Rohan C. Siriwardana

Cryptogenic cirrhosis is the leading cause for listing for liver transplantation in Sri Lanka.

Hepatitis B and C are rare in Sri Lanka. Nonalcoholic fatty liver disease is increasing in the country. Eighty-one patients referred for liver transplantation (LT) over a period of 18 months were prospectively evaluated. Ninety-two percent (n = 74) were males. Cryptogenic cirrhosis was the leading indication for LT (58 %, n = 47) followed by alcohol in 27 % (n = 33). Hepatitis B and C were not seen in our cases. The liver biochemistry and clinical status of cirrhosis were similar in cryptogenic and alcoholic cirrhotics. Fourteen patients died while waiting for transplant, and nine transplants were performed. Cryptogenic cirrhosis is the leading cause for LT in Sri Lanka.

Clinical characteristics and outcome of hepatocellular carcinoma in alcohol related and cryptogenic cirrhosis: a prospective study.

BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of chronic liver disease. Hepatocellular carcinoma (HCC) is one of its complications. Although the pathophysiology is unclear, it is reasonable to expect that cryptogenic cirrhosis related HCC (cryptogenic HCC) behaves differently to other types of HCC. This study prospectively compared patients with cryptogenic HCC and those with HCC related to alcoholic cirrhosis. METHODS A total of 150 consecutive patients with HCC (89 cryptogenic HCC and 61 alcohol related HCC) referred to our unit over a 23-month period were studied. Their demographic data, liver function, tumor characteristics and outcomes were compared. RESULTS Alcohol related HCC was seen only in males. Compared with cryptogenic HCC, alcohol related HCC had significantly higher aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio (1.7 vs 1.4, P=0.002), model for end-stage liver disease score (13 vs 11, P=0.018) and Childs score (7 vs 6, P=0.037). No significant difference was seen in platelet counts, serum sodium and AST to platelet ratio index. Single nodular tumors were more common in cryptogenic HCC, while diffuse type tumors and macroscopic vascular invasion were common in alcohol related HCC. In patients who could not be offered any treatment because of advanced tumors or poor liver function, alcohol related HCC had a significantly lower median survival (5.3 months) compared with cryptogenic HCC (9.3 months, P=0.034). CONCLUSIONS Compared with cryptogenic HCC, alcohol related HCC had worse liver function and aggressive tumor morphology at presentation, and a higher proportion was untreatable. In patients who could not be treated, median survival was lower in patients with alcohol related HCC than in those with cryptogenic HCC.

Effects of the liver volume and donor steatosis on errors in the estimated standard liver volume

An accurate assessment of donor and recipient liver volumes is essential in living donor liver transplantation. Many liver donors are affected by mild to moderate steatosis, and steatotic livers are known to have larger volumes. This study analyzes errors in liver volume estimation by commonly used formulas and the effects of donor steatosis on these errors. Three hundred twenty‐five Asian donors who underwent right lobe donor hepatectomy were the subjects of this study. The percentage differences between the liver volumes from computed tomography (CT) and the liver volumes estimated with each formula (ie, the error percentages) were calculated. Five popular formulas were tested. The degrees of steatosis were categorized as follows: no steatosis [n = 178 (54.8%)], ≤10% steatosis [n = 128 (39.4%)], and >10% to 20% steatosis [n = 19 (5.8%)]. The median errors ranged from 0.6% (7 mL) to 24.6% (360 mL). The lowest was seen with the locally derived formula. All the formulas showed a significant association between the error percentage and the CT liver volume (P < 0.001). Overestimation was seen with smaller liver volumes, whereas underestimation was seen with larger volumes. The locally derived formula was most accurate when the liver volume was 1001 to 1250 mL. A multivariate analysis showed that the estimation error was dependent on the liver volume (P = 0.001) and the anthropometric measurement that was used in the calculation (P < 0.001) rather than steatosis (P ≥ 0.07). In conclusion, all the formulas have a similar pattern of error that is possibly related to the anthropometric measurement. Clinicians should be aware of this pattern of error and the liver volume with which their formula is most accurate. Liver Transpl, 2011.

Effects of donor steatosis on liver biochemistry and significance of body mass index in predicting steatosis

BACKGROUND Hepatic steatosis is a major concern in living donor liver transplantation. Factors affecting hepatic functional status after a donor right hepatectomy (with the middle hepatic vein included in the graft) with a focus on changes owing to steatosis were retrospectively studied. METHODS Donors (n = 325) were categorized into three groups: G0 (no steatosis, n = 178), G1 (< = 10% steatosis, n = 128) and G2 (>10% steatosis, n = 19). Donors with >20% steatosis were excluded. Changes in aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin levels and prothrombin time (PT) were assessed. Factors predicting steatosis were also assessed. A liver biopsy was performed on selected donors. RESULTS The ALT level rose until day 3 in G1 and day 6 in G2 (P < 0.05). The AST level rose until day 7 in G2 (P < 0.05) but stayed unchanged in G1. The bilirubin level was higher only on day 1 in G2 (P < 0.05). By day 30, no significant difference between any groups was noted. Receiver-operating characteristic (ROC) area under the curve for body mass index (BMI) on predicting steatosis was 0.75 [confidence interval (CI) = 69-80]. Among donors with a BMI > 23.5 kg/m(2), 75% had steatosis. Five donors had >20% steatosis and were not assessed. CONCLUSION Using a liver with up to 20% steatosis in right liver donation, even if the middle hepatic vein is included in the graft, is safe. For Asian donors, a BMI > 23.5 kg/m(2) is a guide in deciding whether to perform a liver biopsy for steatosis.

Recurrence of graft steatosis after liver transplantation for cryptogenic cirrhosis in recently commenced liver transplant program

Non-alcoholic fatty liver disease (NAFLD) seems to recur in at least one third of patients transplanted for non-alcoholic steatohepatitis (NASH)-related cirrhosis. While, NASH recurrence does not seem to affect overall graft and patient survival up to 10 years, cardiovascular and infection-related morbidity and mortality seem to be increased in these patients. This report looks at the graft histology in patients who were transplanted for NASH-related cirrhosis after short-term follow up. We report a high prevalence of recurrent NAFLD in liver grafts post-transplant among five patients. The degree of steatosis noted among the recipients is alarming.

Liver Transplantation for Non-Alcoholic Steatohepatitis Related Cirrhosis(A Future Global Epidemic Already Seen in Current Sri Lankan Practice)

Sri Lanka has a unique pattern of chronic liver disease (CLD). The prevalence of hepatitis B and C is very low even among presumed ‘‘high-risk’’ populations. Chronic viral hepatitisrelated liver disease is also rare, with <2% for hepatitis Band <1% for hepatitis C-related cirrhosis. The community prevalence of nonalcoholic fatty liver disease (NAFLD) in Sri Lanka is 33% among urban adults and 18% among rural, physically active adults. With such high prevalence rates of NAFLD and increasing metabolic risk factors due to rapid lifestyle changes and industrialization, cryptogenic or NAFLD-related cirrhosis is increasing rapidly in Sri Lanka. Worldwide, the pattern of CLD is changing. With the implementation of hepatitis B vaccination in national immunization programs and the introduction of highly effective directly acting antiviral agents for the treatment of hepatitis C, there will be a dramatic reductions in hepatitis Band C-related liver disease, with the potential for universal eradication of hepatitis C. Conversely, there is a rising trend for noncommunicable diseases such as obesity, diabetes, and metabolic syndrome, which are strong associations of NAFLD. The progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), is now seen frequently in many parts of the world. NALFD is already the most common CLD in developed countries with a prevalence of 2030%. The prevalence of NAFLD in Asia—depending on location (urban vs rural), gender, ethnicity, and age—is variable— between 15% and 20%. In the not-so-distant future, NAFLD is also likely to be a leading cause of cirrhosis and hepatocellular carcinoma. Therefore, worldwide, the future pattern of CLD will be similar to the already existing pattern that is seen in Sri Lanka. Liver transplantation was started in Sri Lanka in 2010 and is not freely available for the vast majority of patients requiring the intervention. We previously reported that 63% of cases referred to us for transplantation were related to NASH cirrhosis. We also reported that 59% of patients with hepatocellular carcinoma are secondary to cryptogenic or NASH cirrhosis. The second most common cause for both is alcohol-related liver disease. An important obstacle for liver transplantation is the difficulty to identify suitable donors. A large percentage (45%) of our liver donors were rejected due to the presence of NAFLD. Patients with NASH cirrhosis are more likely to be older and have the metabolic syndrome; therefore, they require careful pretransplant evaluation of cardiovascular risk. Posttransplant period is associated with a higher 30-day mortality, predominantly from an increase in cardiovascular events and infections. Furthermore, a significant number of patients may have recurrence of NASH in the graft. Among 5 patients who completed 3-year follow-up posttransplant, a high prevalence of recurrent NASH was observed on the protocol follow-up biopsy of the transplanted liver. The above discussion highlights the challenges of tackling NAFLD-related CLD. Newly established liver transplant (LT) programs, such as in Sri Lanka, are likely to see increasing patients with NAFLD-related cirrhosis as well as limitations in potential liver donors due to the presence of NAFLD.

Association of serum ferritin with diabetes and alcohol in patients with non-viral liver disease-related hepatocellular carcinoma

Introduction: Non-alcoholic fatty liver disease is a leading cause for hepatocellular carcinoma (HCC) in Sri Lanka. Diabetes mellitus, alcohol abuse, and liver inflammation are known to increase the risk of HCC. The present study evaluates serum ferritin levels in a cohort of patients with non-viral HCC (nvHCC). Methodology: Consecutive patients with nvHCC presenting to the Colombo North Liver transplant Service, Ragama, from January 2012 to July 2013 were investigated. All were negative for hepatitis B and C. At registration, 5 mL of serum was separated into plain tubes, stored at -80°C and analysed for ferritin using an enzyme-linked immunosorbent assay. Correlation between the serum ferritin and patient risk factors, liver status, and tumour characteristics were analysed. Results: There were 93 patients with nvHCC (median age 65 [12-82] years; 82 [88.2%] males). The median ferritin level was 246.2 μg/L, and 38 (40.86%) patients had elevated ferritin. Non-diabetics (median 363.5 mg/L, p = 0.003) and alcohol abusers (median 261.2 mg/L, p = 0.018) had higher ferritin levels. On multiple-variable analysis, being non-diabetic (p = 0.013) and alcoholic (p = 0.046) was significantly associated with high serum ferritin. No association was found with body mass index, tumour stage, size, macrovascular invasion, number of nodules, alpha-fetoprotein, bilirubin, international normalized ratio, and survival. Conclusion: In patients with nvHCC, serum ferritin levels are higher in non-diabetics and alcoholics.

Diffuse-Type Hepatoma: A grave prognostic marker

Background: Data on diffuse-type hepatocellular carcinoma (HCC) are rare. HCC in Sri Lanka is rising, and the majority is related to nonalcoholic fatty liver disease. This study was planned to compare nodular- and diffuse-type HCC in this cohort. Methods: CT scans of 227 patients with HCC negative for infective hepatitis were analyzed and grouped as nodular and diffuse from July 2011 to July 2014. Diffuse-type cancer was defined as a tumor without convex/distinct margin, diffusely infiltrating the hepatic parenchyma. There were 45 (20%) cases. The baseline liver functions, etiology, treatment, and the outcome were compared with nodular-type cancers. Stage III diffuse cancers were matched with 2 stage III nodular cancers looking at the T stage and background liver. Results: There was no difference in the age (63 vs. 62 years, p = 0.937) and gender. Diffuse cancers had a low BMI (24 vs. 22, p = 0.009), a higher alpha fetoprotein (AFP) level (p < 0.001), a higher incidence of major vascular invasion (14 vs. 80%, p < 0.001), and a history of significant alcohol consumption (39 vs. 67%, p = 0.001). The baseline liver functions were similar in diffuse and nodular cancers. A large proportion (27 vs.77%, p < 0.001) of diffuse cancers were not candidates for active treatment. Overall survival was poor in the diffuse type (4.7 vs. 25 months, p < 0.001). Diffuse-type stage III cancers had a poor survival compared to matched nodular cancers (2.5 vs. 15.8 months, p = 0.001). Conclusion: HCC without a background of infective hepatitis were common in our cohort. These tumors are associated with high AFP levels, major vascular invasion, and a poor prognosis.

Long-term survival of stage IV hepatocellular carcinoma treated with multimodal approach

A 42 year old diabetic lady presented with a recent history of ankle swelling and shortness of breath. On further evaluation, she was found to have Childs class A cirrhosis with a model for end stage liver disease score of 9. Liver imaging and echocardiogram showed a typical hepatocellular carcinoma (HCC) in segment VIII of the liver extending into the right hepatic vein, inferior vena cava (IVC) and into the right atrium (Figure 1). There was a secondary thrombus in the IVC. Right atrial inflow and outflow showed features of impending obstruction. Considering her excellent general condition, it was decided to perform a combined thoraco-laparotomy. During laparotomy, the liver had significant macroscopic changes of cirrhosis. We decided to abandon the liver resection and to only remove the atrial tumour to palliate symptoms. The right atrium was opened under cardiopulmonary bypass and the atrial tumour was removed from its origin at the right hepatic vein (Figure 2). A secondary clot in the IVC was also removed.

Nasojejunal feeding versus feeding jejunostomy after upper gastrointestinal surgery

The use of enteral nutrition over parenteral nutrition is recommended in the case of patients undergoing major gastrointestinal surgery for cancer, as it reduces sepsis related morbidity. In this study we compared ourexperience of nasojejunal tube feeding with feeding jejunostomy DOI: http://dx.doi.org/10.4038/sljs.v32i2.7353 The Sri Lanka Journal of Surgery 2014; 32(2): 26-31