Bilateral hearing loss as the initial presentation of reversible Wernicke's encephalopathy with splenial lesion.

BACKGROUND: Wernicke's encephalopathy (WE) is an acute neurological syndrome resulting from thiamine (vitamin B1) deficiency. It has been recognized increasingly in non-alcoholic patients, such as in the condition of malnutrition. Recent literature has shed light on uncommon symptoms and neuroimaging findings. CASE REPORT: We reported a case of a 44-year-old male who initially presented with bilateral hearing loss, and exhibited abnormality in the splenium of the corpus callosum on magnetic resonance imaging (MRI) diffusion-weighted imaging sequence. On the following day the patient developed new symptoms, including unstable walking, double vision and hallucination. The subsequent brain MRI demonstrated lesions involving periaqueductal grey matter and bilateral medial thalamus, indicating the diagnosis of WE. Empirical treatment with intravenous thiamine resulted in complete clinical and radiological resolution. CONCLUSION: To the best of our knowledge, the current case is the first report of WE in literature with uncommon but reversible manifestations. This case warns us to maintain a heightened level of suspicion for WE in malnourished patients with neurological deficits, despite the possibility of atypical presentations encompassing bilateral hearing disturbances and unusual neuroradiological results. Early diagnosis and timely administration of thiamine in WE are likely to lead to a favorable outcome and full recovery.

The "No-touch" technique improves the survival of patients with advanced hepatocellular carcinomas treated by liver transplantation: A single-center prospective randomized controlled trial.

BACKGROUND: Liver transplantation (LT) is the best treatment for patients with hepatocellular carcinoma (HCC). However, the surgical technique needs to be improved. The present study aimed to evaluate the "no-touch" technique in LT. METHODS: From January 2018 to December 2019, we performed a prospective randomized controlled trial on HCC patients who underwent LT. The patients were randomized into two groups: a no-touch technique LT group (NT group, n = 38) and a conventional LT technique group (CT group, n = 46). Operative outcomes and survival in the two groups were analyzed. RESULTS: The perioperative parameters were comparable between the two groups (P > 0.05). There was no significant difference between the two groups in disease-free survival (DFS) (P = 0.732) or overall survival (OS) (P = 0.891). Of 36 patients who were beyond the Hangzhou criteria for LT, the DFS of the patients in the NT group was significantly longer than that in the CT group (median 402 vs. 126 days, P = 0.025). In 31 patients who had portal vein tumor thrombosis (PVTT), DFS and OS in the NT group were significantly better than those in the CT group (median DFS 420 vs. 167 days, P = 0.022; 2-year OS rate 93.8% vs. 66.7%, P = 0.043). In 14 patients who had diffuse-type HCCs, DFS and OS were significantly better in the NT group than those in the CT group (median DFS 141 vs. 56 days, P = 0.008; 2-year OS rate 75.0% vs. 33.3%, P = 0.034). Multivariate analysis showed that for patients with PVTT and diffuse-type HCCs, the no-touch technique was an independent favorable factor for OS (PVTT: HR = 0.018, 95% CI: 0.001-0.408, P = 0.012; diffuse-type HCCs: HR = 0.034, 95% CI: 0.002-0.634, P = 0.024). CONCLUSIONS: The no-touch technique improved the survival of patients with advanced HCC compared with the conventional technique. The no-touch technique may provide a new and effective LT technique for advanced HCCs.

Shulan Estimation Model: A New Formula for Estimation of Standard Liver Volume In Chinese Adults.

BACKGROUND: To establish a new and accurate model for standard liver volume (SLV) estimation and graft size prediction in liver transplantation for Chinese adults. METHODS: In this study, the data of morphologic indices and liver volume (LV) were retrospectively obtained on 507 cadaveric liver transplantation donors between June 2017 and September 2020 in Shulan (Hangzhou) Hospital. Linear regression analysis was performed to evaluate the impact of each parameter and develop a new SLV formula. The new formula was then validated prospectively on 97 donors between October 2020 and June 2021, and the prediction accuracy was compared with previous formulas. RESULTS: The average LV in all subjects was 1445.68 ± 309.94 mL. Body weight (BW) showing the strongest correlation (r = 0.453, P < .001). By stepwise multiple linear regression analysis, BW and age were the only 2 independent correlation factors for LV. Shulan estimation model derived: SLV (mL) = 13.266 × BW (kg) - 4.693 × age + 797.16 (R2 = 0.236, P < .001). In the validation cohort, our new model achieved no significant differences between the estimated SLV and the actual LV (P > .05), and showed the lowest mean percentage error of 0.33%. The proportions of estimated SLV within the actual LV ± 20%, ± 15%, and ± 10% percentage errors were 69.1%, 55.7%, and 40.2%, respectively. DISCUSSION: The Shulan SLV estimation model predicted LV more accurately than previous formulas on Chinese adults, which could serve as a simple screening tool during the initial assessment of graft volume for potential donors.

A Non-Linear Relationship between Preoperative Total Bilirubin Level and Postoperative Delirium Incidence after Liver Transplantation.

This study aimed to explore the correlation between preoperative total bilirubin (TBil) level and postoperative delirium (POD) in orthotopic liver transplantation (OLT). All the OLT consecutively performed between April 2019 and March 2021 were retrospectively reviewed with data retrieved from a prospectively collected database. Logistic regression model and generalized additive model were used to identify both linear and non-linear relationships between TBil and POD. A two-piecewise regression model was performed to calculate the saturation effect. Subgroup analyses were performed using stratified logistic regression models. A total of 402 recipients were enrolled. After fully adjusted for covariates, TBil was indicated to have a non-linear relationship with POD. The two-piecewise regression model showed the inflection point was 20 mg/dL. On the left side of the inflection point, the incidence of POD increased by 5% per 1 mg/dL increment of TBil (p = 0.026). On the right side of the inflection point, the effect size had no statistical significance (OR, 0.97; 95% CI, 0.90-1.05; p = 0.482). The relationship between preoperative TBil level and POD incidence is non-linear in OLT recipients. The incidence of POD is positively correlated with TBil level when it is below 20 mg/dL. A saturation effect is observed when TBil level reaches 20 mg/dL.

Migration of fully covered self-expandable metallic stents used to treat anastomotic strictures after orthotopic liver transplantation: A single-center, retrospective analysis.

ABSTRACT: Insertion of a fully covered self-expandable metallic stent (FCEM) through endoscopic retrograde cholangiopancreatography is an effective solution for biliary anastomotic stricture following orthotopic liver transplantation (OLT). However, FCEM migration continues to plague patients. This study aimed to evaluate the FCEM migration rate in our center, and to investigate the factors increasing the migration risk for FCEM.The study enrolled 43 post-OLT patients with confirmed duct-to-duct AS. The effects of age, gender, albumin, alanine aminotransferase, aspartate aminotransferase (AST), γ-glutamyl transpeptidase, alkaline phosphatase, total bilirubin, direct bilirubin, ABO (blood group system consists of four antigens) incompatibility, stricture length, FCEM brand, FCEM length, donor liver and recipient bile duct diameters, size mismatches between the donor and recipient bile ducts >2 mm, diabetes and/or hypertension status, endoscopic sphincterotomy status, the use of plastic stents or nasobiliary drainage prior to FCEM implantation, duration from OLT to FCEM placement, and OLT etiology on FCEM migration were retrospectively analyzed.The FCEM migration rate was 48.8% (21/43) at 6 months. The serum AST level was significantly higher in the migration group than that in the nonmigration group (52.48 vs 29.50 U/L, P < .05). A lower serum AST level was associated with a decreased risk of FCEM migration in post-OLT patients with duct-to-duct anastomotic stricture (hazard ratio = 0.968, 95% confidence interval: 0.940-0.996, P = .028).In this single-center, retrospective cohort study, we showed that an elevated serum AST level was a potential risk factor for FCEM migration.

Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study.

OBJECTIVE: Common bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones. METHODS: Data were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups. RESULTS: Stone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 µmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones. CONCLUSIONS: CBD stones less than 0.33 cm in size may be self-expelled through the papilla.

Serum exosomal long noncoding RNA CRNDE as a prognostic biomarker for hepatocellular carcinoma.

BACKGROUND: Accumulating evidence has shown that long noncoding RNA (lncRNA) CRNDE functions as an oncogene in many cancer types. However, its clinical value has not yet been explored in hepatocellular carcinoma (HCC). METHODS: A total of 166 patients with HCC and 100 healthy volunteers were enrolled in this study. The expression levels of serum exosomal lncRNA CRNDE were detected in patients with HCC and controls by quantitative real-time PCR (qRT-PCR). RESULTS: The serum exosomal lncRNA CRNDE expression levels were significantly increased in patients with HCC compared with normal controls. High serum exosomal lncRNA CRNDE expression was significantly associated with tumor size, tumor differentiation, and TNM stage. Receiver operating characteristic (ROC) analysis revealed that an area under the ROC curve (AUC) of 0.839, with a sensitivity and specificity of 69.3% and 85.0%. In addition, the overall survival (OS) and disease-free survival (DFS) were significantly longer in patients with lower serum exosomal lncRNA CRNDE expression compared to those with higher CRNDE expression. Moreover, HCC patients with cirrhosis had worse OS and DFS than those without cirrhosis. Univariate and multivariate analyses indicated that high serum exosomal lncRNA CRNDE expression was an independent indicator of poor prognosis. CONCLUSION: Taken together, serum exosomal lncRNA CRNDE might serve as a potential biomarker for HCC diagnosis and prognosis.

Safety and efficacy of an integrated endovascular treatment strategy for early hepatic artery occlusion after liver transplantation.

BACKGROUND: Hepatic artery occlusion (HAO) after liver transplantation (LT) is typically comprised of hepatic artery thrombosis (HAT) and stenosis (HAS), both of which are severe complications that coexist and interdependent. This study aimed to evaluate an integrated endovascular treatment (EVT) strategy for the resolution of early HAO and identify the risk factors associated with early HAO as well as the procedural challenge encountered in the treatment strategy. METHODS: Consecutive orthotopic LT recipients (n = 366) who underwent transplantation between June 2017 and December 2018 were retrospectively investigated. EVT was performed using an integrated strategy that involved thrombolytic therapy, shunt artery embolization plus vasodilator therapy, percutaneous transluminal angioplasty, and/or stent placement. Simple EVT was defined as the clinical resolution of HAO by one round of EVT with thrombolytic therapy and/or shunt artery embolization plus vasodilator therapy. Otherwise, it was defined as complex EVT. RESULTS: Twenty-six patients (median age 52 years) underwent EVT for early HAO that occurred within 30 days post-LT. The median interval from LT to EVT was 7 (6-16) days. Revascularization time (OR = 1.027; 95% CI: 1.005-1.050; P = 0.018) and the need for conduit (OR = 3.558; 95% CI: 1.241-10.203, P = 0.018) were independent predictors for early HAO. HAT was diagnosed in eight patients, and four out of those presented with concomitant HAS. We achieved 100% technical success and recanalization by performing simple EVT in 19 patients (3 HAT+/HAS- and 16 HAT-/HAS+) and by performing complex EVT in seven patients (1 HAT+/HAS-, 4 HAT+/HAS+, and 2 HAT-/HAS+), without major complications. The primary assisted patency rates at 1, 6, and 12 months were all 100%. The cumulative overall survival rates at 1, 6, and 12 months were 88.5%, 88.5%, and 80.8%, respectively. Autologous transfusion < 600 mL (94.74% vs. 42.86%, P = 0.010) and interrupted suture for hepatic artery anastomosis (78.95% vs. 14.29%, P = 0.005) were more prevalent in simple EVT. CONCLUSIONS: The integrated EVT strategy was a feasible approach providing effective resolution with excellent safety for early HAO after LT. Appropriate autologous transfusion and interrupted suture technique helped simplify EVT.

Predictive value of tumor markers in patients with recurrent hepatocellular carcinoma in different vascular invasion pattern.

BACKGROUND: Four tumor markers for hepatocellular carcinoma (HCC), alpha-fetoprotein (AFP), glypican-3 (GPC3), vascular endothelial growth factor (VEGF) and des-gamma-carboxy prothrombin (DCP), are closely associated with tumor invasion and patient's survival. This study estimated the predictability of preoperative tumor marker levels along with pathological parameters on HCC recurrence after hepatectomy. METHODS: A total of 140 patients with HCC who underwent hepatectomy between January 2012 and August 2012 were enrolled. The demographics, clinical and follow-up data were collected and analyzed. The patients were divided into two groups: patients with macroscopic vascular invasion (MaVI+) and those without MaVI (MaVI-). The predictive value of tumor markers and clinical parameters were evaluated by univariate and multivariate analysis. RESULTS: In all patients, tumor size (>8 cm) and MaVI were closely related to HCC recurrence after hepatectomy. For MaVI+ patients, VEGF (>900 pg/mL) was a significant predictor for recurrence (RR=2.421; 95% CI: 1.272-4.606; P=0.007). The 1- and 2-year tumor-free survival rates for MaVI+ patients with VEGF ≤900 pg/mL versus for those with VEGF >900 pg/mL were 51.5% and 17.6% versus 19.0% and 4.8% (P<0.001). For MaVI- patients, DCP >445 mAu/mL and tumor size >8 cm were two independent risk factors for tumor recurrence (RR=2.307, 95% CI: 1.132-4.703, P=0.021; RR=3.150, 95% CI: 1.392-7.127, P=0.006; respectively). The 1- and 2-year tumor-free survival rates for the patients with DCP ≤445 mAu/mL and those with DCP >445 mAu/mL were 90.4% and 70.7% versus 73.2% and 50.5% respectively (P=0.048). The 1- and 2-year tumor-free survival rates for the patients with tumor size ≤8 cm and >8 cm were 83.2% and 62.1% versus 50.0% and 30.0%, respectively (P=0.003). CONCLUSIONS: The MaVI+ patients with VEGF ≤900 pg/mL had a relatively high tumor-free survival than those with VEGF >900 pg/mL. In the MaVI- patients, DCP >445 mAu/mL and tumor size >8 cm were predictive factors for postoperative recurrence.