Wai Kuen Tso

Analysis of Recurrence Pattern and Its Influence on Survival Outcome After Radiofrequency Ablation of Hepatocellular Carcinoma

BackgroundRadiofrequency ablation (RFA) is an effective local ablation therapy for hepatocellular carcinoma (HCC) with favorable long-term outcome. There is no data on the analysis of recurrence pattern and its influence on long-term survival outcome after RFA in HCC patients.Aim of StudyTo evaluate the tumor recurrence pattern and its influence on long-term survival in patients with HCC treated with RFA.Patients and MethodsFrom April 2001 to January 2005, 209 patients received RFA using internally cooled electrode as the sole treatment modality for HCC. Among them, 117 patients (56%) had unresectable HCC because of bilobar disease, poor liver function, and/or high medical risk for resection; whereas 92 patients (44%) underwent RFA as the primary treatment for small resectable HCC. The ablation procedure was performed through percutaneous (nu2009=u2009101), laparoscopic (nu2009=u200917), or open approaches (nu2009=u200991). The tumor recurrence pattern and long-term survival were analyzed. Multivariate analysis was carried out to identify independent prognostic factors affecting the overall survival of patients.ResultsThe mortality and morbidity rates were 0.9 and 15.7%, respectively. Complete tumor ablation was achieved in 192 patients (92.7%). With a median follow-up period of 26xa0months, local recurrence occurred in 28 patients (14.5%). Same segment and different segment intrahepatic recurrence occurred in 30 patients (15.6%) and 78 patients (40.6%), respectively. Twenty patients (10.4%) developed distant extrahepatic metastases. The overall 1-, 3-, and 5-year survival rates were 87.2, 66.6, and 42%, respectively. Different segment intrahepatic recurrence and distant recurrence after RFA carried significant poor prognostic influence on overall survival outcome. Using multivariate analysis, Child–Pugh grade (risk ratio [RR]u2009=u20092.918, 95% confident interval [CI] 1.704–4.998, pu2009=u20090.000), tumor size (RRu2009=u20091.231, 95% CI 1.031–1.469, pu2009=u20090.021), and pattern of recurrence (risk ratio [RR]u2009=u20091.464, 95% CI 1.156–1.987, Pu2009=u20090.020) were identified as independent prognostic factors for overall survival.ConclusionThe tumor recurrence pattern after RFA carries significant prognostic value in relation to overall survival. Long-term regular surveillance and aggressive treatment strategy are required for patients with different segment intrahepatic recurrence to optimize the benefits of RFA.

Comparison of Early Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Management of Acute Biliary Pancreatitis: A Prospective Randomized Study

BACKGROUND & AIMSnThe role and potential benefits of endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis have not been documented. We report a large prospective randomized study comparing early EUS and endoscopic retrograde cholangiopancreatography (ERCP) in the management of these patients.nnnMETHODSnA prospective randomized study was performed on 140 patients with acute pancreatitis suspected to have a biliary cause. The patients were randomized to have EUS (n = 70) or ERCP (n = 70) within 24 hours from admission. In the EUS group, when EUS detected choledocholithiasis, therapeutic ERCP was performed during the same endoscopy session. In the ERCP group, diagnostic ERCP was performed, followed by therapeutic endoscopy when choledocholithiasis was detected.nnnRESULTSnExamination of the biliary tree by EUS was successful in all patients in the EUS group, whereas cannulation of the common duct during ERCP was unsuccessful in 10 patients (14%) in the ERCP group (P = .001). Combined percutaneous ultrasonography and ERCP missed detection of cholelithiasis in 6 patients in the ERCP group. The overall morbidity rate was 7% in the EUS group, and that in the ERCP group was 14% (P = .172). The hospital stay and mortality rates were comparable in both groups.nnnCONCLUSIONSnIn selected patients with acute biliary pancreatitis, EUS could safely replace diagnostic ERCP in the management for selecting patients with choledocholithiasis for therapeutic ERCP with a higher successful examination rate, a higher sensitivity in the detection of cholelithiasis, and a comparable morbidity rate.

High-Intensity Focused Ultrasound for Hepatocellular Carcinoma A Single-Center Experience

Objective: This study aims to evaluate the outcome of patients with hepatocellular carcinoma (HCC) treated by high-intensity focused ultrasound (HIFU) in a single tertiary referral center. Background: HIFU is the latest developed local ablation technique for unresectable HCC. The initial experience on its efficacy is promising, but the survival benefit of patients undergoing HIFU for HCC is poorly defined. Methods: From October 2006 to December 2008, 49 patients received HIFU for unresectable HCC. Each patient underwent a single session of HIFU with a curative intent. Treatment efficacy and survival outcome were evaluated. Clinicopathologic factors affecting the primary technique effectiveness and overall survival rates were investigated by univariate analysis. Results: The median size of the treated tumors was 2.2 cm, ranging from 0.9 to 8 cm. The majority of patients had single tumors (n = 41, 83.6%). Thirty-one patients (63.2%) had artificial right pleural effusion during HIFU treatment to reduce damage to the lung and diaphragm. The hospital mortality rate was 2% (n = 1) and the complication rate was 8.1% (n = 4). The primary technique effectiveness rate was 79.5% (39 of 49 patients). It increased from 66.6% in the initial series to 89.2% in the last 28 patients. Tumor size (≥3.0 cm) was the significant risk factor affecting the complete ablation rate. The 1- and 3-year overall survival rates were 87.7% and 62.4%, respectively. Child-Pugh liver function grading was the significant prognostic factor influencing the overall survival rate. Conclusions: HIFU is an effective treatment modality for unresectable HCC with a high technique effectiveness rate and favorable survival outcome.

Hepatic resection for incidentaloma

The study goal was to review a single-center experience in hepatic resection for patients who presented with incidental liver tumors. With recent advances in diagnostic imaging techniques, incidental finding of liver tumors, or incidentalomas, is increasing in asymptomatic and healthy individuals. However, little information is available in the literature regarding the underlying pathology and operative outcomes after hepatic resection. Between January 1989 and December 2002, 1011 patients underwent hepatic resection for liver tumors; of these patients, 107 (11%) were asymptomatic individuals who presented with incidentalomas. Incidentalomas were first detected on percutaneous ultrasonography (n = 83), computed tomography (n = 23), or magnetic resonance imaging (n = 1). Fifteen (14%) patients had preoperative aspiration for cytology or biopsy for histology, and the results correlated with the final pathology in 12 patients. Fifty-six (52%) patients underwent major hepatic resection with resection of three or more Coiunaud’s segments. Median postoperative hospital stay was 8 days (range, 3–66 days). The operative mortality rate was 1%, and the operative morbidity rate was 21%. Histologic examination of the resected specimen revealed malignant liver tumors in 62 (58%) patients, including hepatocellular carcinoma (HCC) (n = 48), cholangiocarcinoma (n = 8), lymphoma (n = 2), cystadenocarcinoma (n = 2), carcinoid tumor (n = 1), and malignant fibrous histiocytoma (n = 1). Benign pathologies were found in 45 (42%) patients, including focal nodular hyperplasia (n = 17), hemangioma (n = 12), angiomyolipoma (n = 5), cirrhotic regenerative nodule (n = 4), hepatic adenoma (n = 2), and others (n = 5). On multivariate analysis, male sex, age of greater than 50 years, and tumor size of greater than 4 cm were the independent predictive factors for malignant diseases. On retrospective analysis, 48 patients with HCC who presented with incidentalomas had signi.cantly better survival outcomes after hepatic resection than did 646 patients with HCC who presented otherwise during the same study period. Hepatic resection for patients with incidentalomas is associated with a low operative mortality and acceptable morbidity. The diagnosis of malignant disease, especially HCC, should be considered in male patients older than 50 years who present with large hepatic lesions.

Duodenopleural Fistula Formation After Percutaneous Radiofrequency Ablation for Recurrent Hepatocellular Carcinoma

Radiofrequency ablation (RFA) is a treatment option in the management of unresectable or recurrent hepatocellular carcinoma (HCC). It can be performed either through laparotomy or in a minimally invasive manner by percutaneous, laparoscopic or thoracoscopic routes. Percutaneous RFA is associated with reduced surgical trauma and thus can be performed in patients with significant comorbidities. The procedure can be repeated after short intervals for sequential ablation of multiple liver lesions. However, the associated risks should not be underestimated. This is the first report of a rare complication of duodeno-pleural fistula after percutaneous RFA of a recurrent subcapsular HCC. The risk of bowel perforation during the ablation of subcapsular HCC requires special attention, since only the position of the tip of the electrode, but not the zone of ablation, can be assessed accurately by imaging during the procedure. Our case demonstrated that there was leakage of bowel content from the duodenal injury site into the pleural cavity through the RFA track. Subsequent uncontrolled infection resulted in empyema thoracis and led to the death of the patient.

Pediatric liver transplantation in Hong Kong-a domain with scarce deceased donors.

AIMnThe study aimed to assess the outcome of live-donor liver transplantation for pediatric patients in a region with limited access to deceased donors.nnnPATIENTS AND METHODSnFrom September 1993 to September 2008, 78 pediatric patients aged between 73 days and 17 years (mean, 40 months) received 83 liver transplants. Sixty-two were living-related liver transplantations (LRLTs), and 21 were deceased-donor liver transplantations (DDLTs). The mean follow-up period was 6.5 years. The prospectively collected data of these patients were analyzed retrospectively.nnnRESULTSnThe 1-, 2-, and 5-year survival rates of patients and grafts were 91%, 90%, 88% and 87%, 86%, 83%, respectively. The survival rates of LRLT patients and DDLT patients were 89%, 89%, 87%, and 90%, 86%, 86%, respectively (P = .58). The survival rates of patients aged 12 months or younger and patients older than 12 months were 95%, 92%, 90% and 90%, 90%, 87%, respectively (P = .65). One live donor developed temporary peroneal palsy, and another developed lung collapse (3%, 2/62). All live donors resumed their normal activities with no difficulty.nnnCONCLUSIONnWith meticulous surgical techniques and postoperative care, it is justifiable to accept donated livers from voluntary live donors for transplantation to save pediatric patients in a place with scarce deceased donors.