. A Cox regression analysis was performed to define factors predicting overall mortality, short‐term mortality (≤90 days after LT), and long‐term mortality (>90 days after LT). One hundred ninety of the analyzed patients (91%) were adults (age ≥ 18 years); 70 patients (34%) were diagnosed with acute ALF, 124 (59%) were diagnosed with subacute ALF, and 15 (7%) were diagnosed with LOHF. Hepatitis B virus was the most common cause of acute ALF (61%), whereas autoimmune hepatitis (14%) and drug allergy–induced hepatitis (14%) were more frequent in patients with subacute ALF or LOHF. The cumulative patient survival rates 1, 5, and 10 years after LT were 79%, 74%, and 73%, respectively. Patient age was associated with short‐ and long‐term mortality after LT, whereas ABO incompatibility affected short‐term mortality, and donor age affected long‐term mortality. In conclusion, the long‐term outcomes of LDLT for ALF in this study were excellent, regardless of the etiology or classification. The majority of the donors were living donors. Increasing the deceased donor pool might be an urgent necessity. Liver Transpl, 2012.