Background
Reports on the risk factors of peritoneal recurrence (PR) after liver resection for hepatocellular carcinoma are lacking. We examined the risk factors of PR after hepatectomy and the ...outcome of resected PR at our institution.
Methods
We retrospectively reviewed the data from 1,222 patients who underwent hepatectomies for hepatocellular carcinoma in Samsung Medical Center from January 2006 to August 2010. We identified patients with PR and studied the risk factors and outcomes of resected PR.
Results
The rate of PR was 3.0% (
n
= 36). The mean ± SD age of patients was 54.0 ± 10.2 years. Among those with PR, 23 patients (63.9%) had unresectable disease and 13 patients (36.1%) had resectable disease. Multivariate analysis found that tumor size >50 mm, presence of microvascular invasion, bile duct invasion, and positive margins were significant risk factors of PR after liver resection. The median overall survival (OS) for resectable PR was 33.0 (28.0–61.6) months compared to 14.0 (6.8–21.2) months for unresectable PR (
P
= 0.009). Cox regression analysis demonstrated that resected PR hazard ratio (HR) 0.042,
P
= 0.001 and interval between hepatectomy and PR (>6months) (HR 0.195,
P
= 0.016) were positive prognostic factors for OS, while alfa-fetoprotein >200 ng/dl at detection of PR (HR 11.321,
P
= 0.015) and serosal involvement of primary hepatocellular carcinoma (HR 25.616,
P
= 0.007) were negative prognostic factors for OS.
Conclusions
We found that tumor size >50 mm, presence of microvascular invasion, bile duct invasion, and positive resection margins were significant risk factors of PR after liver resection. Selected patients with resected PR had significantly better OS.
Donor safety and graft results of pure laparoscopic living donor right hepatectomy (LLDRH) have previously been compared with those of open living donor right hepatectomy (OLDRH). However, the ...clinical outcomes of recipients at 1‐year follow‐up have never been accurately compared. We aimed to compare 1‐year outcomes of recipients of living donor right liver transplantation (LRLT) using pure LLDRH and OLDRH. From May 2013 to May 2017, 197 consecutive recipients underwent LRLT. Donor hepatectomies were performed either by OLDRH (n = 127) or pure LLDRH (n = 70). After propensity score matching, 53 recipients were included in each group for analysis. The clinical outcomes at 1‐year follow‐up were compared between the 2 groups. The primary outcome was recipient death or graft failure during the 1‐year follow‐up period. In the propensity‐matched analysis, the incidence of death or graft failure during the 1‐year follow‐up period was not different between the 2 groups (3.8% versus 5.7%; odds ratio OR, 1.45; 95% confidence interval CI, 0.24‐8.95; P = 0.69). However, the composite of Clavien‐Dindo 3b‐5 complications was more frequent in the pure LLDRH group (OR, 2.62; 95% CI, 1.15‐5.96; P = 0.02). In conclusion, although pure LLDRH affords a comparable incidence of fatal complications in recipients, operative complications may increase at the beginning of the program. The safety of the recipients should be confirmed to accept pure LLDRH as a feasible option.
Background
Several conventional staging systems use tumor count as a variable for tumor classification; however, most conventional staging systems for hepatocellular carcinoma (HCC) are not ...specifically constructed for surgically treated patients. The aim of this study was to create a prognostic nomogram based on patient’ clinical and pathological features for predicting individual patient survival after liver resection as a primary therapy for solitary hepatitis B virus (HBV)-related HCC.
Methods
This study included patients who underwent curative liver resection for preoperative treatment-naïve HBV-related HCC between April 2007 and September 2014. All data were collected prospectively.
Results
A nomogram was generated for HCC recurrence and mortality in 420 hepatectomy patients. HCC recurrence was closely associated with the following factors: increased alkaline phosphatase, low albumin, increased protein induced by vitamin K absence/antagonism-II (PIVKA-II), multiple tumors, tumor hemorrhage, portal vein tumor thrombosis, intrahepatic metastasis, and free resection margin (< 4 cm). Increased alanine transaminase, tumor size ≥ 5 cm, and multiple tumors were predisposing factors for death. Nomograms using those factors had good calibration and discrimination abilities with
C
-indexes of 0.712 and 0.819, respectively.
Conclusions
Our results suggest that prognostic nomograms in hepatectomy patients with HBV-related HCC can more precisely estimate postoperative survival of individual HBV-related HCC patients.
Background Recurrence after liver resection for hepatocellular carcinoma (HCC) is common. Resection of extrahepatic recurrences such as lung metastasectomy (LM) has been well documented. Conversely, ...reports on the long-term outcomes of peritoneal metastasectomy (PM) are lacking. In this study, we compared the outcome of lung and peritoneal metastasectomy after hepatectomies for HCC in a tertiary institution. Methods We reviewed retrospectively the data of 1,222 patients who underwent hepatectomies for HCC in Samsung Medical Center in Korea from January 2006 to August 2010. We studied the clinicopathologic factors between resected lung metastasis (LM) and peritoneal metastases (PM) and the long-term outcome of patient survival. Kaplan-Meier analysis was used to study the survival outcome. Results The recurrence rate of resected HCC in this cohort was 41.6% ( n = 508). Thirty-two patients with lung metastasis (23% of all lung metastasis) underwent LM whereas 13 patients (36% of all peritoneal metastasis) with peritoneal metastasis underwent PM. Two patients underwent PM and LM sequentially. Demographic and clinical data between the LM and PM groups were comparable. The mean prehepatectomy PIVKA-II level was greater in the LM group compared with the PM group ( P = .029). On univariate analysis of pathologic factors, the median tumor size ( P = .005), proportion of patients with tumor >75 mm ( P = .005) and rate of microvascular invasion ( P = .047) were greater in the LM group. The median time-to-recurrence in the LM group was 12 (4–45) months compared with 18 (1–102) months in the PM group ( P = .896). The 1-year, 3-year, and 5-year overall survival of patients in the LM group was 92%, 55%, 55% (4-year) whereas that in the PM group was 90%, 75%, and 75%, respectively. The mean overall survival in the LM was comparable with that in the PM group ( P = .578). Conclusion Twenty-three percent of patients with lung metastasis and 36.1% of patients with peritoneal metastasis could be considered for metastasectomy. The long-term survival of patients with PM and LM was comparable in this study. Although resection of LM improves survival in patients with resected HCC, we demonstrated favorable outcomes for PM as well, which in the past would have been considered palliative.
Living-donor liver transplantation (LDLT) is becoming an important tool in hepatocellular carcinoma (HCC) treatment. However, the oncologic outcome between LDLT and deceased-donor LT (DDLT) for HCC ...remains controversial. This study aims to compare the HCC recurrence rates after LDLT versus DDLT.
Two hundred sixteen patients (166 LDLTs and 50 DDLTs) who underwent LT for HCC within University of California-San Francisco criteria were retrospectively reviewed. LDLT patients were divided into two groups: small living-donor graft (LDG; graft-to-recipient body weight ratio <1.0, n=59) and nonsmall LDG (graft-to-recipient body weight ratio ≥1.0, n=107). Patients were further stratified into low- and high-risk settings by the number of risk factors for recurrence.
The recurrence-free survival was lower in LDLT compared with DDLT (88.6% and 80.7% vs. 96.0% and 94.0% at 1 and 5 years; P=0.045). There was no significant difference between two groups regarding the majority of clinical and tumor characteristics, with the exception of a higher proportion of microvascular invasion presence in LDLT. After the adjustment for microvascular invasion, LDLT was identified as an independent risk factor for recurrence. Moreover, recurrence-free survival between small and nonsmall LDG was not statistically significant. In low-risk setting (≤1 risk factor), LDLT showed comparable outcome with DDLT. However, the risk of recurrence was higher in LDLT than DDLT in high-risk patients.
In conclusion, LDLT showed poorer outcome than DDLT. This should be considered to select optimal strategy for HCC.
Background
Recent advances in technology and accumulation of surgical experience have expanded the indications for laparoscopic liver resection (LLR). However, compared to open liver resection (OLR), ...the feasibility of laparoscopic anatomical liver resection for centrally located tumor (CLT) has not been clearly established. The aim of our study was to assess the feasibility and safety of laparoscopic anatomical major liver resection for CLT.
Methods
From April 2011 to March 2016, 20 cases of anatomical LLR and 86 cases of OLR for CLTs such as central hepatectomy (CH) and right anterior sectionectomy (RAS) were performed at a single institution. We performed one-to-one propensity score matching and analyzed short-term outcomes between the LLR (
n
= 20) and OLR (
n
= 20) groups.
Results
Among 20 cases in the LLR group, two cases underwent open conversion due to common bile duct injury and anatomical distortion, respectively. There were no statistically significant difference between the LLR and OLR groups regarding clamping time of the Pringle maneuver (
p
= 0.502), blood loss (
p
= 0.746), surgical margin (
p
= 0.198), or length of hospital stay (
p
= 0.110). However, surgical time was significantly longer in the LLR group than in the OLR group (388 vs 268 min;
p
< 0.001). There were no significant differences between the two groups with regard to morbidity rate or mean comprehensive complication index (
p
= 0.716 and
p
= 0.819, respectively).
Conclusion
Total anatomical LLR can be performed safely in selected CLT patients by experienced surgeons. Laparoscopic CH or RAS appears feasible with non-inferior perioperative outcomes compared to OLR.
Background
Although invasive fungal infections (IFIs) contribute to substantial morbidity and mortality in liver transplant recipients, only a few randomized studies analyzed the results of ...antifungal prophylaxis with echinocandins. The aim of this open-label, non-inferiority study was to evaluate the efficacy and safety of micafungin in the prophylaxis of IFIs in living-donor liver transplantation recipients (LDLTRs), with fluconazole as the comparator.
Methods
LDLTRs (
N
= 172) from five centers were randomized 1:1 to receive intravenous micafungin 100 mg/day or fluconazole 100~200 mg/day (intravenous or oral). A non-inferiority of micafungin was tested against fluconazole.
Results
The per-protocol set included 144 patients without major clinical trial protocol violations: 69 from the micafungin group and 75 from the fluconazole group. Mean age of the study patients was 54.2 years and mean model for end-stage liver disease (MELD) score amounted to 16.5. Clinical success rates in the micafungin and fluconazole groups were 95.65% and 96.10%, respectively (difference: − 0.45%; 90% confidence interval CI: − 6.93%, 5.59%), which demonstrated micafungin’s non-inferiority (the lower bound for the 90% CI exceeded − 10%). The study groups did not differ significantly in terms of the secondary efficacy endpoints: absence of IFIs at the end of the prophylaxis and the end of the study, time to proven IFI, fungal-free survival, and adverse reactions. A total of 17 drug-related adverse events were observed in both groups; none of them was serious and all resolved.
Conclusion
Micafungin can be used as an alternative to fluconazole in the prevention of IFIs in LDLTRs.
Clinical Trials Registration
NCT01974375
.
Bioartificial livers (BAL) may offer acute liver failure (ALF) patients an opportunity for cure without liver transplantation. We evaluated the efficacy of a spheroid-based BAL system, containing ...aggregates of porcine hepatocytes, in a porcine model of ALF. ALF pigs were divided into three groups. The control group consisted of treatment naïve pigs (n = 5), blank group consisted of pigs that were attached to the BAL system not containing hepatocytes for 12 hours (n = 5) and BAL group consisted of pigs that were attached to the BAL containing hepatocytes for 12 hours (n = 5). Increase in serum ammonia levels were significantly greater in the blank group (P < 0.01) and control group (P < 0.01), compared to the BAL group during the treatment period. Increase in ICP was significantly greater in the control group compared to the BAL group (P = 0.01). Survival was significantly prolonged in the BAL group compared to the blank group (P = 0.03). A BAL system with a bioreactor containing hepatocyte spheroids showed effective clearance of serum ammonia, preservation of renal function and delayed ICP increase in a porcine model of ALF.
Because of the shortage of deceased-donor livers for transplantation, living-donor liver transplantation (LDLT) has become an indispensible treatment strategy for end-stage liver disease. The ...critical prerequisite for LDLT is the maximal safety of healthy donors.
From June 1996 to November 2010, a total of 827 completed donor hepatectomies were performed in our center. We analyzed donor morbidity associated with LDLT.
There was no donor mortality. No complications were observed in 744 (90.0%) donors, and 83 (10.0%) donors experienced complications. Wound complications were most common, occurring in 48 (5.8%) patients. According to a modified Clavien classification, grade I, grade II, grade IIIa, and grade IIIb complications were experienced in 56 (67.5%), 2 (2.4%), 15 (18.1%), and 10 (12.0%) donors, respectively. Surgical or interventional management was successful in all grade IIIa and grade IIIb donors. The incidence of biliary complications was significantly higher in younger donors. Donor morbidity did not decrease below the attained level even after time had passed.
This study demonstrates the safety of donor hepatectomy. Complications were relatively minor and easily controlled. The incidence of biliary complications and donor age was inversely correlated. The procedural experience of the surgeons was not associated with the donor complication rate.
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